Paediatric Blood Transfusion Safety

1. Paediatric Blood Transfusion Safety Temple St., Dublin 1, Ireland www.cuh.ie

2. Consent Where possible always obtain consent before prescribing blood Parents/guardians should be informed of the plan to transfuse their child and given an opportunity to ask questions, raise concerns and discuss alternative treatment available. It is the responsibility of the requesting/prescribing clinician to ensure the following steps are taken prior to transfusion: Provide information on transfusion including benefits and risks. This information should be supplemented with Patient Information leaflet available on all wards (6 languages). If additional information is required, bleep 857 Indicate (tick box) on front of blood prescription form that information has been provided Obtain verbal/ written consent (see point E. on all hospital consent forms) from parent guardian for transfusion Document in medical notes: reason for transfusion, information provided, and indicate that consent has been obtained In emergency situations Where it is not possible to provide information prior to transfusion this should be done retrospectively and documented in medical notes Temple St., Dublin 1, Ireland www.cuh.ie

3. Refer to 3 notices in all clinical areas re. Prescription formulae and transfusion thresholds Indications for giving irradiated blood Indications for giving CMV neg blood Always ask the question : is there a risk this child is immune compromised ? (due to treatment or condition) and specify special requirements on both the request form and prescription sheet- having checked laminated notice or haemovigilance guidelines Special Requirements Temple St., Dublin 1, Ireland www.cuh.ie

4. Blood is irradiated to prevent Transfusion Associated Graft versus Host Disease (TA-GvHD) >90% fatality rate Donor lymphocytes attack the transfusion recipient, resulting in severe organ and tissue damage Risk for immune compromised patients Fever, skin rash , diarrhoea, raised LFT’s All red cell units are not irradiated as it reduces lifespan of pack from 35 days to 14 days Special Requirements Temple St., Dublin 1, Ireland www.cuh.ie

5. Special Requirements Indications for requesting irradiated blood Primary immunodeficiency Solid organ transplant recipients All haematology-oncology patients Patients with malignancy, who are currently or have previously received chemotherapy, stem cell or bone transplant Recipients of intrauterine tx List is not exhaustive Temple St., Dublin 1, Ireland www.cuh.ie

6. Special Requirements Indications for requesting CMV negative blood Primary immunodeficiency All children up to 1yr Solid organ transplant recipients Patients with malignancy, who are currently or have previously received chemotherapy, stem cell or bone transplant All haematology /oncology patients Recipients of intrauterine tx Patients with H.U.S or in renal failure List is not exhaustive Refer to HV folder (Special Requirements section) Temple St., Dublin 1, Ireland www.cuh.ie

7. REQUESTS GROUP & SCREEN: Includes an Antibody screen. Patients serum is stored for 14 days for cross-matching provided there have been no previous transfusions. GROUP & CROSS-MATCH: to determine compatible units for transfusion. Specify number of units or mls required based on paediatric formula (as stated below) Specify time of transfusion / operation. Specify any special requirements (e.g.) CMV Neg or Irradiated. Temple St., Dublin 1, Ireland www.cuh.ie

8. REQUESTING BLOOD/BLOOD PRODUCTS Can be handwritten/label Must be fully completed by requesting doctor Special requirements: CMV neg/irradiated

9. Clinical Information on Transfusion Request form Essential information required to ensure appropriate blood is issued to child Primary diagnosis and clinical details/reason for request (“pre-op” is not sufficient information and could result in special requirements not being met Special Requirements - Failure to indicate the need to give CMV neg/irradiated blood could result in the child receiving an inappropriate blood product (refer to Haemovigilance guidelines/laminated notice in all clinical areas). Date required must be stated as red cells are not issued too far in advance and are taken back the day after surgery (if not used) Transfusion historydetermines the need for crossmatching in case of presence of antibodies If surgery is cancelled and blood has been crossmatched, please inform the blood transfusion laboratory immediately (so it can be used for another patient). Temple St., Dublin 1, Ireland www.cuh.ie

10. PRETRANSFUSION SAMPLING Check 3 identifiers on I.D band against identifiers on request form 3 forms of ID – patients name, hospital number and Date of birth Ask parent to state child’s full name and date of birth Complete sample tube details from patient’s I.D band + following confirmation with parents/guardians Sample tube must be hand written- legal requirement Signed and Dated Label immediately after taking sample Risk of not following correct sample labelling procedure: ABO incompatible transfusion FATAL

11. NEONATES BABIES < 4 MONTHS OLD. One group and screen is all that’s needed until a baby reaches 4 months of age. This is because babies under 4 months are incapable of producing antibodies. No need for a sample each time they’re being transfused. Note: If it is anticipated there will be difficulty in obtaining adequate sample volume, it is recommended to remove beads from the tube prior to taking same (they help clot the sample- this can be done later in lab) Temple St., Dublin 1, Ireland www.cuh.ie

12. Maximum Surgical Blood Ordering Schedule (MSBOS) All elective surgery – refer to the MSBOS for transfusion samples required: hospital intranet>departmentinfo.>haemovigilance/ blood transfusion, red folder in admissions, ICU, Emergency dept. MSBOS reduces blood wastage Blood products are in limited supply and very expensive (1 unit RCC = €400,1 unit platelets = €1000) Clinicians have a direct impact on blood wastage/usage Temple St., Dublin 1, Ireland www.cuh.ie

13. Prescription of Blood and Blood Products All blood products are prescribed in mls per Kg for paediatric patients (exception: covering surgery- number of units required is acceptable in this case as per MSBOS) Refer to laminated notices (available in all clinical areas/admissions folder) to determine special requirements i.e. need for irradiated or CMV negblood This is now stated on Transfusion request form In the case of albumin state 5 or 20% Specify reason for transfusion Signature and bleep no. Prescription is valid for 24 hrs Temple St., Dublin 1, Ireland www.cuh.ie

14. Prescription of Blood Products Red cell top up transfusion dose: Under 1 yr of age: 10-20mls/Kg = volume to be transfused over 4 hrs Over 1 yr of age: 3 x weight in Kg x desired rise in Hb (g/L) ÷ 10 (over 4hrs) Note: if it is calculated that more than one unit is needed for top up, always check FBC before exposing the child to a second unit- it may not be required Temple St., Dublin 1, Ireland www.cuh.ie

15. Prescription of Blood Products Platelets • <15Kg child = 10-20mls/Kg , transfusion time 30-60minutes • >15Kg child = 1 unit (aprox.160-300mls). This is based on 20mls/Kg formula to a Note: maximum transfusion of 1 platelet unit Plasma 10-15mls/Kg transfusion time: 30-60mins Albumin 5% (50g/litre) 10-20mls/Kg as a colloid expander transfusion time: 4hrs Albumin 20%(200g/litre) 2.5mls-5mls/Kg i.e. 0.5g to a max of 1g/Kg for albumin replacement transfusion time:4hrs Refer to Haemovigilance Policy for further details Temple St., Dublin 1, Ireland www.cuh.ie

16. PEDI-PACKS Indications: one or more top up transfusions for infants < 1 yr. Reduces donor exposure Generally not used in theatre (unless unit is < 5 day old) due to K+ content of older blood –risk of hyperkalaemia Allow for giving set priming volume when calculating volume of blood required. Maximum duration of transfusion is 4 hours from removal from storage (to reduce risk of bacterial growth) Temple St., Dublin 1, Ireland www.cuh.ie

17. Traceability Why traceability? To comply with EU Directive 2002/98/EC Legal requirement to have full traceability of all blood products. The blood Transfusion Laboratory is accountable for all blood/blood products from donor vein to patient vein. It is particularly important in the case of look-backs whereby we need to know whether a particular unit was transfused and if so, who received it and when. Look-backs can occur for a number of reasons the most common being: Recall from the IBTS because of query bacterial contamination of the pack Recall due to possible donor infection (e.g) Hep C Recall if donor lets IBTS know they fell ill in the days after donating. Temple St., Dublin 1, Ireland www.cuh.ie

18. Traceability Attached to all issued blood products is a lilac traceability label. This MUST be signed, dated and timed by the person hanging the product . MUST be returned in red post box (in all clinical areas) All emergency products will have a blank traceability label –must be completed in full . . Temple St., Dublin 1, Ireland www.cuh.ie

19. Haemovigilance policies Haemovigilance policies are now only available in electronic version in majority of clinical areas Access via hospital intranet>department info> Haemovigilance/Blood Transfusion Access via Qpuls: Key words: “blood” or “haemovigilance” Blood Track: you can now check if blood/platelets are available on p.c desktop

20. 1.Right click on relevant fridge > inventory list: displays all products in fridge 2. Click on product available > choose product group > enter pt’s hospital number and click on search: shows products available for specific patient

21. Transfusion associated circulatory overload (TACO) • Increased BP • Tachycardia • Dyspnoea • Decreased O2 sats Note: If a child develops circulatory overload as a direct result of blood transfusion please inform the Haemovigilance officer, as this must be reported as a transfusion related serious adverse event Temple St., Dublin 1, Ireland www.cuh.ie

22. Serious Adverse Reaction (SAR) An unintended response in a donor or in a patient associated with the collection or transfusion of blood / blood components that is: - fatal -life-threatening -disabling -incapacitating, anything that prolongs hospitalisation or results in morbidity Temple St., Dublin 1, Ireland www.cuh.ie

23. S.A.R’s • Haemolytic transfusion reactions • Febrile non haemolytic transfusion reaction • Transfusion associated Graft versus Host Disease ta-GVHD • Transfusion associated acute lung injury TRALI • Transfusion associated circulatory overload TACO • TTBI-Transfusion transmitted bacterial infection Refer to HV folder for investigation/management Temple St., Dublin 1, Ireland www.cuh.ie

24. Transfusion related acute lung injury (TRALI) • Respiratory distress syndrome picture • Due to antibodies to granulocytes or HLA antigens in donor plasma • Most implicated donors are females who have had previous pregnancies • Less common with current plasma products Temple St., Dublin 1, Ireland www.cuh.ie

25. Serious Adverse Event (SAE) Any untoward occurrence due to an error associated with the collection , testing, processing, storage or distribution of blood and blood components that might : -lead to death -be life – threatening -Cause disabling conditions for patients -results in or prolongs hospitalisation or morbidity Temple St., Dublin 1, Ireland www.cuh.ie

26. Case 1: Near Miss involving misidentification of patient Incident: WBIT- Wrong Blood in Tube Two groups received in bt. lab, on the same patient (within a few hours). The patient was grouped differently each time Root cause: Sample taken hrs. earlier and wasn’t labelled at that time Risk to patient: ABO incompatible transfusion- potentially lethal Learning Outcome:Always confirm patient identity at the bedside and label the sample tube immediately after taking the sample- Obtain information from parent/guardian (if possible) AND patient’s identity band

27. Case 2: Near Miss involving misidentification of patient Incident: Wrong Blood in Tube FBC, U+E, coag, and blood group sample was received, in lab all labelled with patient details. Forms and specimens all matched Enquiry re.results . No specimens received on this patient. All specimens taken from another patient Root cause: Patient identification was NOT confirmed with parent or using patient’s ID band. Identifiers were taken from incorrect patient’s casenotes, away from patient’s bedside Risk to patient: ABO incompatible transfusion - potentially fatal, and incorrect blood results which could result in inappropriate treatment of patient Learning outcome: Always confirm patient identity at the bedside and label the sample tube immediately after taking the sample Obtain information from parent/guardian AND patient’s identity band

28. Serious Adverse Events (SAE’s) in TSCUH Overtransfusion of platelets • Incident: transfusion of two platelet units in one transfusion episode • Risk to patient: needless additional donor exposure and risk of transfusion associated circulatory overload, bacterial infection • Root cause: knowledge deficit and failure to seek advice from Cons. Haematologist, failure to refer to Haemovigilance guidelines • Learning outcome: NEVER exceed the administration of one platelet unit in a single transfusion episode – there is no added benefit to the child, irrespective of weight. • NOTE: max dose – irrespective of weight or age, is one platelet unit (aprox 200 to 300mls) Temple St., Dublin 1, Ireland www.cuh.ie

29. Serious Adverse Events (SAE’s) in TSCUH Overtransfusion of red cells • Incident: transfusion of two red cell units to a 1yr old child (in one transfusion episode) • Risk to patient: needless additional donor exposure and risk of transfusion associated circulatory overload, bacterial infection • Root cause: Incorrect weight documented on prescription and excessive volume transfused accordingly • Learning outcome: Do not transfuse a second red cell unit to a child before checking FBC (especially in the case of top up transfusions) NOTE: appropriate blood transfusion formulae in paediatrics (previous slides) Temple St., Dublin 1, Ireland www.cuh.ie

30. Root Cause Analysis Top 3 causes of transfusion errors in TSCUH : • Knowledge deficit AND • Failure to refer to guidelines or seek advice AND • Transfusion prescribed outside of normal working hours -avoid unless absolutely necessary Temple St., Dublin 1, Ireland www.cuh.ie

31. Resources Please, if in doubt do not proceed Refer to resources available: • Haemovigilance policies (Hospital tab (Green)>Guidelines >Haemovigilance & Blood Transfusion) • Laminated notices re: prescription and special requirements • NCHD Information leaflet • Blood Transfusion Request form (sp. Requirements) • Haematologist or on call Haematologyreg in Crumlin (via switch board) • Blood Transfusion Laboratory 4697 • HaemovigilanceOfficer on bleep 857

32. E-Learning • Self- directed web based programme -Better Blood Continuing Education Programme , developed by the Effective Use of Blood (EUB) Group of the Scottish National Blood Transfusion Service. • Leased by IBTS and N.H.O • Educate and train staff to promote safe transfusion practice • Approved by The Hospital Blood Transfusion Committee • Provides proof of competency as required by I.N.A.B • Mandatory for all staff since Jan 2010 • Certificate valid for 2yrs and carried from hospital to hospital Temple St., Dublin 1, Ireland www.cuh.ie