Blood Bank and Transfusion Medicine Service
|Director & Clinical Consultant:||Pamela Clark, M.D. PIC 2209|
|Associate Director:||Gay Wehrli, M.D., MSEd PIC 6170|
|Blood Bank Fellow:||Terri Sue Giles PIC 1632|
|Laboratory Manager:||Thomas Brady, MT(ASCP)SBB|
|Hours of Operation:||24 hours per day|
A. Blood Products Availability
|red blood cells||1 - 4 hours|
|washed red blood cells||45 additional minutes per unit|
|product aliquots for neonates||45 minutes|
|plasma, fresh frozen||45 minutes|
|platelet concentrate||45 minutes|
|washed platelet concentrate||2 hours|
|granulocyte concentrate||to be determined|
B. Medical Services Available
Transfusion Medicine and Immunohematologic Consultation
C. Technical Services Available
Platelet Alloimmunization Evaluation
D. Criteria for Transfusion of Blood Components: A detailed circular is available in the Blood Bank and should be consulted for additional information.
1. Red Blood Cells, Washed Red Blood Cells, Leukocyte-reduced Red Blood Cells, Small Volume Aliquots for infants. Indicated for increasing the recipient's O2 carrying capacity.
a) Washed red blood cells are recommended for patients who have experienced severe, systemic allergic reactions to red cell transfusions.
b) All blood products in the Blood Bank are leukocyte reduced. Leukocyte-reduced cellular products reduce the likelihood of alloimmunization to HLA antigens and reduce the risk of CMV transmission.
c) Small aliquots (<50mL) of CMV seronegative, HemoglobinS negative, irradiated red blood cells are available for infants less than four months old. For these neonates, this product does not require a crossmatch under routine circumstances. Further information regarding pretransfusion compatibility testing in infants less than 4 months old is available in the Blood Bank.
2. Plasma. Used to provide coagulation factors and for some plasma exchange procedures. Transfused plasma must not contain ABO alloantibodies that could react with recipient red blood cells but need not be ABO identical. The transfusion transmitted disease risk (TTD) is the same as that of red blood cells.
3. Cryoprecipitate. May be used for replacement of factor VIII in patients with hemophilia A or von Willebrand's Disease. May also be used for replacement of fibrinogen and factor XIII. The TTD risk for cryoprecipitate is the same as that of red blood cells. See Cryoprecipitate Information.
4. Platelets Whole blood derived or by apheresis, Washed, or Leukocyte Reduced. Indicated for treatment or prophylaxis of bleeding due to thrombocytopenia and/or functionally abnormal platelets. Platelet transfusions are often ineffective in thrombocytopenia due to platelet consumption. Because platelets lose their hemostatic effectiveness in stored red blood cell products after approximately one day, massive transfusion may produce hemorrhage that responds to platelet transfusion. Platelets should not be transfused through a microaggregate filter nor cooled below room temperature. The TTD risk is the same as that of red blood cells. Rh immune globulin should be administered to Rh-negative females who have received Rh positive platelets and who are eligible to have children in the future. It also may be administered at the discretion of the physician, to any other Rh negative patient who has received Rh-positive platelets. See Platelet Information and Evaluating for Platelet Refractoriness.
a) Washed platelets are recommended for patients who have experienced severe, systemic allergic reactions to blood product transfusions.
b) Leukocyte-reduced platelets are recommended for patients who have previously had a febrile transfusion reaction to platelet products. Leukocyte-reduced cellular products reduce the likelihood of alloimmunization to HLA antigens and reduces the risk of CMV transmission. All platelets are leukocyte reduced at UVA.
c) HLA matched and/or crossmatch compatible platelets are recommended for patients who have developed a refractoriness to randomly selected platelets as demonstrated by a failure to achieve the expected increment one hour post-transfusion and have documented platelet antibodies. Advance arrangements are required.
5. Granulocyte Concentrate. Used for transfusion of granulocytes to infected, severely granulocytopenic patients unresponsive to appropriate antibiotics. The TTD risk is the same as that of red blood cells. This component has a 24 hour expiration and is collected in response to a specific request and requires advance arrangements.
6. Irradiated Blood Products. Cellular blood products may be irradiated to prevent graft-versus-host disease in immunocompromised patients.
7. CMV Reduced Risk Blood Products. The provision of CMV reduced risk cellular blood products may require consultation with a Blood Bank physician.
8. Skin Products. Used in the treatment of full thickness burns and wound healing. Cadaveric skin, allograft and autologous skin are available.
E. Crossmatch Procedures
Request Procedure. Blood products are routinely requested through the electronic medical record (Epic). During times when Epic is not operational, a Epic Downtime Form must be submitted. If preprinted admission labels are not available, print (ballpoint pen) the requesting physician's name, PIC #, patient's name, history number, location, and date. Most serious transfusion accidents are caused by clerical or identification errors. The TYPENEX system must be used properly for specimen identification. Improperly labeled specimens and requests may be rejected by the Blood Bank staff. See procedure in this manual for questions concerning the use of the TYPENEX identification system.
Blood Specimens Required - 6 mL pink top tube. TYPENEX labels on tubes must show the patient's full name with suffix, history number, date collected, and the first initial and last name of the phlebotomist. MISLABELLED SPECIMENS CAN RESULT IN FATAL HEMOLYTIC TRANSFUSION REACTIONS.
Elective Requests. Elective requests are filled in the order received. If the blood reserve is reduced to the amount designated "EMERGENCY RESERVE," elective requests for which the full number of units is not available are postponed until blood is available. When the supply is inadequate for elective transfusion, the requesting physician will be notified immediately. If ABO/Rh type specific red blood cells are not available, ABO/Rh type compatible red blood cells may be substituted.
Emergency Transfusion Requests. In very urgent situations blood will be issued before a crossmatch is performed. The requesting physician must submit a completed "Emergency Request for Uncrossmatched Blood" (BB:45) form certifying the urgent nature of the request. If the patient's type is unknown and an acceptable sample is not available for testing, as many as four units of Group O, Rh negative red blood cells will be issued. If, after these units have been issued, a sample is still not available and additional blood is requested then:
a) Group O, Rh negative red blood cells will be issued to all females not past child bearing age (<50 years) and for those patients with a known history of Rh sensitization.
b) All other patients will receive Group O Rh negative red blood cells only if inventory is adequate. Otherwise, they will be issued Group O Rh positive red blood cells.
c) Patients who have received 12 or fewer units of Group O red blood cells may be switched to blood of their own group. After more than 12 units of group O blood, only group O will be issued until the absence of isohemagglutinins is documented in a posttransfusion patient specimen. In order to prevent depletion of group O blood inventory, only 4 uncrossmatched units are released for one patient at one time, and a switch to type specific blood should be made as soon as possible.
d) If a current sample (< 3 days old) is available for testing, then uncrossmatched ABO compatible units may be available in approximately five minutes.
1. Schedule. Requests for blood will be filled as follows:
Emergency (no crossmatch) Immediately
Electronic crossmatch 15 minutes
Electronic crossmatch is a computer crossmatch with over 20 checks to assure the red cell product is compatible. Patients with a current Typenexed sample, a negative antibody screen, and no history of antibodies are eligible for this rapid crossmatch.
Anti-human globulin crossmatch, full 2-4 hours
An antihuman globulin crossmatch is performed on specimens from patients with alloantibodies, or a history of alloantibodies.
Type and Hold sample held for 3 days
a) Units crossmatched with patient specimens submitted between 0700 of any day (DAY 1) and 0700 of the next day (DAY 2) will be held in reserve until 0700 of the following day (DAY 3). Units crossmatched on Day 2 or Day 3 against a sample collected on Day 1 will be held in reserve for the patient until 0700 on Day 4.
b) Specimens submitted for "Type and Hold " may be used to provide units of blood (either crossmatched or uncrossmatched) so long as the units are transfused within 3 days of the specimen's being obtained.
c) Special policies exist for neonatal transfusion. Please consult with a Blood Bank Supervisor or Director.
2. Rh-Negative Blood. The limited reserves of Rh-negative blood occasionally obligates use of Rh-positive blood for Rh-negative recipients, especially in patients needing many transfusions. Rh-negative women (with childbearing potential), and patients having Rh antibody (anti-D), should rarely be given Rh positive blood.
F. Consent For Blood Transfusion:
It is the patient's physician's responsibility to obtain informed consent from the patient, or their guardians, for the transfusion of red blood cells and other components.
1. Unless otherwise specifically indicated, informed consent is required for the administration of all components. Blood products that have been treated to inactivate or remove viruses (e.g. albumin, immune globulins, coagulation factor concentrates, fibrin sealant) do not require informed consent.
2. Informed consent is not required for the administration of red blood cells and other components in an emergency when delay resulting from obtaining informed consent would place the patient in jeopardy. Documentation of the urgency of the situation must be included in the patient's medical record.
3. If a patient, or his or her guardian, refuses to give informed consent, this too must be documented, and red blood cells and other components may not be administered.
The completed "Blood Transfusion Consent or Refusal" form is to be placed in the patient's chart prior to transfusion.
G. Blood Product Administration
1. Only Blood Bank staff are authorized to take blood from any refrigerator in the Blood Bank. Routine policy permits the release of only one unit per patient at one time other than to the Operating Room, TCVPO and Emergency Room.
2. It is the responsibility of the individual transfusing the blood to verify that the recipient's identification matches the identification (name, history number, TYPENEX number) on the unit of blood. If there is any doubt of the patient's identity, transfusion should be delayed or, if absolutely necessary, only group O red blood cells should be transfused. Note: Typenex number appears only on red blood cell containing products.
3. Severe hemolytic transfusion reactions are almost always caused by clerical or identification error leading to an ABO incompatible transfusion.
4. The Blood Bank cannot reissue, and must discard, any blood that has been out of an accredited blood storage area for more than 30 minutes, or has been opened in any manner. Therefore, blood which is not transfused promptly should be returned to the Blood Bank as soon as possible. Under no circumstances should blood be stored in a ward refrigerator.
5. Supervision of the transfusion procedure is the responsibility of the clinical service. Vital signs should be obtained immediately before transfusion. The patient should be observed most carefully for reaction while the first 50-100 ml of blood are slowly transfused. 5 ml/minute or slower. Vital signs should be rechecked after this amount is infused. Transfusion should be stopped immediately if any of the following develop: shock (not present before), precordial compression , flushing, cyanosis, back pain, fever, chills, or any other evidence of serious reaction. The patient should be instructed to notify a nurse or physician of any symptoms occurring during a transfusion.
6. All intravenously administered blood products must be transfused through a blood filter. To avoid occluding the filter, mix the unit by gentle inversion for at least two minutes before attaching the administration set.
7. No drug or solution other than 0.9% NaCl should be mixed with any blood product. Lactated Ringers solution may clot blood products and should not be mixed with or used to start any blood product transfusion. Dextrose or a ½ normal saline solution may hemolyze red blood cells.
8. Medicating patients with anti-pyretics prior to a red blood cell transfusion is not recommended as it may mask a fever which is often the first symptom of a hemolytic transfusion reaction. It is permissible to use such agents prior to a platelet transfusion provided the compound does not contain aspirin, since aspirin interferes with platelet function.
9. Blood should be warmed (not greater than 37oC) with a calibrated, specially designed blood warmer if the rate of transfusion is greater than 50 ml/minute or if the patient has a potent cold agglutinin. Blood may be warmed for neonatal exchange transfusion. Care must be taken to avoid exposing blood to temperatures in excess of 37oC since this may result in hemolysis. Blood warmer temperatures should not exceed 42oC.
10. Patients susceptible to circulatory overload should be transfused with red blood cells at a rate no faster than 1 ml per kilogram of body weight per hour. Patients whose condition permits may receive a "routine transfusion" in 30-60 minutes. Red blood cell products should be transfused routinely in less than four hours. If a greater period of time is needed, the blood bank can release a portion of a unit and retain the rest for subsequent transfusion to the patient.
11. Hemostasis may be impaired by massive transfusion due to the deterioration of platelet function in stored red blood cell products. A platelet product should be transfused after ten red cell units have been given in an acute bleeding episode.
12. Citrate induced hypocalcemia with resultant decreased cardiac output is rare but has been associated with massive transfusions, particularly in conjunction with hypothermia or severe liver disease and in neonates.
13. The effects of increased potassium, ammonia, and lactic acid in refrigerated blood are difficult to assess. In patients who may be less likely to tolerate these constituents, transfusion of washed and/or relatively fresh red blood cells may be appropriate.
H. Transfusion Reactions
Immediately notify a physician if any transfusion reaction occurs. If the transfusion is discontinued, immediately deliver to the Blood Bank one 6 mL pink top tube (labeled using the TYPENEX system) of venous blood, the implicated blood product containers, the product administration set including any attached solutions and post- transfusion urine specimen obtained immediately after the transfusion. A transfusion reaction form located on the back of the Transfusion Record Tag attached to the unit, must be completed, signed by the physician evaluating the reaction and returned with the implicated container. If a hemolytic reaction is suspected, a baseline evaluation of coagulation status and renal function should be performed. The presence of free hemoglobin in the serum and/or the development of a positive direct antiglobulin test will be reported promptly. Except in life threatening situations, additional red cell containing products should not be administered until completion of the serologic evaluation of the reaction. A summary of the results of a complete investigation and appropriate recommendations will be entered promptly in the patient's chart.
Mucocutaneous hives and/or erythema that do not progress after temporarily discontinuing the transfusion and antihistamine administration do not require an investigation. The transfusion may be restarted.
The Medical Directors of the Blood Bank are available for hemotherapy consultation. A Director and Laboratory Medicine resident are always on-call and may be reached through the Blood Bank or hospital operator.