Transcript Recipient Blood Samples

Transfusion Safety Vein to Vein
with a Paediatric Focus
Kathleen McShane
CVAA Conference
May 11, 2012
Blood transfusion is a lot like marriage.
It should not be entered into lightly,
unadvisedly or wantonly,
or more often
than is absolutely necessary.
[Beal RW: Aust N Z J Surg 46:309, 1976]
2
Transfusion Deaths
• Most haemolytic transfusion reactions result
from failure to properly identify the patient
at the time of sample collection or
transfusion
• Deaths/major complications arise from
patients receiving the wrong blood
– ~50% of transfusion deaths
– affects 1/10 000 patients
Is the VA RN involved?
• Start IV access are you asked to draw
samples when you start the line?
YES
• Need to know implications of specimen
draw for Transfusion Medicine.
CSA Standard Z902-10
Blood and Blood Components
CAN/CSA-Z902-10
AA National Standard of Canada
Blood and blood components
• Approved by the Canadian
Standards Association as a
National Standard of Canada
• Recipient Blood Samples“There shall be unequivocal
identification of the recipient
before drawing blood
samples.”
Policies & Procedures
Standard Operating Procedures (SOP)
Specimen Collection
Blood specimens sent to blood bank must be
accompanied by a completed requisition :
• Patient Information
– full name
– history number
– date of birth
• Name of ordering physician
• Diagnosis and Weight
• Reason for transfusion
• Previous transfusion?
• Signature of staff who drew and labelled the
sample (no initials) with date and time collected
May 29/06
08:00
Kathleen McShane
The Transfusion Laboratory will
not accept incomplete requisitions

What Specimen for Type & Screen ?
See Guide to Lab Services
• 4 mL EDTA sample, for neonates less than
4 months old - 1 mL EDTA (adult facilities
7 -10 mLs)
• The blood samples must be labelled with
the patient identifiers and the date and
time of collection before leaving the
patient’s side. All specimens, not 1 of 5.
• Don’t take the chance of having a sample
that was difficult to draw discarded by the
Blood Bank for improper labelling.
• Send maternal blood sample and cord blood
if received from referring hospital
Type & Screen (+Crossmatch)
Specimen type:
Blood
Send to:
Transfusion Medicine
Amount:
4 mL
Container type:
EDTA- Lavender top tube
Comments:
• For neonates less than 4 months of age, 1 mL EDTA sample
(SickKids, Guide to Lab Services)
Transfusion planned in
the near future
Transfusion needed now
(within the next 4 hours)
Crossmatch (includes
Type and Screen)
Type and Screen
Type
ABO group
Rh (D) group
Screen
Antibody screen
Crossmatch
When do you need a sample?
If the patient has been transfused in the last 3 months:
• A sample is good for 3 days
– count the day of collection as day 0
– Sample drawn on 24th is ok to use for
crossmatching until 27th midnight.
If the patient has not been transfused in the past three
months:
• A sample can be good for 6 weeks if for pre-op
• Requisition must clearly indicate pre-op, date of
surgery and transfusion history
Different timing for neonates- negative for antibodies
on initial testing, another sample is not needed until
4 months old if Pt remains in the hospital.
(SickKids, Guide to Lab Services)
Lab results screen (Kidcare) for sample age
*new sample required within 3 days of OR,
transfusion history incomplete
Understanding the rules can prevent
Understanding your hospital’s rules can
prevent unnecessary specimen draw.
Specimen Identification
• Verbally confirm ID with the patient/parent whenever
possible.
 Ask “What is your name?” not “Are you John Smith?”
• At the bedside ensure the following items match on the
patient ID band and sample requisition:
Requisition Patient ID band
Patient name
History #
Birth date
Specimen
Specimen Identification continued
• Mislabelled and unlabelled specimens will
not be accepted and will be discarded by the
Blood Bank. Zero tolerance policy.
• Incomplete requisitions will not be accepted
and will be sent back to the ward for
completion.
• A corrected requisition will be accepted by
the Blood Transfusion Lab, if it has been
corrected properly.
Correcting a Requisition
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•
Draw a single line through the error
Write the correction above the error
Date and initial the correction
Do not use ‘white out’
Do not use pencil
3 Bees for Sample Collection
• Bedside
• Band
• Blood
Ordering Blood Products
•
•
•
•
•
•
•
Avoid delays- Ensure ‘Requisition for the Issuing of
Blood Products’ is properly completed. Including:
Legible addressograph (check after stamping)
Ward area ordering the product, the urgency or time
required
Patient weight
The type and amount of product needed
A reason if special preparation is needed, anti-CMV
neg, irradiation, P&P indications only
Printed name of MD and signature MD/RN
MD signature needed for uncrossmatched blood order
Mechanism for Chain of Custody
By Pneumatic Tube
Requisition
for the Issuing
of Blood Products
For pneumatic tube
delivery- blood components
only send whole requisition:
top white and bottom pink
Send with
Blood
Transfusion
Record
Transport Bag
• Pneumatic tube deliveries will come in a transport
bag from BB
• Sign and complete the label on the bag, send it back
to BB within 30 minutes to indicate that the product
was safely received
• BB is required to follow up within 30 minutes if the
transport bag hasn’t been returned
BLOOD PRODUCT TRANSPORT BAG
NAME:
HSC:
DATE AND TIME ISSUED:
WARD:
PLEASE RECORD YOUR NAME AND TIME WHEN BLOOD ARRIVES
THEN RETURN THE BAG IMMEDIATELY.
TIME:
PRINT NAME:
Form OTM0726A_01
For Manual Pick-up
Retain Pink Copy for Manual
Pick-up
Manufactured Products and
Ice Coolers Require Manual
Pick-up
Blood products cannot be
released from Blood Bank
without written patient ID.
Verbal requests by Transport
Personnel are not allowed.
How much time to get blood?
• Uncrossmatched blood in 5 minutes – off the shelf
(by physician request only)
• Urgent is 45 minutes- dedicated technologist will
do Type and Screen and Crossmatch
• Thal /Sickle Pts, same day transfusion- 2 hours
• Routine is 4-6 hours- technologist will do Type
and Screen and Crossmatch with other requests.
Triage priority is STAT orders, ORs, ASAP orders
then routines.
• Extra time needed for patients with antibodies to
identify, phenotype and find compatible units.
• Extra time needed for component prep if units
need to be irradiated, CMV negative, aliquotted,
pooled or reconstituted.
Informed Consent
• Patient or parent must give consent for transfusion
• Physician, fellow, surgeon or clinical nurse
practitioner discusses the benefits, risks and
alternatives to blood transfusion (and risks of no
transfusion) with the patient/parent before the
transfusion is started.
• The discussion must be documented in the
patient’s chart
• Find documentation of consent before transfusing
unless blood is urgently required- medical or
surgical emergency
Consent to Treatment Form – Paper
Kidcom Consent Screen- Electronic
Patient Information Pamphlets
in Print, on internal web, or on external web
AboutKidsHealth
Blood Product Information Card
on DPLM web and Quick Link on SickKids web
‘e-blood Product Info 2008’
CSA Standards
Blood Administration
• “Immediately prior to transfusion, the
transfusionist shall confirm and document
that all information associating the whole
blood or blood component with the
proposed recipient has been matched and
verified in the physical presence of the
recipient…”
Before Infusion
• Check for documented consent
• Two people must confirm the identity of the
blood unit and the patient
– RN, MD or RT ECMO in CCU
– packed cells, FP, plasma, platelets, cryo
• All checks to be done at patient bedside
• Both must sign the Blood Transfusion
Record to document the double-check and
the date and time of transfusion
Recipient Identification
Check:
ID band
Transfusion
Record
Unit: BB label
Ask patient
Patient Name
History #
NA
• Another opportunity for verbal confirmation of ID.
• If there is any discrepancy, the transfusion must not
be started.
Unit Identification and Expiry
Check
Original label on blood
bag/syringe
Transfusion Record
BB label on bag/syringe
Unit ID #
Check product expiration date on the blood bag label.
ABO and Rh Group
• Check ABO/Rh compatibility
• Red cells must be ABO compatible
• Frozen Plasma and Cryosupernatant should
be ABO compatible
PATIENT'S BLOOD GROUP
O
A
B
AB
COMPATIBLE RBC TRANSFUSION
O
A, O
B, O
AB, A, B, O
PATIENT'S BLOOD GROUP
O
A
B
AB
COMPATIBLE PLASMA TRANSFUSION
O, A, B, AB
A, AB
B, AB
AB
Platelets and Cryoprecipitate
Patient’s Blood Group
Compatible Platelet Transfusion
O
A
B
AB
O, A, B, AB
A, B, AB
A, B, AB
A, B, AB
Platelets should be group identical if possible, otherwise only
group O Pt can get group O; groups A, B or AB okay for all Pt.
Note: Cryoprecipitate does not need to be ABO compatible.
CBS Blood Bag
Labelling in
ISBT 128 Format
Pt ID
Blood Group
Compatibility
Physician’s Order
• The blood component should be checked against
the original physician order to verify the correct
component and amount are being given (If the
wrong Pt name stamped and blood arrives for your
Pt- Would they get it?)
• BB is required to question all unusual orders.
All identification attached to the blood container
must remain attached until the transfusion has
been terminated.
Drawing blood product into syringe
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•
•
•
If the blood product is removed from the bag into
a syringe for use on a syringe pump, or
A 250 mL bottle of 5% albumin is drawn into 5 x
50 mL syringes for use over 24 hours
Syringes must be labeled with the patient’s name
HSC #, date and time product was drawn into the
syringe, lot/unit# of product.
There should be no unlabelled blood component
infusing to the patient
4 Bees for Blood Transfusion
• Bedside
• Band
• Blood
• Bring a buddy
Problem with paeds
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Neonates arrive without their moms
Blood arrives from other hospitals with baby
Name changes
mL/kg not whole bags
Give identical blood group
Stop feeds in VLBW infants
Receiving Blood from another
Hospital
If blood arrives with your patient:
• Label the box on receipt with an
addressograph sticker with your patient’s ID
• The hospital of origin may have labeled the
baby’s blood with the mother’s name
• SickKids may have admitted the baby under
a different name (their given name)
• Only RN knows who the blood came with
Stop Feeds for Neonates
• Our NICU now stops feeds during
transfusion -association between red cell
transfusion and necrotizing enterocolitis
(NEC) in premature neonates or VLBW
infants.
• Transfusion related acute gut injury (TRAGI)
(severe neonatal gastrointestinal reaction
proximal to a PRBC transfusion)
• Also a volume issue, feeds to be stopped one
hour before transfusion and one hour after.
Vascular Access
• The most difficult aspect of transfusion
administration in patients less than 4
months of age, especially in preterm infants
who require long term or continuous
intravenous infusions.
• New line? Stop feeds? Stop pain meds?
How small?
• Vascular catheters (25 gauge) and small
needles (25-gauge) have been safely used
for red cell transfusion without causing
haemolysis (require constant flow rate).
• At SickKids the work horse is the 22 gauge
needle- smaller gauge only for premies and
infants with difficult veins
Filters for Blood Products
• Filter requirements vary by blood
component
170 to 260*
micron filter
15 micron filter No filter
e.g. red cells,
e.g. Cytogam,
platelets, FP, cryo Respigam
e.g. albumin,
10% IVIG
*The 40 or 80 filters are appropriate alternatives if the 170
to 260 filters are not available
Filter and Tubing Issue
• Blood needs to be filtered before infusion
• Adds dead volume to the transfusion
• Tubing room ranges from several mLs up to
30 mLs depending on the set
• NICU primes tubing with blood so they
always order what they need to infuse using
“+ tubing” designation.
• BB allows 30 mL extra to the order
• For larger children you can flush the blood
with saline to complete the transfusion
Does order of product infusion
matter?
• Platelets first though clean filter then red
cells
• If red cells are given first there will be small
clots and cellular debris on the blood filter
that can cause activation and adhesion of
the platelets on the filter
• There will be fewer platelets transfused
through a previously used filter
Changing Blood Admin Sets
CAN/CSA-Z902-10 Standard 11.4.12
• Change admin set at least every 24 hours,
sooner if recommended by the manufacturer
• After infusion of a maximum of four units
of red cells
• Or if the set becomes occluded
How to Transfuse
•All double-checks completed at the bedside
•Tubing primed with NS
Record Vital Signs:
Time 
Pre-transfusion
At 0 min
During Transfusion
At 15 min
Every 30 min
Post-transfusion
At 0 min
At 30 min
Record 
Temperature
*
Blood Pressure
*
Pulse
*
Respiration Rate
*
* Patient to be assessed and vitals signs to be taken and recorded if required.
At 60 min
*
*
*
*
• Remain with the patient for at least the first 15 minutes
• Start the transfusion slowly
• After 15 minutes:
-If the patient’s condition is satisfactory, the rate of
infusion can be increased to ordered rate
• Observe the patient periodically during the transfusion and
up to an hour after completion
*
*
*
*
Administration Rates
• Transfusion must be completed within 4
hours of issue from Blood Bank (bag time)
Factor in:
– Time from BB to bedside
– Any interruptions for meds, etc.
• If a longer time is required, have Blood
Bank divide the unit and issue the volume
that can be transfused in 4 hours.
• If blood is flowing slowly, investigate.
Slow Blood Flow
Investigate and correct by:
• Check the patency of the needle, no
swelling at IV site
• Examine the filter of the administration set
for excessive debris, clots or air
• Elevate the blood bag to increase the
hydrostatic pressure
• Consider the addition of saline to PRBC if
unit too viscous (need order to add saline)
Can you use blood tubing for a med?
• No medications or IV solutions other than
normal saline (NS) may be added to blood
or administered simultaneously through the
same tubing as blood or blood components.
• Medications can be infused through the
same line that was used for transfusion if
the blood transfusion is completed and if the
line has been flushed with 0.9% normal
saline.
Delay in Starting the Transfusion
• Look at the time on the blood bag
• If the transfusion cannot be started within 30
minutes from the time of issue, the blood should
be returned to the Blood Bank for proper storage
• It should not be:
– Left at room temperature
– Stored in a ward fridge, not validated
– Stored in a plastic bag full of ice chips
• Units returned to BB after 30 minutes from issue
will be unsuitable for re-issue to another patient
and will be discarded
Transfusion Reactions
• Did you ever come in to fix a line and the
patient was experiencing a transfusion
reaction?
Unused Blood
• If unopened and no longer required, return
product to Blood Bank ASAP for proper
storage and to avoid wasting product
• Even incorrectly stored, blood must be
returned to BB
– Do not discard on the Ward
• Any blood product returned to BB must be
accompanied by the Transfusion Record
Opened Unit of Blood
• If the patient has received all the blood they
need but there is some left in the bag, it
should not be returned to BB, it should be
discarded into a biohazard container on the
ward (sealed or with absorbent material)
• If the transfusion is interrupted but blood is
still required you can continue to infuse if
the transfusion can be completed within 4
hours of issue. (Ask MD if it can be run
faster than the ordered rate if limited time.)
VA RN should know
• IV access lost in the middle of a transfusion
and VA RN called to restart?
• Time sensitive: You have 4 hours from the
time on the bag to use the unit
• Regaining IV access and continuing with
the same unit until the 4 hours is up, limits
donor exposure
Patient Transfer
• Blood products must not be transferred with
the patient
– Only blood products that are already
infusing can accompany the patient.
– Only if the Pt is accompanied by an RN
who will monitor the transfusion.
• Blood products must be returned to the
Blood Bank ASAP with the Transfusion
Record.
Resources ORBCoN website
http://www.transfusionontario.org/
Bloody Easy 3
access to reference
booklet
free online course for
physicians, nurses
and technologists
Blood
Administration
content from
“Bloody Easy for
Nurses” online
learning program
Resources CBS website
http://www.blood.ca/
CBS Clinical
Guide
to Transfusion
CBS Circulars of
Information 2011
For:
•Red Blood Cells
•Platelets
•Plasma Components
CMV-safe blood
• All blood is now leukoreduced before storage and is
considered CMV-safe
• At SickKids CMV-seronegative blood is reserved for:
– CMV-seronegative patients with a malignant
diagnosis (assuming they are on chemotherapy
therefore immunocompromised)
– CMV-seronegative BM or Stem Cell transplant
patients
– CMV-seronegative recipients of a seronegative solid
organ (not potential transplants)
Why Irradiate?
Graft-Versus-Host Disease (TA-GVHD)
• Pathophysiology
– engraftment of transfused donor T lymphocytes
in recipients
• Implicated products: cellular blood components
(red blood cells, platelets)
• Gamma-irradiation prevents lymphocyte
proliferation
– Red cells: shelf-life shortened to 28 days
– Increase in the extracellular potassium
concentration, Sick Kids: plasma deplete or
wash after 72 hours for small patients
Irradiated red cells and platelets
(cellular products) go to:
• Infants under 6 months
• Congenital immunodeficiencies e.g Di George
• All Hem/Onc patients with a malignant diagnosis
(on chemo therapy and immunocompromised)
• All bone marrow transplant/stem cell transplant
patients
• Some solid organ transplants
• Cardiac patients with a diagnosis of truncus
arteriosus/interrupted aortic arch
• All directed donations