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Transfusion Services

SAMPLE COLLECTION PROCESS

Note: Delay of service may result from the omission of required information on the patient’s specimen label or specimen. Patients having Blood Bank testing with the possibility of receiving a transfusion must have a properly labeled (patient’s name and date of birth) Blood Bank armband placed on them prior to the venipuncture. The Blood Bank armband has a barcode-readable Blood Bank ID number with extra barcode readable Blood Bank ID number stickers.  One of the barcode readable BB ID number stickers MUST be placed on the specimen label.  Specimens with handwritten BB ID #'s will be rejected.   

TRANSFUSION SERVICE ORDERS

Order Options

  • Tube to Hold: No testing performed. The specimen is held for three days (Today+3) in the event testing becomes necessary.
  • Type & Screen: Testing performed for ABO, Rh and antibody screen. The specimen is held for three days (Today+3).

Type and Crossmatch: Testing performed for ABO, Rh, antibody screen and Crossmatch for the specified number of units. The specimen will be held for three days (Today+3).

Pre-Admission Blood Bank Collection

If a patient is having pre-admission blood work collected and there are Transfusion Service orders (Type & Screen or Type and Crossmatch) the specimen can be collected up to twenty-one (21) days prior to the surgery date. The Pre-Admission Testing (PAT) questions must be answered at the time of specimen collection.

Pre-Admission Testing Question Criteria:

  • If all answers to the questions are NO, the specimen may be collected and the Patient is twenty-one (21) day Eligible.

If the answer to any question is YES, the specimen may NOT be collected prior to three (3) days before the surgery date and thePatient is three (3) day Eligible.

Transfusion Service Requests

FORMS FOR BLOOD TRANSFUSIONS

Blood Consent Form (Form #5651)

The bloodconsent form must be dated and signed by the physician, the patient and a witness indicating that the patient received and understood the information received.  The page containing blood transfusion education should be given to the patient and the signed consent must be kept on the patient’s chart.  For additional information, refer to the York Hospital Manual of Administrative Policy (MAP), Policy #615 for Institutional Guidelines relating to consent.

https://portals.wellspan.org/sites/yhadmin/Manual%20of%20Administrative%20Policy/615-YH%20Informed%20Consent%20Policy%2016.pdf

 

A Physician’s Treatment Record or Order Sheet for Blood Transfusion must accompany all blood specimens.

INPATIENT ORDERS

All inpatient Blood Bank testing will be computer generated directly to the Transfusion Service department by Order Entry. Any special blood requests (i.e., irradiated, CMV negative, etc.) must be indicated at time of order in the Comment section.

OUTPATIENT ORDERS

All out-patient Blood Bank testing will be computer generated directly to the Transfusion Service department by Order Entry. Any special blood requests (i.e., irradiated, CMV negative, etc.) must be indicated at time of order in the Comment section. The Physician’s Treatment Record should be submitted with the specimen.

SPECIAL SERVICES

Outpatient Transfusions

All outpatient transfusions are to be scheduled through the Gettysburg Hospital Blood Bank at (717) 339-2317, regardless of the day or time or the Apple Hill Infusion Center at (717) 741-8637, located at the Apple Hill Medical Center, Suite #120. The Apple Hill Infusion Center also schedules transfusions for the York Hospital (YH) 5 Main Infusion room. Exceptions are weekends and holidays or after 5:00 p.m. and when a patient needs scheduled for an immediate transfusion, than call the YH 5 Main Infusion number at (717) 851-4070. If calling outside of the YH 5 Main Infusion Room hours which are 3:00-11:00 PM Monday-Friday and 7 a.m. to 3:30 p.m. on weekends and holidays, call the 5 Main 7 South Nurses Station at (717) 851-2625.

The following items are mandatory when ordering blood transfusions:

  • Complete the Consent Form (Form #5651), see above for details.
  • A Physician’s Treatment Record or Order sheet for Blood Transfusions must accompany all blood specimens.
  • Fax the forms to the appropriate infusion center:
  • Apple Hill Infusion Center Fax: (717) 741-8324
  • YH 5 Main 7 South Infusion Center Fax: (717) 851-3076
  • Gettysburg Blood Bank Fax (717) 339-2329.
  • Fax York Hospital Order sheet for Blood Transfusions to YH Transfusion Service: (717) 812-7881
  • Both outpatient facilities must be advised if the patient currently has or has ever had MRSA or VRE.

Pre-transfusion testing should be done the day before the scheduled transfusion. It may take longer to get the blood ready for patients with a history of an antibody, so drawing the sample in advance will provide the best customer service.

Patient’s having their blood drawn by laboratory personnel prior to transfusion must have their blood orders with them when they present to the collection site for York Hospital only. If the patient does not have their blood orders with them, a copy may be faxed to the York Hospital Laboratory at (717) 851-2707. If followed, these steps will prevent a delay in treatment.

Therapeutic Apheresis

Call Dr. Gela McHedlishvili WellSpan Nephrology, at (717) 851-6040 for information or to make scheduling arrangements for Therapeutic Apheresis Services.

Special Test Requests

DAT Negative AIHA Investigation (SUPER COOMBS)

This is a referral test that will be sent to the National Testing Laboratory in Philadelphia. The specimen must be drawn on Monday or Tuesday morning only. Call the Blood Bank at (717) 851-2520 for special instructions and requirements.

PLATELET SEROLOGY TESTING/MOLECULAR PHENOTYPING OF RED BLOOD CELLS

  • Indirect Platelet Antibody
  • Platelet Crossmatch
  • Suspected Neonatal Thrombocytopenia or Neutropenia
  • HLA testing for Platelet Transfusion
  • Molecular Phenotyping for Red Cell Transfusion

These are referral tests that will be sent to the American Red Cross (ARC) or Grifols Reference Laboratory. Call the Blood Bank at (717) 851-2520 for special instructions and requirements.

SPECIAL PRODUCT REQUESTS

  • HLA-Matched Apheresis platelets
  • Crossmatched Apheresis platelets 
  • HPLA 1 Negative Apheresis platelets 
  • Granulocytes

These products require prior notification for procurement. Call the Blood Bank for inquiries at (717) 851-2520.

Blood Component Therapy for Bone Marrow Transplant Patients

Care must be taken in the selection of blood components before and after transplantation. The following information is required from the physician as soon as possible on all transplant candidates:

  • Patient’s name
  • Donor blood type
  • Transplant date
  • Tranfusion requirements (Irradiation, CMV negative, etc.)
  • Transplant center

It is imperative that the information listed above be communicated to the Transfusion Service department who will document all the data as well as any serological changes in the patient’s transfusion record. Documenting these items will aid in selecting the optimum blood components for transplant patients.

Administration of Blood Components

  • Positive identification of the patient and the blood unit are essential prior to transfusion.
  • IV solutions used during administration must be compatible to the red blood cells.
    • Use 0.9% Sodium Chloride for Injection, USP
    • Do not use 5% Dextrose solutions (may induce hemolysis)
    • Do not use Lactated Ringer’s (contains Ca++ which may induce clot formation in the red cell unit or in the administration set)
    • Do not add medications to blood or infusion set.
  • To avoid hemolysis, use only a temperature-monitored blood warmer.
  • Regulate infusion rate depending on patient condition, and type of transfusion.  Set IV to a rate to infuse in desired time frame. (Transfusion Rate will be 3 ½ per unit) and the transfusion must not go longer than 4 hours.)
  • Transfusion Service can divide components for transfusion into smaller amounts upon request, such as for smaller sized patients or patients with history of Congestive Heart failure
  • Leukocyte reduced blood products are used to decrease febrile transfusion reactions, decrease risk of alloimmunization to leukocyte or HLA antigens, and to reduce transmission of CMV.
  • The risk of Transfusion Associated – GVHD in susceptible patients is reduced using a minimum of 25 Gy of irradiation for cellular blood products.

Patients who are at risk of GVHD are listed below:

o    Intrauterine transfusions

o    Premature, low birth weight ( < 1200 grams) infants (routinely until 4 months of age)

o    Newborns with erythroblastosis fetalis

o    Congenital immunodeficiencies

o    Lymphoma patients

o    Leukemia patients

o    Hodgkins disease

o    Some solid tumors:  Neuroblastoma, sarcomas

o    Bone marrow or stem cell transplant patients

o    Fludarabine therapy recipients (other purine analogs: thioguaninepentostatincladribinemercaptopurine6-mercaptopurine,azathioprine)

o    Anyone receiving granulocyte components

o    Malignancy being treated with radiation / cytotoxic agents (or any severely neutropenic cancer patient)

o     Donor-recipient pairs from genetically homogeneous populations (esp. Japanese to Japanese)

o    Irradiate products for all infants < 4 months old.

  • If a patient has Sickle Cell Anemia, the patient must receive sickle negative red cells and C, E and K antigen negative units as appropriate. Notify the Transfusion Service department at (717) 851-2520   

All blood products must be infused through a filter.

Component/Products and Their Indication

Testing Requirements

Component/

Product

Composition

Indications

Turn-Around

Time

Product Order - RBCs

Red Blood Cells*

RBC (approx Hct 75%); reduced plasma; WBCs; plasma

Increase red cell mass in symptomatic anemia

Crossmatched < 45 minutes; Uncrossmatched 15 minutes.

Red Blood Cells* (Leukocytes reduced,

prepared by filtration)

>85% of the original volume of RBC; <5x106WBC; few platelets and minimal plasma

Increase red cell mass in symptomatic anemia; <5x106WBC to decrease the likelihood of febrile reactions; immunization to leukocytes (HLA Ags) or CMV transmission.

 

Red Blood Cells (Washed)

RBC (approx Hct 75%); <5x108 WBC; no plasma

Increase red cell mass in symptomatic anemia; reduce risk of allergic reaction to plasma proteins.

Requires an additional 45 minutes for washing the unit.

 

 

 

Type & Rh

Platelets*

Platelets (>5.5x1010/unit); RBC’s; WBC; plasma

Bleeding due to thrombo-cytopenia or thrombo-cytopathy

Distributed as a pre-pooled platelet pool; 15 minutes.

Platelet Pheresis*

Platelets (>3.0x1011/unit); RBC’s; WBC; plasma

Bleeding due to thrombo-cytopenia or thrombo-cytopathy

15-20 minutes. Reservations preferred.

Type & Rh

Fresh Frozen Plasma

Source of non-labile factors

Treatment of some coagulation disorders

1-3 units/30 minutes; >4 units/45 minutes.

Type & Rh

Cryoprecipitate AHF

Fibrinogen, Factors VIII & XIII; Von Willebrand Factor

Deficiency in Fibrinogen, Factor XIII, Second choice in treatment of Hemophilia A, Von Willebrand Disease; can be used to make topical Fibrin Glue.

Distributed as a 5-6 unit pre-pooled cryoprecipitate pool. 30 minutes

Type & Antibody Screen

Rh Immune Globulin (RIG)

IgG Anti-D; Preparations of IM use.

Prevention of Hemolytic Disease of the Newborn due to the D antigen; prevention of alloimmunization of Anti-D in an Rh negative patient who receives Rh positive red cell products.

1 vial/45 minutes

 

* These products can be requested as irradiated. Irradiation of the product with 25 Gy should be used to reduce the risk of Transfusion Associated-Graft versus Host Disease (TA-GVHD) in susceptible patients such as; immuno compromised recipients (Hematopoietic Progenitor Transplant patients, Congenital Immune Deficiency), a fetus receiving transfusions, recipients of donor units from relatives, recipients of HLA-matched platelets, etc.

Management of Transfusion Reactions

Steps to follow for all reactions:

  • Stop the Blood Component Transfusion Immediately!!!
  • Maintain IV access, and ensure urine output with the appropriate crystalloid or colloid solution.
  • Verify that the correct unit was given to the correct patient
  • Maintain blood pressure and pulse
  • Maintain adequate ventilation
  • Notify the Blood Bank and the attending physician (Call the York Hospital Blood Bank at (717) 851-2520 or the Gettysburg Hospital Blood Bank at (717) 339-2317)
  • Obtain one (1) pink top tube labeled with a barcode readable Blood Bank ID # and a urine sample for the transfusion reaction work-up.
  • Send the following to the Blood Bank:
  • Transfusion Reaction Report – Obtained on the INET for York Hospital (Policy BBT-516) or from the Gettysburg Hospital Blood Bank.
  • Copy of vital sign records (Copy of the Issue and Transfusion Form)
  • One (1) pink top tube labeled with a barcode readable Blood Bank ID # and first urine sample

Note:

If patient has a febrile reaction during the blood transfusion, blood cultures on the patient may be required.

Instructions will be provided by the Blood Bank staff based on the patient’s vital signs.

  • Blood Bag and Administration Set
  • Be prepared to administer supportive therapy, appropriate medications, or emergency care as warranted by the clinical situation
  • Update the Blood Bank as to evolving symptoms and resolution of the reaction.

Note:

If more than one transfusion has been given, send the vital signs (Copy of Issue and Transfusion forms) and blood bag/administration set(s) from the prior transfusion(s), if applicable.

A copy of the Issue and Transfusion Form needs to be provided from those nursing units that do not use the Blood Administration within PowerChart program (out of scope areas).  For those nursing units using Blood Administration within PowerChart (in scope areas), the Transfusion form will automatically print in Blood Bank containing the data and vitals.

  • All transfusion reactions are reviewed and interpreted by a pathologist.

TRANSFUSION REACTION INFORMATION

Assessment:

Description:

Usual Cause:

Recommendation:

Mild Allergic Transfusion Reaction

Itching, few hives, mild rash.  Symptoms should resolve quickly with Benedryl.  Can continue transfusion under close supervision.

Antibodies to plasma proteins (fairly common).

Recommend treating with antihistamine such as diphen-hydramine pre-transfusion and during an episode. Administer blood products slowly.

   

Moderate Allergic Transfusion Reaction

Extensive hives, itching, wheezing, throat tightening, hypotension.

Antibodies to plasma proteins (fairly common).

Recommend pre-treatment with an antihistamine such as diphenhydramine.  Consider combined H1 and H2 blocker pre-treatment or steroids for recurrent allergic reactions. Administer blood slowly, with nursing supervision.

 

Severe Allergic Transfusion Reaction

Anaphylaxis, anaphylactoid shock or laryngeal edema requiring intubation and/or epinephrine administration.

Antibodies to plasma proteins (fairly common).  Antibodies to IgA in IgA deficient individuals (rare).

Recommend administering washed RBC's, and pretreating with antihistamines and steroids prior to transfusions.  Admin-ister blood products slowly under close nursing supervision. 

Consider testing the patient's (pretrans-fusion) IgA level.

 

Hypotensive Transfusion Reaction

Hypotension, tachycardia, facial flushing, and abdominal pain.

Bradykinin generation, may be exacerbated by ACE inhibitors.

Recommend using pre-storage leuko-reduced products, and giving future transfusions slowly with close nursing supervision. 

Stop the transfusion immediately during a hypotensive episode, place patient in the Trendelenburg position, and administer fluids if clinically appropriate. 

   

Unrelated (Patient's symptoms are unrelated to the transfusion)

Any.  May mimic a true transfusion reaction.  Always is appropriate for the nurse to stop the transfusion and initiate a work-up.

Underlying disease process of patient / side effect of medication.  Commonly:  Neutropenia, infection, cardiac failure.

No specific recommendations at this time.  In a compromised or extremely ill patient, recommend leuko-reduced blood to reduce the risk of transfusion reactions.

 

Afebrile (Masked) Febrile Non-hemolytic Transfusion Reaction

Patient on Tylenol has chills/shakes/rigors, but minimal or no temperature increase.

Antibodies to leukocytes, platelets or plasma proteins stimulate endogenous pyogen release; passive cytokine infusion.

Recommend administering leukoreduced blood components and pretreating with an antipyretic such as acetaminophen.

 

Possible Febrile Non-hemolytic Transfusion Reaction

Within 2 hours of transfusion:  Fever (temperature increase of 1 ºC or 1.8 ºF), chills, shakes, rigors.

Antibodies to leuko-cytes, platelets or plasma proteins stimulate endogenous pyogen release; passive cytokine infusion.  Case is complicated by other reasons for fever (neutropenia or infection).

Consider administering leukoreduced blood components and pretreating with an antipyretic such as acetaminophen.

 

Probable Febrile Non-hemolytic Transfusion Reaction

Within 2 hours of transfusion:  Fever (temperature increase of 1 ºC or 1.8 ºF), chills, shakes, rigors.

Antibodies to leukocytes or plasma proteins; passive cytokine infusion.  Case is complicated by other reasons for fever (neutropenia or infection).

Recommend administering leukoreduced blood components and pretreating with an antipyretic such as acetaminophen.

   

Febrile Non-hemolytic Transfusion Reaction

Within 2 hours of transfusion:  Fever (temperature increase of 1 ºC or 1.8 ºF), chills, shakes, rigors.

Antibodies to leukocytes or plasma proteins; passive cytokine infusion.  Case is uncomplicated.

Recommend administering leukoreduced blood components and pretreating with an antipyretic such as acetaminophen.

 

Possible Septic Transfusion Reaction, Pending Cultures

Rigors, chills, fever (usually a rise = 2 ºC or 3.6 ºF), shock, potential death.  May develop quickly or several hours after transfusion. 

Culture transfusion bag AND patient; compare results to confirm.  If clinicians culture the patient, culture the bag.  If clinicians refuse to culture the patient, do NOT culture the bag.  Associated products should be recalled.

Contaminated blood product, usually donor venipuncture site contamination or occult bacteremia. 

Skin flora contaminants:  Staph, Propionibacteria. 

Gram Negative's implicated in clinical reactions and capable of causing death: 

Acinetobacter, Klebsiellla, Serratia, Enterobacter, Escherichia.  Less common, Gram Positive Cocci implicated in clinical reactions:Staphylococcus, Streptococcus.  Likes to grow in RBCs:  Yersina, Pseudomonas

Provide supportive care and appropriate antibiotic coverage.  Follow patient's blood cultures.

Septic Transfusion Reaction

Provide supportive care and appropriate antibiotic coverage. 

Follow patient's blood cultures.

   

Transfusion Related Acute Lung Injury (TRALI)

Within 6 hours of transfusion: Dyspnea, fever, hypoxia, pulmonary edema, hypotension, normal pulmonary capillary wedge pressure.  "White-out" on post-transfusion chest x-ray.  May require intubation.  Differential diagnosis:  Volume Overload.  For TRALI: BNP should remain normal, no left atrial hypertension, non-responsive to diuresis.

Recipient-specific donor HLA or anti-neutrophil antibodies in the plasma component of a transfusion. Other theory - neutrophil priming lipid mediator.  Less commonly, recipient antibody to donor WBCs.

Provide respiratory and blood pressure supportive care.  TRALI reaction is donor specific, and therefore, the patient is at no increased risk during future transfusions if needed.  However, we recommend administering leuko-reduced blood components and pretreating with an antipyretic, such as acetaminophen, and an antihistamine, such as diphen-hydramine, to reduce the risk for febrile or allergic reactions.

 

Possible Transfusion Related Acute Lung Injury (TRALI)

Within 6 hours of transfusion: Dyspnea, fever, hypoxia, pulmonary edema, hypo-tension, normal pulmonary capillary wedge pressure.  Post-transfusion chest x-ray shows edema or infiltrates.  Patient has complicating factors: 

myocardial infarction, cardiac failure, volume overload. 

Recipient-specific donor HLA or anti-neutrophil antibodies in the plasma component of a trans-fusion. Other theory - neutrophil priming lipid mediator.  Less commonly, recipient antibody to donor WBCs.

Provide respiratory and blood pressure supportive care. 

TRALI reaction is donor specific, and therefore, the patient is at no increased risk during future transfusions if needed.  However, we recommend administering leukoreduced blood components and pretreating with an antipyretic, such as acetaminophen, and an antihistamine, such as diphen-hydramine, to reduce the risk for febrile or allergic reactions.

Hypervolemia (Fluid / Circulatory Overload )

Also known as "TACO" (Transfusion Associated Circulatory Overload). Dysnpea, headache, hyper-tension (>50 mmHg rise), pulmonary edema, congestive heart failure, cardiac arrythmias. Severe cases:  Flash pulmonary edema.  Responds to diuresis.

Too rapid and/or excessive fluid and/or blood administration. 

Check volumes of blood and fluid given prior to "reaction"

Induce diuresis. 

Provide cardio-respiratory support as clinically indicated.  If future transfusion is necessary, proceed slowly, or in divided doses (call blood bank to have units divided).

 

Acute Hyperhemolytic Transfusion Reaction

Hemoglobinemia (red serum), hemoglobinuria (red urine - not due to RBCs), fever, chills, anxiety, shock, DIC, dyspnea, chest pain, flank pain, oliguria. 

HCT drops significantly lower than pretransfusion levels. 

Rare - usually seen in chronically transfused hemoglobinopathy patients, with multiple alloantibodies (esp. beta thalassemia, sickle cell disease)

Do not transfuseadditional blood products.  Provide supportive care, including fluid administration and diuresis, blood pressure and respiratory support. 

Monitor the patient for DIC and shock.

 

Acute (Intravascular) Hemolytic Transfusion Reaction

Hemoglobinemia (red serum), hemoglobinuria (red urine - not due to RBCs), fever, chills, anxiety, shock, DIC, dyspnea, chest pain, flank pain, acute renal failure, cardiac arrest.

HCT will drop to Pretrans-fusion levels.  Monitor HCT, LDH, bilirubin, haptoglobin levels, BUN, Creatinine, platelets and coags.  Repeat compatibility testing.

ABO incompatibility (clerical error) or unknown/missed red blood cell alloantibody or other complement fixing red cell antibody.

Do not transfuse additional blood products, until blood bank work up is completed.  Provide supportive care, including fluid administration and diuresis, blood pressure and respiratory support. 

Monitor the patient for DIC and shock.

     

Mild (Extravascular) Delayed Hemolytic Transfusion Reaction

Asymptomatic.  May see gradual HCT drop to pre-transfusion levels.  May see positive DAT, increased LDH, indirect bilirubin.

IgG non-complement fixing antibody (often Rh or Kell).  Coated RBC's are cleared by reticulo-endothelial system (especially spleen). 

Time course:  Reaction within days: anamnestic response; Reaction after 3 weeks - new antibody

Monitor the patient's hematocrit, renal and hepatic function, coagulation profile. 

Acute treatment is generally not required. 

Because of antibody formation, future antibody screens and cross-matches may take additional time.

 

Severe (Extravascular) Delayed Hemolytic Transfusion Reaction

Fever, malaise, indirect hyperbilirubinemia, increased LDH, urine urobilinogen, falling HCT. 

DAT may be negative, if all coated RBCs are cleared.

IgG non-complement fixing antibody (often Rh or Kell).  Coated RBC's are cleared by reticulo-endothelial system (especially spleen).  Time

course: Reaction

within days: anamnestic response; Reaction after 3 weeks - new antibody

Monitor the patient's hematocrit, renal and hepatic function, coagulation profile, and provide supportive care if necessary. 

Because of antibody formation, future antibody screens and crossmatches may take additional time.

 

TRANSMISSION OF INFECTIOUS DISEASES

All cases of patients who develop jaundice or unexplained liver dysfunction two weeks to six months after the transfusion and all patients suspected of having contracted a transfusion-transmitted disease should be reported to the WellSpan Blood Donor Center Manager at (717) 741-8307 or the York Hospital Blood Bank Medical Director at (717) 851-5001. For Gettysburg patients call the Gettysburg Hospital Blood Bank Manager at (717) 339-2311 or Gettysburg Laboratory Medical Director at (717) 337-4120

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