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Lab Manual for Moffitt-Long and Mount Zion

Lab Manual for SFGH

Internal Resources

Transfusion Service/Blood Bank Procedures



  1. GENERAL INFORMATION

  1. Blood Bank Hours:

    Routine Service: Monday – Friday, 8 am - 5 pm.
    Emergency (STAT) Service: 24 hours/7 days.

  2. Telephone Number: 206-8584.

  3. Blood Bank Results (see section V, below)

  4. Transfusion Guidelines (see section VIII, below)

  5. Surgical blood order schedules (see section XIV, below)


  1. TEST CONSULTATION AND APPROVAL

All transfusion related problems or requests that deviate from the listed procedures must be approved by the Laboratory Medicine Resident:

Monday – Friday, 8 am through 5 pm (206-5689, pager (415) 443-0179.) At all other times contact the Blood Bank. They will contact the resident for you.



  1. SPECIMEN COLLECTION

A. Quantity:

1 full 10 mL pink top tube.


B. Identification:

The patient must be positively identified before collection of the blood sample. Check the identification band and ask the patient to state his/her name and birth date, i.e., “What is your name and birth date?” (Do not ask “Are you John/Jane Doe?”) If the patient is unable to respond, rely on the arm band identification.


C. Labeling:

At the bedside, before phlebotomy, label the tube with the following pieces of identification:


  • First and last name, or Trauma Name/Number

  • Hospital Medical Record Number

  • Date of Birth


The phlebotomist must date and initial each specimen. The phlebotomist is responsible for labeling the specimens correctly and signing his/her name on the top middle section of the requisition form in the “collected by” space.


CORD BLOOD:

Cord blood specimens must be labeled with the mother's name and hospital number, and clearly identified as cord blood.


**Inadequately Labeled Specimens Will Be Discarded - No Exceptions**


This policy is mandated by the United States Food and Drug Administration (FDA).


D. Transport:

  1. Routine - Blood samples may be transported to the Blood Bank via the messenger service, 206-8010.

  2. Emergency - Designate a responsible individual to carry the patient’s sample to the Blood Bank and return with the blood product(s).

  3. Blood samples may be sent through the pneumatic tube-system (tube station # 22).


E. Availability:

No blood will be crossmatched on specimens older than 3 days.


  1. REQUISITION

All requests for blood or blood products and all blood bank diagnostic tests should be submitted on the Blood Bank Requisition


A. Addressograph:

  • Required Patient identification Information:

  1. First and last name or trauma name/number

  2. Medical Record number

  3. Date of birth

  4. Account number

  5. Gender

  6. Ward

  7. Date

  8. ICD9 Code - Diagnostic information which establishes medical necessity.

The patient’s name and medical record number must match the specimen label.

  • Required Physician Identification

Include the physician's name, ID code number, and pager number. It may be necessary for the Blood Bank to contact the physician if there are problems.


B. Completion of Blood Bank Requisition:

  1. Emergency Requests:

Sign under “Responsibility Assumed By _______.” Call Blood Bank to release blood before completion of crossmatch. The signature of the ordering physician is mandated by the FDA.

  1. Test Requests:

Fill in diagnosis and indicate test requested.


Cord Blood Specimens:

  1. Requisitions must have both the mother’s and the newborn’s addressograph imprinted.

  2. Cord blood testing consists of determining the ABO group, Rh type and performing a direct antiglobulin test (DAT).

  3. Cord blood testing is automatically performed on all cord blood specimens drawn from the following mothers:

    1. Group O

    2. Rh negative

    3. No previous record

    4. Record of clinically significant antibodies

  4. All other cord bloods are refrigerated and stored for approximately one month in Blood Bank.

  1. Transfusion Requests:

    a. Indicate the transfusion/surgery date;

    b. Check the appropriate box if the patient has arranged for Autologous or Designated Donor transfusions;

    c. Indicate the product(s) requested and how many units of each will be required.

    Note: If the need for red cells is uncertain, request a Type & Screen (Indirect Coombs Test). If a red cell transfusion is necessary later, a crossmatch can be added on to the valid Type & Screen specimen, by request, within a 3 day window.


    BLOOD BANK REQUISITION

    Sample Requisition (Form # 5788120, Rev. 06/10)

    Blood Bank



    1. TEST RESULTS AND PRODUCT AVAILABILITY

    Results of pretransfusion testing, blood availability and usage and diagnostic studies are available in the LCR (“Lifetime Clinical Record”).

    The “Lifetime Clinical Record” is maintained by Hospital Information Systems (HIS). Contact CHN Help Desk, 206-5035, for a password and training in accessing and using the LCR.


    1. REQUEST FOR DELIVERY OF BLOOD

      A. Ordering:

      Telephone the Blood Bank and provide the following information:

      1. Patient’s first and last name or trauma name/number

      2. Hospital medical record number

      3. Ward or clinic

      4. Your name

      B. Transport:

      1. Routine: When you order blood products, the Blood Bank will arrange for delivery via the Messenger Service. When you receive the blood, record date/time and sign the Messenger Delivery Form.

      2. Emergency: In extreme emergencies, the responsible physician should designate a responsible person to transport the blood specimen to the Blood Bank, wait for uncrossmatched blood to be issued, and return with the units to the patient.

        NOTE: Anyone who comes to pick up ordered blood products from the Blood Bank window must identify in writing or print the name and medical record number of the patient for whom the blood product(s) is (are) intended. This safety check will be enforced at all times and under all circumstances, including emergency requests and massive transfusion.

      3. Returning unused blood: If blood is not transfused, it must be returned to the Blood Bank within 30 minutes of the time that it was issued.

        NOTE: Blood must be stored in a Blood Bank monitored refrigerator with an alarm. The only refrigerator outside the Blood Bank that is suitable for blood storage is located in the Operating Room area. Ward refrigerators are NOT suitable for blood storage.


      1. OTHER GENERAL POLICIES

      1. Transfusion of ABO Compatible Versus ABO Identical Red Cell Products:

        1. Group O packed red cells should only be used for group A, B, or AB recipients, if:

          1. ABO group specific blood is not available

          2. Recipient specimen is not available

          3. Patient is a neonate

        2. Before changing from group O to group specific blood, the infusion set MUST be changed.

        3. Rh negative blood may be administered to Rh positive patients.

      2. Elective Surgeries:

        1. Testing protocol: Ideally, specimens from patients who are scheduled for elective surgery the following day must reach the Blood Bank by 5 pm on the day preceeding surgery.

        2. Antibody screen positive: If an antibody is detected, blood may not be available at the time requested.

        3. Maximum Surgical Blood Order Schedule (MSBOS): Requests received by Blood Bank that are not in accordance with the MSBOS list (maximum authorized units of blood for elective surgery, see below ) must be approved by the Laboratory Medicine Resident .


      1. GUIDELINES FOR TRANSFUSION


      Following is a summary of SFGH Transfusion Guidelines for Pediatric and Adult Patients (SFGH Infant Care Center has Special Guidelines for Transfusion in Neonates & Young Infants). These guidelines are intended to provide a rational approach for common clinical conditions and situations. Special circumstances in individual patients may require exceptions or modifications. In these situations, and for other patient management questions involving blood product or coagulation factor use, the Clinical Hematology Service should be consulted (see Clinical Hematology Fellow on-call schedule). For transfusion guidelines in neonates and young infants, contact the Infant Care Center (206-8363).


      Summary Table: Transfusion Guidelines


      Blood Product

      INDICATION

      Appropriate

      Controversial

      Inappropriate

      Red Blood Cells (RBC)






      Therapeutic

      Hgb < 8 g/dL AND symptoms related to anemia OR acute bleeding likely resulting in symptomatic anemia


      Prophylactic (not bleeding)

      1. Hgb < 8 g/dL in patients at risk for symptomatic anemia.


      Maintaining hgb ≥ 10g/dL in “at-risk” patients (co-existing heart / lung disease, ischemic vascular disease).




      1. Stable, asympt-omatic anemia.


      2. Medically correctable anemia (e.g., deficiency in iron or Vit. B12 with mild symptoms responsive to temporary decrease in physical activity while the anemia is being corrected).


      Fresh Frozen Plasma

      (FFP)


























      1. Deficiency in multiple coagulation factors unresponsive to Vit. K, i.e., liver disease, multiple unit transfusion and/or DIC with INR ≥1.5 AND bleeding uncontrollable by local measures OR planned surgical or other significant invasive procedure, for example interventional radiology procedure.


      2. Bleeding or procedure in patients with congenital deficiencies of factors II, V, VII, X, XI or XIII.



      3. Correction of warfarin overdose. Note: in life-threatening bleeding Bebulin (Prothrombin Complex Concentrate) should be used (see SFGH protocol on warfarin overdose).


      4. Treatment of specific plasma factor deficiencies:

      a) awaiting plasma exchange in treatment of TTP,

      b) life-threatening hereditary angioedema due to C1-Esterase deficiency,



      c) Antithrombin (AT) III deficiency in patients who require but are refractory to heparin.

      Treatment / correction of:

      1. Bleeding in patients with INR < 1.5 (except massive transfusion).

      2. Minor invasive bedside procedures (thoracentesis, paracentesis, line placement) AND INR 1.5-2.0.

      2. Treatment of hypovolemia from capillary leak or massive loss of lymph fluid.

      3. Treatment of hepatorenal syndrome.



      Treatment / correction of:

      1. Hypovolemia, unless other intravascular volume expanders are ineffective or are contraindicated

      2. Prolonged INR in the absence of bleeding or planned invasive procedure

      3. Minimally prolonged INR (< 1.5) prior to bedside procedures

      4. Immunoglobulin deficiency

      5. Uremia and bleeding

      6. Correction of PT/PTT in patients undergoing angioplasty or other angiographic procedures where heparin is used.

      7. Heparin overdose

      Platelets














      Therapeutic

      1. Serious bleeding AND platelet count < 50K (< 100K in case of bleeding involving CNS, eyes, airway or severe trauma) OR congenital or aquired platelet dysfunction (for example myelodysplastic / myeloproliferative syndromes) OR medication interfering with platelet function (for example aspirin, anti-platelet agents).


      2. Life-threatening bleeding in DIC, ITP, HIT or TTP.


      Prophylactic (not bleeding)

      1. Platelet count < 10 K AND TTP, HIT ruled out


      2. Platelet count < 40- 50 K AND planned invasive procedure*


      3. Platelet count < 100 K AND CNS*, eye, airway surgery / procedures.


      1. Prophylactic platelet transfusion in patients with life-long platelet dysfunction or chronic decreased platelet production.


      2. Prophylactic platelet transfusion in patients with platelet counts from 10 to 20K due to temporary decreased marrow production (for example in the setting acute leukemia and/or chemotherapy).

      3. Treatment of bleeding or prophylaxis for blind invasive procedures with platelet counts from 50-100K.


      Patients with ITP, DIC, TTP and HIT, unless mandated by severe bleeding attributable to thrombocytopenia.

      Cryoprecipitate

      (Cryo)









      1. Treatment of bleeding:


      a) fibrinogen level < 100 mg/dL (DIC, liver disease, congenital deficiency, dysfibrinogenemia)


      b) von Willebrand’s disease or Hemophilia A (only when suitable coagulation factor preparations are not available).


      c) Factor XIII deficiency


      2. Prophylaxis:

      Perioperative or peripartum patients with congenital fibrinogen deficiencies.

      Bleeding in uremic patients after therapy with dialysis, DDAVP and estrogens has failed.

      1. Treatment of hemophilia A or von Willebrand’s Disease (vWD) when suitable clotting factor concentrates are available.

      2. Prophylaxis in patients with mild Hemophilia A or vWD.



      *Bone marrow aspirate & biopsy may be safely performed with platelet counts < 50 K/µL. Lumbar puncture is probably safe with a minimum platelet count of 10 K/µL in children [24,25] and 20 K/µL in adults [26]. Platelet counts < 50 K/µL are probably also adequate for other minimally to moderately invasive procedures (central & PICC line placements, paracentesis, thoracentesis), but this has not been well documented in the literature. The American Society for Clinical Oncology (ASCO) recommends a flexible threshold of 40-50K prior to surgery or invasive procedures, rather than a rigid threshold of 50K [27].

      References: [24]Howard SC et al. Jama 2002;288:2001-7, [25] Howard SC et al. Jama 2000;284:2222-4, [26] Vavricka SR et al. Ann Hematol 2003;82:570-3, [27] Schiffer et al. J Clin Oncol 2000;1519-1538.


      Abbreviations:

      DIC – Disseminated Intravascular Coagulation

      HIT – Heparin-Induced Thrombocytopenia

      ITP – Idiopathic Thrombocytopenia

      PICC – Peripherally Inserted Central Catheter

      TTP – Thrombotic Thrombocytopenic Purpura



      1. GENERAL INFORMATION REGARDING STANDARD BLOOD PRODUCTS AVAILABLE THROUGH THE BLOOD BANK


      1. Red blood cells


        1. Standard AS-1 units contain red cells in a nearly plasma-free anticogulant-preservative solution. Unit volume is approximately 350 mL, with a hematocrit of 50-60%. Shelf life is 6 weeks at 4-6°C.

        2. Units issued to neonates consist of red cells in CPDA-1 (citrate-phosphate-dextrose-adenine) anticoagulant-preservative solution in plasma. Hematocrit is approximately 80%. Red cell units for neonates are gamma irradiated to prevent transfusion associated graft versus host disease and are CMV seronegative.

        3. Expected response: in the absence of bleeding, one unit should raise the hgb in an average-sized adult by 1 g/dL and the hematocrit by 3%. In neonates with an estimated blood volume of approximately 250 mL, 10-15 mL CPDA-1 red cells can be expected to raise the hgb by 1 g/dL.


      2. Apheresis platelets (AP)

        1. Administration of Apheresis Platelets (AP):

        2. AP units contain approximately 250 mL platelets suspended in plasma.

        3. AP are infused by gravity through an administration set with incorporated filter, issued with the unit(s) from Blood Bank.

        4. A platelet count should be performed on a blood sample collected 10 min - 1 hour after each platelet transfusion to assess appropriateness of the platelet count increment (expected increase 30-60,000/mcL in a 70 kg adult).

        5. If continuously agitated, platelets can be stored at room temperature for 5 days. Do not store in any refrigerator.

        6. Compatibility testing is not necessary, and ABO-incompatible platelets can be used unless there is gross red blood cell contamination.

        7. In neonates, children, and adults receiving large volumes of platelets relative to their plasma volume, ABO compatible platelets are recommended to prevent hemolysis due to ABO antibodies in donor platelets.

        8. If the platelet count is > 20,000 mcL (20x109/L) or there has been no platelet count within the last 24 hours, release of platelets will need approval from the Laboratory Medicine Resident. Approval is not required for bleeding or preinvasive procedure for: (a) patients with platelet count below 50,000 mcL (50x109/L), (b) for neurosurgical or opthalmological procedure patients with platelet count below 100,000/mcL, or (c) during massive transfusions, or d) in DIC or uremic patients with platelet count below 75,000/mcL.

        9. For maximum effect, platelets intended to increase the platelet count prior to surgery or other invasive procedure should be ordered as close to the procedure as possible.

        10. It is essential to obtain a platelet count within 10 - 60 mins of platelet infusion to assess the effect of the transfusion. Counts more than 1 hour after platelet infusion are less informative.


      3. Fresh Frozen Plasma (FFP)


        1. One unit contains 200 – 250 mL of anticoagulated plasma with approximately 400-500 mg (~ 2.0 g/L) of fibrinogen. Each mL of plasma contains 0.7 – 1.0 activity unit of all other clotting factors.

        1. The Blood Bank will thaw FFP; this procedure takes 30 minutes.

        1. FFP should be administered as soon as possible after thawing but can be transfused up to 24 hours provided it has been maintained at 1 - 6°C.

        1. FFP will need approval from the Laboratory Medicine Resident if the PT and PTT are within 1.5 times the normal limits (INR < 1.5), or if no PT and PTT were determined in the last 24 hours.

          Exceptions:

          1. Patients with PT/PTT 1.0-1.5 times normal and significant bleeding ( ≥ 4 units in 24 hours) do not need approval.

          2. TTP patients


        2. Dose and Timing:

          1. The dose of FFP used should be adequate for replacement of coagulation factors. For example, an adult with liver disease will usually require 3 - 9 units (10-15 mL/kg body weight) of FFP to clinically significantly shorten the PT. One or two units accomplish little to correct the deficiency (Spector et al., 1966, NEJM 275:1032-7).

          2. For urgent reversal of warfarin anticoagulation, a lower FFP dose (5-8 mL/kg) may be sufficient (Amer. Soc. Anesthesiologists Task Force on Blood Component Therapy 1996, Anesthesiology 84:732-47), although full correction to an INR of 1.5 or less will usually require the full adult dose. In life-threatening bleeding situations related to warfarin overdose, treatment with a prothrombin complex concentrate (available from Pharmacy) should be considered.

          3. FFP should be administered at the time of bleeding or within an hour of the anticipated bleeding. The maximal effect of FFP declines 2-4 hours after transfusion (Spector et al. 1966, NEJM 275:1032-7).


        3. Monitoring:


            The patient should have a determination of PT/INR and/or PTT:

            • Immediately BEFORE

            • Immediately AFTER the transfusion of FFP


            Laboratory monitoring is necessary before and after each transfusion episode of FFP.


            • The clinical effect of FFP infusion should be monitored. Further FFP transfusion should not be given if bleeding does not decrease after the PT and PTT are corrected to less than 1.5 times normal, i.e., INR < 1.5, PTT < 48-55 secs. In this situation, urgent consultation with Clinical Hematology is advised.


        4. Risks


          1. Hepatitis, HIV (estimated risk in U.S. since 2005: approx. 1:2 million)

          2. Allergic reactions: Urticaria, and rarely, bronchospasm or systemic anaphylactic reaction.

          3. Fluid overload syndromes.

          4. Non-cardiogenic pulmonary edema; i.e., transfusion related acute lung injury (TRALI)


      4. Thawed Fresh Frozen Plasma

        Thawed FFP stored in the Blood Bank at 4-6°C for more than 24 hours will be relabeled Thawed Plasma and issued for up to 5 days after thawing. When available, Thawed Plasma will be issued for the same indications as FFP. The level of stable clotting factors remains the same as in FFP and labile factors V and VIII remain at 75-95% (FV) and 45-75% (FVIII) levels, respectively. Thawed plasma should not be used as sole source for FVIII replacement (Factor VIII concentrate, ordered from pharmacy, should be used instead).

      5. Cryoprecipitate

        1. One bag or unit (12–15 mL) contains approximately 80 units of Factor VIII: C (AHF) and 200 - 350 mg of fibrinogen. This product is usually available in pools of 5 units.

        2. Dosage:

          1. Von Willebrand’s disease (vWD): CRYO should only be used in vWD patients who do not respond to DDAVP and when vWD-containing FVIII concentrate is not available. The loading dose for CRYO is calculated from the desired versus actual patient VIII:C activity as described below. Repeat dose every 12-24 hours, monitoring F VIII:C levels.

            Dose Calculation

            If X% is the desired plasma F VIII:C level, the number of F VIII:C units to be given IV is X/2 per kg of body weight. Since the half-life of F VIII:C is approximately 12 hours, the maintenance dose is 1/2 the initial dose given every 12 hours. Example: To achieve 100% F VIII:C level in a 50 kg patient, (100/2) x 50 = 2500 units are given initially by IV, and 1250 units are given by IV every 12 hours thereafter. These guidelines assume pretreatment F VIII:C levels of 0%.

          2. Hemophilia A: Preferred treatment for Hemophilia A is DDAVP and/or Factor VIII concentrates. These products are available from the pharmacy at SFGH.

            CRYO should only be used for hemophilia in exceptional cases when F VIII products are not available. DDAVP may be more advantageous than Factor VIII Concentrate in mild & moderate hemophilia A.

          Suggested Target Levels for FVIII replacement:

          1. Minor bleeding (i.e., joints) - 30% F VIII:C with or without maintenance therapy.

          2. Major bleeding (i.e., intracranial, retroperitoneal, nervous system involvement, mouth or tongue, deep muscle, hematuria, major surgery) - 100% F VIII:C maintained between 50-100% for at least several days.

            Note: Hemophilia A patients presenting with bleeding usually have F VIII:C levels near 0%.

          3. Fibrinogen deficiency: For Fibrinogen levels < 100 mcg/dL and significant bleeding (or risk thereof) usual adult dose is 10 units of cryoprecipitate, or two pools of 5. This should raise the fibrinogen level by approximately 100 mcg/dL.

          Approval

          1. A Laboratory Medicine Resident must approve all requests, except when a bleeding patient has a fibrinogen level less than 100 mg/dL (1.0 g/L). Exception: No approval is required for patients with known a/dysfibrinogenemia, or for patients receiving streptokinase or TPA.

          2. Cryoprecipitate need not be ABO compatible.

          3. The Blood Bank will thaw cryoprecipitate (pool of 5); this procedure takes 30 minutes.

          4. Cryoprecipitates should be administered within four (4) hours of thawing, using the recipient set issued from the Blood Bank. Thawed cryoprecipitate must be discarded if it is not used within four (4) hours.

        3. Rho (D) Immune Globulin (Human) for intramuscular (i.m.) injection

          Indication: Prevention of maternal immunization to the Rho (D) Factor.

          The following criteria must be met:

          1. Antenatal: Administer at 28 weeks to Rho (D) and weak D (Du) negative mothers who have not been sensitized to Rho (D) antigen.

          2. Post partum: Administer within 72 hours of delivery, to Rho (D) and weak D (Du) negative mothers who deliver an Rho (D) positive baby.

          3. Administer within 72 hours to Rho (D) neg, weak D (Du) negative women who have an ectopic pregnancy, abortion, therapeutic or diagnostic procedure or trauma with the possibility of feto - maternal hemorrhage.


          NOTE: Rho (D) Immune Globulin should be ordered from the Blood Bank – not the Pharmacy – for the patients listed above.


        4. Special Coagulation Products

          Factor VIII and IX concentrates, prothrombin complex concentrates (PCC) and recombinant factor VIIa (rFVIIa) are not available from Blood Bank. Contact SFGH Pharmacy for availability and use guidelines


        1. BLOOD COMPONENTS REQUIRING SPECIAL PROCESSING


        Please note:

        • All first-time requests for special processing must be approved by the Laboratory Medicine Resident.

        • Orders for gamma irradiation, CMV seronegative, and washed units have to be filled by the blood supplier, which will delay availability.


        Exception: Red cell units for neonates are routinely issued gamma irradiated, CMV seronegative.


        A. Leukoreduction:


        1. Most red cell (usually > 90%) and all apheresis platelet units issued by SFGH Blood Bank are pre-storage leukocyte reduced.

        2. Leukoreduction is accomplished by special filters that reduce the WBC count per red cell or platelet unit to < 5x106 (plasma units contain < 104 WBC and therefore do not require filtration). Indications for leukoreduction are evolving and currently include prevention of:


          • Recurrent febrile transfusion reactions

          • Alloimmunization to HLA antigens in selected patients populations

          • CMV transmission in susceptible patients when CMV seronegative units are unavailable


        3. Leukoreduction can be achieved by pre-storage or bedside filtration. In virtually all circumstances, the Blood Bank will issue prestorage leukocyte reduced blood component when leukoreduced red blood cells or platelets are ordered. In case leukocyte reduction filters are issued from Blood Bank for bedside filtration, special filters must be used for red cell and apheresis platelet units; these filters are not interchangeable.


        B. Gamma irradiation:


        Gamma irradiation of whole blood, red cell and apheresis platelet units with 2.5 Gy renders lymphocytes incapable of proliferation. This treatment prevents transfusion associated graft-versus-host disease (TAGVHD) and is indicated for all cellular units (not plasma or cryo) when the transfusion recipient is at increased risk for TAGVHD as outlined in the table below:


        Table 1. Clinical Indications for Irradiated Products


        In Fetus/Infant

        • Intrauterine transfusion

        • Prematurity

        • Congenital immunodeficiency

        • Exchange transfusion for erythroblastosis


        In Child/Adult

        • Congenital immunodeficiency

        • Hematologic malignancy or solid tumor (neuroblastoma, sarcoma, Hodgkin's disease where ablative chemotherapy and/or radiotherapy is administered)

        • Peripheral blood stem cell or marrow transplant

        • Recipient of familial blood donation

        • Human leukocyte antigen-matched products

        • Lupus or any other condition requiring fludarabine


        Potential Indications

        • Recipient and donor pair from a genetically homogeneous population

        • Other patients with hematologic malignancy or solid tumor receiving immunosuppressive agents

        • Infant/Child with congenital heart disease with 22qll deletions, other than DiGeorge syndrome

        • Recipient and donor pair from genetically less homogeneous populations

        • Those receiving "less intensive" immunosuppressive regimens


        No/Limited Indications

        • Patients infected with HIV

        • Term infants

        • Obstetric, surgical, and general medicine patients


        Modified from: Luban, NLC and Wong, ECC. Irradiated Products. In: Blood Banking and Transfusion Medicine. Hillyer et al. (eds.) 2nd ed. 2007 (Elsevier), pp 397-409.


        C. CMV Seronegative (lacking antibodies to CMV):


        CMV seronegative units are indicated for CMV seronegative patients who are pregnant, prematurely born, or severely immunosuppressed in order to prevent CMV infection and disease.


        D. Washed Units:


        Washing of red cell or apheresis platelet units with saline removes plasma, which is indicated in rare cases of severe allergic reaction to plasma proteins or repeated severe febrile reactions that are not prevented by leukocyte reduction.

        NOTE: Irradiated, CMV seronegative and washed units must be specially ordered from the Blood Centers of the Pacific, resulting in a delay in availability of several hours.


        1. BLOOD ADMINISTRATION

        (for details see appropriate Nursing Blood Administration Policy)


        1. Order of Blood Unit Issuance



          When available, the Blood Bank will issue units in the following order for each patient (in each category, the oldest units will be issued first):

          1. Autologous unit

          2. Designated unit

          3. Regular volunteer unit.


        2. Pre-transfusion Checks


          1. Before beginning the transfusion, it is extremely important to correctly identify the patient and blood product. Two individuals; RNs and/or physicians must check the following information at the patient's bedside:

            • Check the patient’s identification arm band and ask the patient to state his/her name and birthdate (if responsive).

            • Verify that the first and last name of the patient and the patient's hospital number on the Unit Tag and the patient’s arm band are identical.

            • Compare the ABO, Rh type and donor number on the blood container label for identical information on the unit tag.

            • Check the expiration date of the blood.

            • Check for special requirements where applicable (i.e., leukoreduced, irradiated, CMV negative).

            • Verify unit as Autologous or Designated Donor by the presence of an extra tag attached to the unit. Autologous is identified by a bright green tag and the Designated Donor is identified by a bright orange tag.


            DO NOT BEGIN THE TRANSFUSION UNTIL ANY DISCREPANCIES HAVE BEEN RESOLVED.



          2. The checker (RN or MD) must sign his/her name on the first line of the requisition under "Identification Check."

          3. The transfusionist (RN or MD) must sign his/her name on the second line of the requisition under "Transfusionist."

          4. The signed form must be placed in the patient's chart.


        3. Infusion


          1. The recommended rate of infusion of one unit of red blood cells is 1 – 1/2 to 2 hours. The transfusion must be completed within 4 hours.

          2. Base line values for temperature, pulse, respiration, and blood pressure must be obtained and recorded in the patient's chart before beginning the transfusion. Infusion of red blood cells should be very slow (approximately 10–25 mL) for the first 15 minutes. The patient should be observed continuously during this time, and then at least after 15 minutes and every half hour to check that the transfusion is proceeding uneventfully. Vital signs must be recorded after 15 minutes, one hour and at the end of the transfusion (except in emergencies when rapid transfusion does not permit recording of vital signs at these time points), or when transfusion concludes before the one hour mark - in this case vital signs must still be recorded at the end of the transfusion.

          3. Administer blood through a filter with normal saline, or Plasmalyte 148. Other solutions may cause hemolysis and/or agglutination.

          4. Do not add medications to blood.


        1. TRANSFUSION REACTIONS

        Please report all transfusion reactions promptly on Blood Bank Transfusion Reaction Report Form F 934. The Joint Commission expects patient care staff to report suspected transfusion-related adverse events immediately to the Blood Bank/Transfusion Service, whether or not the MD repsonsible for the patient deems it necessary to report the event. Exceptions: per SFGH Nursing Blood Administration Policy 3.1, mild allergic reactions and transfusion-associated circulatory overload without other symptoms - such as fever - need not be reported.


        1. Types of Transfusion Reactions:


          1. When possible, before transfusing a patient, the physician should always inquire about a history of previous transfusions, pregnancies, allergies, and possible transfusion reactions. Transfusion reactions are defined as any adverse reaction to blood products. For practical purposes, they are divided into red cell, i.e., hemolytic, and non-hemolytic reactions.

          2. Hemolytic reactions are further divided into intravascular and extravascular reactions:

            1. Symptoms of intravascular (immediate) reactions include: burning along the IV site and arm, anxiety, dyspnea, tightness in the chest, back pain, fever, chills, shock and hemoglobinuria, and abnormal bleeding.

            2. Extravascular reactions may include fever and renal failure, but more commonly, these reactions are evidenced by unexplained post transfusion anemia and hyperbilirubinemia.


          3. Among the most commonly seen non-hemolytic transfusion reactions (~50% of total) is the fever-chill (antileukocyte) reaction, characterized by a sudden temperature rise > 1°C from pre-transfusion value AND oral temperature of ≥ 38.0°C, or chills, cold sensation and discomfort. Reactions typically manifest some time after starting a unit of blood and definitely within 2 hours of transfusion. A temperature rise occurring later than that is probably due to some other cause.

          4. Another commonly seen non-hemolytic reaction is the localized allergic reaction, evidenced by urticaria, pruritis and rarely, fever. It is caused by IgE-mediated hypersensitivity to plasma proteins. A severe systemic allergic reaction, i.e. anaphylaxis, may occur in IgA deficient patients.

          5. Other non-hemolytic reactions include: sepsis due to bacterial contamination of blood components, volume overload, and transfusion related acute lung injury (TRALI), an immune mediated acute respiratory distress syndrome

          6. Remember that incompatible I.V. solutions can cause transfusion reactions secondary to cell lysis or agglutination.


        2. Procedure for Suspected Transfusion Reactions:


          1. Stop the transfusion and check all labels, forms and patient identification to determine if the patient received the correct blood. If there is a concern that the patient received the wrong blood unit, Blood Bank must be notified immediately (see 5. below). In all cases of suspected transfusion reactions the responsible physician must be notified.

          2. Keep the line open with normal saline. If the patient has had previous mild allergic reactions, i.e., localized urticaria without breathing difficulties or hypotension, the physician may continue the transfusion. Antihistamines (benadryl) may be given P.O. or I.V. for symptomatic relief (not given through the transfusion line). If the patient has a mild febrile reaction, additional medication with an antipyretic may control it and allow continued transfusion after a hemolytic reaction has been ruled out. “Mild” febrile reactions may be defined as those without shaking chills and a rise in body temperature less than 2°C (< 3. 5°F), and no significant tachycardia ( < 120/min or rise < 40/min) or blood pressure changes ( < 30 mm Hg) from pre-transfusion values. Report all febrile reactions to the Blood Bank. Febrile reactions may (very rarely) be caused by bacterial sepsis from contaminated blood products. In this situation gram stain and culture of the blood bag is important (Blood Bank will direct the work-up).

          3. In reactions where respiratory symptoms dominate, volume overload and TRALI should be considered. The latter may respond to simply stopping or slowing down the transfusion, or may require I.V. diuretics. TRALI often requires ventilatory support; no other treatment has been shown to be effective. When respiratory distress and circulatory collapse are both present, especially immediately after blood product administration, anaphylaxis may be present and require emergent treatment. All reactions attributable to transfusion should be reported to Blood Bank for appropriate work-up and follow-up.

          4. Monitor the patient’s vital signs and urine output carefully. Start appropriate fluid and pressor therapy for the rare hemolytic or anaphylactic reactions. Intravenous corticosteroids may be considered to prevent worsening of acute reactions due to hemolysis or anaphylaxis. Heparin may have a role in managing acute DIC. Critical care, renal, hematology and blood bank physicians should be consulted as appropriate for advice on management of severe cases.

          5. Refer to the Transfusion Reaction Form obtained from the Nursing Station. Send the completed form with the following to the Blood Bank immediately:

            • One 10 mL labeled pink top tubes of patient's blood for repeat ABO-Rh testing, direct antiglobulin test, and to visually check for hemolysis.
            • The clamped blood container with any unused blood and attached administration set for retesting of ABO-Rh typing, inspection for hemolysis and culture, if indicated.
          6. Other tests such as haptoglobin and urine for hemosiderin should only be obtained if the clinical situation warrants them (red cell reaction) and there is difficulty in establishing the diagnosis. (Remember that haptoglobin is an acute phase reactant and will be elevated in stressed patients.)

          7. Document the findings on the patient’s chart.

          8. For possible red cell reactions and/or anaphylactic reactions, monitor vital signs and urine output frequently for at least 24 hours.

          9. The diagnosis of suspected extravascular (delayed) hemolytic reaction is made by suspecting the possibility, repeating hematocrits for up to 3 weeks post transfusion, checking bilirubin levels, and submitting new specimens to the Blood Bank to check the direct antiglobulin test (direct Coombs) and to attempt antibody identification.

          10. The Blood Bank Resident and Attending will review the case and prepare a report for the electronic medical record (LCR).


        1. BLOOD DONATIONS


        Blood donations may be made at Blood Centers of the Pacific, 270 Masonic Avenue, San Francisco, CA. For appointments, call: (415) 567–6400.


        1. Autologous Blood:

        Note: Autologous units with positive infectious disease markers, i.e., Hepatitis B Surface Antigen (HBsAg), anti- HIV antibody, anti-HCV, HIV, HBV DNA or RNA, HCV DNA or RNA, anti-HTLV, West Nile Virus, or Chagas Disease are not acceptable for transfusion at SFGH. The only exceptions are units positive for Hepatitis B Core antibody or Syphilis screening. If the infectious status of a patient is not clear, it is advisable to have him/her tested for these markers prior to autologous donation.


        PROCEDURE

        1. Obtain Blood Centers of the Pacific’s Special Donations requisition form from the SFGH Blood Bank.

        2. Fill in the form. INCLUDE THE PATIENT'S MEDICAL RECORD NO. (MRN) ON THE FORM.

        3. Prescribe 325 mg FeSO4 to be taken orally 3 times a day between meals.

        4. Start autologous donations at least a month pre-op if possible, to allow for red cell regeneration.

        5. Most patients can donate one unit per week.

        6. Have the patient take the form to Blood Centers of the Pacific. Instruct patient to call the Blood Center for a donation appointment: (415) 567–6400, ext. 500.


        A $300.00 charge per autologous unit is assessed by the blood center at the time of collection. Patients covered by MediCare, MediCal, Worker’s Compensation or General Assistance programs are exempted from prepayment.


        Autologous blood will be discarded at outdate (35 days after donation) unless the Blood Bank is notified (before outdate) of extended surgery date.


        If there is a confirmed surgery date, the autologous units may be frozen at Blood Centers of the Pacific for an additional $390.00 service charge per unit for freezing, storing and thawing.


        NOTE: Blood Centers of the Pacific will not freeze any unit designated as “biohazardous.”


        1. Designated Donor Blood:


        PROCEDURE

          Obtain Blood Centers of the Pacific’s Special Donations form from the SFGH Blood Bank.

        1. Fill the form in completely. INCLUDE THE PATIENT'S MEDICAL RECORD NUMBER (MRN) on the form.

        2. Give form to family member and instruct the designated donor(s) to telephone Blood Centers of the Pacific for a donation appointment (415) 567–6400, ext. 500.

        3. Draw a blood specimen from the patient and send it to SFGH Blood Bank (Room 2M6) for Type and Screen.

          There is an additional $100.00 charge for each component of designated blood collected whether or not the patient uses it.

          Designated donor blood will be automatically released for transfusion to other patients 35 days after collection, unless the Blood Bank is notified.

        4. Information concerning forms for autologous and designated donations can be obtained by calling the Blood Bank at 206–8584.



        1. MAXIMUM AUTHORIZED UNITS OF BLOOD FOR ELECTIVE SURGERY


        Authorized number of blood units or Blood Bank Process,i.e., Type and Antibody Screen (T&S), is expected to be sufficient for at least 90% of the specified elective surgical procedures.


        Procedures requiring only T&S or "zero" blood units in preparation for elective procedures do not routinely require discussion of blood donation options, as stipulated in Calfornia's Paul Gann Act, or informed consent for transfusion, as the expected need for blood administration is low (probability is less than 10%).


        The links below point you towards tables of specific procedures and their maximum authorized units.




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