FOREWORD This document has been produced by the Customer Service Patient Blood Management (PBM) Practitioner Team within NHS Blood and Transplant (NHSBT). It follows on from ‘A Drop of Knowledge – Guidance for New and Developing Transfusion Practitioners’ and contains information on more specialised areas of transfusion to help Transfusion Practitioners to develop a broader knowledge base. References and further information guide the reader to other documents and websites with greater detail. It is designed to be used in conjunction with ‘A Drop of Knowledge – Guidance for New and Developing Transfusion Practitioners’ where an “acronym and abbreviation buster” can be found. The authors have taken care to ensure the information contained in this document is accurate and up to date at the time of print; however we do not accept any legal responsibility for any errors or omissions . The content will be updated regularly. I would very much welcome your feedback on this document and would be grateful to hear from you if you have any comments or suggestions for future versions. Louise Sherliker Interim National Lead - Patient Blood Management Practitioner Team NHS Blood and Transplant Email: [email protected] Mobile: 07764 280247 ACKNOWLEDGEMENTS This document was originally produced by NHS Blood and Transplant Transfusion Liaison Team. We would very much like to acknowledge the following people who provided invaluable feedback on this document: Marina Cronin National Haemovigilance Officer, Irish Blood Transfusion Service Sandra Gray Effective Use of Blood Manager, Scottish National Blood Transfusion Service Joan Jones Manager Hospital Transfusion Practitioners, Welsh Blood Service Shirley Murray Regional Coordinator, Northern Ireland Blood Service Dr Sylvia Benjamin Consultant Haematologist, NHS Blood and Transplant, John Radcliffe Hospital Paul Sharples Hospital Liaison Manager, NHS Blood and Transplant Carol Blears Transfusion Practitioner, Dewsbury and District Hospital Leslie Delieu Transfusion Practitioner, Darent Valley Hospital Tanya Hawkins Transfusion Practitioner, Royal Berkshire Hospital Tina Leppard Transfusion Practitioner, Colchester General Hospital Rachel Moss Transfusion Practitioner, St Mary’s Hospital Jenny Rodger Transfusion Practitioner, Wrexham Maelor Hospital 2 CONTENTS 1. Blood components................................................................................................................4 1.1. Blood collection, processing, testing and issue ............................................................................. 4 1.2. Explanation of a blood pack label ................................................................................................. 7 1.3. Specific requirements................................................................................................................... 9 1.4. Buffy coats and granulocytes...................................................................................................... 11 1.5. Lymphocytes.............................................................................................................................. 12 1.6. Stem cells.................................................................................................................................. 12 1.7. Cord blood ................................................................................................................................. 14 1.8. Blood cell separators and apheresis........................................................................................... 15 1.9. Artificial blood............................................................................................................................. 17 2. Filtration of blood components..........................................................................................19 3. Normal blood values...........................................................................................................21 4. Appropriate use of blood....................................................................................................23 4.1. Patient consent for blood transfusion.......................................................................................... 23 4.2. Refusal of blood transfusion ....................................................................................................... 25 4.3. Transfusion indication codes ...................................................................................................... 25 4.4. (Maximum) Surgical Blood Order Schedule ................................................................................ 26 4.5. Near patient/point of care testing (POCT)................................................................................... 27 4.6. Emergency planning and business continuity ............................................................................. 28 4.7. Nurse authorisation.................................................................................................................... 29 4.8. Home transfusions ..................................................................................................................... 30 5. Patient Blood Management ................................................................................................31 5.1. Pre-operative preparation........................................................................................................... 31 5.2. Autologous blood use................................................................................................................. 32 5.3. Surgical strategies to minimise blood loss .................................................................................. 34 5.4. Anaesthetic methods to minimise blood loss............................................................................... 35 5.5. Pharmacological agents............................................................................................................. 36 5.6. Pharmacological alternatives to transfusion................................................................................ 38 6. Adverse effects of transfusion...........................................................................................41 7. Emergency and massive transfusion ................................................................................48 8. Transfusion therapy for specific groups ...........................................................................51 8.1. Paediatric transfusion................................................................................................................. 51 8.2. Obstetric transfusion .................................................................................................................. 53 9. Examples of haematological disorders .............................................................................57 3 1. Blood Components Whole blood is now rarely used for transfusion. Blood component therapy makes clinical sense as most patients require a specific element of blood (Norfolk, 2013). Blood components include red cell concentrates, platelet concentrates, fresh frozen plasma and cryoprecipitate. Plasma derivatives include albumin, coagulation factors and immunoglobulins and are referred to as blood products. 1.1 Blood Collection, Processing, Testing and Issue Blood collected at static and mobile collection sites is returned to the blood centre’s laboratories for processing and testing. Generally blood is processed into its separate components. This practice has been developed as a response to clinical demand and it is a more efficient use of blood because it means that more than one patient can be treated from a single blood donation and only the blood component required is given. The processing department is responsible for: • Blood component production • Quality monitoring of the components The department routinely produces: • Red cells • Platelet concentrates • Fresh Frozen Plasma / Cryoprecipitate Collection Blood is collected from the donor into a multiple blood pack collection system within a 15 minute bleed time. There are different types and configurations of pack depending on which components are going to be prepared from the donor’s blood. This will be determined by donor blood group, stock requirements and the time of day it is collected (certain blood groups may be required for platelets and the time of day may be important if the blood has to get back to the processing department in time for platelet production). A donation of 450mls (+/- 10%) is required to ensure the final red cell component meets the specification as outlined in ‘Guidelines for the Blood Transfusion Services in the United Kingdom’, 8th Edition 2013, also known as ‘The Red Book’. In general 470-475ml of blood, excluding samples, is collected into the main pack. Three blood samples are also collected, taken for testing and all bar code labelled at the same time. Processing Processing begins with centrifugation of the donation, which accelerates separation of blood into its component parts. Red cells being heavier will settle at the bottom of the bag, white cells and platelets in the middle (often called the buffy coat) and plasma at the top. Under pressure in automated presses, the components are then expressed into the different satellite bags. Bags are then separated by heat sealing the tubing. Labelling of the components is done as part of the process and all the critical stages of processing are under computer