BLOOD TRANSFUSION SAFETY

1. BLOOD TRANSFUSION SAFETY Prepared by : Ashwin Bhatt Through: Education Department

3. The Healing Touch Blood transfusion is a essential part of modern health care. Millions of lives are saved each year through blood transfusions. Blood transfusion can save life but also carries some risk of adverse events among some recipients. BLOOD TRANSFUSION SAFETY Prepared by: Ashwin Bhatt Through: Education Department

5. When is a blood transfusion needed ? • A blood transfusion is needed if a person has had significant blood loss • Or the body cannot make or is losing an important component of blood. Blood may be lost through: • Injury ( e.g. road accident ) or major surgery ( knee replacement). • Bleeding, such as a bleeding ulcer. • An illness that destroys blood cells, such as hemolytic anemia. • When bone marrow doesn't make enough blood, such as aplastic anemia.

6. Processing of donor’s blood at the Blood Bank • Donated blood is subjected to screening tests for infectious diseases. • Processed to separate different components from the whole blood. • Transfusing only selected blood components allows : • The treatment to be specific. • Reduces the risks of side effects. • Can efficiently use the different components from a single unit of • blood to treat more than one patient.

7. Blood or Component may be transfused to : • Restore the lost of blood volume • Enhance the O2 carrying capacity of blood • Maintain Haemostatis • Platelets • Coagulation Factors • Fresh blood • FFP or Appropriate component

8. SEPARATION OF COMPONENTS WHOLE BLOOD CELLULAR PLASMA WBC’S RBC’S PLATELETS Fresh Frozen PACKED CELLS Apheresis Random donor Leucodepleted Cryoprecipitate Apheresis Frozen Factor concentrates Irradiated Washed Immune globins Irradiated

9. Blood Transfusion Safety refers to the overall perspective of delivering transfusion care which includes mainly two types of risks for the recipient : • Blood and Blood component risk.(infectious diseases, adverse reactions) • The risk of human errorwhich can occur prior to transfusion during collecting, storing, testing and administering procedures. The greatest risk from blood transfusion is not, as we imagine, being exposed to a blood-borne infection, but ratherreceiving the wrong blood. The reasons for this are almost exclusively human error, and, In particular, failure to complete the proper checks before commencing the transfusion. • Reasons for error can be distraction,fatigue,inattention or lack of knowledge or information.

10. Precautions • Transfusion is a multi-department process • There are opportunities for error at a number of critical points during the transfusion process starting with : • The decision to transfuse. • Prescribe / Request for transfusion. • Patient blood sampling. • Pretransfusion testing / Cross-match. • Collection of the component from Blood bank refrigerator. • Administration to the patient. As healthcare workers we can take precautionary measures to avoid errors and make transfusion safer for the recipient.

11. Precautions Requesting blood component for Transfusion It is a medical responsibility to prescribe blood components or blood products. The decision to transfuse is based on an assessment of the patient’sclinical condition rather than a given level of hemoglobin. for e.g. blood transfusion of patients with chronic stable anemia is probably unjustifiable if the hemoglobin level is above 7g per 100ml

12. Precautions • A transfusion request • form must be filled • stating the • Clinical details • Required component • Date of intended transfusion • Number of units • Signature of the requesting doctor.

13. Precautions Blood sampling for transfusion : Blood samples can be collected by a registered medical practitioner, or by a healthcare worker, nurse or midwife who should be appropriately trained and licenced. Sample labeling should be—"From the Patient, at the Bedside” • The identity of the patient must be confirmed before collection. • The label on the sample tube must be clearly hand-written by the blood collector at the site of blood collection, immediately after collecting the blood –“On the site of collection by the collector” Never pre-label transfusion sample tubes

14. Precautions Good practices for sample labeling Blood sampling for transfusion : Risky practices • Failure to check patient identity. • Labeling of sample tubes away from the bedside. • Use of preprinted labels. Such practices can lead to‘Wrong Blood In Tube’ (WBIT). Drawing the blood sample then carrying it away to a ‘labeling site’ (e.g., a nursing station) invites labeling the sample with data from another patient. Correcting of details on the Label after sample is dispatched from the collection site is considered a risky practice the consequences of such practice in transfusion cases can be severe. Therefore corrected labels, tubes, requests - are notacceptable.

15. Precautions Compatibility procedures : Done at the Laboratory. Error can occur at the laboratory bench while performing compatibility procedures such as Blood Grouping and Cross Matching. Group and Cross matching tests must be done by well trained, licenced and experienced technologist. • A sample identification or clerical error can occur especially during urgent or bleeding emergencies. • Errors can take place outside of ‘core hours’, when staff are fewer in number,and may be relatively inexperienced and working under pressure or distracted by telephone inquiries.

16. Precautions • Standard reagents and appropriate equipment must be used to perform all types of pre-transfusion testing and Cross Matching procedures. • If doubts persist about Incompatibility - the component must not be released for transfusion - A senior personnel must be alerted. • Transportation of components must be done by using suitable ice boxes and ice packs

17. Precautions Dispatching procedure from laboratory fridge • The technologist must handover the correct blood component to the nurse after checking the request form and blood unit details. • Written documentation including patient’s details, component details, name and signature of the technician and nursing staff and time of dispatch must be noted in the “Blood Dispatch Book”.

18. Precautions Component details and patient’s details must be entered in clear handwriting – “ These are legal documents “

19. Precautions If a unit is not transfused and returned to the laboratory for any reason, a second entry with time of return and reason for not transfusing, must be noted in the blood dispatch book.

20. Precautions Compatibility label To be written and signed by the technician in legible handwriting, filling in the patient’s and unit details correctly. Compatibility Form (Cross-match request) To be written in legible handwriting (overwriting or using correcting ink is prohibited), date and signature are mandatory.

21. Precautions Unit group Screening tests performed Component Type Expiry date Unit number

22. Precautions • Administration of Blood component to the patient . • Ideally the transfusion should start within thirty minutes of dispatch • from the controlled temperature storage (laboratory fridge), • extended time can lead to bacterial growth or lysis. • All cellular blood products must be infused through an approved blood administration set which already incorporates an in-line filter (170u). It is recommended that administration sets be replaced every 12 hours to prevent bacterial growth. Only sodium chloride 0.9% (normal saline) must be used for priming and flushing. • Special white cell reduction filters are no longer required ( unless a special sticker is found on the blood unit ) as all blood products are filtered at the Blood Transfusion Centre soon after collection from the donor using highly effective techniques.

23. Precautions All the Universal safe handling precautions must be observed in order to minimise the risk of infections.

24. Precautions Safe transfusion requires a final patient identity check at the patient bedside,this is vital to ensure that right blood is given to the right patient.  Recipient's identity can be confirmed by asking the recepient directly his/her name and date of birth. If the recepient is unconscious or under anesthesia then the identity can be confirmed by the incharge nurse or attending doctor. If the recepient is a child or infant the identity should be confirmed by asking the parent/relative. Transfusion should not be started if any discrepancies or doubts persist

25. Precautions Before transfusion is started, the patient's wristband, blood unit label, and compatibility test report must be checked at the bedside,

26. Precautions Use of Blood Warmers • Only specially designed and regulated blood warmers with a visible thermometer and audible warning must be used. • Blood must not be warmed by any other method, such as immersion in warm water, as lack of control of the temperature may lead to dangerous haemolysis. Devices that meet international standards must be used. For faster rates of infusion special warmers may be required.

27. Adverse Events and Reactions Before commencing a blood transfusion : Any reaction to a previous transfusion should be taken into consideration, measures must be taken to prevent them happening again. Temperature, pulse and blood pressure to be measured and recorded before the start of each unit , 15 minutes afterthe start of unit and at the end of each transfusion episode. More frequent observations may be needed if the patient becomes unwell, shows signs of a transfusion reaction. Careful monitoring of clinical signs is especially important in unconscious patients.

28. Adverse Events and Reactions A transfusion reaction may be a medical emergency.

29. Adverse Events and Reactions Remain with the patient, & watch for the signs of a transfusion reaction, such as fever, chills, & wheezing.

30. Adverse Events and Reactions If such sign develop, record vital signs and stop the transfusion. Inform the nurse incharge / R.M.O.

31. Adverse Events and Reactions Transfusion Complications : • Immunogenic • Non-immunogenic • Infectious Transfusion reactions : • Hemolytic • Febrile • Circulatory over load • Allergic. Reactions can be Major or Minor and can occur Immediately or at a Delayed time (few hours or even weeks) after transfusion.

32. Adverse Events and Reactions COMPLICATIONS IMMUNOLOGICAL PLASMA WBC’S RBC’S PLATELETS INFECTIOUS FEBRILE HAEMOLYTICAL REACTIONS POST TRANSFUSIO PURPURA (PTP) BACTERIA VIRUSES TRALI ACUTE PROTOZOES PARASITES Anaphylactoid DELAYED Ta-GvHD PRIONS NON-IMMUNOLOGICAL VASOACTIVE SUBSTANCES COLD BLOOD CITRATE TOXICITY POTTASIUM TOXICITY AIR EMBOLISM MICRO EMBOLISM SEPTIC THROMBOPHL-EBITIS OVERLOAD HAEMOSIDEROSIS PYROGENS

33. Adverse Events and Reactions Major reactions :Are usually a result of administering incompatible blood and the commonest causes are mistaken identity in blood sampling, collecting the wrong blood from the storage refrigerator. They can be lethal because of resulting immune reaction which can cause Disseminated Intravascular Coagulation (DIC) and renal failure. Minor reactions :Are common and include unexplained minor elevation in temperature (to 37.5 deg.C), urticaria, rashes and headaches.

34. Adverse Events and Reactions Immediate • Febrile Reactions • Urticarial (Allergic) Reactions • Severe Allergic (Anaphylactic) Reactions • Acute Haemolytic Reactions • Bacterial Contamination • Transfusion-Related Acute Lung Injury • Volume Overload • Hypothermia • Citrate Toxicity • Potassium Effects

35. Adverse Events and Reactions Febrile Reactions Signs :Fever and chills during transfusion Cause : By recipient antibodies reacting with white cell antigens or white cell fragments in the blood product or due to cytokines which accumulate in the blood product during storage. Urticarial (Allergic) Reactions Cause:Seen in approximately 1% of recipients and caused by foreign plasma proteins. On rare occasions they may be associated with laryngeal oedema and bronchospasm.

36. Adverse Events and Reactions Severe Allergic (Anaphylactic) Reactions : Anaphylactic reactions have signs of cardiovascular instability including hypotension, tachycardia, loss of consciousness, cardiac arrhythmia, shock and cardiac arrest. Cause:In some cases patients with IgA deficiency who have anti-IgA antibodies can have these reactions. Transfusion-Related Acute Lung Injury(TRALI) : Is characterised by acute respiratory distress and bilateral symmetrical pulmonary oedema with hypoxaemia developing within 2 to 8 hours after a transfusion. Cause:Pulmonary vascular effects are thought to occur secondary to cytokines in the transfused product or from interaction between patient white cell antigens and donor antibodies (or vice versa).

37. Adverse Events and Reactions Acute Haemolytic Reactions This are the most serious type of transfusion reaction, but it is very rare. They happen when donor and patient blood types do not match. Cause:The majority of haemolytic reactions are caused by transfusion of ABO incompatible blood, eg group A, B or AB red cells to a group O patient A hemolytic reaction can cause death if the transfusion is not stopped as soon as the reaction starts. Non-immune haemolysis of RBCsin the blood container or during administration can occur due to physical disruption (temperature changes, mechanical forces, non-isotonic fluid).

38. Adverse Events and Reactions Potassium Effects : Cause:Stored red cells leak potassium proportionately throughout their storage life. Irradiation of red cells increases the rate of potassium leakage. Clinically significant hyperkalaemia can occur during rapid, large volume transfusion of older red cell units in small infants and children. Bacterial Contamination : Cause:Bacteria may be introduced into the pack at the time of blood collection from sources such as donor skin, (donor bacteraemia) or equipment used during blood collection or processing. Bacteria may multiply during storage. Gram positive or Gram negative organisms can been found. Platelets are more frequently implicated than red cells.

39. Adverse Events and Reactions Volume Overload : • Cause:Patients with cardiopulmonary disease and infants are at risk of volume overload especially during rapid transfusion. Hypothermia : • Cause:Rapid infusion of large volumes of stored blood contributes to hypothermia. Infants are particularly at risk during exchange or massive transfusion.

40. Adverse Events and Reactions Delayed reactions • Delayed Haemolysis • Alloimmunisation • Transfusion associated Graft Versus Host Disease • Immunomodulatory effects • Iron accumulation • Infectious Disease transmission

41. Adverse Events and Reactions Delayed Haemolysis : Cause:A delayed haemolytic reaction occurs when a patient develops an antibody directed against an antigen on transfused red cells. Antibodies can occur naturally, or may arise as a consequence of previous transfusion or pregnancy. The antibody may cause shortened red cell survival, with clinical features of fever, jaundice and lower than expected haemoglobin following transfusion. Most delayed haemolytic reactions produce few symptoms and may go unrecognized, however there are reports of serious consequences in critically ill patients.

42. Adverse Events and Reactions Alloimmunisation : Patients experiencing alloantibody formation are asymptomatic. The alloantibody is discovered at the time of pretransfusion testing. Appropriate antigen negative blood must be transfused. Platelets : When thrombocytopenic patients do not achieve the expected post-transfusion platelet count increment they are said to be refractory. This usually occurs in patients receiving frequent platelet transfusions. There are clinical and immunological causes of platelet refractoriness. Cause:Immunological causes include the development of antibodies to human leucocyte antigens (HLA) or human platelet antigens (HPA).

43. Adverse Events and Reactions • Transfusion associated Graft Versus-Host Disease (Ta-GVHD) : • Cause:Transfusion associated -GVHD occurs when donor lymphocytes in cellular blood products engraft the tissues of recipient. • These donor lymphocytes proliferate and damage target organs especially bone marrow, skin, liver and gastrointestinal tract. • The usual onset is 8-10 days post transfusion. • Recipients of blood from biologically related donors are at risk • The disease is also reported in immunologically compromised patients.

44. Adverse Events and Reactions Immunomodulatory effects : Some studies suggest a link between blood transfusion and increased risk of infection and cancer recurrence. However this is currently considered unproven. Cause:Unknown, possibly mediated by donor white cells or plasma. Iron accumulation : Cause:Iron accumulation is a predictable consequence of chronic RBC transfusion. Organ toxicity begins when reticuloendothelial sites of iron storage become saturated. Liver and endocrine dysfunction creates significant morbidity and the most serious complication is cardiotoxicity which causes arrhythmias, and congestive heart failure. Patients receiving chronic transfusion usually have their iron status monitored and managed by their physician.

45. Adverse Events and Reactions • Infectious Disease transmission : • A variety of infectious agents may be transmitted by transfusion. • Viruses : • HIV-1,2 … • HTLV-I,II • Cytomegalovirus • Epstein-Barr virus • Parvovirus B19 • Creutzfeldt-Jakob disease(CJD) • West Nile etc.

46. Adverse Events and Reactions Infectious complications Parasites • Plasmodia • Babesia microlti • Trypanosoma cruzi • Toxoplasma gondii • Leishmania donovani • Bacteria • Staphylococcus • Salmonella • Yersinia enterocolitica • Spirochetes • Treponema pallidum • Borrelia burgdorferi

47. If no signs of a reaction appear within first 15 minutes, the flow clamp can be adjusted to the ordered rate and transfusion proceeded. Patient should be observed at intervals until all fluid is given.

48. A unit of RBCs may be given within 1- 4 hours, depending on the ordered rate of transfusion.

49. A “Record of Transfusion”form must be filled up for each unit transfused and sent to laboratory with the empty bag. Any reaction/s or abnormalities noted should be well documented. This form must be filled by the transfusing doctor, mentioning details like Unit No. Component transfused, Amount Transfused and Reaction/s if any.

50. Is there a substitute for blood? There are no widely utilized oxygen-carrying blood substitutes for humans. The human body is the only “manufacturer” of this precious fluid literally, the “Liquid of Life.” All the money or insurance in the world is valueless if the right type or quantity of blood is not available. ( As quoted by American Red Cross )