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NOTTINGHAMUNIVERSITYHOSPITALSNHSTRUST TRANSFUSIONPOLICY DocumentationControl Reference ApprovingBody DateApproved ImplementationDate Version Supersedes Consultation CL/CGP/008 DirectorsGroup August2011 August2011 4 NUHVersion3(March2010)

HospitalTransfusionCommittee HaematologyConsultantwithresponsibilityforBlood Transfusion BloodBankManagers TransfusionPractitioners ConsultantsfromGeneralandVascularSurgery,Trauma &Orthopaedics,Anaesthetics,EmergencyDepartment, Medicine,Obs&GynaeandIntensiveCare SeniorNurses TrustLegalAdvisers LocalJehovahsWitnessLiaisonCommittee th 7 January2010
rd 3 June2011

DateofCompletionof EqualityImpact Assessment DateofCompletionofWe AreHereforYou Assessment TargetAudience SupportingDocumentsand References ReviewDate LeadExecutive Author/LeadManager Further Guidance/Information

Allstaffinvolvedinthetransfusionprocess Appendices112 July2013 MedicalDirector MrSimonParsons DrCherryChang,ConsultantHaematologist DrKForman,ConsultantHaematologist DrDolan,ConsultantHaematologist MsLHoyland,BloodBankManager MrMSkill, DeputyBloodBankManager MrSCliffeLeadTransfusionPractitioner MrsHBond,TransfusionPractitioner MsBWard,TransfusionPractitioner

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Contents Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Appendix1 Appendix2 Appendix3 Title PolicyStatement RolesandResponsibilities TransfusionDecisions SampleCollectionandBloodTransfusionRequests IssueandCollectionofBloodComponentsfromBlood Bank AdministrationofBloodComponents BloodTransfusionReactionsandIncidents ManagementofMassiveBloodLoss PatientsRefusingTransfusion UseofAutologousBlood Training ImplementationandMonitoring EqualityandDiversityStatement EqualityImpactAssessmentStatement References GuidetoTransfusionDecisions ProcedureforSampleCollectionandBloodTransfusion Requests ProcedurefortheIssueandCollectionofBloodandBlood ComponentsfromBloodBankandReturningUnused Units ProcedurefortheAdministrationofBloodandBlood Components GuidetotheRecognitionandManagementofTransfusion ReactionsandIncidents TransfusionManagementofMassiveBloodLoss AGuidetotheManagementofPatientsRefusing TransfusionofBloodandBloodComponents PolicyfortheUseofIntraOperativeCellSalvage ProtocolforPostOperativeDrainBloodSalvage EqualityImpactAssessmentReport Wearehereforyou CertificationofEmployeeAwareness Page 3 3 8 9 9 10 10 11 12 12 13 14 15 16 16 18 23 28

Appendix4 Appendix5 Appendix6 Appendix7 Appendix8 Appendix9 Appendix10 Appendix11 Appendix12

36 43 51 62 69 73 75 77 78

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TRANSFUSIONPOLICY 1. POLICYSTATEMENT Thispolicyaimstopromoteandsupportsafeandeffectivetransfusionpractice in Nottingham University Hospitals NHS Trust and thereby provide our patientswithtimelyandappropriatetransfusiontherapywhileminimisingtheir exposuretothepotentialhazards. We aim to provide patients with accessible, authoritative and comprehensive information about transfusion therapy and its intended benefits, significant, unavoidable and frequently occurring risks and any available alternative treatments. Thepolicydetailsallstagesofthetransfusionprocess. The policy is supported by clinical guidelines and detailed procedures. The policy, guidelines and supporting procedures comply with currently available nationalguidelinesandrecogniselocalrequirements. 2. 2.1 ROLES&RESPONSIBILITIES TheTrustBoard The Trust Board is ultimately responsible for ensuring that the Trust has effective Policies, Procedures and arrangements in place to manage Transfusionissues. 2.2 TheQualityRisk&SafetyCommittee TheQuality,Risk&SafetyCommitteeensuresthatanysignificantrisksonthe TrustsriskregisterrelatingtotheprovisionoftheTrustsTransfusionService arebeingmanagedeffectively. 2.3 TheClinicalRiskCommittee The Clinical Risk Committee (CRC) is responsible for overseeing the implementationoftheTrustsTransfusionPolicies,proceduresandprocesses. The CRC will receive bimonthly reports from the Transfusion Committee on the effectiveness of Transfusion provision, and on associated risks. CRC will considertherisksraised,andwillmanageorescalatetheminaccordancewith thearrangementssetoutintheTrustsRiskManagementPolicy.
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The CRC will receive an annual report from the Hospital Transfusion Committee. 2.4 TheHospitalTransfusionCommittee TheHospitalTransfusionCommittee(HTC)will Develop and regularly review the Trusts transfusion strategy and associatedoperationalpolicies,basedoncurrentbestpractice,national guidelinesandlegislation, Support the hospital transfusion team and Clinical Directorates in the implementationofTrustTransfusionrelatedpoliciesandprocedures, MaintainaRiskRegisterofallTransfusionrelatedrisksandensurethat any risks are added to Directorate and Corporate Risk Registers as appropriate, Developrobusteducationalstrategieswhichensurestaffarecompetent inallaspectsofbloodtransfusionasappropriatetotheirrole. Promote blood conservation, including alternatives to transfusion, thus ensuringtheeffectiveuseofnationalbloodresources. Develop contingency plans in case of blood shortages. This will be the task of the Emergency Blood Management Group, a subgroup of the HTC. [TrustContingencyPlanforBloodShortagesPolicyCL/CGP/043] Promote the Trusts compliance with legislation and provide timely reportsofriskareastotheclinicalriskcommittee. Monitor the Trusts compliance with relevant national guidelines and legislation through the implementation of this Policy and to report any risks/areasofnoncompliancestotheClinicalRiskCommittee. ProduceanannualTransfusion Report for CRConthe effectivenessof theTrustsTransfusionprovision(andcontroloftherisksassociatedwith it)andtheworkundertakenduringtheyearbytheHTC.

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2.5

MembersoftheTransfusionCommittee ThemembersoftheTransfusionCommitteemust: Attend transfusion committee meetings (or ensure a deputy attends on theirbehalf). Act as the lead for blood transfusion within their Directorate, providing two waycommunicationbetweenthecommitteeandthe Directoratein mattersrelatingtotransfusion. EncouragethereportingofTransfusionrelatedincidents. Be involved with and develop relevant audits to encourage changes to improvetransfusionpractices. Work with relevant Directorate managers to identify staff in their directoratewhorequirerelevanttransfusiontraining.

2.6

AllStaffinvolvedinthetransfusionprocessmust complywiththerequirementsofthisPolicy(andassociatedprocedures) regarding Positive Patient Identification, which is essential for safe transfusionpractice. make Positive Patient Identification at each stage of the process [as detailedintheTrustPositivePatientIdentificationPolicyCL/CGP/037].

2.7

MedicalStaffOnly It is the duty of the person making the decision to prescribe blood or blood products to consider the potential risks and intended benefits of thetransfusionfortheindividualpatient. The responsible doctor has a duty to ensure the patient receives informationabouttransfusiontherapyandthatthepatientgivesinformed consent to receive a transfusion, based on an explanation of the intended benefits, significant, unavoidable or frequently occurring risks, and any available alternatives to transfusion therapy. This standard of consentisexpectedinallbutthemosturgentsituations(pleasereferto theTrustsConsenttoExaminationandTreatmentandMentalCapacity

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Act policies for the best interests protocol to follow in urgent situations and/orwhenapatientlacksthecapacitytoconsenttotreatment). The prescription of blood (including autologous blood) and blood componentsisamedicalresponsibility. Itisamedicalresponsibilitytoensuredocumentationof thetransfusion episode is in the clinical notes (including the decision to transfuse and theoutcomeofthetransfusionepisode). MedicalStaffandRegisteredNursingStaff,Midwives,Perfusionists and Operating Department Practitioners actions and responsibilities: Explaining the intended benefits, significant, unavoidable or frequently occurring risks and any available alternative treatments to transfusion therapy (a patient information leaflet is available in many clinical areas and is obtainable from the Blood Bank, The leaflet is available in other languagesandformatsuponrequest) RequestingbloodandbloodcomponentsfromBloodBank.NOTE:Only medicalstaffcanprescribeblood Takingbloodsamplesforcrossmatch(iftrainedtodoso).Qualifiedand trained nurses may take samples but must sign as the requesting clinician CollectionofbloodandcomponentsfromBloodBank(iftrainedtodoso) The administration of blood and components to patients following prescriptionby,orundertheimmediatesupervisionof,medicalstaff Monitoringpatientsduringtransfusion[asdescribedinAppendix4] Takingappropriateactionintheeventofadverseeffects Reporting transfusion reactions or other clinical incidents related to transfusion according to the NUH Trust Incident Reporting Policy and Procedures

2.8

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2.9

Phlebotomists Responsibilities are restricted to the taking of blood samples for cross matching.

2.10

NonRegisteredStaffincludingPorters,WardReceptionists,HealthCare AssistantsandNursingAuxiliaries Responsibilitiesarerestrictedtothecollectionofbloodandcomponents fromBloodBank,oncetherequiredtraininghastakenplace.

2.11

LaboratoryStaffandTransfusionPractitioners Responsibilitiesfor nonstateregisteredstaffarerestrictedtogeneralclerical andsupportiveduties. Stateregisteredstaffhaveresponsibilityfor: Maintenanceofsufficientandsuitablestock Selection, testing and issue of suitable blood, blood components and bloodproductsrequestedbymedicalstaff Ensuringcorrectstorageconditionsforblood,componentsandproducts aremaintained Monitoringcoldchainandtraceability Investigationandmonitoringofadversereactionsandeventsassociated withbloodtransfusionandreportingincidentsappropriatelytotheTrust andexternalbodies Coordinating,deliveringandmonitoringeffectivetraining. Coordinating,planningandreportingofrelevantaudits

2.12

Ward/DepartmentalManagers Ward/DepartmentalManagersareresponsiblefor: Ensuring that all of their staff members involved in the transfusion process have received training, and are assessed as competent in all aspectsofbloodadministration.
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EnsuringincidentsarereportedasperTrustpolicy(GG/CM/021). EnsuringpromptreturnofTransfusionRecordSheetstotheTransfusion Department. Ensuringcompliancewiththispolicyintheirareaofresponsibility. 3. TRANSFUSIONDECISIONS Thedecisiontotransfusebloodorcomponentsmustbalancetheneedto provide adequate tissue oxygenation or effective haemostasis against the potential risks of transfusion and the appropriate use of blood (a limitedresource). Decisions must be made in accordance with the patients wishes (see Section9forpatientswhorefusetransfusion). Guidelines for red cell transfusions are contained in Appendix 1. Decisions must always be based on clinical judgement, according to individualpatientneedandspecificclinicalcircumstances. Indications for the transfusion of components such as Fresh Frozen PlasmaandPlateletshaverecentlybeencomprehensivelyreviewedand national recommendations have been published (refer to section 10 referenceNo3). Local guidelines for component use are also contained in Appendix 1, butinmanysituationsexpertadviceshouldbesoughtfromBloodBank and/orHaematologymedicalstaff. Blood transfusion should not take place between the hours of 21:00 to 08:00,exceptinclinicallyurgent/emergencysituations. Routine, nonemergency transfusions should not be based solely on pointofcare testing (i.e., HemoCue, ABG, etc.). Unless it is an emergency these results should be confirmed by standard laboratory testingbeforetransfusion.

4.

GuidetoTransfusionDecisionsiscontainedinAppendix1. SAMPLECOLLECTIONANDBLOODTRANSFUSIONREQUESTS

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Allrequestsforbloodorbloodcomponents/productsmustbemadeon afullycompletedBloodBankrequestform. The accompanying blood sample label must be fully hand written in CAPITAL LETTERS using a black pen that does not smudge. The details must correspond to those on the request form, otherwise the samplewillberejected.PatientIDlabelsmustnotbeused. It is essential that the person taking the sample labels the tube at the bedside immediately after venepuncture and verifies by checking the patients identification band / photo identification card (and where possible with the patient) that the sample details are correct. The identificationbandmustspecifythepatientssurname,firstname,dateof birth, gender and unique identification number, preferably the NHS number. InalifethreateningsituationGroupORhNegativebloodwillbeissued untilacorrectlylabelledsampleisprovided.

Procedure for Sample Collection and Blood Transfusion Requests is containedinAppendix2. 5. ISSUE&COLLECTIONOFBLOOD/COMPONENTSFROMBLOODBANK

WARNING! The collection of the wrong blood from Blood Bank has been identifiedasthemostfrequentsiteofFirstErrorinUKincidents wherepatientshavebeengiventhewrongblood.
Collection must only be undertaken by staff that have received training and have been assessed as being competent in the importance of correct identification procedures and of the potential consequences of identification errors. Procedure for the Issue and Collection of Blood or Components from BloodBankiscontainedinAppendix3.

6.

ADMINISTRATIONOFBLOODANDCOMPONENTS

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Bloodmust onlybetransfusedinrecognisedclinical areas withavailable resuscitationfacilities. Patients must, where possible, be informed in advance of their need for transfusionanditsrisksandbenefitsdiscussedwiththem.Confirmationof thepatientsverbalconsentmustberecordedinthepatientsnotes. For planned transfusion, suitable I.V. access must be secured before collectionofproductfromBloodBank. Allpatientsreceivingtransfusionsmust haveidentificationbands/photo identification cards. The identification band must specify the patients surname, first name, date of birth, gender and unique identification number,preferablytheNHSnumber. The primary checker must positively identify the patient by checking the details on the patient identification band / photo identification card and wherepossible, byaskingthemtostatetheirfullnameanddateof birth. The details on the ID band and the compatibility label on the blood product/componentmustalsobeidenticalandconfirmed Thefinalcheckingprocedure beforetheadministrationof thetransfusion isessentialtoensurecorrectpatientidentification.It mustbedoneatthe patientsbedside,immediatelypriortostartingthetransfusion. Thecareandmonitoringofpatientsduringtransfusionmustbeaccording to the procedure in Appendix 4 of the policy, which concurs with local nursingpracticeguidelines.Patientsmustbemadeawareofsymptomsto benotifiedtonursingormedicalstaffduringthetransfusion.

ProcedurefortheAdministrationofBloodandComponentsiscontained inAppendix4.

7.

BLOODTRANSFUSIONREACTIONSANDINCIDENTS Some transfusionrelated adverse events may be unavoidable and unpredictablebutmanyaretheresultofavoidableerrors. All suspected adverse consequences of transfusion, whether acute or delayed,mustbereportedtoBloodBank.

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All transfusionrelated incidents, reactions and near misses must be reportedtotheTrustbysubmittingaPatientSafetyIncidentReportForm (DATIX) BloodBank willreportallsignificantadverseeventsnationallytoSerious Hazards of Transfusion (SHOT) scheme, to Medicines & Healthcare RegulatoryAgencysSeriousAdverseBloodReactions&Events(MHRAs SABRE),andtotheNationalBloodService(whenappropriate).

GuidetotheRecognitionandManagementofTransfusionReactionsand IncidentsiscontainedinAppendix5 8. MANAGEMENTOFMASSIVEBLOODLOSS Massive blood loss is defined as the loss of 50% of blood volume in 3 hoursorbloodlossattherateof150ml/min. Patients with massive blood loss are not a homogenous group. They presentinarangeofspecialties,andthedefinitivetreatmenttoarrestthe bleedingwilldependontheclinicalsituation. Prioritiesfortreatmentare: o restoration of circulating volume to maintain tissue perfusion and oxygendelivery o achieving haemostasis through surgical or other interventional proceduresand/orcorrectionofcoagulopathywithbloodcomponent therapyasindicated. A successful outcome requires prompt action and good communication between various clinical specialties, diagnostic laboratories and Blood Bankstaff. Earlyinvolvementofseniorstaffisessential. EarlyconsiderationshouldbegiventotheuseofCellSalvage.

A Template Guide for the Transfusion Management of Massive HaemorrhageiscontainedinAppendix6.

9.

PATIENTSREFUSINGTRANSFUSION

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Any competent adult is entitled to accept surgical or other interventions buttospecificallyexcludecertainaspectsofclinicalmanagementsuchas a blood transfusion (except in certain circumstances governed by the Mental Health Act 1983). The patient must be fully informed of (and understand) the potential consequences of the refusal and this must be documentedclearlyinthepatientsnotes. Healthcareprofessionalsmust ensurethattheycontinuetoprovideanyotherappropriatecareto which the patient has consented, and that the patient realises they are free to changetheirmindandaccepttransfusiontreatmentiftheylaterwishtodo so. Validandapplicableadvancedecisionsmustberespected. Most followers of the Jehovahs Witness faith will not accept a transfusion of whole blood or its major derivatives including FFP, platelets and white cells. However individual beliefs and the acceptabilityofclinicalinterventionsvarybetweenJehovahsWitnesses andtheviewsoftheindividualpatientshouldbeascertained. A Jehovahs Witness may wish to involve a support network known as the Hospital Liaison Committee which is contactable 24 hours a day (viaswitchboard).Patientsconsentmustbeobtainedbeforecontacting thisbody. In all patients, alternatives to blood transfusion must be considered, as mustotherclinicalstrategiesformanaginghaemorrhageandanaemia.

Appendix 7 contains a Guide to the Management of Patients Refusing BloodandComponentTransfusion.

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USEOFAUTOLOGOUSBLOOD Theuseofautologousbloodisarecommendedandvalidalternativetothatof homologousorbankedblood. Criteriafor theidentification of suitable patients, and the use of intra operative and post operative salvage for autologous transfusion, are outlined in Appendices8&9. The use of predeposit autologous transfusion (PAD) is not recommended exceptincasesofverycomplexserology.
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TRAINING The Trust recognises that the provision of education and training to support thedeliveryofthisPolicywillbekeytoitssuccess. All new clinical staff will receive general transfusion training at Nursing and MidwiferyInductionprogram, whenapplicabletotheirpost. Newmedicalstaff(FY1)mustcompletetheelearningpackagepriortoarrival on site and present their certificates on their first day induction. Competency assessment willbearrangedandperformedbythetransfusionpractitioneras soonaspossibleaftertheystart,thiswillberecordedontheESR. Training is detailed in the Trust Training Needs Analysis (TNA) which is updated yearly. Further details about the TNA and course booking can be found on the Learning and Development web site, or by contacting the TransfusionPractitioners.Staffinvolvedinanypartofthetransfusionprocess willrequireannualtrainingonthefollowingtopicsasappropriatetotheirrole. TakingaBloodTransfusionSample PrescribingBlood Laboratoryprocessing Collectionofbloodfortransfusion Receiptofbloodfortransfusion Administrationoftransfusions Prescribe Process (Sample) (Prescribe) (Process) (Collect) (Receipt) (Administ) Receipt Administ

Phlebotomists Ancillary with patientcontact Haps and helpers Admin and clerical with patientcontact Nurses, midwives &HCAs Doctors Scientific technical and

Sample

Collect

Competencyassessmentisevery3years,withannualupdateinyears2and3 mandatory for all staff involved in the transfusion pathway (to comply with NPSA,NHSLAandMHRArequirements).

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EachdirectorateshouldnominatestaffintheirareatoactasAssessors.These staffwillreceiveappropriatecompetencybasedtrainingtoallowthemtoactas assessors of transfusion competency within their area. All assessors are recordedontheTrustElectronicStaffRecords TrainingrecordswillbeheldontheTrustsElectronicStaffRecord,andwillbe monitored by the Hospital Transfusion Team to ensure appropriate and effectivetrainingistakingplace.

12.

IMPLEMENTATIONANDMONITORING Clinical Directors and Executive Directors (as Heads of Corporate Services) areresponsibleforthelocalimplementationofthispolicy. The HospitalTransfusion Committee will undertake formal monitoring against Key Performance Indicators that measure the effectiveness of the Trusts TransfusionprovisionasdetailedinthisPolicy. The Hospital Transfusion Committee will formally review at each meeting (4 timesperannum) TransfusionIncidents,ComplaintsandClaimsdataandtrends Anyrelevantdata[national/local]relatingtotransfusionaudits The effectiveness of the Trusts Transfusion Educational Strategies TrainingdeliveryandTransfusionCompetencies Trust performance and adherence to procedures relating to Transfusion(includingtheprocessforrequestingbloodsamplesfor pretransfusion compatibility testing, the effectiveness of the processes for the administration of blood and blood products and thecareofpatientreceivingtransfusion) MonitoringoftheTransfusionRiskRegisteranddeliveryagainst agreedactionplans.(Thiswillalsoformpartofroutinemonitoring ateachTransfusionCommitteemeeting. TheHospitalTransfusionCommitteewillsubmitquarterlyreportstotheClinical RiskCommitteedetailingprogressagainstworkplansandraisinganyrisksor concernswiththeTrustsTransfusionprovisionand/orarrangements.
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The Hospital Transfusion Committee will produce an annual report which reviewstheongoingeffectivenessoftheTrustsTransfusionProvision 13. EQUALITYANDDIVERSITYSTATEMENT Allpatients,employeesandmembersofthepublicshouldbetreatedfairlyand withrespect,regardlessofage,disability,gender,maritalstatus,membership or nonmembership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status,orgenderreassignment. All trust polices and trust wide procedures must comply with the relevant legislation(nonexhaustivelist)whereapplicable: EqualPayAct(1970andamended1983) SexDiscriminationAct(1975amended1986) RaceRelations(Amendment)Act2000 DisabilityDiscriminationAct(1995) EmploymentRelationsAct(1999) RehabilitationofOffendersAct(1974) HumanRightsAct(1998) TradeUnionandLabourRelations(Consolidation)Act1999 CodeofPracticeonAgeDiversityinEmployment(1999) Part Time Workers Prevention of Less Favourable Treatment Regulations (2000) CivilPartnershipAct2004 Fixed Term Employees Prevention of Less Favourable Treatment Regulations(2001) EmploymentEquality(SexualOrientation)Regulations2003 EmploymentEquality(ReligionorBelief)Regulations2003 EmploymentEquality(Age)Regulations2006 EqualityAct(SexualOrientation)Regulations2007

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14.

EQUALITYIMPACTASSESSMENTSTATEMENT NUH is committed to ensuring that none of its policies, procedures, services, projects or functions discriminate unlawfully. In order to ensure this commitment all policies, procedures, services, projects or functions will undergoanEqualityImpactAssessment. Reviews of Equality Impact Assessments will be conducted inline with the reviewofthepolicy,procedure,service,projectorfunction

15 REFERENCES DepartmentofHealthHSC2002/009BetterBloodTransfusion Department of Health HSC 2007/001: Better Blood Transfusion appropriate useofblood. SHOTAnnualReports www.shotuk.org BritishCommitteeforStandardsinHaematologyGuidelines:Guidelineonthe AdministrationofBloodComponents2009www.bcshguidelines.com Theclinicaluseofredcelltransfusion.BrJHaem.113:2431 Guidelinesfortheuseofplatelettransfusions.BrJHaem.122:1023 Guidelines for the use of fresh frozen plasma, cryoprecipitate and cryosupernatant.BrJHaem.126:1128 Guidelines for the administration of blood and blood components and the managementoftransfusedpatients.Transf.Med.9:22739 Transfusionguidelinesforneonatesandolderchildren.BrJHaem.124:433 53 Guidelines for compatibility testing procedures in blood transfusion laboratories.TransfusionMedicine.200414573 Guidelinesonthemanagementofmassivebloodloss.BJHaem135634641 ManagementofMassiveBloodLossBrJAnaesth.85(3):48791 Management of Anaesthesia for Jehovahs Witnesses www.aagbi.org/pdf/7doc.pdf TheBloodSafetyandQualityRegulations.2005(SI2005/50) th TheHandbookofTransfusionMedicine.4 Edition.2007 NPSASaferPracticeNotice14Rightpatient,RightBlood. Internal: TrustwidePGD:AdministrationofDrugsduringAnaphylacticReactions2009 SeriousUntowardIncidentPolicyandProcedures:2009GG/CM/019 ConsenttoExaminationorTreatmentPolicy,2008:CL/CGP/020 InfectionPreventionandControlPolicy:2009CL/CGP/031 Protocol for the Use of Octaplex for the Reversal of Coumarin Induced AnticoagulationinLifeThreateningSituations.2009 MassiveTraumaticHaemorrhagePolicy2009:CL/CGP/046
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RequestandSpecimenLabellingPolicyv12007 Personal Development Review Policy v2 2008Contingency Plan for Blood ShortagesPolicy2008:CL/CGP/043 PositiveIdentificationofPatientsProcedure2009:CL/CGP/037 RiskManagementPolicy,2010,GG/CM/007 IncidentReportingandManagementPolicy,2009,GG/CM/021

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NUHTRANSFUSIONPOLICY:APPENDIX1 GUIDETOTRANSFUSIONDECISIONS 1. REDCELLTRANSFUSIONS Thedecisiontotransfusebloodmustbalancetheneedtoprovideadequatetissue oxygenationagainstthepotentialrisksoftransfusionandtheappropriateuseofa limited resource. It should be based on clinical judgement according to the individualpatientsneedsandtheclinicalsituation. Aredcelltransfusionmaybeindicatedto: replaceacutebloodlossduetohaemorrhage,traumaorsurgery increasetheoxygencarryingcapacityofthebloodinanaemia Thereisnouniversaltriggerortargethaemoglobinfortransfusion. Insituationsofacutebloodloss,theeffectsofhypovolaemiaandanaemiashould be considered separately. Crystalloids and synthetic colloids should always be usedforinitialvolumereplacementandinsomepatientsbloodlossof3040%of circulatingvolumemaybemanagedwithoutbloodtransfusion. Inthesettingofacutebloodloss,thefollowingguidelineshavebeensuggested: Hb>10g/d Hb<5g/dl Hb<7g/dl Noindicationfortransfusion Transfusionusuallyessential Strong indication for transfusion two units should be transfusedandthepatientreassessed. No consensus. If the patient is stable with no anticipated further blood loss then transfusion may only be indicated if symptomatic. Older patients or those with significant cardiovascular or respiratory disease may not tolerate anaemia and clinicians may need to aim for a Hb closer to 9g/dl

Hb710g/dl

Autologous blood alternatives to the transfusion of bank blood should be encouraged whenever appropriate particularly the use of intraoperative salvageforsomesurgicalandtraumapatients.
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Inchronicanaemiawithoutsignificantsymptomsor haemodynamiccompromise, the cause should be established and alternative treatment given whenever possible. Theminimumnumberofredcellunitsshouldbetransfusedtoachieve symptomcontrolsingleunittransfusionsmaybeappropriate. There is no consensus on the management of anaemia associated with malignancy. Some evidence suggests patients with higher haemoglobin concentrationsreportlessfatigueandabetterqualityoflife.Eachpatientshould beindividuallyassessed.

2. PLATELETTRANSFUSIONS Platelets for transfusion are normally only issued after consultation with Haematologymedicalstaff. Platelet transfusions may be indicated for the prevention and treatment of haemorrhage in patients with thrombocytopenia or platelet function defects. Platelet transfusions are not indicated in all types of thrombocytopenia and in some situations are contraindicated, notably in thrombotic thrombocytopenic purpura (TTP) and heparininduced thrombocytopenia (HIT). Therefore the underlyingcauseofthedeficiencyshouldbeidentifiedandexpertadvicesought. Bonemarrowfailure 9 Spontaneoushaemorrhageisunlikelywithaplateletcountof10x10 /L unless additionalriskfactorsarepresent(abnormalcoagulation,concurrentantibiotic therapy,sepsis). ProphylaxisforSurgeryandInvasiveProcedures Bone marrow aspiration and biopsy may be performed in severe thrombocytopenia without platelet support providing adequate surface pressureisapplied. For lumbar puncture, epidural anaesthesia, gastroscopy and biopsy, transbronchialbiopsy,liverbiopsy,insertionoflinesandlaparotomyorsimilar 9 procedurestheplateletcountshouldberaisedtoatleast50x10 /L. For operations at critical sites such as the brain or eyes, the platelet count 9 shouldberaisedto100x10 /L. Itshouldnotbeassumedthattheplateletcountwillrisejustbecauseplatelet transfusions are given a preoperative count should be checked to ensure thedesiredthresholdhasbeenreached.

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PlateletFunctionDisorders Recommendations for the management of bleeding and prophylaxis before invasive procedures include the withdrawal of drugs with antiplatelet activity andconsiderationoftheuseof DDAVPinpatientswithinheriteddisordersor uraemia. Platelet transfusions may be necessary when the above methods areineffectiveorinappropriate. MassiveTransfusion 9 Aplateletcountof50x10 /Lisexpectedwhenredcellconcentratesequivalent toapproximatelytwobloodvolumeshavebeentransfused. 9 The platelet count should be maintained above 75 x10 /L in patients with 9 massive haemorrhage. A higher target level of 100x10 /L has been recommendedforthosewithmultipleinjuriesorcentralnervoussysteminjury. DisseminatedIntravascularCoagulation(DIC) PlatelettransfusionsarepartofthemanagementofacuteDIConlywhenthere is actual bleeding or a high risk of bleeding, or if a procedure is required, in additiontothemanagement of theunderlyingdisorder andcoagulationfactor 9 replacement. A target platelet count of 30 x 10 /L is adequate for minor 9 bleedingorminorprocedures,50x10 /Lformajorbleedingorprocedureswith a higher risk of bleeding. The platelet count should be checked after transfusion, but it may not be possible to achieve the desired target. This shouldbediscussedwithHaematologyclinicalstaff. 3. FRESHFROZENPLASMAANDCRYOPRECIPITATETRANSFUSIONS Theindicationsfortransfusingfreshfrozenplasma(FFP),cryoprecipitateand cryosupernatant plasma are very limited. When transfused they can have unpredictableadverseeffects. Pathogenreduced FFP and cryoprecipitate (methylene blue or solvent detergenttreated)iscurrentlyrecommendedforallchildrenunder16yearsof age. MultipleCoagulationFactorDeficienciesandDIC FFP is indicated when there are multiple coagulation factor deficiencies associatedwithseverebleeding. In DIC associated with bleeding, blood product support including FFP and cryoprecipitate is indicated guided by coagulation tests, but expert advice shouldbesought. Cryoprecipitate may be used to enhance the fibrinogen levels in dysfibrinogenaemia and the acquired hypofibrinogenaemia seen in DIC and massive transfusion. Treatment is usually indicated if plasma fibrinogen is <1.0g/L
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ReversalofWarfarinEffect FFP should never be used for urgent reversal of warfarin. FFP contains insufficientconcentrationsof thevitaminKdependent factors(especiallyFIX) to achieve physiological correction of anticoagulation (although it will reduce theINR). Over anticoagulation can be reversed by a range of measures depending on the urgency of the clinical situation. Expert advice should be sought from Haematologyclinicalstaff. Measures include the use of oral or parenteral vitamin K, and Prothrombin ComplexConcentrates(factorsII,VII,IXandX).

TheProthrombincomplexconcentrateofchoiceintheTrustisOctaplex.This is available from the Blood Bank Laboratories following consultation with and authorisation by Haematology Medical staff. Octaplex should be reserved for lifethreateningsituationssuchas: Severehaemorrhagee.g.gastrointestinalhaemorrhage Haemorrhageintovitalorganse.g.intracranialhaemorrhage Whenurgentsurgeryisrequiredinacoumarintreatedpatient. The decision to reverse anticoagulation must be made only after an assessment of the risk. In the majority of cases where warfarin reversal is requiredtheadministrationofVitaminKandwithholdinganticoagulantdrugsis sufficient. Forfurtherinformationsee:ProtocolfortheuseofOctaplexforthereversalof coumarininducedanticoagulationinlifethreateningsituationsonthehospital Intranet. Liverdisease Available evidence suggests that patients with liver disease are unlikely to benefit from FFP as prophylaxis before liver biopsy. If FFP is given the response may be unpredictable and the impact should be assessed by repeatedcoagulationtests. SurgicalBleedingandMassiveHaemorrhage Transfusion of FFP in the management of major haemorrhage should be guidedbytimelytestsofcoagulationandthromboelastometry(ROTEM)when available.
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Formulae to guide replacement strategies are not recommended. FFP and cryoprecipitate should be given to maintain a fibrinogen concentration > 1.5 2.0g/LandPTandAPTTratioswithin1.5xcontrols.

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NUHTRANSFUSIONPOLICY:APPENDIX2 PROCEDUREFORSAMPLECOLLECTION ANDBLOODTRANSFUSIONREQUESTS

1. BloodTransfusionRequestForm Mustbecompletedandsignedbymedicalstafforstateregisteredmemberof staff. Mustcontainfullpatientidentificationdetailsincludingfamilyname,firstname, genderandatleasttwoofthefollowing: DateofBirth UniquepatientIDNumber Addressonlyifnouniqueidentifyingnumberavailable The unique patient identification number will usually be the NHS number (preferrednumber),hospitalnumberorEmergencyDepartmentnumber(theK number),oramajorincidentnumber. TheEmergencyDepartmentidentificationsystemforunidentifiedunconscious patients is acceptable however, Blood Bank must be informed when additionalidentificationdetailsbecomeavailable. AddressographlabelsareacceptableonTransfusionRequestForms. Theformshouldalsostate: ThenumberandtypeofunitsrequiredorwhetherforGroupandSaveonly. Thedateandtimerequired. Thediagnosisandreasonfortransfusion(ifdifferent) ThepatientswardandConsultant Anyrelevanttransfusionhistory:e.g.priortransfusionreactions. Any additional special requirements: e.g. whether irradiated or CMV negative products are required. Please see Irradiated and CMV Negative Blood Products,Guidelinefortheuseof,(Version8,Aug2010)inClinicalGuidelines ontheTrustIntranet. Ifthereisuncertaintyaboutwhetherthesespecialrequirementsareindicated, pleasecontacttheBloodBank.

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TheformandsampleshouldbesenttotheBloodBank. Urgentrequests, in addition, should be telephoned to Blood Bank to help prioritise work on receiptofthesample.

2. ThePreTransfusionBloodSample Samples may be taken by a doctor or a trained and competent registered nurse/midwife/operatingdepartmentpractitioner,perfusionistorphlebotomist. Only one patient at a time should be bled and the patient must be positively identified by checking the details on the patient identification band / photo identificationcardandwherepossible,byaskingthemtostatetheirfullname anddateofbirth. Note: It is accepted that out patients will not be wearing ID bands. In these cases,beparticularlydiligentinobtainingandconfirmingpatientidentification. Patient ID bands or photo ID card however, MUST be worn if a patient is to receiveatransfusion. The sample should be sent in pinktopped EDTA vacutainer (6ml). A 1ml sampleisacceptableforinfantsaged<4months,accompaniedbyamaternal sampleforthefirsttransfusion. Patients over the age of 4 months are treated serologically as adults and thereforeasample>2mlisrequiredinapinktoppedadult(6ml)EDTAbottle. Thelabelshouldbehandwrittenimmediatelyaftertakingthesample,infront ofthepatientONLYbythepersonwhotakesthesample. Do not prelabel tubes. This significantly increases the risk of identification errorsandisdangerous. Addressographlabelsmustnotbeusedtolabelsamplesforbloodtransfusion work. Thesamplelabelmustbesignedbytheindividualtakingthebloodsample. The sample must carry the same patient identification information as the requestform Ifapatientsnamechanges(eg aneonate),arepeatsamplewiththecorrect newdetailsMUSTbesenttotheBloodBankbeforeanybloodcanbeissued forthepatient.

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NOTE: A zero tolerance towards sample labelling is adopted for transfusion samples. Samples received in the Blood Bank Laboratory which are completely unlabelled, are labelled withanaddressograph label, or are labelled withdetails whichdonotmatchtheaccompanyingrequestcardwillbediscarded. TheBlood Bank Laboratory will contact the person sending the blood sample and inform themifthesamplesaretobe/havebeendiscarded.

2 GroupandSaveSamples Group and Save samples are screened for the presence of red cell antibodies and kept in Blood Bank for 7 days. Samples required after the 7 day period, if indicatedontherequest form,arecurrentlyseparatedandfrozenandkeptfora maximum of 3months.Thisprocedureisbeingphasedout and samples will no st longerbefrozenafter31 December2011. Ifnoantibodyispresent,crossmatchedbloodcanusuallybeprovidedwithin30 minutesofatelephonerequest.Thismaynotbepossiblewhenanantibodyhas beenidentified. If an antibody is present which will delay the provision of compatible blood, the transfusionlaboratorywillliaisewithappropriatestaffregardinglogisticsofblood supply. Electronic crossmatching is available for patients who have no antibodies and who havehad nohistoryof antibodies detectedor transfusionreactions.Avalid samplealong with ahistoricalsample(from any date)isrequired.Bloodcanbe providedwithin510minutesofrequestviathismethod. It is possible to convert a previous Group and Save sample to a request for transfusion,providedthatthesampleisstillinBloodBankandthepatienthasnot beentransfusedsincethesamplewastaken. ThestatusofgroupandsavesamplescanbecheckedonNotIS.. The initial request can be done by telephone, but this must be followed by a completed crossmatch request form. Verbally requested products will not be issueduntiltheformisreceivedintheBloodBanklaboratory. The Blood Bank staff will keep a record of the individual making the telephone requestandthepersonreceivingit.Thefollowinginformationwillberequired: Patientidentification. Numberofunitsrequestedwithanyspecialrequirements.
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Reasonfortransfusion Timeanddateproductsrequired

4. TimingofRequests TheNUHBloodBanklaboratoriesprovidea24houremergencyserviceonboth campuses.Inordertobeabletorespondpromptlytoagenuineemergencyitis importantthatroutinerequestsarehandledinacontrolledmanner. Requestsforelectivesurgeryandplannedtransfusionsshouldbesentatleast24 hours prior to the intended transfusion, during routine laboratory hours (08.00 21.00). Should samples be received at shorter notice it may not be possible to providesuitablebloodinthetimeavailable. Urgent crossmatch requests should always be directly notified to Blood Bankstaffbytelephoneor,outofhours,bybleepviaswitchboard. CityCampusextension55600bleep 7807054 QMCCampusextension63660bleep7841340 Urgentlyrequestedfullycrossmatchedbloodwillnormallybeavailablewithin40 minutes of receipt of a blood specimen in the laboratory, 30 minutes if there is alreadyaGroupandSavesampleand510minutesifthepatientiseligiblefor electroniccrossmatch.(Pleaseseebelow.) 5.ElectronicCrossmatch If there is a current valid group and screen available in the laboratory which matcheshistoricaldatafromapreviousgroupandscreen,then providingneither sample has shown the presence of atypical antibodies and the patient has not had a previous transfusion reaction investigated, blood may be electronically issued.Nophysicalcrossmatchisrequiredandbloodcanbeavailablewithin5 minutes. The use of electronic issue is actively promoted by the department as its use resultsinlessneedforbloodtobecrossmatchedpriortoaprocedure.

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6 EmergencyTransfusion Intheeventofrapidmajorbloodloss,transfusionmayberequiredbeforecross matchedbloodisavailable. Always notify the Blood Bank staff and send an urgent sample as soon as possible. Groupspecificredcells(unmatched,butofthepatientsABOandRhtype) will beavailablewithin5minutesofreceiptofsample. If transfusion is considered essential before this short time Emergency O Rh D negativeunitsareavailableat alltimes. Locationsof ORhDnegativebloodfor emergencytransfusionsareoutlinedbelow.

NumberandLocationofEmergencyORhDNegativeRedCellUnits CityCampus AdultUnits NeonatalUnits 0

Issue Fridge Blood Bank 2 Laboratory

MaternitySatelliteFridge 2

QMCCampus

AdultUnits

NeonatalUnits

AFloorWestBlockIssue 2 Fridge

In addition 2 units of O Rh D Negative Red Cells suitable for adults are alsoavailableatTheParkandRamseyWoodthorpehospitals

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NUHTRANSFUSIONPOLICY:APPENDIX3 PROCEDUREFORTHEISSUEANDCOLLECTIONOFBLOODANDBLOOD COMPONENTSFROMBLOODBANKandRETURNINGUNUSEDUNITS 1. ProcedurefortheCollectionofBloodandComponents 1.1 BloodBankIssueofBloodorComponents Onsuccessfulcompletionoftesting,anidentificationlabel(crossmatchlabel) is attached to each unit issued. All products except platelets and cryoprecipitatearethenplacedintheissuefridgesintheappropriatedrawer. Platelets and cryoprecipitate are retained under controlled storage conditions withinthelaboratoryuntilcollectedforimmediatetransfusion. Issuereports aregenerated.Theyarefiledinalphabetical order intheBlood BankIssueRecordBoxnexttotheissuefridges.Thisreportformspartofthe transfusionrecordtobecompletedonthewardandfiledinthepatientsnotes. AvailabilityofbloodandcomponentscanbecheckedonNoTIS NOTE: Unused red cells will be returned to stock 24 hours after they have beenrequested,unlessthelaboratorystaffarespecificallyrequestednotto doso. FFP,Cryoprecipitateandplateletsshouldonlybeissuedwhentransfusion is imminent. Once issued, if the decision is taken not to transfuse the patient,pleaseinformBloodBankstaffassoonaspossibleandreturnthe componentstoBloodBank.Theymaybeusedforotherpatients.

1.2

CollectionofBloodandComponents Collection of blood and products has been shown to be the most frequent source of wrong blood incidents in the transfusion process. For this reason, onlystaffwhohavebeentrainedandfoundcompetenttodosoandgiven appropriatedoorandITaccesscodescancollectbloodandproducts. Staff collecting blood must bring a completed blood transfusion record sheet orcollectionofbloodproductsfortheatresheettocrosscheckpatientdetails.

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RedCells Exceptincasesoflifethreateninghaemorrhageortransfertoasatellitefridge, only1unitofredcellsperpatientistobecollectedatanyonetime. Red cells must only be stored in designated blood fridges, never in ward, domesticordrugsfridges. Complete the transfusion of the unit within 4 hours after it is removed from controlledtemperaturestorage If the red cell unit has been out of the fridge for more than 30 minutes and thereisnoprospectofitstransfusiontotheintendedrecipientbeingcompleted within4hoursofremovalfromthefridge,itmustbereturnedtothebloodbank laboratoryfordisposal.Handtheunittoamemberofstaff.Donotreturnitto thefridge.Outofhours,pleasebleepBMSsoyoucanhandtheunitstothem. FFPandCryoprecipitate Cross matching is not required for these products although blood group matchingispreferred. Inordertoachievetheoptimumbenefitfromtheseproducts,itisimportantthat theircoagulationfactoractivitybepreserved.Oncethawedthisactivitystarts to decay and it is vital to avoid delays in the collection and transfusion of thawedplasmaproducts.Forthisreason,allunitsoffreshfrozenplasmaand cryoprecipitateissuedforapatientshouldbecollectedatonceandtransfused assoonaspossible. Oncethawed,theseproductscannotberefrozen. Cryoprecipitate once thawed has a 4 hours expiry time it is stored in the Laboratoryatroomtemperate.ItiscollecteddirectlyfromtheLaboratory.
o FFP once thawed can be stored at 4 C for up to 24 hours (8 hours for Octaplas),butformaximumbenefittothepatient,itshouldbeusedASAP.

Stand by requests are permitted, but the product will not be thawed until transfusionisimminent. Irradiation and CMV negative status is not applicable to these noncellular products.
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Iftransfusionisnottotakeplace,informBloodBankstaffandreturntheunitto aBMSinthelaboratory(donotreturnittothefridge)itmaybepossibleto useitforanotherpatient. Platelets Plateletsmustbetransfusedimmediatelyfollowingissueandcollection,using a platelet giving set or a fresh blood administration set. Theymust never be placedinafridgeortransportedwithredbloodcellsorFFPasthiswilldestroy theirfunctionality.Ifthereisadelayinthetransfusingofplatelets,theymustbe returned to a BMS in the blood bank laboratory to be placed under correct storageconditions. 1.3 ProcedureforCollection Locatethecorrectissuereportfromtherecordboxnexttotheissuefridge,or st fromthereportslipinthe1 unitforthepatient Check that all the identification details on the blood unit component correspond with those of the intended recipient as detailed on the blood transfusion record sheet, and then follow the procedure outlined in the diagram. This procedure must be followed for each individual unit being collected. DO NOT use the paperwork supplied by the laboratory to check againsttheunit,thisisnotanindependentcheck. Thesigningoutprocedurewillbeexplainedatstafftrainingsessions.Staffnot trainedtocollectbloodorbloodproductsmustnotdoso. 1.4CollectingBloodforMassiveLifeThreateningHaemorrhage Itisrecognisedthatinsomecasesofmassivehaemorrhage,itisimpracticalto take only one unit of red cells to the clinical area. If there is a need to take more than one red cell unit, blood must be transferred in a designated blood transferbox. Followthecollectionandsignoutprocedure,thenrequestatransportboxfrom the blood bank laboratory (see section 2 Use of Transport Boxes). Note: blood must never be transported in other containers. Leave cold chain managementformwiththelaboratorystaff

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GuidetoCollectingBloodandComponentsforTransfusion
BeforeLeavingtheClinicalarea
Checktheprescriptioniscompletedonatransfusionrecordsheet Checktheproductisavailable(NOTiS) Checkthepatienthasvenousaccess Takeandrecordbaselineobservationsandensuretheyare acceptablefortransfusiontostart Youhavenecessaryaccesstodoors,bloodfridgesandIT Takepatientidentificationwithyoutothecollectionpoint

IdentifyUnit(s)tobeCollected

ForEachUnitCheck
Thepatientdetailsontheunitareidenticaltothoseonthetransfusion recordsheetorpatientidentification Thedonationnumber(theGnumber)isthesameonthefrontofthe packasitisonthereverseofthepack Theunitisnotexpired Allspecialrequirementshavebeenmet Therearenoleaksinthepack

Inadditionforeachcomponent,check

RedCells
Checktherearenoclots Checkthepackiscold Checkfordiscolouration

Platelets
Checkforabnormal clumpinganddisolouration

FFPandCryo
Ensuretherearenoice crystals

Alldetailscorrect? No Donot taketheunitto theclinicalarea Contactbloodbankstaff andresolvetheproblem

Yes

Proceedto Signingout

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1.5 Collecting Blood for Surgical Procedure in Clinical Areas with no Satellite Fridge Bloodtakenforsurgicalcoverinareaswithnosatellitefridgemustbestoredin abloodtransportbox. Followthecollectionandsignoutprocedure,thenrequestatransportboxfrom the blood bank laboratory (see section 2 Use of Transport Boxes). Note: blood must never be transported in other containers. Leave cold chain managementformwiththeLaboratorystaff 1.6.CollectingBloodforTransferwithaPatienttoanotherHospital Blood is sometimes transferred with a patient to another hospital. This blood must be transported under controlled storage conditions and the audit trail maintained. Informbloodbankthatbloodistobetransferred.Theywillneedthepatients details,howmanyunitsaretobetransferred,whentheyaretobetransferred andthedestinationhospital. When transfer is imminent, collect the units by following the collection and signingoutprocedure.Taketheunitstothebloodbanklaboratorywherethey willbepackedintoabloodtransportbox. Bloodmustremaininthissealedbox(unlesstransfusionisrequiredenroute) untildeliveryatthereceivinghospitalwheretheboxmustbesenttotheblood banklaboratoryonarrival. 1.7MovingBloodtoaSatelliteBloodFridge Satellitebloodfridgesarefridgesdedicatedtothestorageofblood.Theymust comply with British Standard BS4376 and have a continual temperature monitoringsystemandmaintenanceschedule.Theymustnotbeusedtostore drugs,samplesoranyothermaterials. BloodmustNOTbestoredinotherdomestic,drugor wardfridgesunderany circumstances. To comply with the Blood Safety and Quality Regulations (2005), a complete record of the contents of the fridge with full audit trails for each unit placed withinit,ortakenfromit,mustberecordedandkept.
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Onlyofficiallydesignatedbloodfridgesmaybeusedtostoreblood. Designatedsatellitefridgesarelocatedin: CityCampus Maintheatre Maternitytheatre CICU HaematologyUnit QMCcampus WestBlockMainTheatresPhase1 TherearealsosatellitefridgesatParkandWoodthorpeHospitals. Followthecollectionandsignoutprocedureasoutlinedinsection1.3. Obtainthecoldchainform.Placethebloodinthesatellitefridgeandcomplete thecoldchaindocument. Placethecoldchaindocumentinthefoldernexttothesatellitefridge. 1.8CollectingBloodfromaSatelliteFridge Thesatellitefridgeineffectnowbecomestheissuefridge Followthecollectionandsigningoutprocedureoutlinedinsection1.3 1.9ReceivingBloodfromanotherHospitalwithaPatient Bloodissometimestransferredwithapatientfromanotherhospital.Thisblood willbetransferredundercontrolledstorageconditionsandtheaudittrailmust bemaintained. Leave the blood (if possible) in the transport box and take it, along with any accompanyingpaperworktothebloodbanklaboratoryassoonaspossible. Providing the Cold Chain documentation is correct the laboratory staff will enterthebloodontothehospitalITsystemandreissueitforthepatient.

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2. UseofTransportBoxes Blood transport boxes are designed to allow the temporarystorage of blood andbloodcomponentswhentheyarebeingtransferredfrompermanentblood storagefacilities.Theyarenotintendedforuseaspermanentstoragefacilities as they are not refrigerated or continually monitored in accordance with legislation. Appropriateusefortransportboxesare: o transferofbloodorcomponentsfromonehospitalbloodbanktoanother o transfer of blood or components with a patient to another hospital or clinicalunit o temporary storage of blood in clinical areas to cover procedures when therearenopermanentbloodstoragefacilities o situations of acute haemorrhage and when it is impractical to collect unitsindividuallythismustonlybedoneattherequestoftheattending clinician Inappropriateuseoftransportboxesincludes: o storageofbloodforroutinebloodtransfusion o use as temporary storage for staff convenience or at times of staff shortages 2.1ProcedureforUse Follow the collection and sign out procedure as outlined in section 1.3, then requestatransportboxfromthebloodbanklaboratory. Theboxwillbeissuedcontainingthebloodproductsandcoolpacks.Takethe box immediately to the clinical area. Leave the cold chain form with the laboratorystaff. Onlyonepatientsbloodmaybetransportedinasinglebox. Do not open the box until transfusion is imminent. Remove the packaging, locatetheunittobetransfusedandreplaceallthepackagingandcoolpacks. Ensurethelidisplacedbackonthebox. Thebloodboxeshavebeenvalidatedandbloodcanbestoredforamaximum oftimeasindicatedonthetransportboxprovidingthelidremainsonthebox.If the blood is still required after this period of time, it must be returned to the transfusionlaboratorywhereitwillberepackedwithfreshcoolpacks.
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Whenbloodisnolongerrequired(orisalltransfused)pleasereturntheblood transportbox andanyunusedunitstothetransfusion laboratoryassoonas possible.DoNOTplacethebloodintheissuefridge,ensureitishandedtoa member of the transfusion team who will check the blood integrity before decidingbloodissuitableforissueorneedstobedisposed. 3.ReturningUnusedUnits Itisimportantthatanyunusedunitsarereturnedtothebloodbankastheymay beutilisedforanotherpatient. Units may only be accepted back if the correct storage conditions have been maintained. RedCells Ifunitshavebeenoutofthefridgeforlessthan30minutes,theymaybereused. Handbacktoamemberofthetransfusionteamwhowillcheckthebloodintegrity beforedecidingbloodissuitableforissueorneedstobedisposed. If unit(s) has been out of the fridge for more than 30 minutes and there is no prospect of transfusion to the intended recipient, they are no longer suitable for transfusionandmustbediscarded.Returnthemtothebloodbanklaboratoryand handthemovertoamemberofthelaboratorystaff.Donotputthembackintothe blood fridge. Raise a clinical incident to explain the wastage (send copy to TransfusionPractitioners). If units are being returned from a satellite fridge, indicate on the cold chain documentthetimeof removalfrom the fridge.Takethedocument andtheunits backtotheissuefridge.Placetheunit(s)backintostorageandindicatetheunit hasbeenreturnedonthecoldchaindocument. Ifunitsarebeingreturnedwhichhavebeeninabloodtransportbox,handthebox (with contents) to a member of the blood bank laboratory staff. Do not put the unitsinthebloodfridge. Platelets,FFPandCryoprecipitatae Hand unwanted platelets, FFP and Cryoprecipitate to the blood bank laboratory staff.Donotputtheminthebloodfridge.

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NUHTRANSFUSIONPOLICY:APPENDIX4 PROCEDUREFORTHEADMINISTRATIONOFBLOOD ANDBLOODCOMPONENTS 1. ThePrescription CurrentlyBloodanditscomponentsmustbeprescribedbyMedicalStaff. Itistheresponsibilityoftheprescribertoensurethattherecipienthasreceived anexplanationoftherisks,benefitsandalternativestotransfusion,inlinewith theNUHTrustConsenttoExaminationorTreatmentpolicyCL/CGP/020. Theprescriptionshouldbewrittenlegiblyonabloodtransfusionrecordsheet which carries full patient identification details. The transfusion plan and indicationsshouldalsoberecorded. Itshouldspecifytheproduct tobegiven,includingany autologous blood,the quantity(eachunitshouldbeprescribedonaseparateline)andthedurationof transfusion. Any medication required before or during the transfusion must also be specifiedbutprescribedonthedrugchart. 2. ChecksPriortoAdministration Bloodshouldonlybeadministeredbyadoctor,aregisterednurse,aregistered midwife,oraregisteredoperatingdepartmentpractitioner. The preadministration check should be made by two individuals. One, who must be qualified as defined above, acts as the primary checker and is responsible and accountable for the bedside identity check. The secondary checkeractsaswitnesstotheaccuracyofthecheckingprocess. The check must only be performed at the side of the patient about to be transfused. Patientsnot wearingidentificationbandsor photo IDcards must notreceive transfusions.TheidentificationbandorphotoIDcardmustspecifythepatients surname, first name, date of birth, gender and unique identification number (preferablyNHSnumber).NOIDband/card=NOBLOOD

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Thepatientmustbepositivelyidentifiedbycheckingthedetailsonthepatient identification band or photo ID card and where possible, by asking them to state their full name and date of birth as per the Trust Positive Patient IdentificationProcedureCL/CGP/037. Be particularly diligent in the checking procedure where patients are confused, unable to communicate, unconscious or anaesthetised as they cannotverballyconfirmtheiridentity,noraretheyideallyplacedtoreportearly symptoms of a serious transfusion reaction. Also be careful in emergency situations,especiallywithunidentifiedpatientsandmultiplecasualties. ThepatientID(fullname,DOBanduniqueidentifier(preferablyNHSnumber) mustbefoundtobeidenticalon: thepatientIDband/photoIDcard theidentificationlabelattachedtotheunittobetransfused. thebloodtransfusionrecordsheet Also check the donation number (the G number) is identical on the patient identificationlabelonthebackoftheunit(orontheattachedluggagelabelin thecaseofplatelets)andthelabelonthefrontofthepack.Ensurethattheunit hasnotpasseditsexpirydateandtime.

On occasions the blood group of the unit issued may differ from that of the patient. The unit will, however, still be compatible with the patient. Contact bloodbankifthereisanydoubt. Check that any special requirements have been met e.g. irradiation, CMV negative Checktheintegrityofthepackforclots,leaksordiscolouration. Should any discrepancies in identification be noted, the unit found to be beyond its expiry date or special requirements appear lacking, do not commence infusion of the unit. Report to the senior nurse in the department/wardwhocandiscusswithmedicalstaffand/orBloodBank. Thecheckingproceduremustberepeatedforeachunittobetransfused 3. AdministrationofBloodandComponents Blood should be transfused through a sterile giving set designed for the purpose.Suchsets containanintegralfilter sufficienttoremovefibrindebris
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etc.Ifbloodisbeingtransfusedtosmallinfantsviasyringe,however,ascreen filtershouldbeincludedinthecircuit. Electronic Infusion pumps may be used for the administration of red cells PROVIDED that the manufacturers instructions confirm that the pump has been validated for that purpose (Graseby 500 and IVAC pumps are safe to use).Otherwiseredcelldamageandhaemolysiscanresult. Bloodshouldnotroutinelybewarmedinmostclinicalareas. ABloodWarmer is indicated in rapid, high volume transfusions or if the patient has clinically significantcoldagglutininantibodies.Incaseofthelatter,theuseofawarmer willbeadvisedbyBloodBank. If indicated, a regularly maintained, purposedesigned Blood Warmer with thermostatcontrolandaudiblealarmshouldbeused. NEVER WARM BLOOD ON RADIATORS, IN HOT WATER OR IN A MICROWAVEOVENtheresultwillbepotentiallylethalredcelldamage. Nodrugsshouldbeaddedtobloodorcomponentpacks. Ifprimingabloodgivingsetuse0.9%sodiumchlorideintravenousinfusion. Thenumberofredcellsunitstobetransfusedviaasinglegivingsetissubject tomanufacturersinstruction,however twounitspergivingset or amaximum ofeighthoursusefortransfusionisthenorm. IfanI.V.infusionistocontinueafterthetransfusion,doNOTflushtheline,use anewgivingset If platelets are to follow a red cell transfusion, use a new blood or platelet givingset. Startthetransfusionassoonaspossibleaftercollection,butalwayswithin30 minutes. Recommendedtransfusiontimesareoutlinedbelow. If the transfusion is delayed, return the component to the collection fridge or bloodbanklaboratory. NOTE:Theexpirydateshownontheunitis23:59hoursonthe dateshown. ForliabilityreasonsNOunitsmustbeinfusedbeyondthistime.Ifaunitisstill runningitmustbestoppedanddiscardedimmediately.

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Recommendedtransfusiontimes Alltransfusionproductsshouldbegivenintheminimumtimepossibleasdictated bytheclinicalsituation.Ageneralguideforroutinetransfusiononadultsisgiven below. RedCells Platelets FFP Cryoprecipitate Maximumof 30minutes peradultpack

2hours Maximum of Maximumof (Maximumof 30minutes 30minutes 4 hours from peradultpack when removed fromfridge)

For transfusionof neonatesandchildren pleaseseebeloworseekspecialist clinicaladvice. Component RedCell ExchangeTransfusion Volume InfusionRate

80100ml/kg (for Depends on anaemia) stabilityofbaby 160200ml/kg (for hyperbilirubinaemia) 1020ml/kg 5ml/kg/hr

TopupTransfusions

Emergency largevolume 1020ml/kg transfusions Plateletconcentration (adultapheresispackssplit 1020ml/kg into5070ml) FFP Pathogenreduced 1020ml/kg Cryoprecipitate Pathogenreduced

Rapid infusion only for resuscitation 1020ml/kg/hr

1020ml/kg/hr

510ml/kg

1020ml/kg/hr

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Blood components volumes and rates of administration for infants and children Component Volume Rate Red Cell Vol(ml)=desiredHbrise(g/dl)xwt 5ml/kg/hr Concentrate (kg)x3 (usual max 150ml/hr) Platelet Children<15kg1020ml/kg 1020ml/kg/hr Concentrate Children>15kg1adultdose FFP 1020ml/kg 1020ml/kg/hr 1020ml/kg/hr 60mins) (30

rate

Cryoprecipitate 510ml/kg(max300ml)

Bloodcomponentsforneonataltransfusion(www.bcsh.guidelines.com) 4. CareandMonitoringofPatientsUndergoingTransfusion Foreachunittransfused: Check and record the baseline observations (temperature, pulse and blood pressure)onthetransfusionrecord sheet of thepatientprior tocollectingthe bloodfortransfusion. Washhands, andconnect the administrationset accordingtotheProcedure for The Preparation Of An Intravenous Infusion And Care Of A Patient Receiving an Intravenous Infusion (see Nottingham Nursing Procedure and Guidelines file). Gloves and an apron should be worn whilst attaching the bloodtotheadministrationset. Ifmultiplevenousaccessesarepresent,ensurethatbloodisnotadministered at the same time as any other drug likely to also cause an anaphylactic reaction.Ifsinglevenousaccessispresentdonotintroduceotherdrugsinto the cannula or blood administration set unless absolutely necessary. In rare instanceswhereitisnecessary,ensurethatthelineisflushedwith0.9%saline beforeandafterthedrugadministrationasprescribed.Drugsshouldneverbe addedtothebloodcomponentpack. Ensurethecomponentisadministeredattheprescribedrate.

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Observations MUST be performed, recorded and timed on the transfusion record sheet prior to collection of each unit and 15 minutes into each units transfusion(BCSHGuidelines). Thepatientshouldbeaskedtoinformthenurse/midwife/ODPiftheyfeelatall different during the transfusion. This should be repeated for each unit of bloodcommenced. Theadministratorshouldobservethepatientforthefirst5minutesaftereach unit of blood is commenced to identify any indication of transfusion complications. Furtherobservationsduringthetransfusionofeachbloodunitareaccordingto practice in that clinical area. Observations must be taken should the patient becomeunwellorshowsignsoftransfusionreaction. ObservationsMUSTbetakenandrecordedoncompletionofeachunit,along withthefinishtimeforthattransfusion. Patients should be advised not to leave the clinical area without appropriate qualifiedsupervisionwhilereceivingatransfusion. Unconscious patientsare lesseasyto monitor for possiblereaction andas a result observations should be more frequent than for conscious patients, accordingtothepatientscondition. Duringthetransfusionobservethepatientforsignsof:flushing,itching,fever, vomiting,diarrhoea,urticaria,painatorneartransfusionsite,rigor,backache, haemoglobinuria,collapse,anaphylaxisandcirculatoryfailure.Ifanyofthese occur the transfusion should be stopped and a member of the medical staff shouldbecontactedimmediately. If the decision is to stop the transfusion, disconnect the administration set immediatelyandwithdrawblood(approx2mls)fromthevenousaccessdevice. This prevents any further transfused blood from entering the patients circulation. Flush with normal saline to maintain its patency. The patients observationsMUSTberecorded. SEEAppendix5Guidetotherecognitionandmanagementoftransfusion reactionsandincidents

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PostTransfusion Disconnection Oncethetransfusioniscompleted,disconnectthebloodadministrationsetand then flush the access device, or change for a fluid administration set if prescribed. Donotattachaninfusionbagof0.9%sodiumchloridedirectlyto thebloodadministrationsettoflushthroughtheblood,asthismaydislodge unwantedmaterialfromthefilter. Disposalofwaste Emptybloodbagsdonotneedtobekeptandshouldbediscardedaccording to the hospital policies for the disposal of clinical waste and infection control. Half empty bags and administration set should be disposed of together in a newsharpsbincontainingabsorbentgellingagent. Ensurealldocumentationiscompleted. Therecordingofallpatientdetailsandthedonationnumberofthepacksgiven isnowalegalrequirementtoallowcompletetraceabilityofallunitsforaperiod ofthirtyyears.ReturnthetopcopyofthebloodtransfusionrecordtotheBlood Banklaboratory.

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NUHTRANSFUSIONPOLICY:APPENDIX5 GUIDETOTHERECOGNITIONANDMANAGEMENTOFTRANSFUSION REACTIONSANDINCIDENTS 1. GeneralPrinciples Transfusion of blood and components does carry a small but significant risk. All staff involved in the transfusion process must be aware of these risks, be abletorecognisetheclinicalmanifestationsof transfusionreactionsandtheir correctmanagement. If a transfusion reaction is suspected, the patient needs to be assessed immediatelybyadoctor All transfusion reactions serious enough to warrant stopping the transfusion mustbereportedtotheBloodBanklaboratory SeriousincidentsandreactionsmustalsobereportedtoSHOTandtheMHRA via SABRE. Inform Blood Bank staff of any events and they will report these occurrences. Foralladverseevents,aTrustClinicalIncident(DATIX)mustbegenerated. Aguidetotheclinicalmanagementoftransfusionreactions,andtheirpossible causes,isoutlinedbelow

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AcuteTransfusionReactions
(Adaptedfrom HandbookofTransfus ionM edicine.4 Edition)
th

Symp toms/SignsofAc uteTran sfusion Reaction


Feverchillstac hyc ardiahyper orhypotensi oncollapserigors flushingurticariabone,m us cle,chestand/orabdom inalpain shortnessofbreathnauseagenerallyfeelingunwell respiratorydistress

Stopthe Transfu sionandCa llaDoc tor


Measuretem perature,pulse,bloodpressure,res piratoryrate,O2 saturation Checktheidentityoftherecipientw iththedetailsontheunit com patibilitylabelortag

FebrileNon Haem olytic Tran sfusio nReactio n


0 I ftem perat urerises < 1.5 C, the obs erv ati ons ares tab le and the p atient is oth erwis ewe ll,give parac et omo l. Res ta rt trans fus io ns lowe r ra tea nd obs erve mo re frequ entl y

MildallergicReaction
M ild F e ver

R eactioninvolves mildfeveror urtica ria lrasho nly


No

Ur ticar ia

G ive ch lorph enam in e10 mgI V s lo wlyan dr es tartth etrans fu sionat a slowerrat ean dobs erv em ore fr eq uent ly

ABO Incompatibility
Sto p the tr ans fus ion T ak e down unitan dgivings et Ret urnintac tt oBlood Ba nk Com me nc eivs alin ei nfus ion Mon ito r urine out put/ ca thet eris e M aintainu rine outp utat greate r t han 100m lp erhou r G ivef uros emideifu rine outpu t falls /a bse nt T reat any DIC with approp riate blo odc om pon ents Inf orm bloo dba nk imm ediate ly

S usp ecte dABO Incompatibility Yes


No

Se vereAllergicRe ac tion
Bron ch os pasm a ngiodem a abdom in al pain hy pote ns io n S to p t hetr an sf usion Ta k edo wn unita ndg iving s et R eturn int act toB lo odB ank along with all oth erus ed/ unus ed units Giv ec hlophe nam ine 10m gs lo wlyiv Com men ce oxy ge n G ive s alb utam ol nebu lise r If se vere hyp ote ns ion giv ea drena line0 .5m lof 1i n1 000 int ram us c ula r (e quiva lent to0 .5mg im) S alin ewas h futurec om pon ents

S eve reAllergic Reaction Yes No

HaemolyticReaction/ B acterialInfection of U nit


St opth etr an sfu sion T a ke down unita ndgiv ing se t Ret urnintac tto Blood Ba nk alo ng wit hall othe r use d/u nus ed units Tak e blo odc ultures an dr epea t b loo dgrou p/c ros sm atc h,F bc , c oa gulations c re en, bioc he mistr y , urina ly s is Mon ito r urine out put Comm enc eb ro ads pe ct rum a nti bio tic s if su sp ect edba ct erial infec tion Com men ce oxy gen and fluid s up port Se ek haem at olo gicaland inte ns ivec area dvic e

Yes

O th erH aem olytic Re ac tion/Ba cterial Contamination N o

AcuteD yspnoe a/H ypote ns io n


Monitorb loo dga se s P erform Ches tX Ray Me as ureC V P, pulmon aryc ap illary pres s ure

TR ALI FluidOverload
G iveox yg en Giv efuros em id e40 80 mg iv

Raised CV P

No rmal CV P

Clinic alfea tures ofa cu teLV F w it h fev eran dc hills Disc ont inu etrans fu sion G ive 100 % ox yge n T rea tas A RDS &v en tilateifh yp oxia indic ates

InALLcaseswhenitisnecessarytostopthetransfusioninformBloodBankimmediately

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TransfusionReactions

2.1 Febrile(NonHaemolytic)TransfusionReactions(FNHTR) Fever, and shivering during transfusion usually results from the action of anti leucocyte antibodies in the patient reacting against residual leucocytes in the transfusedblood.Suchpatientsusuallyhaveahistoryofpreviouspregnancyor transfusion. Cytokines released from white cells in stored products (particularly platelets)canalsoprovokesuchareaction. Suchreactionscaninitiallymimicanacutehaemolyticreactionbutthesymptoms are less severe. They are seen less often since the universal leucodepletion of redcellsandplatelets. ACTION: Slowdownthetransfusion Observethepatient Giveantipyretic,e.g.Paracetamol 2.2 UrticarialReactions Mildallergicreactionsusuallyresultinurticariaandpruritusshortlyafterthestart of the transfusion. They are usually due to the recipients antibody reaction against infused plasma proteins. They occur more often as a result of platelet and/orplasmatransfusionratherthanofredcells. ACTION: Slowtransfusion,stopifunpleasantsymptomspersist. Seekmedicalreviewandconsiderchlorphenamine10mgIV Can usually complete transfusion if no progression of symptoms after approximately30minutes If recurrent problem then premedicate with chlorphenamine to cover subsequenttransfusion. 2.3 TransfusionTransmittedInfection Theinfusionofbacterialendotoxininacontaminatedunitcanmimicthefever and acute hypotension of a major Acute Haemolytic Reaction. The risk of bacterialcontaminationisgreaterwithplateletthanredcelltransfusion.Ifsuch a reaction is suspected the packs must be returned to the Blood Bank for culture,inadditiontotakingbloodculturesfromthepatient.

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If a TTI is suspected, the blood bank will notify the national blood service who will investigate the donor in accordance with national policy (further informationfromwww.blood.co.uk/hospitals) 2.4 Severe Anaphylaxis: See Trustwide PGD: Administration of Drugs during AnaphylacticReactions This can be a rare complication of transfusion. A common cause is IgA deficiencyintherecipient. Serious allergic reactions may result in life threatening anaphylaxis with cardiovascularcollapseand/oracutebronchospasmandairwaycompromise. The infusion should be stopped, CALL FOR HELP, assess and maintain airway,breathingandcirculation. Ensure antianaphylactic measures instituted including high flow oxygen and epinephrine (adrenaline) according to the Trust wide PGD: Administration of Drugs during Anaphylactic Reactions 2009. See also Acute Transfusion flow chartinthisdocument(page42)

CheckIgAstatusandthepresenceofHLAantibodies.

IntheeventofCirculatoryArrest,ACTIVATECARDIACARRESTCALL. ReturnunitbeingtransfusedplusanyusedandunusedpackstoBloodBank. Blood samples should also be taken for investigation of the anaphylactic reaction according to the Trust wide PGD: Administration of Drugs during Anaphylactic Reactions2009

2.5 TransfusionRelatedAcuteLungInjury(TRALI) TRALIpresentsduringorsoonaftertransfusionwithfeverandnoncardiogenic pulmonaryoedema.Thepatientcomplainsofshortnessofbreathandcough andtherearetypicalappearancesonchestXray. TRALIiscausedbyantibodiesinthedonorplasmatopatientleucocytesandit isseenmostcommonly,butnotexclusively,afterFFP. ItmaybelifethreateningrequiringexpertmanagementinIntensiveCareUnit.


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Thetransfusionmust bestoppedandsupportivemeasures, includingoxygen therapy, commenced. The blood or blood components must be returned to bloodbank. Any suspected case of TRALI must be reported to the Blood Bank immediately. Ensure that Medical Staff discuss further management with the oncall HaematologyMedicalStaff. Furthersamples2x6mlclotted(redtop)and2x6mlEDTA(pinktop),together with the donation numbers of all blood products transfused in the 24 hours precedingtheevent,shouldbesenttoBloodBankforfurtherinvestigations 2.6 TransfusionAssociatedCirculatoryOverload(TACO) Usually associated with RBC transfusions, but can occur with any blood component.TransfusionofonlymodestvolumescancauseTACO,especially inelderlypatients. Isamajorcauseoftransfusionassociatedmorbidityandmortality Consider the diagnosis if any 4 of the following occur within 6 hours of transfusion Acuterespiratorydistress Tachycardia Increasedbloodpressure Acuteorworseningpulmonaryoedema Evidenceofpositivefluidbalance 2.7AcuteHaemolyticReactions These are most often the result of clerical error or failure of the checking proceduresatoneormorestagesinthetransfusionprocess. Such reactions occur within a short time of the start of transfusion, and can be recognised in the patient who becomes increasingly restless, has a sense of impendingdoomanddevelopsahighfever.Thiscanbefollowedbychestpain and dyspnoea, loin pain, abdominal pain, hypotension, shock and oliguria. Haemoglobinuriaandrenalfailurecanfollow.Recognitionismoredifficultinthe unconsciousoranaesthetisedpatient.

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URGENTACTION: Stopthetransfusionandcallformedicalassistance Ensureadequacyofpatientsairway,respirationandcirculation CheckpatientID,compatibilitylabelonunitbeingtransfusedandBloodBank CompatibilityForm. Takedownbloodpackandadministrationset (leaveconnected)andplacein waterproofcontainere.g.plasticbag. MaintainIVaccesswith0.9%sodiumchlorideviafreshgivingset. Informnurseinchargewhowillurgentlynotifymedicalstaff&BloodBank. Monitor urineoutputandcatheteriseifnecessary.Test urinefor presenceof haemoglobinandurobilinogen. SendbaselineFBC,Coag(PT/APTT/FIBRINOGEN),U&E'sandLFTs. Frequent observations should be continued until the patients condition is stable. SendbloodculturesandrequestthatBloodBankculturetheimplicatedpack, as it can be difficult to distinguish between an acute haemolytic transfusion reactionandsepsis. TakeafreshcrossmatchsampleandsendtoBloodBankalongwiththeblood packandadministrationset.Alsoreturnanyemptyorunusedbloodpacksto BloodBank.
EnsureMedicalstaffdiscusswithaHaematologist.

2.8 DelayedTransfusionComplications Delayed haemolysis presents 510 days after transfusion and is due to recipientIgGantibodiesfromasecondaryimmuneresponsetothetransfusion. Clinical features include fever, a falling haemoglobin, jaundice and haemoglobinuria.ExpertadviceshouldbesoughtfromHaematologymedical staff.

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Furthersamples2x6mlEDTA(pinktop)shouldbesenttotheBloodBankfor investigation. PostTransfusionPurpurapresents512daysaftertransfusionwithpurpuric bruising or bleeding with associated thrombocytopenia. It is most commonly seeninparouswomenandisduetoanimmunemediatedthrombocytopenia. ExpertadviceshouldbesoughtfromHaematologymedicalstaff. Furthersamples1x6mlEDTA(pinktop)and1x6mlClotted(redtop)shouldbe sentforinvestigation. TransfusionAssociatedGraftVersusHostDisease(TAGvHD)presents5 30 days after transfusion and is due to an immune reaction of donor T cells againsttherecipient,whoisusuallyseverelyimmunodeficient.Itisprevented byirradiationof cellular bloodcomponents for susceptiblerecipients.Clinical features include fever, rash, pancytopenia, liver and renal failure. Expert adviceshouldbesoughtfromHaematologymedicalstaff.Therehavebeenno reportedcasesofTAGvHDintheUKsince2001. 3 TransfusionRelatedIncidents Reportingincidentsisimportantinordertoidentifyerrors,poorpracticesand potential risks in the transfusion process. Reporting and subsequent investigation of these incidents will identify training needs and deficiencies in the system, which can be addressed, thereby enabling promotion of best practicesandimprovingpatientsafety. All incidents involving any part of the transfusion process must therefore be reportedviatheTrustClinicalIncidentReportingsystem. In addition, all serious incidents (including reactions) must be reported immediately to the blood bank laboratory, transfusion practitioner or to a member of the Haematology medical team who may have to report them to SHOTand/ortheMHRAviaSABREandtheNHSBT. AmorecompletelistofreportableincidentscanbefoundintheTrustIncident reportingpolicy,butsomeexamplesaregivenbelow. Inappropriatetransfusion IncorrectBloodComponenttransfused Anytransfusionreaction(seeprevioussection)
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Any component which is wasted or expired, including out of temperature control Bloodfridgefailure Samplingorprescriptionerror Delayinobtainingbloodorcomponentwhichcompromisespatientcare Laboratoryerrors FurtherinformationregardingreportableincidentscanbeobtainedfromtheTrust Incident Reporting policy, the blood bank laboratory senior staff, Transfusion Practitioners,oranymemberofthehospitaltransfusionteam. Ifyouareinanydoubt,contacthaematologymedicalstaff

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NUHTRANSFUSIONPOLICY:APPENDIX6 TRANSFUSIONMANAGEMENTOFMASSIVEHAEMORRHAGE Definitionsofmassivebleeding 50%lossofbloodvolumewithin3hours Bloodlossatarateof150ml/min. Massive bleeding can jeopardise the survival of patients. Early recognition and effective action, including the timely provision of blood and blood components, are essential to prevent shock and its consequences. The aim of this protocol is to provide a rational and, where possible, evidencebased approach to transfusion therapy and laboratory testing in this setting, and to facilitate the most appropriate andclinicallyeffectiveuseofbloodcomponents.Intheinitialstagesofhaemorrhage, combinations of blood components and products will be issued together as haemorrhagepacks Alongsideplanningfordamagecontrolresuscitation,surgery,andurgentradiological interventions,theattachedflowchartillustratesthestrategyfortransfusionsupportin acutemajorbleeding. Althoughtheevidencebasefortheuseofanyspecificratiosofbloodcomponentsis poor, in patients in whom there is early evidence of coagulopathy (notably trauma andobstetricpatients)theearlyuseofplasmaproductsisrecommended.Inallother patients it is recommended that blood component (platelets, plasma, and cryoprecipitate) therapy should be guided by laboratory results and ROTEM, if available. 1. PROCEDUREPRIORITIESINMANAGEMENT
1.1 Communication

Early communication with the Biomedical Scientist (BMS) in the blood transfusion laboratoryisessential. A member of the clinical team should be nominated to act as Medical Coordinator responsible for liaison with the transfusion laboratory and other clinical specialities. TheCoordinatorsresponsibilitiesarelistedbelowinsection3 Regular,ongoingcontactshouldbemaintainedbetweentheCoordinatorandtheon callhaematologist,ideallybeforetransfusingsubsequenthaemorrhagepackstohelp guidetransfusionandadditionalproductsupport.
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1.2 Bloodsamplesandlaboratorytests Bloodsamplesshouldbesentattheearliestpossibleopportunityfor: Crossmatch FBC Coagulationscreen,fibrinogen Biochemistry It is essential that these are labelled correctly (Cross match samples must be labelledbyhand)andthenhanddeliveredtothetransfusionlaboratory. Theseshouldberepeatedafterthetransfusionofeachhaemorrhagepackwiththe uptodateresultsrecorded,ifpossible,beforetransfusingthenextpack. Responsibility for communication of results lies JOINTLY with the Medical CoordinatorandtheBloodBankBMS. Thromoboelastrometry/ ROTEM, if available, may be used to guide transfusion support. There is little data about its use in paediatric patients in this setting, and referencerangesinthispatientpopulationareunknown.

1.3Restorationofcirculatingvolume Inthemassivehaemorrhagepatient,thisincludesupfrontuseofbloodandblood components. 1.4Bloodproductsupport Redcells RBCtransfusionisnearlyalwayslikelytoberequiredwhen3040%bloodvolumeis lost>40%bloodvolumelossisimmediatelylifethreatening. Intraoperative cell salvage may be of great value in reducing requirements for allogeneicblood. If the patients blood group is known, type specific, uncrossmatched blood will be availablewithin5minutesofthebloodbanklaboratoryreceivingabloodsample(or activationoftheprotocolifavalidsampleisalreadyinthebloodbank).. In rare, extreme situations when blood is required more urgently than 5 minutes, emergencystockORhDnegativeunitsareavailableinthemainissuefridges:
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QMC: City:

BloodBank,Afloor,Westblock BloodBank,Pathologycorridor MaternityTheatre

IfemergencyORhnegativeunitsaretaken,informthelaboratoryIMMEDIATELYto ensureitisreplaced. Freshfrozenplasma(FFP)andcryoprecipitate Thesewillbethawedonactivationoftheprotocol.FFPandcryotake2030minutes to thaw from time of request. In a massive haemorrhage setting, it may not be appropriatetowaitforthecoagulationresultsbeforetransfusing. Allchildrenundertheageof16yearswillbeissuedwithpathogenreducedFFPand cryoprecipitate. At NUH, we stock Octaplas, a solventdetergent pooled plasma productandmethylenebluetreatedcryoprecipitateforchildren FFPshouldbegiventomaintainaPT/PTT<1.5xnormal.Cryoprecipitateshouldbe giventomaintainafibrinogen>1.52.0g/L.

Platelets
9 A platelet count of 50 x 10 /L is expected when approximately two blood volumes have been replaced by red cells, but there is marked individual variation. Expert 9 consensussuggeststhatplateletsshouldbetransfusedtoatargetof75x10 /L(in 9 ordertomaintainacriticallevel>50x10 /L).

Iflaboratoryresultsarenotrapidlyavailable,transfuseoneATDplateletsforevery6 unitsRBCs. rFVIIa rFVIIamayenhancehaemostasisandhasbeenusedinnumerous,offlabelsettings such as major haemorrhage. However, a Cochrane review indicated that evidence for effectiveness of rFVIIa as a more general haemostatic drug, either prophylacticallyortherapeutically,remainsuncertain. A recent New England Journal of Medicine analysis (Levi, NEJM 2010: 363) concluded that there was a significantly increased risk of arterial thromboembolic
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eventsassociatedwithofflabeluseofrFVIIa.Thisshouldbeusedwithcautionand onlywiththeapprovaloftheMedicalCoordinator. Tranexamicacid Thisisanantifibrinolyticdrugshowntoreducemorbidityandmortalitysignificantlyin trauma patients (CRASH2).Though there is a theoretical risk of thromboses, it is widely used perioperatively in orthopaedic and cardiac surgery with no significant increased incidence of thromboses. Its use should be strongly considered in all cases of major haemorrhage, but used with caution in patients with a recently diagnosedthrombosis. Doseinadultsis1gIVbolusfollowedby1gover8hours.Doseinchildrenis20 mg/kgover10minutes,then10mg/kg/hrinfusion. 1.5. Reversalofknownanticoagulantdrugs Please see NUH document Reversal of bleeding caused by anticoagulant, antiplateletandantifibrinolyticdrugsfordetails. If a patient with massive haemorrhage is known to be on a Vitamin K antagonist (warfarin, nicoumalone, phenindione), Vitamin K 10 mg IV should be given IMMEDIATELY,andProthrombincomplexconcentrateafterdiscussionwiththeon callhaematologist. Heparin is reversed by protamine. Unfractionated (IV) heparin can be completely reversed,butlowmolecularweightheparinsareonlypartiallyreversed.FFPwillnot reverseheparin. There is no proven reversal agent for newer anticoagulants (fondaparinux, danaparoid, rivaroxaban, dabigatran, apixaban) though some manufacturers recommend rFVIIa. If a patient is known to be on these agents, the Haematologist shouldbecontactedimmediately. 1.6Complicationsofmassivebleedingandtransfusion/fluidtreatments Useofbloodcomponentsisassociatedwithrecognisedrisks(egtransfusionrelated acute lung injury (TRALI), haemolytic transfusion reactions). Blood must be used appropriately even in a massive transfusion setting. Mislabelling and incorrect administration of components remains a danger in the emergency setting. It is essentialtoadheretobestpracticeforpatientidentificationandsamplelabelling.

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Hypothermia and acidosis must be corrected, along with hypocalcaemia and hyperkalaemia. Standard venous thromboprophylaxis should be considered after haemostasis has been secured, as patients may develop a prothrombotic state following massive haemorrhage. 2. ACTIVATION CRITERIA FOR TRANSFUSION SUPPORT IN LIFE THREATENINGHAEMORRHAGE Patientswithhaemorrhagicshock,orimpendinghaemorrhagicshock,duetoamajor haemorrhage OR Systolicbloodpressurelowerthan80mmHgonadmission,lowerthan90mmHgafter initial fluid challenge, with actual or suspected haemorrhagic cause, or when haemorrhagecausesa25%reductioninthesystolicbloodpressure. OR Bloodloss150ml/min ActivationismadethoughtheBMSontheMassiveHaemorrhagepager QMC 7841342 City 7807882 Information required includes giving the name of the Medical Activator, details of theMedicalCoordinatorandpatientdetails,includingabriefhistoryandcauseof bleeding,ifknown. NOTE: activation of the policy will initiate the issue of blood, components and productsinhaemorrhagepacksasdetailedinsection4.Thereisnorequirementto request further products until after the issue of pack 3 when advice will be sought fromaconsultanthaematologist.ThiswillbefacilitatedbythebloodbankBMS. IMPORTANT:BloodBankwillcontinuetoissueproductsinlinewiththispolicyuntil anofficialstanddownisreceived.Pleaseensurestanddowniscommunicatedina timelymannertopreservebloodstocks.

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3.RESPONSIBILITIES MedicalActivator The decision to activate the Massive Haemorrhage Protocol is the responsibility of themost seniorattending clinician.TheActivatormust clearlyrecordtheiridentity, thetimeanddecisioninthecaserecord. MedicalCoCoordinator The Medical Coordinator (MC) is the clinician who will establish and maintain effective communication between the transfusion laboratory and the clinical team. The MC will normally be the most senior clinician (preferably a consultant) dealing withthecase.ItisanticipatedthattheMedicalActivatorwillusuallybetheMC. TheMedicalCoordinatorwilldelegatethefollowingrolestoteammembers: 1. Communication Lead (The Coordinator may take on this role.)the dedicated personforcommunicationwithotherteamsandthetransfusionlaboratory 2.Documentationofactivity/observations/bloodproducttransfusion 3.Collectionandtransportofbloodsamples,bloodproducts. Otherresponsibilitiesare:

To provide a reliable means of contact name and bleep number or telephone extension. Tonotifythelaboratoryifthepatientismovedwithinthehospital. To notify the laboratory of any significant clinical issues that arise (e.g. transfusion reaction). To notify the laboratory if the identity of the Medical Coordinator or their contact detailschange(e.g.withchangeofshiftorlocation). To ensure accurate records are made of the transfused blood products and any drugssuppliedbythetransfusionlaboratory.Thispersonwillalsoberesponsiblefor ensuring full traceability of any blood components and blood products according to Trustpolicy.

Todeclareanofficialstanddownfromtheprotocolattheappropriatetime.
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BloodTransfusionBiomedicalScientist The Biomedical Scientist is responsible for the provision of blood, components and products as described by the protocol and as further instructed by the Consultant Haematologist. They will also inform the Haematology Registrar that the Massive Haemorrhage Protocol has been activated and at regular intervals after each haemorrhagepackhasbeenissued.Theyareresponsibleforensuringsufficientblood suppliesaremaintainedandtocommunicateanypotentialproblemstotheMedicalCo ordinatorand/orConsultantHaematologist. HaematologyRegistrar TheHaematologyRegistrarisresponsiblefor: alerting the Haematology Consultant that the Massive Haemorrhage protocol has beenactivated

maintaining regular contact between clinical teams, Consultant Haematologist and thetransfusionlaboratorytoprovideadvice

ConsultantHaematologist TheConsultantHaematologistisresponsiblefor:

deliveringguidanceandadviceregardingongoingtransfusionsupport.

monitoring whether the demands of the bleeding patient will adversely affect the abilityofthetransfusiondepartmenttocontinuenormalservices.

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4.HAEMORRHAGEPACKS Tobecollectedfromthetransfusionlaboratory(NOTtheissuefridge) Pack1 RedCells Adults 4unitsofRedcells Paediatrics 20ml/kg

(GroupspecificifpossibleorORhDnegative) Pack2 (Tobeavailablewithin30minutesoftheprotocolactivation) Adults 6units 4adultbags 1adultdose 1adultdose(2pools) 1dose(90mcg/kgforallpatients) Paediatrics 40ml/kg 15ml/kg 15ml/kg 15ml/kg

RedCells* FFP Platelets Cryoprecipitate rFVIIa

ImmediatelyafterPack2isissued,beginpreparingPack3. Pack3 Adults 6units 4adultbags 1adultdose 1adultdose(2pools) 1dose(90mcg/kgforallpatients) Paediatrics 40ml/kg 15ml/kg 15ml/kg 15ml/kg

RedCells FFP Platelets Cryoprecipitate rFVIIa

FollowingIssueofPack3 The BMS will immediately contact the Haematology registrar, who will discuss with theConsultantHaematologistforauthorisationoffurtherunits. Except red cells, further components will NOT be issued without this authorisation. NOTE:IfRhDpositiveplateletsareissuedtoanRhDnegativefemaleofchild bearingpotential,antiDmustbeissued.
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5.STANDDOWN When the acute haemorrhage is under control, the Medical Coordinator will informbloodbankanddiscussanticipatedrequirements. All unused products should be returned immediately to the blood bank to ensuretheyarenotwasted. Documentationmustbecompletedbytheclinicalteam. 6.BLOODCOMPONENTTRACEABILITYANDCOLDCHAIN The clinical team is required to comply with NUH procedures for blood and producthandlingandtraceability. REFERENCES 1. The transfusion of blood and blood components in an emergency: National Patient Safety Agency Rapid Response Report NPSA/2010/RRR017 October 2010. Association of Anaesthetists of Great Britain and Ireland. Blood transfusion and anaesthetist: management of massive haemorrhage. Anaesthesia 2010 65: 11531161. BritishCommitteeforStandardsinHaematology,StainsbyD,etal.Guidelineson themanagementofmassivebloodloss.BrJHaematology.2006135:63441. Managementofbleedingfollowingmajortrauma:anupdatedEuropeanguideline. Rossaintetal.CriticalCare2010,14:R52. ORH RadcliffeHospitals NHSTrust:Guidelinesfor thetransfusionmanagement ofmassivebleeding2010v.5.)

2.

3.

4.

5.

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MassiveHaemorrhageinAdults
ActivateMassiveHaemorrhageProtocol QMCBleep7841342 CityBleep7807882

SendSamplesbyHand (XMatch,Fbc,Coagulation,Fibrinogen) UseROTEMifavailable Collect&TransfuseHaemorrhagePack1 Instigateresuscitation&haemorrhagicprevention measures ConsiderTranexamicAcid(1gIVbolus,then1gover8hr) CorrectAcidosis&Hypothermia ContactHaematologist(maybeinitiatedbyBloodBank)

Collect&TransfuseHaemorrhagePack2accordingly EnquireaboutavailablebloodresultsbutDONOTWAIT forresultsbeforetransfusing UseROTEMresultsasaguideifavailable Sendrepeatsamples + ++ InadditioncheckABG,K ,Ca PatientStillBleeding? SendforHaemorrhagePack3 LiaisewithConsultantHaematologist

CollectHaemorrhagePack3&Transfuseaccordingly Checkavailablebloodresults Sendrepeatsamples UseROTEMasaguideifavailable PatientStillBleeding? DiscusswithConsultantHaematologist FurthercomponentsrequireauthorisationformConsultant Haematologist

TransfusionTargets Hb810g/dl Platelets>75x109/l PT/PTT<1.5xnormal Fibrinogen>1.52.0g/l


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MassiveHaemorrhageinPaediatrics
ActivateMassiveHaemorrhageProtocol QMCBleep7841342 CityBleep7807882

SendSamplesbyHand (XMatch,Fbc,Coagulation,Fibrinogen) Collect&TransfuseRedCells(20ml/kg) Instigateresuscitation&haemorrhagicprevention measures ConsiderTranexamicAcid (20mg/kgIVbolusthen10ml/kg/hrinfusion) CorrectAcidosis&Hypothermia ContactHaematologist(maybeinitiatedbyBloodBank)

Collect&TransfuseHaemorrhagePack2accordingly EnquireaboutavailablebloodresultsbutDONOTWAIT forresultsbeforetransfusing Sendrepeatsamples + ++ InadditioncheckABG,K ,Ca PatientStillBleeding? SendforHaemorrhagePack3 LiaisewithConsultantHaematologist

CollectHaemorrhagePack3&Transfuseaccordingly Checkavailablebloodresults Sendrepeatsamples PatientStillBleeding? DiscusswithConsultantHaematologist FurthercomponentsrequireauthorisationformConsultant Haematologist

TransfusionTargets Hb810g/dl Platelets>75x109/l PT/PTT<1.5xnormal Fibrinogen>1.52.0g/l


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NUHTRANSFUSIONPOLICYAPPENDIX7 GUIDETOTHEMANAGEMENTOFPATIENTSREFUSINGTRANSFUSIONOF BLOODANDBLOODCOMPONENTS 1. GeneralPrinciples

Any competent adult is entitled to accept surgical or other interventions but to specificallyexcludecertainaspectsofclinicalmanagementsuchasablood transfusion(exceptincertaincircumstancesgovernedbytheMentalHealthAct 1983). The patient must be fully informed of (and understand) the potential consequences of the refusal and this must be documented clearly in the patients notes. Health care professionals must ensure that they continue to provide any other appropriate care to which the patient has consented, and that the patient realises they are free to change their mind and accept transfusion treatment if they laterwishtodoso. Clinicians should establish the patients view of acceptable treatments in private,awayfromtheinfluenceofrelativesorcommunityrepresentatives. Validandapplicableadvancedecisionsmustberespected. Most JehovahsWitnesses will not accept a transfusion of whole blood or its majorderivativesincludingFFP,plateletsandwhitecells. Individual beliefs and the acceptability of clinical interventions vary between JehovahsWitnessesandtheviewsofthepatientshouldbeascertained. A Jehovahs Witness patient may wish to involve the Hospital Liaison Committee(HLC)anetworksetupbyJehovahsWitnessestogivesupportin thesecircumstances.TheHLCisavailable24hoursadayandiscontactable via switchboard but the patients' consent must be obtained before contacting thisbody. Many Jehovahs Witness patients will present having already completed an advanceddecision. TheformatusedincludesarequesttoinvolvetheHLC. ARecordofRefusalofSpecificTreatmentproformaaccompaniesthisguide.

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2.

TheLegalPosition Any competent adult is entitled to accept surgical or other interventions but to specifically exclude certain aspects of clinical management such as a blood transfusion (except in certain circumstances governed by the Mental Health Act 1983). The patient must be fully informed of (and understand) the potential consequences of the refusal and this must be documented clearly in thepatientsnotes.Healthcareprofessionalsmustensurethattheycontinueto provideanyotherappropriatecaretowhichthepatienthasconsented,andthat the patient realises they are free to change their mind and accept transfusion treatmentiftheylaterwishtodoso. Toadministerbloodtoapatientwhohassteadfastlyrefusedtoacceptitbythe provision of an advance directive or by its exclusion in consent form (or verbally)isunlawful(willconstituteandassault). If a documentary record has been made of the patients wishes, which is signed, datedand witnessed, andthereisnoreasonabledoubtof itsvalidity, thenthewishesexpressedshouldberespected. When dealing with an emergency patient in an extreme condition or an unconscious patient whose wishes regarding blood transfusions may be unknown,thedoctorcaringforthepatientwillbeexpectedtoactonthebasis ofwhatisknownofthepatientswishes,whatisclinicallynecessary,andwhat is in the bestinterests of the patient. This decision making process must be documentedattheearliestopportunity. Nootherperson,includingrelativesorfriends,hastheauthoritytoconsentto or refuse treatment on behalf of another adult, unless they have a Lasting Power of Attorney (LPA) specifically for personal welfare matters or are a Court Appointed Deputy. Treatment should proceed without restriction from others. Iflegaladviceisrequired,accesstotheTrustlegaladvisorsmaybeobtained throughtheDutyNurseManagerforthehospital. Medical staff have the right to refuse to provide clinical care for a patient refusingtransfusioninanelectivesituationwheretheyconsidertransfusionis clearly or likelytobenecessaryandthatthepatientsrefusal willsignificantly compromisetheoutcome.Insuchacircumstancetheclinicianshouldattempt to refer the patient to a suitably qualified colleague who is prepared to undertake care. The HLC have a list of medical staff who have agreed to sharetheirexperienceofnonbloodmanagement.Inanemergency,clinicians
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are obliged to provide all reasonable care and must respect the patients wishes. 3. AdvicefortheManagementofChildren Parentshavearighttobeinvolvedandrepresentedinlegaldiscussionsandto express their views at any meeting and should in all circumstances be remindedoftheirrighttoseeklegaladvice. Forchildrenbelow 16 yearsof agethe wellbeingof thechildisoverriding.If parents refuse permission for a blood transfusion it may be necessary to involve Trust Solicitors and apply for a legal Specific Issue Order. Prior to this,twodoctorsofconsultantstatusshoulddocumentwithclaritythatintheir view blood or component transfusion is essential, or likely to become so, in order to prevent harm to the child. They should also document discussions withthechildand,inparticular,anyviewexpressedbythechild. Achildover12yearsofagewhoiscapableofunderstandingtheissuesmay beabletogive/withholdaconsentandthushavethesamerightsasanadult. Howeverthisisacomplexareaasitmaybearguedthatthechildsviewsmay be based on the context of his/her family experience alone rather than the constructive formulation of an opinion which has occurred with adult experience.Legaladviceisstronglyrecommended. In the emergency management of a child when there is no time to make an application to the courts and the child is likely to die or suffer serious harm withouttransfusion,bloodshouldbegivenwhateverthewishesoftheparents. Fulldocumentationofthedecisionbytwoseniorcliniciansisessential,andthe TrustLegalDepartment/DutyManagermustbeinformed. Most Jehovahs Witness parents are well informed with regard to the legal position. In an elective situation a less confrontational path may be taken. This may take the form of a written understanding between the parents andclinicians(andwhereappropriatethechild).Thisdocumentshould setoutanunderstandingthatallpossiblealternativestotransfusionwill beemployedanddescribethecircumstancesunderwhichatransfusion wouldtakeplace.TheTrustSolicitorsshouldreviewanysuchdocument andtheparentsmustbeinformedoftheirrighttolegaladvice.

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4.

ClinicalStrategies When surgery or other interventions (including childbirth) are planned or anticipated for patients refusing transfusions, all the clinicians likely to be involvedshouldbealertedinadvance. If appropriate, consider consulting with colleagues experienced in nonblood management Thedegreeoflimitationofpatientmanagementshouldbeascertained. Alternatives to blood transfusion and other clinical strategies for managing haemorrhageandanaemiashouldbeconsidered. Nonblood therapies to raise the haemoglobin before the procedure may be indicated on the advice of a Haematologist, including treatment with haematinicsand/orerythropoietin. Techniquestominimizebloodlossshouldbeemployedduringtheprocedure. Considerationshouldbegiventoemployanyalternativesthatareacceptable tothepatientincludingintraoperativecellsalvage. Insevereacuteanaemiafollowingbloodloss,strategiesshouldbeconsidered tomaximizeoxygendelivery,includingrespiratorysupportinintensivecare.

5.

REFERENCES: Management of Anaesthesia for Jehovahs Witnesses www.aagbi.org/pdf/7doc.pdf Clinical Strategies for Managing Haemorrhage and Anaemia without Blood Transfusion.HospitalInformationServicesJan.2002 Clinical Strategies for Managing Haemorrhage and Anaemia without Blood Transfusion in Obstetrics and Gynaecology. Hospital Information Services Jan.2002 CodeofPracticefortheSurgicalManagementofJehovah'sWitnesses.Royal CollegeofSurgeonsofEngland2002 Developing a Blood Conservation Care Plan for Jehovahs Witness Patients with Malignant Disease. UK Blood Transfusion and Tissue Transplantation th Service.(Presented at 47 Annual Scientific Meeting of Royal Society of Haematology)April2007
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GreentopGuidelineNo47BloodTransfusioninObstetricsRoyalCollegeof ObstetriciansandGynaecologists2008 www.transfusionguidelines.org.uk/docs/pdfs/bbt03 carries Care Plans for patients refusing blood transfusion who are Women in Labour or are being treated for Malignant Disease. It also provides guidelines on Use of Cell Salvageinsuchpatients.

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RECORDOFREFUSALOFSPECIFICTREATMENT TRANSFUSIONOFBLOODANDBLOODCOMPONENTS SHOULDBEPLACEDINSIDETHECOVEROFTHE PATIENTSNOTES

1. PRINTFULLNAME_____________________

DATEOFBIRTH_______________________

Thisdocumentsupersedesanyprior healthcareadvancedirectiveor decisionwith regardtotransfusionof bloodandbloodproducts andshalltakeeffect immediately and remain in force, including on my incapacity, until specifically revoked in writing byme. 2. Iabsolutelyrefuseallogeneicblood(anotherpersonsblood)theprimaryblood components red cells, white cells, platelets and plasma under any and all circumstancesnomatterwhattheconsequences(includingmydeath).Ialso refusetopredonateanyofmybloodforstorageandlaterreinfusion. Iwillacceptalternativenonbloodmedicalmanagementtobuilduporconserve myownblood,toavoidorminimisebloodloss,toreplacelostcirculatingvolume,or tostopfurtherbleeding. Volume expanders such as saline modified fluid gelatine, dextran, starch solutions andperfluorochemicalsareacceptabletome. Othermedicalproducts:(initialonechoicebelow) Irefuseallfractionsderivedfromanyprimarycomponentofblood Iacceptallfractionsderivedfromanycomponentofblood Myinstructionsregardingmedicalproductsareasfollows:

3.

4.

5.

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6.

Medicalproceduresinvolvingmyownblood:(initialonechoicebelow) Irefuseanyprocedureinvolvingtheuseofmyownbloodduringanoperationor othertreatment Iacceptanyprocedureinvolvingtheuseofmyownbloodduringanoperationor othertreatment

Myinstructionsforproceduresinvolvingtheuseofmyownbloodareasfollows:

7.

I understand the importance of this document and verify that it reflects my personal choice. I have been informed of alternative treatments and of their limitations. I appreciate that complying with this request may cause me serious adverse consequences. I accept full responsibility for this decision andreleaseallthosetreatingmefromanyliabilityforconsequencesresulting fromsuchrefusal.

SIGNED:_________________________________________ DATE:______________________

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NUHTRANSFUSIONPOLICYAPPENDIX8 1 POLICYFORTHEUSEOFINTRAOPERATIVECELLSALVAGE 1.1 Indications

Surgery in a clean operative field, when the anticipated blood loss is greater than 20% of blood volume or approximately one litre in an adult. For example the technique is widely used during cardiac surgery, noninfected major joint revision arthroplasty,scoliosissurgery,aorticsurgery,majorurologicalsurgeryandtrauma. 1.2 Contraindications

Patientdeclinestheprocedure. Contaminationofthesurgicalfieldwithfaeces,urineoramnioticfluid. Thepresenceofinfectionintheoperativefield. The presence in the operative field of malignant tumours with the potential for metastaticspread. Patientswithsicklecelldisease,traitandotherredcelldisorders. Someof thesecontraindicationsarerelative.Forexample, theuseof cellsalvagein thepresenceoftumourswiththepotentialformetastaticspreadremainscontroversial. Intraoperative cell salvage is routinely used in major urological surgery such as cystectomyandradicalprostatectomywherethetumourisenclosedwithintheorgan being removed. Cell salvage has been used successfully during obstetric surgery. Theremaybesituationswherethepotentialbenefitoutweighstheunquantifiablerisk i.e. the lack of allogeneic blood is life threatening. If blood is salvaged in these situationsitshouldbereinfusedthroughaleucocytedepletionfilter. AVOIDcollectingagentsnotintendedforparenteraluse,e.g.betadine/chlorhexidine, hydrogen peroxide, alcohol, distilled water, some antibiotics,fibrin adhesives, topical clottingagents(collagen,thrombin),bonecement. Duringsurgerythisproblemcanbeminimisedbyusingtwosetsofsuctionapparatus, one to the cell salvage collection reservoir and the other to unsterile collection for disposal,andbyensuringthatthesurgicalfieldisirrigatedwellwithnormalsalineora balancedsaltsolutionbeforerecommencingcollectionforcellsalvage.

1.3ConditionsforUse Useofcellsalvageshouldbediscussedwiththepatientinadvance(whenpossible) andthisshouldbedocumented.


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If used in cancer surgery the patient must be informed of the potential risks and benefitsof cellsalvageand, whereavailable writteninformationshouldbesupplied tothem. Thecellsalvageoperator must benamedandmust havereceivedspecifictraining andbenamedonatheatreregisteroftrainedoperators. Theresponsiblemedicalofficermustbenamedforeachindividualcaseandshould befamiliarwiththeclinicalaspectsofcellsalvage. Theequipmentmustbeusedinaccordancewiththemanufacturersinstructionsand salvaged blood packs must be clearly labelled with the patients name, hospital number,dateofbirthandausebytime. Beware dilutional coagulopathy and anaemia with large volume losses. Measure haematocrit/haemoglobin/coagulationprofileduringtheprocedure. An audit form should be completed for each individual case, even when blood is collectedbutnotprocessed. ProcedureforBloodSalvageintheEmergencyDepartment

2.

2.1 Indicationsforbloodsalvage: Bloodlossdirectlyfromchestdraintubeindrainageofhaemothorax. Blood loss from chest drain bottle (only when disconnected from chest drain tube first,andwithnormalsalineunderwaterseal.) Bloodlossfromsurgicalfieldduringemergencydepartmentthoracotomy. Blood loss from surgical field during emergency department surgery for any catastrophichaemorrhagewherebloodissalvageable.

2.2 Contraindicationtobloodsalvage Contaminationofthesalvagefield,particularlyifhaemorrhageisnotlifethreatening. Blood salvage may be initiated in the emergency department where collection reservoirsystemsareavailable. Processing of salvaged blood and subsequent reinfusion would in most circumstancestakeplaceintheoperatingdepartmentorintensivecareunit.
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2.3 Conditionsforuseofbloodsalvage Healthcareprofessionalssettingupcollectionforbloodsalvagemustbetrainedand competent according to the knowledge and performance criteria set out in national occupationalstandards. Allmedicalstaffinvolvedinpatientmanagementshouldbemadeawarethatblood salvageistakingplace. The collection reservoir must be clearly and securely labelled with a patient identificationlabelandthetimeofcommencementofbloodsalvagerecorded. Asickletestshouldberequestedifappropriateforthepatientsethnicoriginpriorto reinfusionofsalvagedbloodwhichmustnotbetransfusedifpositive. Thecollectionreservoirshouldaccompanythepatienttotheoperatingdepartmentor ICUideallyremainingwiththepatientatalltimes. If a significant delay in transfer to theatre is anticipated or nonoperative management is planned, the theatre coordinator should be contacted to arrange processing of the blood in the emergency department or intensive care unit by a trainedcompetentequipmentoperatornamedonthelocalregister. Salvaged blood volumes of less than 500mls are not cost effective to process. In specialcircumstancesprocessingmaybeindicatede.g.JehovahsWitness. Transfusionof processedbloodisalwaysamedicalresponsibility.Theautologous bloodmustbeprescribedbymedicalstaff. Anaudit/recordformmustbecompleted.

TheUseofIntraOperativeCellSalvageinObstetricSurgery

3.1 IndicationsforCellSalvageinObstetricsurgery: Actual or anticipated major haemorrhage during caesarean section e.g. placenta praeviawithriskfactorsfor placentaaccreta(i.e.praeviainawoman whohas had previoussections). Caesareansectioninthepatientwithobjectionstodonorbloodtransfusion. Difficultyintheprovisionofcrossmatchedbloode.g.rarebloodtype.
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3.2 ContraindicationstoCellSalvage Thepresenceofinfectionintheoperativefield. Thepresenceofmalignanttumoursintheoperativefield. Sicklecelldisease. Recoveryofbloodfromthevagina(potentialforbacterialcontaminationfromnormal residentbacteria Note: The use of cell salvage is a clinical decision and each case should be consideredindividually. In some situationsthebenefittothepatientmayoutweigh the risks of usual contraindications, particularly in situations of lifethreatening haemorrhage. 3.3 ConditionsofUseinObstetricSurgery

Whenever possible the use of cell salvage should be discussed with the patient in advanceandthisdiscussionshouldbedocumented. The responsible clinician must be familiar with the clinical aspects of cell salvage particularlyintheobstetricsituation. The cell salvage machine operator must be competent and named on the theatre registeroftrainedpersonnelandunderstandcellsalvageintheobstetricsituation. Aspiration of amniotic fluid into the cell salvage collection reservoir must be minimized. Blood recovery should not take place during removal of the amniotic fluid. Salvaged blood for reinfusion must be clearly labelled with the patients name, hospitalnumber,dateofbirthandausebytimeandmustbeprescribedbymedical staff,accordingtostandardoperatingprocedures. Salvagedcellsshouldbeinfusedwithinsixhoursofthecommencementofcollection accordingtostandardoperatingprocedures. When blood is infused, it should be through a leucocyte depletion filter in ordertominimizetheriskofinfusingfoetalcelldebris

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NUHTRANSFUSIONPOLICYAPPENDIX9 ProtocolforPostOpDrainBloodSalvage 1. Aim To provide safe and effective collection of wound drainage for autologous bloodtransfusionforallsuitableorthopaedicpatientsundergoingsurgery. To reduced risks to patients and reduce the use of donated blood from the bloodtransfusionservice 2. Criteria The use of autologous blood is at the discretion of the surgeon and anaesthetist Itistobeusedinpatientsundergoingelectiveorthopaedicandspinalsurgery. Patients must be consulted and give verbal consent before administration of autologousblood.Ideallythisshouldbeundertakenatpreadmissionclinicor beforethepatientgoestotheatre. All staff involved (theatre, recovery and ward staff) in the process of post operative autologous blood collection and transfusion, must have received appropriatetraining. 3. ContraIndications An autologous blood transfusion device should not be used for patients with abnormal renal or hepatic function, malignancy, infection or coagulation disorder,orhaemoglobinopathye.g.sicklecell. NoLocalanaesthetic,epinephrine,iodine,antibioticsoranyotherdrugshould be left in the wound. The wound must be washed with 0.9% saline before insertion of wound drain. If there is a possibility of drugs going outside the capsuleandbeingcollectedintothedrain,thenitmustnotbeused. 4.StaffResponsibilities To act in compliance with Codes of Conduct and Scope of Professional Practice. Attend training and be competent in the use of autologous blood transfusion devices.
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To provide information to patients preoperatively and act as patients advocate. Accuratelyrecordtimethedrainageclampisreleased.Documenttimesystem shouldbediscontinued. Monitoranddocumentwounddrainage. Recordvolumeofautologousbloodinfused. Monitor patients condition before, during and after the collection and transfusion of autologous blood and report any change in the patients conditiontomedicalstaff.Anyreactionshouldbetreatedasper homologous blood. 5. SpecificInstructions Undernocircumstancesshouldanybloodcollectedfromthepatientbestored inafridgebeforeuse

If the patient is undergoing bilateral knee or hip replacement, early anticipationoftransfusionafter250300mlmayberequire


6. Bibliography&References AmericanAssociationofBloodBanks(1997)Guidelinesforblood recovery andreinfusioninsurgeryandtrauma. BernardPlace(1998)TheTransfusionofBloodanditsProduct. 94(34) NursingTimes. BetterBloodTransfusionHSCDecember1998. BritishJournalofHaematology(2001)Guidelinesfortheclinicaluse of red celltransfusions,113,2431 MallettandBailey(2000)TheRoyalMarsdenNHSTrustManual of th ClinicalNursingProcedures5 Edition. RecordkeepingasperUKCC&HospitalGuidelines. nd Soloman,SchmidtandAdragna(1990)2 Edition.Human Anatomy and Physiology. Transfusion Medicine (1999): The administration of blood and blood componentsandthemanagementofthetransfusedpatient.

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NUHTRANSFUSIONPOLICYAPPENDIX10 EqualityImpactAssessmentReportOutline

1.

NameofPolicyorService TransfusionPolicy

2.

ResponsibleManager SimonParsons

3.

NameofPersonCompletingAssessment AntoniaKingaby

4.

DateEIACompleted 7January2010

5.

DescriptionandAimsofPolicy/Service(includingrelevancetoequalities) Thispolicyaimstopromoteandsupportsafeandeffectivetransfusionpracticewithin NottinghamUniversityHospitalsNHSTrustandthusprovideourpatientswithtimely andappropriatetransfusiontherapywhilstminimisingtheirexposuretothepotential hazards. Thepolicydetailsallstagesofthetransfusionprocess.

6. 7.

BriefSummaryofResearchandRelevantData MethodsandOutcomeofConsultation HospitalTransfusionCommittee HaematologyConsultantwithresponsibilityforBloodTransfusion BloodBankManagers TransfusionPractitioners Consultants from General and Vascular Surgery, Trauma & Orthopaedics, Anaesthetics,EmergencyDepartment,Medicine,Obs& Gynae and Intensive Care SeniorNurses TrustLegalAdvisers LocalJehovahsWitnessLiaisonCommittee ResultsofInitialScreening/FullEqualityImpactAssessment:
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8.

TransfusionPolicy Version4 August2011

EqualityGroup Age Gender Race SexualOrientation Religionorbelief

AssessmentofImpact NoImpactIdentified NoImpactIdentified NoImpactIdentified NoImpactIdentified HighpositiveImpact LownegativeImpact NoImpactIdentified NoImpactIdentified NoImpactIdentified NoImpactIdentified

Disability DignityandHumanRights WorkingPatterns SocialDeprivation 9.

Decisionsand/orRecommendations(includingsupportingrationale) Itisrecommendedthatthispolicydoesnotrequireafullequalityimpactassessment. The policy has clearly taken into account religious beliefs and made provision accordingly. The Human Rights Act Article 9: Freedom of thought, conscience and religion protects your right to have your own thoughts, beliefs and religion and to put your thoughtsandbeliefsintoaction. Unlessapersonwithinanyareasoftheabovestrandsofequalityhasanadvanced directiveinplace,staffwillproceedwithtreatmentaccordingtoindividualsneeds.

10.

EqualityActionPlan Notapplicable

11.

MonitoringandReviewArrangements Onceimplemented,thispolicyandassociateddocumentsshouldbereviewedinline with NUH guidelines.

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Appendix11 WeAreHereForYouPolicy

TheWeAreHerefor Youservicestandardshave been developedtogether withmore than1,000 staffandpatients. They can helpusto bemoreconsistentin what wedo and say to help people to feel cared for, safe and confident in their treatment. The standardsapplytohowwebehavenotonlywithpatientsandvisitors,butwithallofour colleaguestoo. Theyapplytoallofus,everyday,ineverythingthatwedo.Therefore,theirinclusionin PoliciesandTrustwideProceduresisessentialtoembedtheminourorganization. WeAreHereForYoustandardmissionstatement: This Trust is committed to providing the highest quality of care to our patients, so we can pledge to them that we are here for you. This Trust supports a patient centred culture of continuous improvement delivered by our staff. The Trust established the Values and Behaviours programme to enable Nottingham University Hospitals to continue to improve patient safety, outcomes and experiences. The set of twelve agreed values and behaviours explicitly describe to employees the required way of workingandbehaving,bothtopatientsandeachother,whichwouldenablepatientsto haveclearexpectationsastotheirexperienceofourservices.

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Appendix12 CERTIFICATIONOFEMPLOYEEAWARENESS
TransfusionPolicy DocumentTitle Version(number) 4 Version(date) 4August2011 IherebycertifythatIhave: Identified (by reference to the document control sheet of the above policy/ procedure)thestaffgroups withinmy areaofresponsibilitytowhomthispolicy/ procedureapplies. Madearrangementstoensurethatsuchmembersofstaffhavetheopportunityto beawareoftheexistenceofthisdocumentandhavethemeanstoaccess,read andunderstandit. Signature

Printname Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented).Thesuggestedlevelofcertificationis Clinicaldirectoratesgeneralmanager Nonclinicaldirectoratesdeputydirectororequivalent. The manager may, at their discretion, also require that subordinate levels of their directorate/departmentutilizethis form inasimilar way, butthis would always be an additional(notreplacement)action.

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