Blood Transfusion. Laboratory Handbook

Transcription

1 SNBTS Clinical Directorate Edinburgh & South East Scotland Blood Transfusion Centre Royal Infirmary Edinburgh 51 Little France Crescent Edinburgh EH16 4SA Blood Transfusion Laboratory Handbook 2011 edition Date of issue: MAY 2011

2 SECTION 1 TABLE OF CONTENTS 1.1 Introduction Contact Details Location Clinical Advice Quality Assurance Accreditation Traceability Enquiries and/or Complaints General Laboratory Information 6 SECTION Blood Sampling Sample Labelling & Request Forms Request for Supplies Clinical Details Special Requirements Unidentified Patients Urgent Requests Infant Samples Transport of Samples High Risk Samples Sample Factors Sample Retention 10 SECTION Table of tests Blood Bank Turnaround Times 12 SECTION Compatibility Test Identification of Red Cell Antibodies Provision of Blood which is not fully compatible with the Patient Issue of Blood of a Different ABO/Rhesus Group Issue of Blood Products to Patients who have undergone a Stem Cell 13 Transplant 4.6 Compatibility Testing of Patients for Surgical Procedures 13 SECTION Suggested Scheme for Antenatal Serology Testing Rhesus Programme/Antenatal Anti-D Prophylaxis Indications for Anti-D Prophylaxis Anti-D doses Repeated Administration of Anti-D Immunoglobulin in the Antenatal Period Antibody Quantitation 15 SECTION Antibody Identification Investigation of Transfusion Reactions 16 SECTION Blood Components Transfusion of Adults Transfusion of Neonates, Infants and Children Platelets Transfusion of Neonates 17 CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK2011 2

3 7.3 Fresh Frozen Plasma (FFP) Transfusion of Neonates Cryoprecipitate Transfusion of Neonates Flying Squad Ordering Blood Products Delivery of Blood Products Urgent Delivery of Blood Products Transfer of Blood to Another Hospital Receiving Patients Who have been transferred with Blood Plasma Derivatives 19 APPENDICES Appendix 1 MSBOS 21 Appendix 2 Management of Transfusion Reactions 22 Appendix 3 Major Haemorrhage Protocol - LUHD 23 Appendix 4 Major Haemorrhage Protocol - RHSC 24 Bibliography, reference and further reading 25 Complaints, enquiries and audit 26 CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK2011 3

4 1.1 INTRODUCTION The Scottish National Blood Transfusion Service (SNBTS) is part of the National Health Service (NHS) and operates as a core component of NHS National Services Scotland (NSS). The SNBTS plays a fundamental role in the delivery of healthcare in Scotland, transforming the donor s gift of blood or tissues into a safe and effective medicinal product. The SNBTS Clinical Directorate delivers front line medical care for patients in Scotland over a range of specialties including hospital blood banking, histocompatibility and immunogenetics (H&I) for solid organ transplantation, clinical apheresis and stem cell services. This handbook is intended for users of the services provided by the South East of Scotland Blood Transfusion Service (SEBTS) Clinical Directorate for pre blood transfusion testing, antenatal service provision and a reference laboratory service for blood serology investigations: 1. Pre blood transfusion testing and provision of blood components for the following hospitals: Royal Infirmary Edinburgh (RIE) Royal Hospital for Sick Children (RHSC) Liberton Hospital Astley Ainslie Hospital Roodlands General Hospital The Fairmile Marie Curie Centre St. Columba s Hospice Edington Cottage Hospital Ellens Glen House And Belhaven Hospital 2. An Antenatal testing service is provided for: Lothian Maternity Hospitals and GP practices Fife Maternity and GP practices 3. A reference blood serology and crossmatch service is provided for Hospital Blood Banks located in: Kirkcaldy Victoria Hospital Queen Margaret Hospital St. John s Hospital at Howden Borders General Hospital Western General Hospital and Bupa Murrayfield Information on donor services can be found on the SNBTS website: CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK2011 4

5 1.2 CONTACT DETAILS Red Cell Integrated Laboratory 2 nd Floor Royal Infirmary of Edinburgh 51 Little France Crescent Edinburgh EH16 4SA Blood Transfusion Laboratory (24hrs) /2 Including Antenatal enquiries Blood Transfusion Laboratory (Emergency use only) Red Cell Investigation Laboratory Blood Transfusion Laboratory Fax Blood Transfusion Specialist Registrar Bleep (110) 2215 Blood Transfusion Duty Registrar #6466 Staff Consultant Staff Telephone Number Address Dr Lynn Manson lynnmanson@nhs.net Other Medical Staff Specialist Registrar Bleep (110) 2215 N/A Duty Registrar #6466 N/A Laboratory Clinical Laboratory Manager Michael Maginnis Blood Bank/Antenatal Serology Carol McFarlane Serological Investigations Raymond Steven michael.maginnis@nhs.net carol.mcfarlane@nhs.net raymond.steven@nhs.net 1.3 LOCATION The Edinburgh and South East Scotland Blood Transfusion Centre is located on the 2 nd Floor of the Royal Infirmary Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA. This site is home to the Red Cell Integrated Laboratory, Histocompatibility & Immunogenetics Laboratory and Immunology Laboratory. The processing, testing and dispatch facility is situated within Lauriston Building at Lauriston Place and also houses the Blood Donor Centre. 1.4 CLINICAL ADVICE For advice on transfusion matters and the clinical use of components and/or plasma derivatives:

6 Mon-Fri 9-8 Bleep Duty Registrar #6466 if calling from within RIE, from all other Hospitals contact RIE switchboard and ask for Blood Transfusion Duty Registrar. Evenings/Night/Weekend and Public Holidays Contact RIE switchboard and ask for Blood Transfusion Duty Registrar. 24 hour on-call rotas operate for the Duty Registrar (first point of contact) and Consultant cover. This cover is for all Lothian Hospitals, including St John s Hospital and Western General Hospital. Please restrict out-of-hours calls to clinically urgent matters. 1.5 QUALITY ASSURANCE A quality Management System monitors and audits all aspects of the service. All laboratory investigations and clerical procedures are governed and maintained by compliance with the SEBTS Quality Manual, Management Procedures and relevant Standard Operating Procedures (SOPs) Standards of testing are maintained by the rigorous use of internal quality assurance protocols and through participation in appropriate UK National Quality Assessment Schemes (UK NEQAS) and the Welsh Assessment of Serological Proficiency Scheme (WASP). A copy of last year s participation certificate and results summary is available on request. 1.6 ACCREDITATION All SNBTS laboratories are accredited through Clinical Pathology Accreditation (Uk) Ltd (CPA). The blood transfusion laboratory is Medicines and Healthcare Regulatory Agency (MHRA) complicate. 1.7 TRACEABILITY All issued blood components, including emergency O Negative have a Blood Transfusion label attached. The blue tear off section MUST be completed by the individual giving the transfusion and the details MUST be completed fully. The blood bank must receive these tags back within 24 hours of transfusion. Returning these tags is a legal requirement (BSQR 2005). For further information on blood transfusion please refer to the Handbook of Transfusion Medicine (4 th Edition 2007 UK Blood Services) and the 'Blood and Blood Components Manual' from your Division. 1.8 ENQUIRIES AND/OR COMPLAINTS We are constantly trying to improve the service and would be happy to receive your comments and suggestions. If you are dissatisfied with any aspect of our service and are unhappy with the response that your initial comments receive, we would encourage you to pass on your concerns in writing to the Clinical Director, Professor Marc Turner, who will ensure that they are dealt with promptly and thoroughly. Further information: This document, information for patients and information for clinical staff can be found at GENERAL LABORATORY INFORMATION RIE Blood Transfusion Laboratory Routine Hours Monday - Friday CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK2011 6

7 There is a 24 hour service for pre transfusion testing, issue of blood & blood products, serological investigations and transfusion reaction investigations. For all blood product requests, results and general queries please contact ext: /2 For serological Investigations contact during routine hours, /2 out with routine hours SECTION BLOOD SAMPLING Mis-identification of a patient at the time of blood sampling or transfusion is the commonest cause of transfusion error. Correct identification of the patient, sample and component are of paramount importance in ensuring safe transfusion practice. Only one patient should be sampled at a time. Aim to send an adequate sample: Adults-4.5 mls in a blue topped Monovette 4.5 ml EDTA tube (Fife Antenatal samples- 6 ml pink topped EDTA tube) Children over 10kgs 4-5mls in a blue topped EDTA Monovette 4.5ml tube or pink topped 5 ml EDTA tube Children under 10kgs 1-2 mls in a clear (pink label) or pink topped EDTA tube The sample should not be taken from an arm that has an IV infusion running All Kleihauer test request must have two 4.5 ml EDTA samples. Post delivery maternal samples should be taken minutes post delivery Sample tubes must not be pre labeled Cold agglutinin samples are only tested by prior arrangement with the Blood Transfusion Laboratory contact Serological Investigations laboratory REQUIREMENTS FOR LABELLING SPECIMENS & REQUEST FORMS It is of vital importance that the details on the laboratory request form and the sample tube must be accurate and complete. The laboratory will not accept requests that do not have the minimum information as described below. Incorrectly or incompletely labelled samples will be destroyed or returned for amendment. Samples will not be accepted where there is evidence of another name being written on the tube, even if this has been obliterated. It is essential that patient identity is confirmed at the time of blood sampling by asking the patient to confirm their details or by checking the details given on the patient identity bracelet. Patient details on the request form and sample tube MUST match exactly. The specimen must be hand written. All details must correspond; any discrepancies will be clarified with the ward/medical Officer / Requestor. Request forms and any other paperwork should be enclosed in a separate compartment and protected from potential leakage from samples. ESSENTIAL DESIRABLE Patient's surname Date sample taken Patient's forename Patient's DOB Sample CHI/Hospital/A+E Number* Signature Sample tube has not expired Patient's surname Date sample taken Patient's forename Sex Patient's DOB Patients address CHI/Hospital/A+E Number* EDD (antenatal samples only) Form Name of Requesting doctor Contact Number Signature of individual taking sample Diagnosis/Reason for request Maternal information (Baby/Paternal samples only) CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK2011 7

8 The minimum data set acceptance criteria is: Surname First name Date of Birth CHI number* *The hospital number is not acceptable- see exception categories. All request forms and/or sample tubes that do not give the CHI number*, as the unique identifier will be discarded, following receipt. A repeat request form and/or sample will be required. Do not amend the request form or the sample yourself. Where the hospital number has been written on the sample, the requestor cannot amend the sample tube; a new sample must be requested and the incorrectly labelled sample discarded. In an emergency, where blood is required - Emergency O Negatives should be issued until an adequately labelled sample has been receipted and processed. *The exception categories are- 1. Foreign visitors 2. Patients not registered with a GP in Scotland 3. Patients from England, Wales and Ireland 4. Patients currently resident in HM prison 5. Patients in the Armed Forces 6. SCRH, RHSC Neonatal Unit Babies 7. Home Births*-Surname, Forename & DOB (3 Data set points only) 8. Fife, Borders & Murrayfield samples - register Hospital number 9. Unknown patients in A&E RIE - use A&E number as unique identifier In these cases, the hospital number should be used as the unique patient identifier An incorrect detail on the request form may be corrected on instruction of the Medical Officer responsible for the request. If details on the specimen are incorrect or absent, the requesting individual will be invited to call at Blood Issue, or if it is an outside hospital, and it is convenient, the sample and form can be sent back for amendment and the amendment form completed. Alternatively the requesting individual can send another correctly labeled fresh specimen. Unlabelled specimens must be discarded and the ward/medical officer informed. Addressograph labels on samples are unacceptable and must be discarded and the ward/medical officer informed. **Addressograph labels may be used on request forms only.** If information relating to another patient has been altered on the specimen, including Baby of (Maternal details) the specimen must not be accepted, discarded and the ward informed. 2.3 REQUEST FORMS SUPPLIES CAN BE OBTAINED FROM ASTLEY AINSLIE STORES TEL: CLINICAL DETAILS Details of the patients risk status, previous name(s), known antibodies and previous pregnancies should be included on the request form. In obstetric cases, gestation, expected date of delivery and dates of any Anti-D injections should all be noted on the request form. Clinical details must be given in the diagnosis section of the Blood Transfusion Service request form. This allows samples to be prioritised appropriately and for the correct tests to be carried out. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK2011 8

9 2.5 SPECIAL REQUIREMENTS - IRRADIATED OR CMV NEGATIVE PRODUCTS We can supply blood and blood products to meet a variety of special needs. The reason for these special requirements must be clarified. It is the responsibility of the requesting doctor to identify these special needs. Please discuss with the duty haematologist if you are unsure. If a patient must receive specialist products, an entry will be made in their computer records and will be available when any future request is received. 2.6 UNIDENTIFIED PATIENTS Patients admitted to hospital without being fully identified must have unknown in place of any information which is not available. The A&E number and the location must be written on the sample tube. The Blood Bank must be contacted when patient details become available to allow essential update of laboratory records. N.B In the event of a Major Incident, all patients will be identified by a unique major incident number on admission. This number will be used on all issued blood component labels to identify such patients until additional information becomes available. 2.7 URGENT SAMPLES Fully crossmatched red cells are available within 40 minutes of sample receipt for the vast majority of patients. Should red cells be needed sooner, uncrossmatched, group specific red cells may be issued in emergency situations only. Urgent samples must meet the mandatory labelling requirements or they risk being destroyed or returned for amendment. Please contact the laboratory before dispatching urgent samples as this will ensure they are processed in the shortest time possible. 2.8 INFANT SAMPLES Newborn infants are identified in their own right. All samples from this group of patients must only be labelled with the individuals details. Samples which contain details of the mother on the blood sample tube will be destroyed. Maternal details must be given ONLY on the request form. Neonates rarely make antibodies in response to blood transfusion but may have passively acquired red cell antibodies in their plasma from the mother. At the time of the first request please send a maternal sample (4.5ml blue top EDTA) which will be screened for antibodies infant sample (1.0ml pink top EDTA), which will be used for ABO & RhD grouping and a DAT. If no maternal sample is available a larger infant sample (1-1.5ml) is required. 2.9 SAMPLE TRANSPORT From with in the Royal Infirmary, samples may be sent via the Quire Pace Pneumatic Tube Delivery System to user number: 222. Urgent samples may be sent via porter by contacting the Balfour Beatty helpdesk on ext: To ensure that any leakages are contained samples should be sent in sealed plastic bags with the request form protected from the samples; plastic bags should be placed in an appropriate outer container with sufficient packaging to protect the health of individuals handling these packages. The packaging of all referred samples must conform to Post Office regulations ( HIGH RISK SPECIMENS Any specimen from a patient who has (or is suspected to have) a hazardous infection must be labelled with a 'Risk of Infection' label on both the request form and sample tube. The sample should first be sealed in a separate bag before being placed in a double compartment bag. The request form must NOT be sealed in the bag with the specimen. Samples taken from a patient considered to be from an at risk group e.g. intravenous drug users must be labelled as High Risk. The request form should state the confirmed/suspected infection. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK2011 9

10 Hazardous infections include Category 3 pathogens such as HIV, Hepatitis B and Hepatitis C. NO sample should be taken from a patient suffering from a viral haemorrhagic fever (Lassa, Marburg or Ebola) until a consultant Medical Microbiologist has been informed SAMPLE FACTORS INFLUENCING TEST PERFORMANCE AND RESULTS Haemolysed samples may influence test results and receipt of a haemolysed sample may result in the request for a replacement. Samples more than 7 days old will not normally be processed SAMPLE RETENTION Routine Blood Bank samples are kept for a period of 7-10 days. Advance Group & Save samples are kept for a maximum of 14 days. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

11 SECTION 3 -DIAGNOSTIC TESTS 3.1 TABLE OF TESTS AND SPECIFICATIONS FOR SAMPLE COLLECTION All samples in 4.5ml EDTA sample tubes except where stated otherwise. Samples should be sent for testing as soon as reasonably possible after withdrawal. Additional tests may be requested up to 7 days from sample withdrawal or 72 hours from first transfusion. TEST* Group & Antibody Screen +/- crossmatch Advance Group & Save Important notes This determines the patient s ABO and Rh(D) group and tests for the presence of atypical red cell antibodies. Takes 40 minutes to complete. Samples are stored for 7 days. If a compatibility test is subsequently required, blood can be available within minutes. Issue of red cells reduces the sample expiry time to 72 hours from first issue. Sample labelled with an Advance Group & Save sticker on receipt may be used for crossmatching for up to 14 days from the date drawn or for up to 10 days for obstetric patients. May be requested if haemolysis is suspected. ABO, RhD, DAT & antibody screen for allo and autoantibodies. Antibody identification. Provision of red cells if required. DAT Direct Antiglobulin Test AIHA (Auto Immune Heamolytic Anaemia) Require 3 x 4.5ml EDTA Cold Agglutinin Screen (1 x ABO, RhD, DAT & antibody screen and identification. Prior arrangement only 4.5ml EDTA & 1 x 10ml clotted) Suspected Transfusion Reaction Any suspected incompatibility or significant transfusion reaction should be investigated and the transfusion laboratory informed immediately. A transfusion reaction form (obtained from the laboratory) must be completed. The reaction must be reported on Datix as a transfusion incident. The blood pack and any empty packsand giving sets should be returned to the hospital transfusion laboratory immediately in an appropriate, sealed double plastic bag. All untransfused units should be returned in the original blood transport box. Antenatal Group & Screen Antenatal antibody follow-up Postnatal antibody follow-up Rhesus Programme (2 x 4.5ml EDTA maternal samples and 1 x EDTA cord blood sample - if available. Alternatively a 0.5ml Neonatal sample may be sent.) Kleihauer (2 x 4.5ml EDTA samples) Requests form should be completed fully with EDD, previous pregnancies, known antibodies, transfusions, previous names, dates of injection of Prophylactic Anti-D and history of HDN. Rhesus negative women will have a Rhesus negative card and information sheet provided as well as the comment This patient is eligible to participate in the Anti-D Prophylaxis Programme on their report form. Patients showing presence of allo antibodies in their plasma or who have a history of such will have relevant information and indications for repeat specimens on their report form. (See suggested schemata on page 14). Antenatal patients with red cell antibodies require regular monitoring of their antibody titre. Appropriate timing of the follow-up samples will be given on the report form. (See suggested schemata on page 14. Both the mother and baby samples will have Group & Antibody Screen carried out. A DAT will be performed on the cord blood to investigate whether the baby is at risk of anaemia or jaundice. Carried out on Rhesus negative mothers. Both the mother and baby samples will have a Group & Antibody Screen carried out and the need for maternal Prophylactic Anti-D determined. Mothers giving birth to a RhD positive infant and therefore requiring Prophylaxis will have a Kleihauer test carried out by the end of the next working day. Patients showing a volume of feto-maternal haemorrhage greater than 4ml will be issued further Anti-D to the appropriate ward or out-patient clinic. Only available during normal working hours. Should be requested for any RhD negative ante-natal patient after any potentially traumatic procedure (including delivery) after 20 weeks gestation. This test determines the volume CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

12 Newborn Group & DAT (Coombs Test) Paternal Investigations Private Blood Group Requests of foetal cells in the maternal circulation. Large fetomaternal bleeds (>4mls foetal red cells) may indicate a requirement for larger doses of anti-d immunoglobulin. This test may also reveal a large fetomaternal bleed in the event of an unexpected intrauterine death or anaemia in a newborn infant. False positive results may be obtained in conditions resulting in a raised maternal HbF level e.g. thalassaemia. Cord blood is acceptable but must NOT contain any of the mother s details on the sample tube. This may be given on the request form to allow essential update of laboratory records. Paternal samples will only be tested free of charge if they have been specifically requested by the laboratory. Please include his partner s details and clinical information on the request form. These samples are used to indicate whether the foetus is likely to be at risk of HDN from the maternal antibody. Where there is no medical indication for the tests to be performed e.g. for foreign travel, SEBTS will invoice the requesting medical practitioner for the costs (approximately 25). In this circumstance, please allow at least 1 working week to process the sample and issue a report bearing the patients details and blood group. 3.2 BLOOD BANK TURNAROUND TIMES INVESTIGATION Average turnaround time Group & Save 2 Hours Urgent Group & Save 40 Minutes Group, Save & 1 Hour Crossmatch Kleihauer Next working day Complex crossmatch Varies according to patient red cell requirement. Notice of 1-2 days may be required for individual patients. DAT Rh Programme Group Specific uncrossmatched Blood Antibody Investigation Antibody Investigation with provision of compatible red cells Antibody Investigation requiring Alloabsorption studies Transfusion Reaction Investigation Elution Studies Cold Agglutinins 30 minutes 3 hours, Kleihauer result available next working day minutes Up to 3 working days Up to 1 working day 1 full working day 1 hour on receipt of offending unit(s) and post transfusion G&S sample By special arrangement only By special arrangement only Reporting of results- written & telephoned Printed reports are produced for all samples tested. These reports are returned to the original ward/dept where the sample was taken. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

13 SECTION 4 RED CELL IMMUNOHAEMATOLOGY 4.1 COMPATIBILITY TEST This consists of a G & S and selection of compatible units of red cells. Where no antibodies are identified blood can be released rapidly by electronic issue or using a rapid compatibility test (immediate spin). To permit electronic issue the following criteria must apply: Historical record of patient s group available* *not required in the case of a patient who is blood Group O. No atypical red cell antibodies Sample suitable for automated testing No history of solid organ or bone marrow transplant In the presence of red cell antibodies a more lengthy compatibility procedure using the indirect antiglobulin test is required. Identification of compatible blood for patients with antibodies can be a difficult and timeconsuming procedure. Blood transfusion can stimulate new antibody production so each sample is valid for 72 hours from first red cell issue. 4.2 IDENTIFICATION OF RED CELL ANTIBODIES If red cell antibodies are detected these will be identified where possible and appropriate units of blood selected. A further sample may be requested and you may be notified that provision of blood will be delayed. 4.3 PROVISION OF BLOOD WHICH IS NOT FULLY COMPATIBLE WITH THE PATIENT In certain circumstances it may not be possible to find blood, which is serologically compatible with the patient s plasma. We will always try to select the units, which we feel are safest for the patient in this instance. The doctor prescribing the blood will be notified of any concerns and advised if any special precautions are required. 4.4 ISSUE OF BLOOD OF A DIFFERENT ABO/RHESUS GROUP Occasionally blood may be issued which is not the same group as the patient. This may be because of a shortage of suitable blood of the patient s group e.g. during a large volume transfusion, or a patient with a rare blood group. The blood issued will always be ABO and Rh (D) compatible and an information card will be provided with each pack. 4.5 ISSUE OF BLOOD PRODUCTS TO PATIENTS WHO HAVE UNDERGONE A STEM CELL TRANSPLANT Patients who undergo this procedure often change blood group as a result. During the change from one blood group to another, the blood bank will provide the best suited products for these patients often meaning the patient will receive plasma products of one group and red cells of another. 4.6 COMPATIBILITY TESTING OF PATIENTS FOR SURGICAL PROCEDURES Many hospitals use a maximum surgical blood ordering schedule (MSBOS) for patients undergoing surgery. This is a locally agreed tariff for blood ordering. It is designed to reduce blood wastage and unnecessary testing of blood for procedures where the likelihood of transfusion is small. For all operations requiring a G & S, CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

14 compatible blood can be made available rapidly if required. In exceptional circumstances adaptations may be required e.g. if a patient has a bleeding tendency. SECTION 5 ANTENETAL IMMUNOHAEMATOLOGY 5.1 SUGGESTED SCHEME FOR ANTENATAL SEROLOGY TESTING (adapted from BSCH guidelines on blood grouping & red cell antibody screening in pregnancy 1996) weeks Test ABO & RhD groups All Pregnant Women Anti D Anti C K related Antibodies Other antibodies No antibodies + Antibody Screen Test at least monthly weeks Recheck RhD group All Pregnant Women Test 2 weekly Anti D Anti C K related Antibodies Other antibodies No antibodies + Antibody testing Delivery Perform cord red cell DAT Monitor infant for HDN Test cord cell D group if mother D negative 5.2 RHESUS PROGRAMME/ANTENATAL ANTI-D PROPHYLAXIS Rh(D) negative women detected at booking, require prophylactic anti-d immunoglobulin for all sensitising events in pregnancy and at delivery. Routine antenatal administration of Anti-D at 28 weeks is offered to all Rh(D) negative women who have not already developed Anti-D. These Anti-D doses are generally administered in the community by the midwife or GP. If a woman has already developed allo Anti-D, prophylactic anti-d immunoglobulin will be of no benefit 5.3 INDICATIONS FOR ANTI-D PROPHYLAXIS Routine prophylaxis at 28 weeks Sensitising events:- Hydatidiform mole Ectopic pregnancy Abortion or threatened abortion after 12 weeks Abortion or threatened abortion at any gestation where instrumentation required Threatened abortion with ongoing pregnancy before 12 weeks if heavy bleeding or abdominal pain CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

15 Chorionic villus sampling Amniocentesis or cordocentesis External version or abdominal trauma Ante partum haemorrhage Delivery Anti-D must be given within 72 hours of a sensitising event. 5.4 ANTI-D DOSES < 20 weeks: 250iu. Kleihauer test not indicated >20 weeks: 500iu. Kleihauer test indicated and follow-up essential to determine if further Anti-D required. 28 weeks: 1500IU Routine Prophylaxis for eligible patients. 5.5 REPEATED ADMINISTRATION OF ANTI-D IMMUNOGLOBULIN IN THE ANTENATAL PERIOD Further doses of Anti-D will be required for each new sensitizing event. However, for patients with ongoing intermittent bleeding in the antenatal period, repeated doses are required only at approximately 6 weekly intervals. A further dose will be required at delivery of a Rh(D) positive infant. Kleihauer Testing Kleihauer testing is carried out to measure the level of feto-maternal haemorrhage after a sensitising event after 20 weeks gestation. Bleeds which are estimated to be >2ml are referred to the Obstetric Reference Laboratory within Gartnavel Hospital to assess the volume of the bleed by flow cytometry. Initial Kleihauer test results will be communicated back to the requesting ward by telephone in cases where there has been a large bleed requiring more than the standard dose of Prophylactic Anti-D or when follow-up samples are required for further testing. All other Kleihauer results will be reported via the SNBTS Immunohaematology report form. 5.6 ANTIBODY QUANTITATION Currently, quantitation is only carried out on antibodies of Anti-D or Anti-c specificities. When either of these antibodies are detected in an antenatal patient, this will be reported first as an antibody titration value, then quantified in international units. These antibodies are considered the most likely to cause HDN. The quantitation value correlates better with the risk of intrauterine haemolysis. Antibody quantitation is not carried out on-site. Samples requiring this test are sent to the Obstetric Reference Laboratory within Gartnavel Hospital and paper reports are issued. Where an antibody quantitation has shown a significant rise, results are communicated by telephone to allow us to contact the patient s midwifery team as soon as possible. Anti-D Quantitation <4IU/ml HDN unlikely 4-15IU/ml Moderate risk of HDN Anti-c Quantitiation >15IU/ml Severe risk of HDN <7.5IU/ml HDN unlikely IU/ml Moderate risk of HDN >20IU/ml Severe risk of HDN CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

16 Section 6 - REFERENCE RED CELL IMMUNOHAEMATOLOGY This laboratory offers a comprehensive reference service for the investigation and confirmation of red cell antibodies, investigation of autoimmune haemolytic anemia and possible transfusion reactions. 6.1 ANTIBODY IDENTIFICATION Following antibody identification suitable red cell units can be selected if required antibody notification cards are issued to patients 6.2 INVESTIGATION OF TRANSFUSION REACTIONS Please refer to appendix 2 CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

17 SECTION 7 - BLOOD COMPONENTS AND PRODUCTS This is summary of the products available from SEBTS. More detailed information is available from the department. Blood products should only be administered where there is a clear indication and expectation of clinical benefit. The reasons for transfusion should be clearly documented in the medical notes. None of these products is guaranteed to be free from the risk of transmission of infectious diseases or other adverse events. All products are now leucodepleted at the time of manufacture. 7.1 BLOOD COMPONENTS Red Cell Products TRANSFUSION OF ADULTS- VOLUME MLS Shelf life -35 days. Must be stored in a designated temperature monitored blood refrigerator linked to an alarm system. Must never be stored in a domestic or drug fridge. Transfused within 4hrs of removal form designated temperature controlled storage. If not required must be returned to the Blood Transfusion laboratory within 30mins of removal from designated temperature controlled storage TRANSFUSION OF NEONATES, INFANTS AND CHILDREN All red cell Transfusions Shelf life -35 days. Must be stored in a designated temperature monitored blood refrigerator linked to an alarm system. Must never be stored in a domestic or drug fridge. Transfused within 4hrs of removal form designated temperature controlled storage. If not required must be returned to the Blood Transfusion laboratory within 30mins of removal from designated temperature controlled storage Neonatal Exchange Transfusion-Volume 324 mls(mean) Plasma reduced whole blood in citrate phosphate dextrose (CPD) anticoagulant Haematocrit Irradiated <5days old, units are give a 24 hr expiry post-irradiation Top-up Transfusion-Pedipack- volume varies 50-70mls Available in 4 aliquots Children > 1 year old Volume mls If not required must be returned to the Blood Transfusion laboratory within 30mins of removal from designated temperature controlled storage 7.2 PLATELETS TRANSFUSION OF ADULTS- APHERESIS MLS, POOLED MLS Shelf life of 5 days Stored at +20 to 24 degrees Celsius, with gentle agitation- do not refrigerate! Only usually available as Group O or A. If not required must be returned to the Blood Transfusion laboratory within 30mins TRANSFUSION OF NEONATES, INFANTS AND CHILDREN- NEONATAL (APHERESIS)- 55MLS (MEAN), FULL PACK (APHERESIS) MLS, POOLED MLS Shelf life of 5 days Stored at +20 to 24 degrees Celsius, with gentle agitation- do not refrigerate! Only usually available as Group O or A. Apheresis platelets should be used for all children <16 years If not required must be returned to the Blood Transfusion laboratory within 30mins. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

18 7.3 FRESH FROZEN PLASMA (FFP) TRANSFUSION OF ADULTS- VOLUME MLS Shelf life of 24 months frozen Stored in the Blood Transfusion Laboratory in a designated temperature controlled freezer at -30 degrees Celsius Prior to transfusion FFP must be thawed under controlled conditions. Thawing takes mins. A small stock of group A pre thawed plasma is available. These are suitable for us in patients of blood group A or O with no special requirements. Once Thawed cannot be re-frozen Transfusion Fresh must Frozen be Plasma completed (FFP)-continued within 4 hrs of thawing. If not required must be returned to the Blood Transfusion laboratory TRANSFUSION OF NEONATES, INFANTS AND CHILDREN- METHYLENE BLUE TREATED (MBT) FFP VOLUME- NEONATAL 56 MLS (MEAN), PAEDIATRIC 233 MLS (MEAN) Shelf life of 24 months frozen Stored in the Blood Transfusion Laboratory in a designated temperature controlled freezer at -30 degrees Celsius MBT FFP should be used for children<16 years Prior to transfusion FFP must be thawed under controlled conditions. Thawing takes mins. Once Thawed cannot be re-frozen Transfusion must be completed within 4 hrs of thawing. If not required must be returned to the Blood Transfusion laboratory 7.4 CRYOPRECIPITATE TRANSFUSION OF ADULTS- VOLUME POOL (5 DONOR UNITS). Shelf life of 24 months frozen Stored in the Blood Transfusion Laboratory in a designated temperature controlled freezer at -30 degrees Celsius MBT FFP should be used for children<16 years Prior to transfusion FFP must be thawed under controlled conditions. Thawing takes mins. Once Thawed cannot be re-frozen Transfusion must be completed within 4 hrs of thawing. If not required must be returned to the Blood Transfusion laboratory 7.5 TRANSFUSION OF NEONATES, INFANTS AND CHILDREN- METHYLENE BLUE TREATED (MBT)- VOLUME 38 MLS (MEAN) Shelf life of 24 months frozen Stored in the Blood Transfusion Laboratory in a designated temperature controlled freezer at -30 degrees Celsius MBT Cryoprecipitate should be used for children<16 years Prior to transfusion Cryoprecipitate must be thawed under controlled conditions. Thawing takes mins. Once Thawed cannot be re-frozen Transfusion must be completed within 4 hrs of thawing. If not required must be returned to the Blood Transfusion laboratory 7.6 FLYING SQUAD (EMERGENCY O NEGATIVE) 4 units of O, CDE negative, K negative blood are available at all times in the fridge in Resus Ward of the Accident and Emergency Department RIE. 2 units of O, CDE negative, K negative, CMV negative blood are available at all times in the fridge in Delivery Suite RIE. 6 units of O, CDE negative, K negative blood are available at all times from the Blood Bank. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

19 Please advise the Blood Bank if any of these emergency units are used to allow them to be replaced as soon as possible. 7.7 ORDERING BLOOD PRODUCTS Requests for FFP and platelets should normally be discussed with the duty haematology/bts registrar or consultant. Medical staff from selected units can order directly from Blood Bank according to the locally agreed protocol. All requests for cryoprecipitate must be discussed with BTS medical staff. 7.8 DELIVERY OF BLOOD PRODUCTS Within the RIE, blood will be delivered by the portering service provided by Balfour Beatty(ext: 24242). Please contact this number to arrange uplift of any unused blood products. Delivery of blood products out with the RIE will be by SNBTS driver or taxi. Please contact ext 27501/2 to arrange uplift of unused blood products or empty blood transport boxes. 7.9 URGENT DELIVERY OF BLOOD PRODUCTS Within the RIE, blood will be delivered by the emergency portering service provided by Balfour Beatty (ext 27700) Urgent delivery of blood products out with the RIE will be by SNBTS driver or taxi. Emergency Blue Light delivery may be provided if there is a SNBTS driver available TRANSFER OF BLOOD TO ANOTHER HOSPITAL If a patient is going to be transferred to another hospital and requires ongoing transfusion support, the Blood Transfusion Laboratory must be informed immediately. Blood components will be prepared for transport and will send them to the clinical area in a validated transport box with accompanying documentation and marked with the time of dispatch. Previously issued blood components must not be sent directly from the clinical area In general no more than 2 units are required to travel with the patient. If crossmatched blood is not available, Emergency O Negative will be issued RECEIVING PATIENTS WHO HAVE BEEN TRANSFERRED WITH BLOOD If blood arrives with a transferred patient it should be sent to the Blood Transfusion Laboratory without delay. If urgent transfusion is required the blood can still be transfused as long as the blood has been transported correctly in an approved cooled transport box with appropriate accompanying documentation. Documentation should be completed by the receiving clinical area prior to transfusion. Send a sample for crossmatch to the Blood Transfusion Laboratory without delay to maintain ongoing transfusion support. If crossmatched blood is not available, Emergency O Negative will be issued PLASMA DERIVATIVES Plasma derivatives, with the exception of Anti-D are all now provided by Pharmacy. Coagulation Factor Concentrates OCTAPLEX/BERIPLEX Concentrate rich in factors II, VII, IX and X. Indicated for the reversal of warfarin in life threatening haemorrhage or some congenital factor deficiencies. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

20 Major Incidents During Major Incidents patients will be identified by a unique major incident number on admission, samples must be labelled appropriately. In these cases, the patients unique Major Incident number will be used on all issued blood component labels to identify such patients until additional information becomes available.. Inadequately or incompletely labelled samples will be discarded without discussion. Any non-urgent requests received during a Major Incident will be processed when possible but may be significantly delayed. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

21 APPENDIX 1 MAXIMUM SURGICAL BLOOD ORDERING SCHEDULE A maximum surgical blood-ordering schedule (MSBOS) is designed to reduce blood wastage rates. It is a locally agreed tariff for ordering in elective surgery, which has been agreed by the surgeons, anaesthetists and Blood Bank. An individual clinician can over-ride the MSBOS if deemed appropriate, however where an MSBOS has been agreed Blood Bank will prepare blood according to the given tariff unless a reason for deviation is expressly given. If patients have significant cardiac or respiratory disease, anticipated excessive blood loss or antibodies, they may need to be crossmatched. For a copy of the current MSBOS contact the blood bank. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

22 APPENDIX 2: MANAGEMENT OF TRANSFUSION REACTIONS Reaction features cause management Acute haemolytic transfusion reaction Dyspnoea fever, chest/back pain, ABO incompatible transfusion hypotension haemoglobinuria Anaphylaxis Acute collapse, hypotension, dyspnoea Reaction to plasma constituent eg IgA Fever/rigors Chills, fever, rigors Antileucocyte antibodies or bacterial infection Urticaria Rash, itch Antibodies to plasma protein Infective shock Acute collapse, Bacteria or hypotension, fever endotoxin in Non cardiogenic pulmonary oedema Acute respiratory decompensation component Anti leucocyte antibodies Stop blood. Give IV saline. Establish diuresis. Monitor U&E + coagulation. Send blood & new sample to BTS labs. Stop transfusion. Give O 2, IV antihistamines, nebulised salbutamol, iv adrenaline Slow or stop transfusion. Paracetamol Slow transfusion. Oral or IV antihistamine Stop transfusion. Broad spectrum antibiotics. Maintain BP & O 2 Stop transfusion. Intensive respiratory support. High dose steroids. Diuretics CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

23 APPENDIX 3 Major Haemorrhage Protocol - LUHD To trigger the Major Haemorrhage Protocol 1. Phone 2222 and state that there is a Major Haemorrhage and the location of the patient. Remain on the line while the switchboard operator transfers your call to the Blood Bank. Tell Blood Bank: The diagnosis e.g. ruptured aortic aneurysm, haematemesis The patient's details - name, DOB, CHI number What blood components are required e.g. red cells, FFP, platelets and how many units How urgently the blood components are required Where the patient will be Your name and contact details What samples are being sent to Blood Bank / Haematology and whether they are ready for collection. (Blood Bank will inform you whether a sample for blood grouping is required.) Switchboard will inform: Porters - a dedicated emergency porter will report to Blood Bank and will be available to transport blood components and blood samples until stood down. Haematology lab and on-call Haematologist. Emergency FBC and coagulation samples will be expected and will receive priority handling. 2. Send blood samples with the dedicated emergency porter (not the pod system). a sample for blood grouping to the Blood Bank (unless Blood Bank have informed you this is not required because they already have a suitable sample). FBC and coagulation screen samples to Haematology If further blood components are required or blood samples are ready for collection. Contact the Blood Bank directly on the numbers given in the box below. Haematology advice is available from the on-call Haematologist - contact via switchboard. When the Major Haemorrhage is over. Inform the Blood Bank directly. Blood Bank will stand down the dedicated MHP emergency porter and inform the Haematology laboratory. (It will still be possible to ask Blood Bank to arrange urgent transport for any blood components that are subsequently requested if this is considered necessary.) Do you need to trigger the Major Haemorrhage Protocol (MHP)? Blood components can be obtained rapidly from Blood Bank without triggering the MHP. Contact blood bank directly, explain how urgent the need for blood components is and ask them to arrange urgent transport to the clinical area. RIE Phone or WGH Phone or Bleep 8539(emergency only) St John's Bleep 3729 (or phone 2222 and ask switchboard to "fast bleep" 3729) O negative blood is kept in Blood Bank at each hospital. At RIE, there is also O neg. in the blood fridges in A&E (6 units) and Labour Ward (2 units). Inform Blood Bank immediately if these units are used so that they can be replaced. CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

24 Appendix 3 RHSC MAJOR HAEMORRHAGE PROTOCOL Attending clinicians should dial 222 (the switchboard emergency number for RHSC) and inform them: There is a major haemorrhage. The name and location of the patient. Your contact telephone number and contact name. To fast page a specific doctor you require help from if they are not already on the Arrest Team. Switchboard will then inform in the following order: 1. The Cardiac Arrest Team RHSC 2. Blood Bank RIE 3. Fast Page any additional requested doctor 4. RIE Haematology duty doctor 5. RHSC Haematology Technician 6. Arrange emergency transport for BTS samples Taxi authorization has been previously agreed by the General Manager. Blood Issue RIE (ext or 27502) should be rung directly by the Clincian to clarify the following:- How urgent the need for blood is Patient s minimum data set (full name, date of birth, hospital number if available, A&E number or Major Incident number if necessary). The number and nature of blood components requested (ie red cells, FFP, platelets). For children the normal dose is ml/kg for these components). The exact location of the patient In case of Emergency one unit of screened O negative blood is held in RHSC blood fridge. The Blood Fridge Key is available at RHSC Reception (PICU, Theatre, Wards 2, 4 and 5 also have Blood Fridge Keys) When the full blood count and coagulation screen are available they will be phoned to both the clinical team and to the RIE Haematology duty doctor (via RIE switchboard #6466). The Haematology duty doctor will liaise with the attending clinicians with regard to the haematological results and further blood component requirements. For further FBC/coagulation, the clinical team should liaise direct with the RHSC haematology technician (via RHSC switchboard). For further blood or components, the clinical team should liaise direct with the NRIE Blood Bank (ext 27501/27502). CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

25 BIBLIOGRAPHY, REFERENCES AND FURTHER READING Handbook of Transfusion Medicine (HMSO) 4 th Edition (2007) accessed at British Committee for Standards in Hematology (BCSH) guidelines accessed at o Guidelines on the Management of Massive Blood Loss (2006) o Guidelines for use of prophylactic anti-d immunoglobulin (2006) o Guideline for blood grouping and antibody testing in pregnancy (2006) o Guidelines on the use of Fresh Frozen Plasma, Cryoprecipitate and Cryosupernatant (2004) o Transfusion guidelines for Neonates and Older Children (2004) o Guidelines for the use of Platelet Transfusions (2003) o Guidelines on the estimation of feto-maternal haemorrhage (2009) o Guidelines for compatibility procedures in transfusion laboratories (2004) o The clinical use of red cell transfusion (2001) Serious hazards of transfusion (SHOT) annual reports accessed at SNBTS online transfusion training programme. National patient safety agency (NPSA) Safer practice notice 14 Right patient, right blood accessed at Other policies of interest are available on NHS Lothian intranet (Healthcare>Clinical Guidance>NHS Lothian Local Policies o NHS Lothian Major Haemorrhage Protocol o NHS Lothian Surgical Blood Ordering Schedule o NHS Lothian Emergency Blood Management Arrangements o Anti-D Policy (via Reproductive Medicine>RIE Maternity>Antenatal o NHS Lothian Satellite Blood Fridge Policy o NHS Lothian Blood Transfusion Clinical Policy and Procedures CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK

26 USEFUL ADDRESSES: West of Scotland Blood Transfusion Centre Obstetric Reference Laboratory Gartnavel General Hospital 25 Shelley Road Glasgow G12 0XB IBGRL (International Blood Group Reference Laboratory) NHSBT Filton Blood Centre Filton BRISTOL BS34 7QG CT/G DRIVE/WRITING2011/LABORATORY HANDBOOK