Final FRCA Study Day Blood Transfusion Issues

1. Final FRCA Study Day Blood Transfusion Issues Mary P. Mc Nicholl Haemovigilance Practitioner 25th October 2013

2. Overview • How to respond in a timely & appropriate manner when a patient has a massive haemorrhage. • ABO incompatible transfusions. • Transfusion Reactions.

3. Background - MHP • Oct 2006 to Sep 2010 - 11 deaths & 83 incidents - patient harm relating to delays in provision of blood in acute situation (NPSA). • RRR issued by NPSA 21.10.10. • Approved by DHSSPS 18.11.10 - Circular Reference: HSC (SQSD) 16/10. • WHSCT Major Haemorrhage Protocol (MHP) active since May 2011.

5. Key Points • Local protocols with a trigger phrase. • Dedicated communicator with Blood Bank & Support Services (ie Porters). • Early / easy release of blood components from Blood Bank. • All cases reviewed by Hospital Transfusion Committee & delays/problems investigated locally / reported externally as required.

6. DEFINITION OF MAJOR BLOOD LOSS • Loss of one blood volume within a 24hr period • Normal adult blood volume approx 70ml/kg ideal body weight; 80-90ml/kg in children. • Loss of 50% blood volume within 3 hours. • Loss of blood at rate in excess of 150mls/minute.

7. Correction of low haemoglobin • Immediately – uncrossmatched group O negative • Group Specific – 15 minutes after accurately labelled sample delivered to Blood Bank • Crossmatched – 45 minutes after accurately labelled sample delivered to Blood Bank Accurately labelled sample required. Uncrossmatched Group O Negative blood available in Altnagelvin – Satellite Blood Fridge, Recovery Area, Theatres

8. Communication of Emergency • Clinical area must ensure Blood Bank aware of patient with haemorrhage ASAP. • Locally agreed & well understood trigger term:- • ‘I want to activate the Major Haemorrhage Protocol’ • Provide the following information: • Patient details. • Clinical situation. • Clinical area. • Urgency of Blood Components. • What Blood Components to be sent to Clinical Area. • Contact details (Name & Contact Number) of person nominated to be responsible for liaising with Blood Bank. Use term ‘In relation to Activation of Major Haemorrhage Protocol in A&E …’ for all subsequent calls to Blood Bank.

9. 2nd Phone Call when activating MHP • Contact Porters. • State ‘I have activated the Major Haemorrhage Protocol.’ • Inform Porter: • Clinical Area • Where to go (eg to Satellite Blood Fridge for uncrossmatched O negative blood; to clinical area to collect sample; to Blood Bank to collect units). Porter will remain between Clinical Area & Blood Bank until the MHP is deactivated.

10. Blood Bank Protocol on Activation • BMS will prepare:- • 6 units red cells (45 minutes from receipt of sample) • 4 units Fresh Frozen Plasma (takes 30 minutes to thaw) • Order 2 units Platelets from NIBTS, Belfast • Group specific blood (available 15 minutes after accurately labelled sample sent to Blood Bank) – safer than emergency O negative.

11. 213830 213830

12. Stand Down • At the point where emergency is perceived to be ended contact Blood Bank. • State‘I want to deactivate the Major Haemorrhage Protocol.’ • Blood Bank will then make contact with Porters.

13. Key Learning Points • Need for positive patient identification. • Need for accurately labelled samples. • Excellent communication required between Clinical Area/Blood Bank/Porters. • Know the WHSCT Major Haemorrhage Protocol…

14. Emergency Transfusions BBT3 states:- • Every effort must be made to monitor vital signs during emergency transfusions. • A list of all blood components / blood products transfused during the emergency should be recorded.

15. Uncrossmatched O negative units have no patient details. Prior to administering units: - - Confirm units are O Rh D negative. - Check expiry date and pack for leaks/ clumping. If uncrossmatched O negative unit used, remove this label & stick in the patient casenotes under current admission notes. Please ensure that accurate patient identification details are completed on the Blood Traceability Record as well as details, time & date that staff members remove, receive & administer the unit & then return to Blood Bank.

16. ABO incompatible transfusions

17. SHOT 2012 • Transfusions in UK remains very safe (2.9 million components issued in 2012, very few deaths*). • However, errors continue to put patients’ lives at risk, particularly from ABO incompatible transfusions. • 13 ABO incompatible transfusions. • 4 transfusions resulted in major morbidity (“Never Event”). *Risk of death: 1 in 322, 580 components issued; Risk of major morbidity 1 in 21,413 components issued. Risk of transfusion-transmitted infection much lower.

18. DoH ‘Never Events’ list 2011/12 • New addition – Death or serious harm as a result of the inadvertent transfusion of ABO-incompatible blood components

21. Transfusion Reactions

22. Transfusion Reactions • Most common is an Acute Transfusion Reaction (allergic, severe febrile or anaphylactic). • Acute Transfusion Reactions & Transfusion-Associated Circulatory Overload (TACO) carries highest risk for morbidity & death. • SHOT 2012 – 43% of reported cases of TACO resulted in death or major morbidity.

24. TACO Transfusion Associated Circulatory Overload • Any 4 of the following that occur within 6 hours of a transfusion:- • Acute respiratory distress • Tachycardia • Increased blood pressure • Acute or worsening pulmonary oedema • Evidence of positive fluid balance

26. If transfusion not going to be recommenced due to Suspected Transfusion Reaction, inform Blood Bank & complete relevant WHSCT Investigation of Moderate/Severe Transfusion Reaction Form. (BCSH, 2012)

27. Remember Importance of correct completion of all steps in the transfusion process, particularly the final check at the bedside, & not making assumptions about the safety of the steps prior to this (SHOT, 2012).

28. Advice & Enquiries Haemovigilance Practitioners, Altnagelvin Hospital 02871345171 Ext 213794 / 213793 Or Bleep 8434 Or Contact Blood Bank EXT 213830