Transfusion Third Year Medical Student Teaching

1. TransfusionThird Year Medical Student Teaching Friday 11th March 2016 Dr Dawn Swan – Haematology ST4 Registrar Dr Holly Owen – Foundation Year Two Slides by Dr Jayne Peters- Haematology ST5 Registrar

2. Overview • The Journey of Blood • Matching blood • Team learning session • Review of answers • Summary and questions

3. The Journey of Blood Donor Screening Arm Washing Samples for group and viral testing Donor NHS BT Hospital Blood Bank Ward Area Patient Manufacturing of the components from whole blood Store units Cross match Designate units and label Prescription Positive patient identification Wrist band

4. Blood Collection Packs

5. Blood Components Fresh Frozen Plasma* Imported plasma from non-UK source Cryoprecipitate* Plasma Whole blood donation Mix with citrate to stop clotting (CPD) Buffy Coat Granulocytes Pooled Platelets Plateletpheresis Platelet dose Red cell units* Mix with SAG-M (preservative) Red cells *Leucodepletion

6. Red Cell Groups

7. Cross Matching Cards ‘Reverse group’ Adding patients plasma to the two end columns: Does the patient have anti-A? Does the patient have anti-B? ‘Forward group’ Adding patient’s red cells to the first four columns: Does the patient have A antigen expressed on the cell surface? Does the patient have B antigen expressed on the cell surface? Does the patient have D antigen expressed on the cell surface?

8. Cross Matching Cards

9. Ordering and Matching Blood • Group and Save: • Identify the patients blood group • Identify if any antibodies present • Hold the sample • Cross-match: • To issue blood • Locate the compatible red cell units • Mix small amount of patient’s plasma with donor’s red cells • No reaction? Can issue unit

10. Ordering and Matching Blood • In an emergency (major haemorrhage) • Group O negative may be issued • Stored in A+E, theatres and blood bank • Important antibodies may cause a reaction • 15 minutes from sample arriving • Group specific blood (ABO and RhD compatible) • Important antibodies may cause a reaction • 45-60 minutes from sample arriving • Fully matched and screened for antibodies

11. Team Learning: Discuss your answers as a small group using the materials provided to help guide your decisions.

12. Red Cells Questions 1 and 4

13. Question Question 1: A GP refers in an asymptomatic 30 year old female with a history of menorrhagia and a Hb 44g/L. Initial treatment should include a 2 unit transfusion of packed red cells. True or false?

14. Question Question 1: A GP refers in an asymptomatic 30 year old female with a history of menorrhagia and a Hb 44g/L. Initial treatment should include a 2 unit transfusion of packed red cells. True or false?

15. Question Question 4: An 82 year old male with known diabetes and hypertension has a repeat Hb of 101g/L following admission for recurrent chest pain. It is appropriate to transfuse him packed red cells. True or false?

16. Question Question 4: An 82 year old male with known diabetes and hypertension has a repeat Hb of 101g/L following admission for recurrent chest pain. It is appropriate to transfuse him packed red cells. True or false?

17. Red Cells • Provided in leucodepleted ‘units’ measuring • approximately 280ml • Each unit of red cells rises the Hb by • approximately 10g/l (4mls/kg) • Transfused over 2-4 hours • Patients should receive written • information prior to receiving a • blood transfusion including the • risks of reaction and viral • transmission • Decision to transfuse should be documented Storage: Temperature: 4°C +/- 2°C Shelf life: up to 35 days

18. Red Cells • No universal trigger for transfusion • Decision to transfuse should be based on clinical judgement • Asymptomatic patients with chronic anaemia secondary to iron deficiency may benefit from iron replacement rather than transfusion • Always assess haemotinics if not already done so for a patient presenting in an anaemic state • Is the result in keeping with what is expected? • ?dilutional or from a different patient

19. Red Cells

20. Red Cells • CMFT indications for blood transfusion: • R1. Acute blood loss • R2. Hb <70 g/l • R3. Hb <90 g/l in patient with known cardiovascular disease • R4. Transfuse to maintain Hb over 70g/l • R5. Post-chemotherapy (threshold Hb 80-90 g/l) • R6. Radiotherapy (Maintain Hb>100 g/l) • R7. Chronic anaemia – maintain above the lowest concentration that is not associated with symptoms

21. FFP (Fresh Frozen Plasma) Questions 2 and 6

22. Question Question 2: A 45 year old male with alcoholic liver disease presents with gross ascites. You are asked to do a diagnostic tap, however note that the clotting screen is abnormal; PT 17.2 (11-14), APTT 26 (22-28). It is recommended to administer FFP prior to proceeding True or false?

23. Question Question 2: A 45 year old male with alcoholic liver disease presents with gross ascites. You are asked to do a diagnostic tap, however note that the clotting screen is abnormal; PT 17.2 (11-14), APTT 26 (22-28). It is recommended to administer FFP prior to proceeding True or false?

24. Question Question 6: FFP is dosed according to patient weight. When clinically indicated, the average sized adult requires 2 units of FFP True or false?

25. Question Question 6: FFP is dosed according to patient weight. When clinically indicated, the average sized adult requires 2 units of FFP True or false?

26. FFP • FFP is prepared from anticoagulated whole blood by separating and freezing to a temperature of -30°C within 6 hours of collection • The volume of a typical unit: 200-250ml • FFP contains all coagulation factors • Sample needed for transfusion lab as group specific Storage: Shelf life: up to 36 months frozen (24 hours at 4°C after thawing- changing to 5 days)

27. Octoplas • Octaplas is a solvent detergent treated, prion reduced human plasma product • It has standardised coagulation factors content and is available in 200 ml bags with A, B, O and AB groups • Patients born on or after 1st January 1996 should receive plasma from a country with a low risk of vCJD • This product is also used for plasma exchanges for certain diagnoses such as thrombotic thrombocytopenic purpura

28. FFP

29. FFP

30. Produced by thawing FFP at 4°C Contains: Factor XIII Factor VIII vWF Fibrinogen Indicated if fibrinogen <1.5 and bleeding Cryoprecipitate Storage: Shelf life: up to 36 months frozen (24 hours at 4°C after thawing)

31. Platelets Questions 3, 5 and 7

32. Question Question 3: During massive haemorrhage secondary to GI bleeding, it is advisable to keep the platelet count above 100 x109/L? True or false?

33. Question Question 3: During massive haemorrhage secondary to GI bleeding, it is advisable to keep the platelet count above 100 x109/L? Trueor false?

34. Question Question 5: A full blood count states the platelet count to be ‘6x109/l’ with an associated peripheral blood film comment of ‘platelet clumping seen. A prophylactic platelet transfusion (1 ATD) is indicated as the platelet count is <10 x109/l? True or false?

35. Question Question 5: A full blood count states the platelet count to be ‘6x109/l’ with an associated peripheral blood film comment of ‘platelet clumping seen. A prophylactic platelet transfusion (1 ATD) is indicated as the platelet count is <10 x109/l? True or false?

36. Question Question 7: A patient with thrombocytopenia secondary to sepsis has a repeat platelet count of 70x109/L and requires neurosurgery. You should give 1 ATD (adult treatment dose) of platelets then recheck the FBC. True or false?

37. Question Question 7: A patient with thrombocytopenia secondary to sepsis has a repeat platelet count of 70x109/L and requires neurosurgery. You should give 1 ATD (adult treatment dose) of platelets then recheck the FBC. True or false?

38. Platelets Platelets Each ‘ATD’ – adult therapeutic dose is ‘pooled’ from 4 different platelet donations One ATD of platelets would be expected to rise the platelet count by 20-40 x109, we can check this by doing a ‘1 hour increment’ Given over 30 minutes Storage: Agitation Temp: 20-24°C Shelf life: 5 days (7 days if bacterial screening)

39. Platelets

40. Platelets • Platelet Indications: • P1 – reversible bone marrow failure + count <10 X109/L • P2- <20 with additional risk factors for bleeding • P3– • Prevent bleeding associated with invasive procedures: • > 20 for Central Venous Catheters (CVC) • > 50 for lumbar puncture or surgery • > 80 for spinal/epidural anaesthetic • > 100 for critical surgical sites • brain, eyes, spinal cord

41. Platelets Platelet Indications: P4 – massive blood transfusion (after 1 circulating blood volume) P5– acquired platelet dysfunction P6–acute DIC and bleeding P7 – inherited platelet dysfunction P8 – primary immune thrombocytopenia for emergency treatment in advance of surgery or in major haemorrhage P9– post-transfusion purpura in the presence of major haemorrhage P10 – Neonatal alloimmune thrombocytopenia (bleeding or prophylaxis, maintain >30)

42. Massive Haemorrhage What laboratory parameters would you aim for during a massive transfusion in a bleeding patient?

43. Platelets Platelet Clumping:

44. Platelets • Platelet Clumping: • If unexpected low platelet count, ask for a blood film • If platelet clumping seen, repeat the FBC using a citrate bottle (the one used for clotting) • Patients with platelet clumping do not need platelet transfusions

45. Warfarin Reversal Question 8

46. Question Question 8: Fresh Frozen Plasma (FFP) is the optimal treatment available to treat life threatening bleeding in patients on warfarin True or false?

47. Question Question 8: Fresh Frozen Plasma (FFP) is the optimal treatment available to treat life threatening bleeding in patients on warfarin True or false?

48. Warfarin Reversal

49. Patients who refuse blood products Question 9

50. Question Question 9: Jehovah’s Witnesses do not accept red blood cell transfusions but on the whole are happy to accept platelets or plasma True or false?