Document Name: Blood Transfusion User Guidehkbh.org.hk › doc › medical_procedure ›...
Transcript of Document Name: Blood Transfusion User Guidehkbh.org.hk › doc › medical_procedure ›...
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
1
Document Name:
[Blood Transfusion User Guide]
Document Owner: [GM]
Department: [Pathology Laboratory]
Next Review Date: [01.09.2018]
Last Review Date: [01.09.2016]
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
2
HONG KONG BAPTIST HOSPITAL
BLOOD TRANSFUSION USER GUIDE
Prepared by
Pathology Department
Hong Kong Baptist Hospital
Third Edition Sept 2016
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
3
Table of Contents
PREFACE P.4
INTRODUCTION P.5
1. BLOOD SAMPLING, LABELING & ADMINISTRATION P.5
2. REQUEST FOR WHOLE BLOOD / BLOOD COMPONENTS (PACKED CELLS AND BUFFY
COAT)
P.8
3. REQUEST FOR BLOOD COMPONENTS (PLATELET CONCENTRATES, FFP,
CRYOPRECEPITATES)
P.9
4. ABO / Rh(D) COMPATIBILITY & COMPATIBILITY TESTS (FULL CROSSMATCH, TYPE &
SCREEN)
P.9
5. WHOLE BLOOD / BLOOD COMPONENTS: STORAGE AND REQUEST REQUIREMENT,
DOSAGE, ADMINISTRATION AND INDICATIONS
P.10
6. ISSUE OF WHOLE BLOOD / BLOOD COMPONENTS P.20
7. WHOLE BLOOD / BLOOD COMPONENT ISSUE GUIDELINES P.20
8. ISSUE OF UNMATCHED BLOOD P.21
9. TRANSFUSION GUIDELINES TO SPECIAL CLINICAL SITUATIONS P.21
10. RETURN OF ISSUED WHOLE BLOOD OR BLOOD COMPONENTS P.22
11. TYPE & SCREEN OR BLOOD VALIDITY P.22
12. MANAGEMENT AND NOTIFICATION OF ADVERSE TRANSFUSION REACTIONS P.23
13. TRANSFUSION INCIDENT REPORTING P.23
14. AUTOLOGOUS TRANSFUSION (PRE-OPERATIVE BLOOD DEPOSIT) P.24
15. RESIDUAL INFECTIOUS RISK OF HOMOLOGOUS TRANSFUSION P.24
16. ROUTINE SURGICAL BLOOD ORDERING SCHEDULE P.25
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
4
PREFACE
This is the third edition of Blood Transfusion User Guide published by our department. It is my great honor
to have this opportunity to say a few words in the preface. Blood transfusion and blood banking certainly
play an important role in all subspecialties of medicine. Therefore, understanding the basic principle and
essential features of blood transfusion is crucial in providing good and holistic care of all patients. Patient
safety and efficiency of blood transfusion are certainly the traditional core elements in transfusion medicine.
Currently, patient blood management is a multidisciplinary approach to enhance appropriate use of all blood
components. In order to have good utilization of our blood bank service and to achieve the above goals, this
user guide serves as an important guideline to provide update information on most of the practical issues of
blood transfusion.
Special acknowledgement goes to Dr. Mak Yiu Kwong, clinical hematologist, who continuously gives a lot
of invaluable advices and updates to our blood transfusion service and also refines some of the details in our
current transfusion user guide. Moreover, I would like to thank our blood bank staff, especially Ms. Doris
Kwok, our blood bank in-charge, who has put great effort in managing our blood bank and facilitates an
efficient blood transfusion service. I sincerely hope that this user guide is helpful in your daily clinical
practice. Your valuable advices and comments are always welcome.
Dr. Lai Kin Chung Chris
Chairman, Blood Transfusion Committee
Pathology Department
Hong Kong Baptist Hospital
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
5
INTRODUCTION
Blood transfusion involves collecting blood from one person (a donor) and then transfuse to another (a recipient).
Blood transfusion is often needed to replace blood loss in major accidents, during major operations and after childbirth. It may
also be needed to treat other conditions when a patient is anaemic, or suffering for inherited forms of anaemia such as
thalassaemia
Blood transfusion using whole blood is not commonly used in Hong Kong. Instead, whole blood is firstly separated into its three
main components:
Red blood cells,
Plasma, and
Platelet concentrates.
Each component requires specific storage condition and is transfused to patients under different situations. Transfusion therapy
provides the optimal method of transfusing patients who require large amounts of a specific blood component and is associated
with lower risk of having adversed transfusion reactions.
Blood transfusion is a significant medical advancement. The ability to transfer blood components from one person to another has
saved countless lives. It is also a therapy that requires careful preparation and pretreatment testing to minimize the risks and
complications associated with the procedure.
The following information is an overview of blood transfusion, specifically the types of blood transfusions and the methods of
blood typing.
Blood banking, the process of specimen collecting, testing, processing, and storing blood for later use (transfusion), is a
cornerstone of emergency and surgical medicine and is dependent on the clinical laboratory for ensuring the safe use of whole
blood and its components.
1. BLOOD SAMPLING, LABELING & ADMINISTRATION
Blood Sampling
All transfusion recipients should be identified by his/her patient identification information:
A minimum of two patient identification information should be used (e.g. name , hospital number)
The patient should be positively identified by open-ended questions on full name, Hong Kong ID number, date of birth,
hospital number, and etc, from the identification wrist bracelet of the patient should be counter-checked. Never offer a
name and ask the patient if it is correct. If the patient is unconscious or who is incommunicable, this information should
be checked from the identification bracelet of the patient’s wrist or ask the patient’s family member to give
identification of the patient.
The procedure of Handheld Device (Please refer to P.35-P.49, Phlebotomy Manual 2016) have to be followed for
verifying the patient identity and labels printing.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
6
Labeling the Sample
Preferably 6 ml EDTA blood (not less than 3 ml).
The person who draws and labels the sample should sign on the Lab Order List (or any other request form) and will be
accountable for any sampling errors.
Patient identity should be verified independently by another clinical staff at bedside, and he or she would also sign on
the Lab Order List. This procedure must be carried out before the blood taking.
Before leaving the bedside, the specimen must be labeled with a Handheld Device printed or handwritten label
including patient’s names, Hospital number, and date and time taken.
Any corrections made on the Lab Order List or on the specimen labels should be counter-signed.
For infants aged below 4 months requesting blood for the first time, mother’s blood sample is also required.
(Occasionally, the infant may not be accompanied by his or her mother and the maternal blood sample may not be
available. The infant’s blood should be required for full cross-matching. If the infant’s blood cannot be taken then
select group “O” Rh(D) negative & anti-A/B haemolysin free blood component for the infant.) The maternal blood
sample and the accompanied form should also be properly labeled and signed. The mother’s name, ID number/
Hospital number, baby’s name and Hospital number should be noted on the baby’s Lab Order List. The Lab Order List
and all specimens should be sent to Blood Bank together.
The patient’s blood group, if known, should be entered through the computer request or on the CES for reference.
Cross-check demographic information on the specimen and the Lab Order List.
The blood sampling procedures should be completed as a single event before going to take samples from another
patient.
Blood Bank must not accept a crossmatch request showing discrepancy in the identification description between the
sample label and the Section Test List. Blood Bank staff should not make any corrections for this purpose.
Should there be a subsequent change in patients’ demographic data after computer registration, the ward staff should
cross-check the old and the updated information before the transfusion procedure.
Blood Administration and Monitoring Procedure
1 All whole blood and blood components should be transfused under the instruction of the ordering doctor)
2 Ward staff shall use suitable clean thermal box for whole blood / blood components collection and transportation. All whole
blood / blood components should properly handle to avoid damage and contamination from the environment.
2.1 The thermal box is installed with a timer and should be started counting down from 20 minutes when the ward staff
picks up whole blood / blood components from Blood Bank. The ward staff should take action while it is buzzing.
3 Transfusion should start within 30 minutes of blood issued from Blood Bank and should be completed within 4 hours.
4 Transfusion of platelets or FFP should commence as soon as possible to preserve the maximum viability and activity of the
platelets and coagulation factors respectively.
5 All pre-transfusion checking procedures, include patient identity and the blood component label, must be performed
independently by two qualified ward staff and/ or doctors in front of the recipient before starting transfusion. At least one of
the ward staff should be a registered nurse or of a high rank.
6 Peripheral intravenous access: 18-20G size needles are recommended for adults and 22-24G or smaller needles are
recommended for paediatric patients.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
7
7 All whole blood and blood components including filtered components must be administered through a standard sterile,
pyrogen-free blood administration set.
8 No drugs should be added to or administered together with the blood or blood components.
9 The administration set should be changed after a maximum of 4 whole blood / packed cell units have been given, or every 12
hours, or when the flow rate becomes inadequate, whichever comes first.
9.1 A separate administration set should be used for platelet conc., and should be started immediately after been issued
from Blood Bank.
10 Always begin platelet transfusion with a new administration set. Transfusion of platelets should be started immediately after
been issued from the Blood Bank and should normally be completed within 30 minutes.
11 Discard administration set once transfusion is completed.
12 Blood warming: Patient receiving blood at a normal rate does not routinely require warmed blood. However, warmed blood
may be necessary in special circumstances such as rapid massive transfusion, exchange transfusion in neonates and severe
cold haemagglutinin disease.
12.1 Blood warming should be accomplished by a blood warmer whereby the blood is warmed to body temperature during
its passage through the transfusion set.
12.2 The blood warmer must be equipped with a visible temperature measuring device and audible warning alarm to alert
the user of malfunctions. It must be operated and maintained according to the manufacturer’s instructions.
12.3 Do not warm blood in water bath or hot water or any uncontrolled heat source. Overheating (>40oC) will cause
haemolysis.
12.4 A unit of blood shall not be attached to a blood warming device for more than four hours.
13 Monitoring of patients during transfusion
13.1 The patient shall be observed for potential adverse reactions during transfusion and for an appropriate time interval
thereafter.
13.2 As a minimum requirement, measure and record the vital signs (BP, pulse rate, and temperature) before the start of
each unit of whole blood / packed cells and at 15 minutes after the start as well as at the end of each whole blood or
packed cells unit.
13.3 For platelet concentrates, fresh frozen plasma and cryoprecipitates transfusion, the transfusion time is usually much
shorter. As a minimum requirement, measure and record the vital signs (BP, pulse rate, and temperature) before
starting, at 15 minutes and at the end of each transfusion episode of a batch of components.
13.4 Start the transfusion slowly (1 ml per minute), and observe for any reaction in the first 10 minutes of the transfusion.
13.5 Provided no adverse reaction occurs, the rate of transfusion can be increased as prescribed.
13.6 The patient should be observed periodically during the transfusion and for an appropriate time period thereafter for
potential adverse reactions.
13.7 Measure the patient’s vital signs when symptoms of a transfusion reaction are suspected. In some circumstances, you
may need to measure the respiratory rate.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
8
13.8 Advice the patient to report any symptoms and signs of transfusion reaction, e.g. fever, chills, skin rash, shortness of
breath, hypotension, shock, and chest discomfort and back pain.
13.9 Unconscious and paediatric patients require more vigilance when monitoring the signs of transfusion reactions,
14 Discontinue the transfusion in case of any untoward reactions and keep the I.V line patent with saline drip. Report the
incident to the attending physician and Blood Bank immediately.
15 Upon completion of transfusion, the empty or partially transfused blood bags should be kept for a period of 24 hours so that
they would be available for investigation of transfusion reaction if necessary. The blood bags are then disposed according to
infection control policies.
16 There must be a complete record for each unit of whole blood / blood component transfused indicating the recipient’s
identity, blood type, donor unit Whole Blood Number (WBN), date and time of start and finish of transfusion and outcome.
Record the volume transfused according to the reference volume started on the blood bag label.
2. REQUEST FOR WHOLE BLOOD / BLOOD COMPONENTS (PACKED CELLS AND BUFFY
COAT)
Blood samples required for crossmatch: 1 x 6 ml PINK capped plastic bottle or 2 x 3.0 ml PURPLE capped plastic bottle
Blood samples once collected should be sent to Blood Bank as soon as possible.
Blood Bank always keeps a reasonably sufficient stock of packed cells to meet the physicians’ requirement on a
first-come-first-served basis. However, the packed cells stock supply level depends on the stock condition of the Hong
Kong Red Cross Blood Transfusion Service (HKRCBTS).
Other blood components, subjected to the prior arrangement with the HKRCBTS. Those requests should reach Blood Bank
before noon on weekdays and the ward will be informed when they are available. Late requests would cause delay in
transfusion.
These components are:
Buffy coat
Washed red cells
Irradiated whole blood / cellular blood components
Leukocyte depleted (reduced) red cells by filtration
CMV negative blood
Fresh whole blood (less than 5 days old) or Reconstituted whole blood for neonatal exchange transfusion
Mini-packs of red cells from a single donor for neonatal transfusion
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
9
3. REQUEST FOR BLOOD COMPONENTS (PLATELET CONCENTRATES, FFP,
CRYOPRECEPITATES)
Patient’s blood sample for blood grouping is required if his/her blood group is unknown.
FFP, once available, as requested by ward staff, can be thawed (normally takes 30 minutes) and then issued. Once
thawed, FFP is not returnable and should be transfused within 24 hours.
With sufficient laboratory data and clinical information for each individual requisition for platelet concentrates and
cryoprecipitates, Blood Bank will arrange with the HKRCBTS for the required units. Subject to the approval from
the HKRCBTS, Blood Bank will inform the ward for availability of the units.
4. ABO / Rh(D) COMPATIBILITY & COMPATIBILITY TESTS (FULL CROSSMATCH AND
TYPE & SCREEN)
ABO
Compatibility
Donor’s Blood Group
Patient’s Group Whole blood Red cells / Buffy coat FFP Platelet / Cryo-ppt
A A A, O A, AB A, AB, B, O
B B B, O B, AB B, AB, A, O
O O O O, A, B, AB O, A, B, AB
AB AB AB, A, B, O AB AB, A, B, O
Unknown Not recommended O AB AB, A, B, O
For platelet or cryoprecipitates transfusion:
Identical ABO blood group is NOT essential in adults, but avoid units with high titre immune anti-A and /
or anti-B if ABO- compatible units are used.
Infant (< 1 year of age) should receive ABO plasma compatible platelet concentrates and other blood
components.
Patient with documented platelet refractoriness should receive ABO identical platelet if available.
Patient with PNH (Paroxysmal nocturnal haemoglobinuria) should receive ABO identical blood units.
For Rh (D) compatibility, refer to “ Indications” column for Rh (D) negative blood in Section 5. (Whole blood / blood
Components’ storage and request requirement, dosage, administration and indications).
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
10
Full crossmatch
Only the “major” cross-match between the patient’s plasma/serum and the donor red cells is required. The function of
the cross-match is to prevent incompatibility. This is most serious when there is ABO incompatibility. Methods that
demonstrate ABO incompatibility and other clinically significant antibodies should be used.
Type and Screen (T&S) Type and Screen is a procedure in which the patient’s blood sample is tested for ABO, Rh, and clinical significant RBC
antibodies, then stored in the computer database for immediate crossmatch. Particular units are not reserved for
individual patients. If transfusion is required, ABO- and Rh-compatible blood units can be safely released after an
immediate-spin method. However, if the antibody screen is positive, antibody identification and full crossmatch will be
done and compatible blood units will be reserved for that particular patient.
5. WHOLE BLOOD / BLOOD COMPONENTS: STORAGE AND REQUEST REQUIREMENT,
DOSAGE, ADMINISTRATION AND INDICATIONS Generally, all non-urgent components request in the morning, such as Platelet Concentrate, Cryoprecipitate or Leucocyte-
reduced Red Cells etc. would be ready by 15:30 in the afternoon during the weekdays. Once they are ready ward staff will be
informed.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
11
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
1
Whole blood / Packed
cells
--Stored at 2-6oC in
monitored refrigerator
--Approx. vol.:
-whole blood:
370-510mL
-packed cells:
220-340mL
--Specimen:
needed for
crossmatch or
Type & Screen
--One standard unit of
whole blood or packed
cells should raise Hb level
by about 1.2g/dL in a
70kg adult.
--Small units are about
70% of large unit. One
small unit should raise Hb
level by about 0.85g/dL
in a 70kg adult.
--For children, 4ml/kg
should raise Hb level by
1g/dL
--Due to the risk of
bacterial proliferation at
room temperature, blood
transfusion must be
started within 30 minutes
of removing the blood
pack from refrigeration
and should normally be
completed within 4 hours.
1. Acute blood loss > 750mL (15% of
blood volume)
Paediatric patient: 10-15mL/kg.
2. Acute blood loss and at least one of the
following:
Loss of > 15% patient blood volume
Hb < 8g/dL
Blood pressure decreases by > 20% or is
< 90 mm Hg systolic
Clinical evidence of inadequate oxygen
carrying capacity.
3. Haemoglobin <8g/dL (haematocrit
>0.24) if not due to a treatable cause.
4. Patient receiving general anaesthesia
Preoperative Hb <8g/dL
Major blood letting operation and with
Hb <10g/dL (haematocrit < 0.3)
5. Cooley’s anaemia or thalassemia major
Notes:
Patients with asymptomatic stable
chronic anaemia, red cell replacement
therapy is not necessary, treat the
underlying cause.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
12
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
2 Fresh whole blood
(≤ 5 days from
donation)
--stored at 2-6oC, in
monitored refrigerator
--Approx. vol.:
370-510mL
--Specimen:
needed for
crossmatch or
Type & Screen
--Require prior
arrangement with
HKRCBTS
--1-2 units
-- Due to the risk of
bacterial proliferation at
room temperature, blood
transfusion must be
started within 30 minutes
of removing the blood
pack from refrigeration
and should normally be
completed within 4 hours.
1. Neonates with massive blood loss or
requiring exchange transfusion.
(Avoid transfuse RBC in additive)
2. Infant or small child scheduled for open
heart surgery.
3 Reconstituted whole
blood (leukoreduced
red blood cells plus
fresh frozen plasma)
--stored at 2-6oC, in
monitored refrigerator
--Specimen:
needed for
crossmatch or
Type & Screen
--Require prior
arrangement with
HKRCBTS
Transfuse within 24 hr of
preparation
1. When the rare phenotype (e.g.,
D-negative) fresh whole blood is not
available for neonatal exchange
transfusion.
4 Mini-pack red cells
--stored at 2-6oC, in
monitored refrigerator
--Approx. vol.:
50-100mL
--Specimen:
needed for
crossmatch or
Type & Screen
According to clinical
indication
-- Due to the risk of
bacterial proliferation at
room temperature, blood
transfusion must be
started within 30 minutes
of removing the blood
pack from refrigeration
and should normally be
completed within 4 hours.
Patients less than 4 months of age:
1. Venous Hb <13 g/dL in neonates <24 hrs
old
2. Hb level <13 g/dL and severe pulmonary
disease, cyanotic heart disease or heart
failure
3. Acute blood loss >10% of total blood
volume
4. Removal of blood for laboratory testing
when the cumulative volume removed
exceeds 10% of the infant’s blood
volume within 1 week period and the
circulating Hb level is < 13 g/dL
5. Hb level <8 g/dL in stable new-born
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
13
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
infants with clinical manifestation of
anaemia.
5
Leukocyte reduced red
cells by filtration
(LRBF)
--Stored at 2-6oC in
monitored refrigerator
--Approx.vol: 300 ml
with <0.01X108 WBC
per unit
--Specimen
needed for
crossmatch or
Type & Screen
--Require prior
arrangement with
HKRCBTS
Refer to 1 above
-- Due to the risk of
bacterial proliferation at
room temperature, blood
transfusion must be
started within 30 minutes
of removing the blood
pack from refrigeration
and should normally be
completed within 4 hours.
1. History of > 2 episodes of febrile
non-haemolytic transfusion reaction.
2. Patients requiring chronic or regular
transfusion
3. Haematological disease
6 Rh(D) Negative blood
--Stored at 2-6oC, in
monitored refrigerator
--Approx. vol.:
see 1,2,3,4, above
--Specimen:
needed for
crossmatch or
Type & Screen
Refer to 1 above
-- Due to the risk of
bacterial proliferation at
room temperature, blood
transfusion must be
started within 30 minutes
of removing the blood
pack from refrigeration
and should normally be
completed within 4 hours.
Due to limited supply, RhD negative
blood have to be used in the following
priority:
i. Neonates with HDN caused by anti-D and
D-negative patients with anti-D present
MUST receive D-negative red cells.
ii. D-negative females prior to menopause
SHOULD receive D-negative blood.
iii. Other D-negative patients with no anti-D
and Chinese with unknown D status
MAY receive D-positive blood when
D-negative blood is in short supply.
D-negative females in their reproductive
age, if D-positive platelet concentrates or
FFP were given to them, they should
receive RhIg prophylaxis (250 i.u. for <
18 random donor platelet concentrates or
< 3 singe donor platelet concentrates or
50 i.u. per unit of FFP transfused).
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
14
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
7 Platelets concentrates
--Stored at 20-24oC
with constant agitation
--Approx. vol.:
50mL with >55x109
platelets per unit
** volume of single
donor platelet:
200-240mL with
310x109 platelet per
unit
--Specimen:
needed for blood
group checking
--Require prior
arrangement with
HKRCBTS
--1 unit / 10kg for
bleeding patient
--0.5-0.75 units / 10 kg
for prophylactic use
--1 unit (from 450mL
whole blood) should raise
platelet count by
7-10x109 / L., small unit
(from 350mL whole
blood): about 70% of the
above figure
--1 unit of apheresis
platelet concentrates is
equivalent to one standard
adult dose (for adults up
to 70 kg)
--Document platelet count
within 8 hours before and
at 1 hr after transfusion
for reference is suggested.
--Do not refrigerate,
transfuse immediately,
flush infusion set with
saline after platelet bag
empties
1. Prophylactic administration in patients
with platelet count <20x109 / L if
platelet is not due to accelerated platelet
destruction.
2. Patients with active bleeding or
scheduled for invasive procedure (e.g.
liver biopsy, lumbar puncture) with
platelet count <50X109 /L.
3. Patients undergoing major operative
procedure and their platelet count is
<70x109/ L.
4. Patient with platelet <100 x 109 / L
undergoing retinal or CNS surgery.
5. Patient with platelet < 100 x 109 / L and
active bleeding in post-cardiopulmonary
bypass.
6. Patients undergoing major operative
procedure and their bleeding time is > 13
minutes.
7. Patients massive transfusion with diffuse
microvascular bleeding and inadequate
time to obtain platelet count.
8. Platelet count < 50 x 109/ L for stable
premature neonate or < 100 x 109 / L for
sick premature neonates.
Notes:
Non-emergency platelet transfusion in
ITP, TTP, or HUS requires proper
haematology consultation.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
15
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
8 Fresh Frozen Plasma
(FFP)
--Stored at
< -30oC in monitored
freezer
--Approx.vol.
(refer to unit’s label)
--Specimen
needed for blood
group checking
--2-4 units of FFP (usual
starting dose is 12-15mL /
kg)
--Document PT / APTT
pre transfusion and post
transfusion within 4 hours
for reference is suggested.
--Maximum of 6 units
thawed at one time
--Transfuse within 24
hours after thawing in
Cytotherm-DR (never
under hot water tap).
Taking care to avoid
contaminating the bag’s
entry ports.
--The validity of FFP is
24 hours (Stored at 2 - 6
oC) after thawing
1. Patient’s PT or APTT >1.5 times mid
reference range with actively bleeding or
invasive procedures contemplated.
2. Patient’s specific factor deficiencies
where treatment with factor concentrates
or cryoprecipitates is not appropriate (i.e.
factors V, VII and XI).
3. Correction of warfarin overdose
inpatients who are bleeding and not
treatable with vitamin K.
4. Treatment of Thrombotic
Thrombocytopenic Purpura (TTP).
5. Management of acute DIC.
6. Clinical coagulopathy associated with:
a. Massive transfusion (> 10 units of
Blood in 24 hrs.):
FFP should be used only IF there is
Documented laboratory evidence of
Coagulopathy or clinical evidence of
diffuse microvascular bleeding.
b. Dilutional coagulopathy:
Patients resuscitated with large amount of
crystalloid/colloid solution usually have
prolonged PT/APTT not associated with
diffuse micro-vascular bleeding. These
patients should receive FFP only if there
is diffuse microvascular bleeding not
caused by thrombocytopenia.
7. Presence of post-operative or
micro-vascular bleeding after
cardiopulmonary bypass, with exclusion
of surgically correctable cause, platelet
dysfunction and residual heparin effect.
8. Hepatic Failure
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
16
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
9 Methylene blue treated
FFP
--Stored at
< -30oC in monitored
freezer
--Approx.vol.
(refer to unit’s label)
--Specimen
needed for blood
group checking
Same with the FFP 1. This component is targeted for clinical
transfusion in paediatric patient group
only.
2. Please note after treatment with
Methylene Blue, the MB PR-treated
plasma is tinted green colour.
3. MB-treated plasma should not be given to
patients with known allergies towards
MB
4. Extra caution should be exercised with
the use of MB PR-treated FFP in a known
G6PD deficient patient.
10 Cryoprecipitates
--Stored at < -30oC in
monitored freezer
--Approx. vol.:
10-30 ml with 80 i.u.
factor VIII and 210 mg
fibrinogen per unit
--Specimen
needed for blood
group checking
--Usual recommended
dose is 10 units
--Document fibrinogen
pre-transfusion and
post-transfusion for the
first indication.
--Transfuse within 6
hours after thawing in
Cytotherm-DR. Taking
care to avoid
contaminating the bag’s
entry ports.
--The validity of
cryoprecipitates is 6 hours
(Stored at 2 - 6 oC) after
thawing
1. Documented fibrinogen deficiency (<100
mg/dL) or dysfunction.
2. Haemophilia A if DDAVP or factor
concentrates is not appropriate.
3. Von Willebrand’s disease if DDAVP or
intermediate-purity Factor VIII
concentrates is inappropriate.
4. Uraemia bleeding with prolonged
bleeding time, unresponsive to DDAVP.
5. Factor XIII deficiency.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
17
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
11 CMV-seronegative
blood components
-stored at temperature
specific for the
components
--approx. vol.: see
specific components
--Specimen:
needed for
crossmatch or
Type & Screen
--Require prior
arrangement with
HKRCBTS
--Refer to relevant
components
1. For premature newborn less than 1 week
old, use fresh CMV negative blood (less
than 7 days old)
2. Low-birth-weight neonates (< 1200g)
born to seronegative mothers (or if the
status unknown).
3. Seronegative recipients of seronegative
donor bone marrow (allogenic BMT).
4. Seronegative recipients of seronegative
solid-organ transplant.
5. Patients severely immuno-deficient or
immuno-suppressed due to disease or
therapy.
Note:
If CMV negative red cells are not
available, use leukocyte-depleted red
cells by filtration to reduce risk of CMV
transmission.
Plasma components, particularly FFP,
have very low risk of CMV transmission.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
18
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
12 Irradiated blood
components (>25Gy
γirradiation)
--Stored at temperature
for specific
components.
--Specimen:
needed for
crossmatch or
Type & Screen
--Refer to
relevant
components.
-- Require prior
arrangement with
HKRCBTS
--Refer to relevant
components.
--Platelets/granulocytes
should be used with
minimal delay.
--Whole blood/packed
cells should be used
within 24 hr for neonatal
transfusion
--Irradiated whole blood
and packed cells should
be used within 14 days.
For prevention of transfusion-related
graft versus host disease in circumstances
such as:
1. Patients with severely suppressed cellular
immunity.
2. Post-bone marrow transplantation.
3. Foetus requiring intrauterine transfusion.
4. Transfusion from first-degree blood
relatives.
13 Washed red cells
--Stored at 2-6o C in
monitored refrigerator
--Approx. vol.: 200 ml
--Specimen
needed for
crossmatch or
Type & Screen
--Require prior
arrangement with
HKRCBTS
--Transfuse within 12 hr
of preparation
-- Due to the risk of
bacterial proliferation at
room temperature, blood
transfusion must be
started within 30 minutes
of removing the blood
pack from refrigeration
and should normally be
completed within 4 hours.
1. For IgA deficient recipients who may
develop anaphylaxis to transfused plasma
proteins.
2. Patients with PNH (Paroxysmal nocturnal
haemoglobinuria) do not use washed red
cells but use red cells of the same group
as the patient.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
19
Blood / components
(storage, approx. vol.)
Request
requirements
Dosage / administration Indications
14 Buffy coat
(Leucocytes)
--Stored at 20 – 24o C
WITHOUT agitation
--Approx.vol.:
50 ml with 2x109WBC
per unit
--Specimen
needed for
crossmatch or
Type & Screen
--Require prior
arrangement with
HKRCBTS
--Do not refrigerate
--Transfuse immediately
and slowly.
--Transfuse within 24
hours of preparation.
--Closely monitor patient
1. For documented severe neutrophil
dysfunction, neutropenia (<0.5×109/L) or
persistent infection not responding to
appropriate antimicrobial drugs.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
20
6. ISSUE OF WHOLE BLOOD / BLOOD COMPONENTS
Whole blood and blood components are issued when a transfusion is needed.
Check the crossmatch record from the Hospital Information System. A qualified staff brings along with the
Compatibility Report to Blood Bank in the Pathology Department to collect the required units. All the units will
not be re-used to other patients if the units have been taken out of the Blood Bank refrigerator for more than 30
minutes.
Platelet concentrates and buffy coat may be issued for emergency use before bacterial surveillance is completed.
Such unit will be labeled with a special tag. Blood Bank staff will inform the requesting physician for this
situation and send or fax the Blood Component Emergency Release Form to the physician. Physician should
observe the transfusion criteria and prescribe the minimal recommended dose. Recipient should be closely
monitored and all febrile reactions after platelet transfusion should be investigated.
7. WHOLE BLOOD / BLOOD COMPONENT ISSUE GUIDELINES
1. A competent lab staff is responsible for issuing the allocated unit(s) at Blood Bank
2. Cross-check data on Compatibility Report and whole blood / blood component’s label:
(Read aloud please!)
Patient Name
Hospital Number
Patient’s Blood Group
Donor unit’s Blood Group , DIN and Product Code
Donor unit’s expiry date
3. Check any abnormal finding: Clot / Haemolysis / Leakage
4. The Issue Log will be generated by lab staff in the TrakLab System.
5. Cross-check data on Issue Log as above. Do not issue the donor unit if
***WARNING: HOLD DATE IS EXPIRED***
***BLOOD ISSUE IS NOT ALLOWED***
is indicated on the Issue Log
6. Both Blood Bank staff and nursing staff should sign on the Issue Log.
7. Thermal box will be provided when necessary.
8. The thermal box is installed with a timer and should be started counting down from 20 minutes when the
nursing staff picks up whole blood / blood components from Blood Bank.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
21
8. ISSUE OF UNMATCHED BLOOD
Blood samples for crossmatch should be sent to Blood Bank as soon as possible.
The blood should be drawn into 1 x 6 ml PINK capped plastic bottle or 2 x 3.0 ml PURPLE capped plastic
bottle for blood grouping and antibody screening.
The clinician can ask the nursing staff to collect the blood by signing an authorization request form (Form
number: HPLD(MR)002-P19). A copy of the signed Unmatched Blood Transfusion Record must be sent to
Blood Bank for record.
Four units of group-specific unmatched blood can be issued, within 20 minutes upon receiving the patient’s
blood sample. The clinician will be informed by phone immediately as the issued unmatched unit found
incompatible at any stage of testing. Final Compatibility Report and antibody investigation results will be
released as ready.
Up to 4 units of group-O unmatched blood can be issued for patients with unknown blood group within 10
minutes under desperate situations. Routinely no group-O Rh (D) negative blood kept in hospital Blood Bank.
9. TRANSFUSION GUIDELINES TO SPECIAL CLINICAL SITUATIONS
A) Massive blood transfusion
1. Massive transfusion is arbitrarily defined as transfusion of a volume equivalent to the patient’s total blood
volume within 24 hours or transfusion of more than 6 units of blood (in an adult) within a 6-hour period.
2. The prime objectives are to restore blood volume and secure haemostasis.
3. Packed cells: Refer to Point 8. ISSUE OF UNMATCHED BLOOD, under urgent request for unmatched
but ABO and Rh(D) compatible blood. Always obtain a blood sample before transfusion and complete
pre-transfusion compatibility testing when time permits. It is advisable to use a micro-aggregate filter
and blood warmer when a large volume of blood is transfused within a short period of time.
4. Platelets: Aim to maintain platelet count > 50x 109/L.
5. FFP: Aim to maintain INR < 1.5 and APTT < 1.5 times of control value (i.e. 30 seconds). Allow for 30
minutes thawing time.
6. Cryoprecipitates: Replaces fibrinogen, aiming to maintain fibrinogen level > 100 mg/dL.
B) Autoimmune haemolytic anaemia [Direct Antiglobulin Test (DAT) result positive]
It is impossible to find compatible blood in patients with AIHA, the red cell autoantibodies interfere with
blood grouping, alloantibody detection and compatibility testing, and cause haemolysis of red cells.
1. Clinical indications for blood transfusion for autoimmune haemolytic anaemia include: incipient heart
failure, development of neurological signs, rapidly progressive anaemia and preparation for splenectomy.
Blood transfusion that is not strictly indicated on clinical grounds should be avoided.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
22
2. The autoantibody may mask the presence of red cell alloantibody which is capable of causing a
haemolytic transfusion reaction.
3. Serological investigations will be referred to Reference Laboratory of Hong Kong Red Cross Blood
Transfusion Service.
4. The strength of the DAT does not predict the severity of disease. For instance, some patients with a
strongly positive DAT may have mild hemolysis, while other patients with a weakly positive DAT may
have extensive hemolysis. Also, the strength of the DAT may not be changed after treatment, even though
the clinical condition greatly improves.
5. For patients with autoantibody that show broad red cell antigen specificity and lack of alloantibody,
transfusion of Rh phenotype-matched blood is preferable. These units are ‘incompatible but considered
suitable for transfusion.’ Patients with presence of alloantibody as well as autoantibody should receive
appropriately selected antigen negative units.
10. RETURN OF ISSUED WHOLE BLOOD OR BLOOD COMPONENTS
Whole Blood and Blood Components are issued only when there is a genuine transfusion needed. Any issued
but unused Whole Blood and Blood Components should be returned to Blood Bank and be avoided to keep in
an uncontrolled temperature storage. Responsible nursing staff should return the unused Whole Blood and
Blood Components to Blood Bank along with the Return of Blood/ Blood Components Form (Form Number:
HPLD(MR)004-N13 ).
Whole blood or Packed cells that have been taken out of the Blood Bank refrigerator for more than 30 minutes,
or that have been warmed to above 10oC or cooled below 1oC should not be re-issued for transfusion.
Platelets that have been stored in refrigerator should not be re-issued for transfusion.
FFP and cryoprecipitates that has been thawed after 24 hours and 6 hours respectively should not be re-issued
for transfusion. The thawed FFP or cryoprecipitate should be kept in 2-6˚ C refrigerator to maintain its upmost
functionality.
11. TYPE & SCREEN OR BLOOD VALIDITY
Routinely, cross-match or Type & Screen test is valid for 3 days unless there is a clear history that the patient
has not been previously transfused within 3 months or the patient is not pregnant. Otherwise, a second blood
sample should be collected for the compatibility testing. This is to reflect the current immunological status of
the patient , as recent transfusion or pregnancy may stimulate the production of alloantibody(ies).
1. Extension of reserved blood units is allowed and should be performed after 3 p.m. on the hold date of
expiry of the reserved blood units.
2. For the best benefit to the patient with negative antibody screen but with history of transfusion /
pregnancy within the past 3 months, a new specimen should be requested after 3 days.
3. If extension of Type & Screen test or blood reservation is required, Blood Bank staff must be informed
and the “Extension of Blood Reservation Request Form” (Form Number: HPLD/006v01/May11) is
necessary.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
23
12. MANAGEMENT AND NOTIFICATION OF ADVERSE TRANSFUSION
REACTIONS
1. Blood administration procedures should be strictly followed and every patient receiving blood transfusion
shall be monitored closely for development of any transfusion reaction during the entire administration
process.
2. The following signs and symptoms are of concern and can precede or accompany a major, life-threatening
reaction.
Fever Nausea Generalized Bleeding
Chills Flushing Haemoglobinuria / Oliguria
Chest Pain Dyspnoea Back Pain
Hypotension Shock Pain at Infusion Site
3. When symptoms and / or signs of adverse transfusion reactions occur, transfusion shall be withheld and
appropriate management of the patients should be initiated promptly.
3.1 Stop the transfusion immediately.
3.2 Keep IV line open with 0.9% normal saline using new administration set.
3.3 Monitor patient’s vital signs.
3.4 Perform clerical check at bedside immediately to verify the identity of the blood units with that of
the recipient. If there is any discrepancy noted, inform Blood Bank immediately.
3.5 The clinician should be informed immediately for assessment and management of the patient.
3.6 For the benefit to the patient, any minor transfusion reaction should be reported to Blood Bank with
the Transfusion Reaction Investigation Form (HPLD/MR001v02/Sep15).
3.7 For a major transfusion reaction, if the transfusion is discontinued, the residual blood units should be
returned to Blood Bank for appropriate investigations and documentation. Collect appropriate blood
and send to Blood Bank for further investigation if indicated:
Residual donor pack (or the empty bag if transfusion completed)
At least 3 ml EDTA blood (post-transfusion sample)
3.8 All transfusion reactions (major or minor) should be documented in the patient’s medical record and
reported to Blood Bank with Transfusion Reaction Investigation Form. Keep the second copy in the
patient’s medical record.
3.9 Continue to observe and monitor patient.
13. TRANSFUSION INCIDENT REPORTING
All adverse transfusion incidents should be recorded and reported to Blood Bank for registry. Each serious
incident must be reported in the “RiskMan” within 24 hours.
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
24
14. AUTOLOGOUS TRANSFUSION (PRE-OPERATIVE BLOOD DEPOSIT)
Red blood cells can be kept under refrigeration for 21 to 42 days. Patients undergoing elective surgery may
donate blood and reserve it for their own use in the 3 to 5 weeks' period prior to the scheduled operation date.
Arrange with HKRCBTS at least 6 weeks before the scheduled OT. A suitable patient may deposit 2 ~ 5 units
for one’s own use in the 5 weeks preceding surgery. A standard explanation form is available in Blood Bank
for reference.
15. RESIDUAL INFECTIOUS RISK OF HOMOLOGOUS TRANSFUSION
Infectious Agents Residual risk
HIV around 1 in 106
HTLV <1 in 106
HBV 0.5 - 1 in 105
HCV 0.5 - 1 in 105
CMV related complication avoidable if use CMV negative blood
Other virus unknown
Syphilis negligible
Other bacteria contamination rate: 1 in 104
major septic reaction < 1 in 105
Malaria <1 in 105
Other parasites Negligible
Classical CJD and new variant CJD Classical CJD is not considered a risk in blood while
nv CJD could be
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
25
16. ROUTINE SURGICAL BLOOD ORDERING SCHEDULE
(T&S = Type and Screen) (M-T&S = Mandatory Type and Screen)
General Surgery Units required
Adrenalectomy 2
Burst abdomen, Repair T&S
Cholecystectomy & exploration of CBD (open or laparoscopic) T&S
Choledochojejunostomy, sphincteroplasty T&S
Gastrectomy: Partial/Total M-T&S
Gastro-jejunostomy 0
Hepatectomy M-T&S
Ileostomy 0
Laparotomy, no diagnosis 2
Liver abscess, drainage 0
Mastectomy, simple T&S
Oesophagectomy M-T&S
Oesophago-gastrectomy M-T&S
Pancreatectomy: Partial/ Whipple’s Operation M-T&S
Pancreatic pseudocyst drainage 2
Pancreatico-duodenectomy 6
Skin graft T&S
Splenectomy M-T&S
Thyroidectomy (partial & total) T&S
Vagotomy +/- drainage T&S
Vascular Surgery
Aneurysm (Abdominal aortic, infra-renal aortic, peripheral vascular,
ruptured, thoracic / thoracic-abdominal)
M-T&S
Bypass (aorto-femoral, aorto-iliac) M-T&S
Bypass (axillo-femoral, bifemoral, femoro-popliteal) 2
Endarterectomy: Carotid /Femoral M-T&S
Embolectomy T&S
Renal artery graft M-T&S
Shunt V-P / V-A 0
Varicose vein stripping 0
Cardio-Thoracic Surgery
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
26
CABG M-T&S
Bronchoscopy – lung biopsy T&S
Decortication 3
Open pleural / lung biopsy T&S
Mediastinal Tumour Resection M-T&S
Mediastinoscopy T&S
Pleurodesis T&S
Pneumonectomy 3
Thoracotomy / lobectomy M-T&S
Valve Replacement M-T&S
Ventricular Septal Defect M-T&S
Head and Neck
Alveolar bone grafting with iliac crest or chin bone M-T&S
Cleft palate repair T&S
Head and neck reconstruction M-T&S
Glossectomy T&S
Laryngectomy / PLO M-T&S
Maxillectomy M-T&S
Neck dissection M-T&S
Odontogenic tumour, excision M-T&S
Osteotomy of facial bones for facial deformities
- genioplasty
T&S
- maxillar Le Fort osteotomy 4
- ramus osteotomy (sagital split or vertical subsigmoid osteotomy) 2
- segmental osteotomy (Wunderer, Schuchart or Hofer Osteotomy) 2
Parotidectomy T&S
Pharyngectomy 2
Reduction & fixation of facial bones fracture
(zygoma, maxilla and/or mandible)
T&S
Temporomandibular joint surgery T&S
Neurosurgery
Craniectomy M-T&S
Burr Hole M-T&S
Transphenoidal Operation M-T&S
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
27
Cervical Spine Surgery M-T&S
Paediatric Surgery
Cleft lip palate T&S
Hirschsprungs disease T&S
Hypospaddias reconstruction T&S
Intussusception T&S
Urology
Total Cystectomy + Urinary Diversion M-T&S
Cystoplasty M-T&S
Cystectomy & urethrectomy M-T&S
Cystolithotomy 0
Cystotomy 0
Hydrocele 0
Nephrectomy, Open M-T&S
Lithopaxy 0
Nephrolithomy, Open M-T&S
Nephrolithomy, percutaneous T&S
Optical urethrotomy 0
Orchidectomy 0
Prostatectomy: Open T&S
Prostatectomy: TURP T&S
Pyelolithotomy T&S
Pyeloplasty T&S
Radical Prostatectomy M-T&S
Renal transplantation 2
Renal transplantation, graft nephrectomy T&S
Renal transplantation, donor nephrectomy T&S
TUR bladder tumour T&S
Ureteral reimplantation or repair 2
Ureterolithotomy T&S
Urethroplasty 2
All maternity cases M-T&S
Gynaecological Surgery
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
28
Wertheim’s Operation M-T&S
Radical Hysterectomy + Staging M-T&S
Myomectomy T&S
Spine Operation
Laminectomy: Single level T&S
Multiple level + fusion 2
Spinal Fusion: Anterior/Posterior M-T&S
Hip Operation
THR M-T&S
AMA T&S
Cemented Thompson T&S
DHS T&S
Revision THR 4
Knee Operation
TKR M-T&S
Synovectomy T&S
Fusion T&S
Amputations
Above knee T&S
Below knee T&S
Micro-Reconstruction
Free flap 2
Vascularized bone graft 2
Replantation (digit, single) T&S
Brachial plexus repair (without vascular complication) 2
Trauma
Femoral fracture: AO Nail T&S
DHS / gamma nail T&S
Condylar T&S
AO screw T&S
Compound fractures 2
Tibial fractures: AOnail T&S
Pilon fracture T&S
Plateau fracture T&S
Open fracture 2
Complicated Fracture M-T&S
Pelvis & Acetabulum 4
Humeral fractures
Proximal T&S
Shaft T&S
Colo-Rectal Surgery
Hong Kong Baptist Hospital Blood Transfusion User Guide
This document is only current as at the date of printing.
Refer to electronic version in the System for Document Management for current version.
29
Anterior resection 2
Bowel resection: abdominal perineal 3
Colon resection 2
Colostomy 0
Colostomy closure 0
Haemorrhoidectomy 0
Rectum-pouch: resection / excision, etc. T&S
Rectopexy T&S
Investigative or biopsy
Procedures Units required
Cardiac catheterization +/- angioplasty T&S
Liver biopsy T&S
Renal biopsy T&S
Blood Bank Telephone: 2339 8929
Blood Bank Fax: 2339 8934
REFERENCES
American Association of Blood Bank Technical Manual. 17th edition
Transfusion Guideline for HA Hospitals 2013