In this article, we will go through the three most common scenarios you will encounter. These are: (1) Does this patient need a transfusion? (2) Can you group & save or transfuse this patient? (3) This patient may be having a transfusion reaction, could you please advise?

Scenario 1: Does this patient need a transfusion?

When approaching this scenario some key questions to answer are:

• Is the patient symptomatic?
  • SOB, tired, lifeless – this can be an indication to transfuse in those with borderline haemoglobin levels
• What is the reason for the patient’s anaemia?
  • This could be blood loss from trauma, the GI tract, part of a pancytopenic picture in oncology patients or the result of a Vitamin B12, Folate or Iron deficiency
  • If the reasons are unclear, ensure you have sent haematinics BEFORE TRANSFUSION – as post-transfusion bloods will include a contribution from the donor. Otherwise, easily correctable deficiencies will be missed.
• Is the patient regularly transfused?
  • If so it is worthwhile checking for any haematology clinic letters as very often these chronically anaemic patients will have their own individual thresholds and haemoglobin targets.

Transfusion threshold

• Use local guidelines
• NICE suggests a transfusion threshold of 70g/L for haemoglobin (or 80 in those with an acute coronary syndrome or requiring orthopaedic/cardiac surgery) and a target of 70-90g/L after transfusion (90-100 in ACS)

Prescribing blood

• 1 unit of RBC will raise the Hb by around 10g/L (where there is no ongoing loss)
• Transfusions should occur in hours unless it is an emergency – the close monitoring & regular observations that are required of nursing staff puts them under pressure when staffing levels are reduced
• RBCs should only be out of the fridge for less than 4 hours – for this reason, it should be prescribed over 2-3 hours in elective transfusion
• Consider prescription of IV furosemide boluses (20-40mg) if giving several units and in those with LV impairment at risk of TACO (transfusion-associated circulatory overload). They are usually given after the unit
• Usually, each unit has to be prescribed separately but check local guidelines

Scenario 2: This patient needs a Group & Save or Transfusion

This is a very common bleep, particularly on surgery!

Ensure a valid group & save

• Even in an emergency, whilst awaiting the emergency O-ve blood, take a group and save. Then as soon as this is processed you can switch from O-ve to appropriate grouped blood. 
• In most trusts, the blood bottle & form need to be handwritten. 
• Two samples are required (ideally different days & times). You can call the lab to check if the group & save is already valid or if they’ve received your sample. 
• Usually 72 hours after a transfusion, you will require a new group and save as new antibodies can develop

In an emergency

• Emergency universal donor O-ve blood is usually stored in ED, theatres, blood bank & maternity. You should familiarise yourself with the local policies
• ABO and Rh(D) group-specific blood takes 15 minutes to come back. Cross-matching blood to test for other antibodies takes around a further 30 minutes 

Consent

• Do not assume that the need for a transfusion has been explained to the patient already, you will need to obtain full consent
• Most trusts will have a signed consent form to make sure nothing is missed; if your trust does not, ensure the conversation is documented in the notes.
• Give the patient +/- carer verbal and written information related to;
  • the type of blood/component being given
  • the reason for and benefits of the transfusion
  • the possible risk of transfusion (acute and delayed reactions including fever, rash and feeling unwell, fluid overload and transfusion-transmitted infection)
  • That following a transfusion they are unable to be a blood donor
  • Alternatives to transfusion and how they might reduce the need for transfusion – oral or IV iron such as monofer transfusions, erythropoietin – this is standard practice in renal anaemia, Intraoperative and Postoperative cell salvage – these are generally acceptable to Jehovah’s witnesses and tranexamic acid which is good for traumatic and surgical blood loss.

Special Requirements

The lab, intranet guidelines or haematology will have more accurate & up to date information on special requirements in transfusion. There are also Transfusion Guidelines available online.

• Irradiated blood – This prevents donor lymphocytes from mounting a transfusion-associated graft versus host disease by inactivating lymphocytes in cellular blood products.
  • Since immunocompromised individuals are at the greatest risk irradiated blood is indicated in
    • Patients who have received a stem cell/bone marrow transplant (or those due to give stem cells in the next 7 days)
    • Patients with Hodgkins lymphoma
    • Intrauterine or neonatal transfusions
    • Patients receiving purine analogues and related drugs e.g azathioprine
• CMV negative – >50% of adults in the UK are CMV +ve however new infection in immunocompromised patients can be fatal, give the risk of infection during pregnancy it should be given in pregnancy, intrauterine and neonatal transfusion.
• Hep E negative blood should be given in transplant patients

From TranfusionGudelines.org

Scenario 3: This patient is being transfused and is scoring on their EWS what should you do?

If the patient is becoming unwell STOP THE TRANSFUSION immediately until you can review them. It is worthwhile asking how long after starting transfusion they became unwell.
Transfusion reactions are potentially fatal and should be dealt with urgently.

A small rise in heart rate and temperature is normal during transfusion

Types of transfusion reactions

Always follow local guidelines! Always start with an ABCDE

• Febrile (Non-Haemolytic) transfusion reactions – 1 degree rise in temperature with associated chills and malaise & temperature below 40c
  • Supportive treatment with paracetamol & a slower rate of transfusion
• Haemolytic transfusion reactions – Most likely ABO incompatibility with rapid onset rise in temperature above 40c, agitation, hypotension, flushing, abdominal and chest pain, oozing venepuncture sites
  • Stop the transfusion
  • Recheck the ID on the blood unit against the patient’s wristband
  • ABCDE assessment with 15L of oxygen, fluid resuscitation, 200mg IV hydrocortisone
  • Resend a group & save. Also send FBC, U&Es (↑K+), Clotting, Cultures, Urine free haemoglobin
  • Inform your seniors, the haematology team and transfusion
  • Treat for DIC (involve your seniors again! Usually various blood products: platelets, clotting factors etc.)
• Allergic reaction including anaphylaxis
  • ABCDE for anaphylaxis (tachycardia, hypotension, bronchospasm, cyanosis, oedema) – if so stop the transfusion & treat as per the usual protocol of adrenaline, fluid resuscitation, hydrocortisone & chlorphenamine
  • If mild (urticaria, itch), then slow the rate down & treat with hydrocortisone 200mg IV and Chlorphenamine 10mg IV
• TACO (Transfusion-associated circulatory overload) – presents like pulmonary oedema
  • Slow the transfusion down
  • Treat as fluid overload/pulmonary oedema with sitting the patient up, 15L oxygen, furosemide
• TRALI ( Transfusion-related lung injury) – Dysponea, Cough, CXR – ‘White Out’ like ARDS
  • Stop the transfusion
  • ABCDE with 15L oxygen
  • Call ITU as ventilatory support is often required
  • Call seniors

Written by Dr Emma Monteith FY1
Edits by Dr Akash Doshi CT2