Transfusion Medicine Best Practice Single Red Blood Cell Unit Transfusion (Adult)

Transcription

1 Transfusion Medicine Best Practice

2 1.0 Policy Statements 1.1 Regional Health Authorities (RHAs) shall develop policies, processes and procedures for appropriate prescribing of transfusion of red blood cells (RBCs) to elective non-bleeding hemodynamically stable hospitalized patients that comply with Provincial Blood policies. *Note: This policy does not apply to intraoperative patients, patients who are bleeding, or patients who are receiving transfusion therapy in outpatient settings. 1.2 The transfusion order shall specify the clinical indication for transfusion. 1.3 A restrictive threshold (hemoglobin 70-80g/L) should be used for hospitalized patients who are hemodynamically stable, without significant symptoms of decreased oxygen carrying capacity. (Refer to 1.1). 1.4 Transfusion of red blood cells should be administered by a single unit at a time, when appropriate. (Refer to 1.1). 1.5 Consider transfusion (not dependent on hemoglobin level) if symptoms of decreased oxygen carrying capacity (e.g. shortness of breath, chest pain) are present. 1.6 Reassessment of the patient shall be completed prior to release of a second red blood cell unit in a stable non-bleeding patient Post transfusion hemoglobin result is required The issue/transfusion card shall include text to prompt the transfusionist to ensure a complete blood count (CBC) is completed post transfusion Reassessment for continued clinical indication(s) for transfusion of additional red blood cell unit(s) is required. Note: Please follow Massive Hemorrhage Protocol (NL NUR) in the event of massive hemorrhage. Page 2 of 10

3 2.0 Linkages Consent or refusal to transfusion of blood components or administration of plasmaderived blood products. Available at: Guidelines for initiation and termination of blood components and blood products. Available at: _termination_of_blood_components_and_products_vers1.pdf Identification and management of adverse transfusion events. Available at: _termination_of_blood_components_and_products_vers1.pdf Patient monitoring during a transfusion. Available at: Patient notification of transfusion of blood components or blood products. Available at: Policy for blood component and blood product administration. Available at: _product_administration_ver_4.pdf Transfusion orders for blood components and blood products. Available at: pdf Transport of blood components or blood products within a facility. Available at: Scope This policy applies to: 3.1 All health care professionals who prescribe transfusion of red blood cells. Page 3 of 10

4 3.2 All health care professionals who participate in transfusion of red blood cells. 3.3 All transfusion medicine laboratory technologists. 4.0 General Information 4.1 Each unit of red blood cells transfused increases the hemoglobin value by approximately 10g/L. 4.2 Transfusion is a temporary measure to alleviate symptoms of anemia, not a definitive treatment. The underlying cause of anemia must be determined. 4.3 Red blood cell transfusion should be used to treat symptomatic anemia; not used to correct hemoglobin concentration only. 4.4 Liberal transfusion strategies do not improve patient outcomes when compared to restrictive transfusion strategies. 4.5 Unnecessary transfusion is associated with increased health care costs and increased risk of adverse events to the patient. 4.6 The patient s hemoglobin should be reassessed pre and post each unit of red blood cells. The end-point of treatment is relief of signs and symptoms of anemia. 4.7 Alternative therapies should be discussed including cell salvage in preoperative individuals, erythropoiesis-stimulating agents and iron therapy in certain patient populations. When possible, treat the underlying cause of the anemia. 5.0 Process 5.1 Quality Control Each facility is responsible to ensure that red blood cells are transfused for appropriate indications. Page 4 of 10

5 5.2 Procedure Prescriber Assess the patient Prescribe transfusion. Indicate the reason for transfusion on the transfusion order Ensure a CBC test is ordered pre-transfusion and post transfusion for each red blood cell unit Re-assess the patient for signs and symptoms of decreased oxygen carrying capacity post transfusion of each red blood cell unit. Transfusion Laboratory Technologist 6.0 Acronyms Review the order for red blood cell transfusion Confirm hemoglobin Release a single red blood cell unit. (Refer to 1.1) Ensure issue transfusion card includes a prompt to perform CBC post transfusion For subsequent requests for red blood cells: Confirm post transfusion hemoglobin (if completed) Release a single red blood cell unit If indications for release of red blood cell unit(s) are not met, notify the prescribing physician or the physician on call for the facility transfusion service. CBC LIS RBC Complete blood count Laboratory Information System Red blood cells Page 5 of 10

6 7.0 Definitions Laboratory Information System (LIS) Single Unit Transfusion Transfusion Medicine Laboratory (TML) Computer software that is used to enter, manage, and store data pertaining to laboratory tests, treatments or procedures for a specific patient/client/resident. The practice of transfusing one unit at a time with clinical and laboratory assessment post each unit to assess need for further transfusions. Transfusion Medicine Laboratory 8.0 Key Words Patient blood management, red blood cell, single unit transfusion, transfusion 9.0 Records Management 9.1 The transfusion medicine laboratory shall retain the recipient administration data file indefinitely. 9.2 All administration records in the recipient s health record shall be retained in accordance with the health care facility policy. 9.3 Each facility shall have a record system that ensures a copy of all information relating to the patient and the administered blood component forms a permanent transfusion record for the patient. 9.4 The records system shall be organized and maintained in such a way that it is possible to trace blood components from distribution to final disposition. The records system shall also provide a means to locate and access all records in the facility related to a given product. Page 6 of 10

7 References American Society of Hematology. (2013). Ten things physicians and patients should question. Available at: Quality/502.aspx Berger, M. D., Gerber, B., Arn,K., Senn, O., Schanz, U., & Stusi, G. (2012). Significant reduction of red blood cell transfusion requirements by changing form a double-unit to a single-unit transfusion policy in patients receiving intensive chemotherapy or stem cell transplantation. Haematologica, 97(1), DOI: /haematol Capital Health. (2013, January 2nd). Transfusion of ONE Red Cell Unit at a time for Elective Non-Bleeding Stable Anemic Patients (Memorandum and Algorithm). Available at: red-cell-time-elective-non-bleeding-stable-anemic-patients pdf Canadian Society for Transfusion Medicine. (2014). Choosing Wisely Canada: Five things patients and physicians should question. Available at: Carson, J.L., Grossman, B.J., Kleinman, S., Tinmouth, A.T., Marques, M.B., Fung, M.K., Holcomb, J.B., Djulbeqovic, B. (2012). Red blood cell transfusion: A clinical practice guideline from the AABB. Ann Intern Med, 157(1), DOI: / Hoffman, A., Farmer, S., & Shander, A. (2011). Five drivers shifting the paradigm from product-focused transfusion practice to patient blood management. The Oncologist, 16(2011), DOI: /theoncologist.2011-S3-3. Minck,S. Single unit red blood cell transfusion. Transfusion Fact Sheet, 4(9). Available at: /rec/57 National Blood Authority. (2012). Patient blood management guidelines: Module 3- Medical. Canberra: ACT. Author. Page 7 of 10

8 National Blood Authority. (2012). Single unit transfusion guide: Every ONE matters. Canberra, AU: Author. Public Health Agency of Canada. (2007). Transfusion Transmitted Injuries Surveillance System User s Manual. (Version 3.0). Ottawa, ON: Author. Shander, A., Gross, I., Hill,S., Javidroozi, M., & Sledge, S. (2013). A new perspective on best transfusion practices. Blood Transfus, 11(2), DOI: / Warwick, R., Mediratta, N., Chalmers, J., Pullan, M., Shaw, M., Mcshane, J. & Poullis,M. (2013). Is single-unit blood transfusion bad post coronary artery bypass graft? Interactive Cardiovascular and Thoracic Surgery, 16(2013), DOI: /icvts/ivt062. Page 8 of 10

9 NL Provincial Blood Red Blood Cell Transfusion Decision Pathway (Adults) Transfusion Medicine Laboratory Technologists Request for RBC sent to TML Yes Bleeding patient, intraoperative patient, hematology patient, or receiving treatment as an outpatient? Release as requested No Confirm baseline hemoglobin Release single unit RBC If additional units requested confirm post transfusion hemoglobin Incremental increase in hemoglobin No clinical indication for transfusion (if information available) Incremental increase in hemoglobin and Clinical indication for transfusion (if information available) No incremental increase in hemoglobin Clinical indication for transfusion (if information available) Discuss with laboratory Hematologist/ Hematopathologist on call or prescribing physician Release additional RBC unit Release RBC as requested *Each unit of RBC increases the Hemoglobin approximately 10 g/l. Check Hemoglobin after every unit to ensure incremental increase with each red cell unit transfused. Page 9 of 10

10 NL Provincial Blood Red Blood Cell Transfusion Decision Pathway (Adults) Medical / Nursing Request for RBC sent to TML YES Bleeding patient, intraoperative transfusion, or receiving treatment as an outpatient Transfuse as indicated NO Confirm baseline hemoglobin and Reason for transfusion - signs of decreased oxygen carrying capacity, chest pain, orthostatic hypotension, tachycardia Transfuse single unit RBC Confirm post transfusion hemoglobin Reassess for signs of decreased oxygen carrying capacity, chest pain, or tachycardia unresponsive to fluid resuscitation Incremental increase in hemoglobin No clinical indication for transfusion Incremental increase in hemoglobin AND Clinical indication for transfusion Incremental increase in hemoglobin Clinical indication for transfusion Transfusion not indicated Transfuse additional unit RBC Investigate cause of anemia Treat as indicated *Each unit of RBC increases the Hemoglobin approximately 10 g/l. Check Hemoglobin after every unit to ensure incremental increase with each red cell unit transfused. Page 10 of 10