Blood Transfusion. Dr William Dooley

Transcription

1 Blood Transfusion Dr William Dooley

2 Plan Cases OSCE practice scenario Blood groups / Indications Monitoring / Reactions

3 Cases For following cases: - Would you give them a blood transfusion? - How many units you would prescribe? - What other investigations/management would you consider? 1. Miss Irene Bleede, 23 yo asymptomatic, healthy woman with menorrhagia Hb 84 g/l, MCV 73fl 2. Mr Oliver Negg, 86 yo asymptomatic man with occasional angina Hb 96 g/l, MCV 104fl 3. Mr Oscar Dere, 73 yo man presenting with acute upper GI bleed BP 80/60, Pulse 120 thready. Hb 82 g/dl, MCV 101fl 4. Mrs A Smith, 35yo woman post Caesarean Section, blood loss 2000mls. Seen on Day 1: obs stable. Hb 66 g/dl (pre op 112)

4 Cases 1. Miss I Bleede, 23 yo asymptomatic, healthy woman with menorrhagia Hb 84 g/l, MCV 73fl Microcytic anaemia Iron deficiency Mx: Oral iron replacement (e.g. Ferrous Sulphate 200mg TDS) No transfusion required Ix: If severe 2. Mr O Negg, 86 yo asymptomatic man with occasional angina Hb 96 g/l, MCV 104fl Macrocytic anaemia Mx: Treat cause Ix:?cause: alcohol, meds, hypothyroidism, haemolysis

5 Cases 3. Mr O Dere, 73 yo man presenting with acute/severe upper GI bleed BP 80/60, Pulse 120 thready. Hb 82 g/l, MCV 101fl Acute anaemia Mx: Stabilise (ABCDE) Cross Match and transfuse 4-6 units Urgent OGD Ix: Clotting screen 4. Mrs A Smith, 35yo woman post Caesarean Section, blood loss 2000mls. Obs stable. Day 1 Hb 66 g/dl (pre op 101) Acute anaemia from blood loss Mx: Advise blood transfusion

6 Indications for Blood Transfusion Acute Anaemia (rarely chronic anaemia) Symptomatic anaemia and blood loss Peri-operative: replacing losses Haemolysis (treat underlying cause) Case-case basis Co-morbidities Symptoms Patient choice Threshold of Hb? Hb < 70 g/l transfusion is usually indicated (NICE 2015) Hb < 80 g/l if acute coronary syndrome Alternatives? Iron transfusion or Oral iron replacement

7 Blood products Packed Red Cells 1 unit raise haemoglobin by ~10-15g/l in 70kg patient NICE 2015: Restrictive transfusion (1 unit and aim for 70-90g/L post Hb) Platelets For severe thrombocytopenia; consider if patient still actively bleeding 1 unit raise platelets by 20x10 9 Same bedside checks and ABO/RhD checks as with red cells Fresh Frozen Plasma (FFP) Contains all the coagulation factors e.g. Disseminated Intracellular Coagulopathy Whole blood Rarely used components more valuable

8 OSCE Scenario Mrs Andrew Smith, 35yo woman post Caesarean Section, blood loss 2000mls. Obs stable. Seen on day 1 post op: Obs: HR 88 BP 125/89 RR 16 FBC: Hb 66 g/dl (pre op 101) MCV 69fl Management: Offer blood transfusion

9 Transfusion discussion

10 Transfusion discussion 1. Indication / Benefits 1. Risks (Inform patient that following a blood transfusion they can no longer be a blood donor) 2. Alternatives 3. How administered 4. Provide written information. Offer time to consider 5. Document discussion

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12 Chronic: Infections Risk of HIV per unit transfused = 1 in 6 million Risk of Hep B per unit transfused = 1 in 1.3 million Risk of Hep C per unit transfused = 1 in 28 million All tested for Hep B / Hep C / HIV 1&2 / Human T-cell lymphotropic virus / syphilis +/- CMV and malaria Risk = asymptomatic window period

13 Taking blood sample

14 Taking blood sample Positive identification- Full name and DOB Confirm with ID wrist band and request form Group and Save vs Cross Match Write details on blood bottle after blood added and at bedside 1. Who? Name/DOB/hospital number 2. Where? Location 3. When? Date/time 4. Who?? Signature

15 Prescribing Blood

16 Prescribing Blood Different at different Trusts but principles the same Usually on separate blood transfusion chart, prescribe: PACKED RED CELLS Timing: Needs to be complete in 4 hours (so logistically usually over 1-3 hours) Same prescribing principles as with normal meds: Who? Sign/Print name/contact number When? Date/Time

17 Pre Transfusion Checks

18 Pre Transfusion Checks 1. IDENTIFICATION CHECKS a) Positive identification with TWO STAFF: Ask patient full name / DOB b) Check against wristband on the patient c) Check against compatibility label on blood unit / request form 2. BLOOD UNIT CHECK a) Check blood unit expiry date / number and blood group b) Check blood bag: ensure free from clots / leaks 3. DOCUMENTATION a) Record- blood pack number, date/time and signature of both staff b) Send request label back to lab to monitor completion

19 Pre Transfusion Checks what to check

20 Putting up the blood

21 Putting up the blood 1. PRE CHECKS Aseptic technique wash hands, gloves, apron Giving set: Double lumen, check expiry Patient observations (baseline) 2. CONNECT BAG Connect the giving set to the blood bag Squeeze blood into both chambers Prime the giving set with blood Attach to cannula 3. GO! Set drip rate 4. DOCUMENT Record when started / by who / checks done

22 During procedure checks

23 Checks during procedure When should observations be checked? Initial/baseline observations 15 minutes after starting Hourly thereafter At end of transfusion What should you be checking for? Temperature Heart rate/blood Pressure Respiratory rate/saturation What symptoms should you be advising the patient to report? ANY! Chest/Abdo pain SOB Restlessness/anxiety Rash Blood in urine

24 Mrs Smith Baseline observations: Temperature: 36.5 Blood pressure: 120/80 Heart rate: 80 Saturations: 99% OA 15 mins into transfusion Patient c/o difficulty breathing What would you do?

25 Mrs Smith... Baseline observations: Temperature: 36.5 Blood pressure: 120/80 Heart rate: 80 Saturations: 99% OA 15 mins into transfusion Patient c/o difficulty breathing 1. ABCDE Assessment A- patent, B- wheeze throughout, C- well perfused, good cap refill 2. Consider stopping transfusion 1. Repeat Observations Temperature: 36.7 Blood pressure: 105/70 Heart rate: 90 Saturations: 94% OA

26 When to stop the transfusion

27 When to stop the transfusion Temperature - Increase by 1 degree Blood Pressure - Significant change (+/- 10mmHg) Heart Rate - Significant rise Symptoms

28 Complications which one? Acute haemolytic reaction Allergic rxn Graft vs host disease TRALI Infections TACO Anaphylaxis Post-transfusion purpura Fluid overload Bacterial contamination Non-haemolytic febrile transfusion rxn

29 Complications which one? Acute haemolytic reaction Allergic rxn Graft vs host disease TRALI Infections TACO Anaphylaxis Post-transfusion purpura Fluid overload Bacterial contamination Non-haemolytic febrile transfusion rxn

30 Transfusion Reactions General management: STOP Transfusion Send blood product to lab Maintain line with IV Fluid Call for help New FBC/U+E/Clotting samples Clear history of symptoms Document Think specifics for management Early vs Late reactions

31 Blood Groups UNIVERSAL RECIPIENT UNIVERSAL DONOR UK Frequency 42% 8% 3% 47%

32 Early vs. Delayed complications Early (<24hrs) Acute haemolytic reaction Anaphylaxis Bacterial contamination TRALI / TACO Non-haemolytic febrile transfusion rxn Allergic rxn Late (>24hrs) Infections Iron overload Graft vs host disease Post-transfusion purpura

33 Early: Acute haemolytic reaction e.g. ABO incompatibility commonly clerical errors Signs/symptoms: agitation, rapid onset fever, hypotension, flusing, abdominal/chest pain, DIC +/- death LARGELY PREVENTABLE COMMONEST CAUSE = HUMAN ERROR

34 Acute Lung Complications TRALI vs. TACO Transfusion Related Acute Lung Injury Dysponea, cough Transfusion Associated Circulatory Overload Signs/symptoms Dysponea, hypoxia, tachycardia, creps +/- echo/bnp General principles Oxygen Treat as ARDS Management General principles Oxygen Diuretic (furosemide)

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36 Acute: Other reactions Non-haemolytic febrile transfusion reaction Shivering and fever (1-1.5hrs post starting) Unpleasant but not life threatening Mx: Consider anti-pyretic (paracetamol) Bacterial Contamination Fever, hypotension and rigors Mx: Urgent septic screen, Broad spec ABx Anaphylaxis Bronchospasm, cyanosis, hypotension, soft tissue swelling Mx: Maintain airway + Oxygen. Call help/2222 Allergic reaction Urticaria and itch Mx: Chlorphenamine

37 Chronic: Other Post Transfusion Purpura 5-7 days post transfusion Platelets fall can be lethal Graft-versus-host disease Rare. Fatal. Donor lympocytes mount an immune response against the immunocompromised host Prevented by irradiation of donor blood

38 the life of all flesh is the blood thereof: whoever eat it shall be cut off (Lev. 17:10 16) abstain from the meats offered to idols and from blood (Acts 15:28 29) (1 3).

39 Summary Is blood transfusion necessary? If so, ensure: Right blood Right patient Right time Right place ANY QUESTIONS???

40 SMITH, Andrew 01/10/

41 20/01/ /03/2016 SMITH, Andrew DOB: 01/10/1987 Hospital Number:

42 Fluid with food dye in Giving sets fluid and blood one Gloves Cannula Prescription chart Name badges