New clinical resource: blood assist app
We are very excited to share with you a brand-new patient safety resource to support and promote safe blood component administration in clinical practice. The app can be downloaded onto personal devices or centrally onto trust devices in clinical areas. http://bloodassist.co.uk
It is great new clinical resource created by NHSBT patient blood management team with easily accessible up-to-date recommendations on compatibility, special requirements, consent, transfusion reactions and TACO.
The Hampshire Hospitals blood transfusion department provides a comprehensive service to the Trust and other purchasers including GP’s. There are two transfusion laboratories and they operate 24 hours a day, 365 days a year issuing blood products on completion of appropriate pre-transfusion testing. Transfusion services are provided to all sites at HHFT in addition to a number of private hospitals and Alton Community Hospital.
Red cells, fresh frozen plasma and cryoprecipitate are stocked routinely in the laboratory whilst platelets are ordered for named patients only as they have a shorter shelf life.
Approximately 13,400 units of blood products are administered each year within the Trust. Both Winchester and Basingstoke sites have the main blood fridge situated within Pathology and a smaller designated fridge in maternity for the storage of a single emergency blood unit.
The Transfusion Team consists of the Transfusion Operational Manager, Clinical Lead for Transfusion, Transfusion Senior Biomedical Scientists and Transfusion Practitioners.
The purpose of the Transfusion Team is to ensure a high level of patient safety and adherence to the Blood Safety Quality Regulations (BSQR) and The British Society for Haematology (BSH) recommendations through active promotion and implementation of good transfusion practice.
The team will conduct audits, and investigate transfusion-related clinical incidents, ensuring these are reported externally as appropriate. Feedback and information are then provided to the Hospital Transfusion Committee (HTC), which is responsible for ensuring the Transfusion Policy is reviewed and updated to reflect national guidelines. The committee meets quarterly to discuss transfusion-related issues and incidents.
| Name | Job title | Contact |
|---|---|---|
| Dr Henna Wong | Transfusion, Clinical Lead | 01265 314200 |
| Jo Lawrence | Transfusion Operational Manager | 01256 314756 |
| Linda Holloway | Transfusion Senior Biomedical Scientist | 01962 824450 |
| Olivia Martins | Transfusion Senior Biomedical Scientist | 01256 314756 |
| Jenny Bodkin | Transfusion Practitioner | 01962 824447 |
| Jane Owen | Transfusion Practitioner | 01256 314756 |
Transfusion is a 2 yearly training requirement and is found on Green Brain.
Doctors training:
Medical Training: 2 yearly e-learning modules
Please refer to the Transfusion Training Exemption Form if you think you have been inappropriately assigned transfusion training.
Click here to view HHFT transfusion training compliance figures
Click here for the Blood Transfusion Exemption Form for Healthcare Staff
Dose - in the absence of active bleeding, use the minimum number of units required to achieve a target Hb. Assume an increment of 10g/l per unit for an average adult (weight 70kg).
The national red cell indication codes have been added to ICE for crossmatch requests to help guide transfusion and the most uptodate codes can be found here:
R1 Acute bleeding. Acute blood loss with haemodynamic instability. After normovolaemia has been achieved/maintained, frequent measurement of Hb (including by near patient testing) should be used to guide the use of red cell transfusion-see suggested thresholds below.
R2 Hb ≤ 70g/L stable patient. Acute anaemia. Consider a Hb threshold of 70g/l and a target Hb of 70-90g/l to guide red cell transfusion. There are different recommendations (based on weak evidence) from other organisations e.g. Association of Anaesthetists.
R3 Hb ≤ 80g/L stable patient and acute coronary syndrome. Use an Hb threshold of 80g/l and a target Hb of 80-100g/l.
R4 Chronic transfusion-dependent anaemia. Transfuse to maintain an Hb which prevents symptoms. Suggest an Hb threshold of 80g/l initially and adjust as required.
Haemoglobinopathy patients require individualised Hb thresholds depending on age and diagnosis.
R4a Chronic bone marrow failure
R4b Haemoglobinopathies
R5 Radiotherapy - maintain Hb> 100g/L. There is some evidence for maintaining an Hb of 100g/l in patients receiving radiotherapy for cervical and possibly other tumours.
R6 Exchange transfusion
R7 Severe chronic anaemia: non-transfusion dependent (e.g. haematinic deficiency, anaemia of chronic disorder
Weight-based prescriptions for red cells:
Transfusing 4mL/kg of red cells (one unit = 280mLs) will give a rise in Hb of 10g/l (wt 70-80kg). Patients with a lower body weight will require less blood.
Reference:
Anaemia in the perioperative pathway. Anaemia Guideline Paediatric information. CPOC 2022. https://cpoc.org.uk/sites/cpoc/files/documents/2022-10/CPOC_AnaemiaGuideline_2022_PaedsSummary.pdf
Platelet concentrates
Dose – for prophylaxis, do not routinely transfuse more than 1 adult therapeutic dose.
Prior to invasive procedure or to treat bleeding, consider the size of the patient, previous increments and the target count.
National blood transfusion codes for platelets:
Prophylactic platelet transfusion
- P1 Plt <10 x 10*9/L in reversible bone marrow failure
Not indicated in chronic bone marrow failure if not on intensive treatment, and not bleeding
- P2 Plt 10 – 20 x 10⁹/L with sepsis/haemostatic abnormality, or other additional risk factor for bleeding
Prior to invasive procedure or surgery:
To prevent bleeding associated with invasive procedures
- P3a Plt ≤20 x 10⁹/L central venous line
- P3b Plt ≤40 x 10⁹/L pre lumbar puncture/spinal anaesthesia
- P3c Plt ≤50 x 10⁹/L pre-percutaneous liver biopsy/major surgery
- P3d Plt ≤80 x 10⁹/L epidural anaesthesia
- P3e Plt ≤100 x 10⁹/L pre critical site surgery e.g. CNS/eye
Transfusion prior to bone marrow biopsy or PICC line is not required.
Therapeutic use to treat bleeding (WHO bleeding grade 2 or above)
- P4a Plt <50 x 10⁹/L – major haemorrhage
- may involve commencing transfusion at a higher platelet count
- P4b Empirically in a major haemorrhage pack/protocol
- P4c Plt <100 x 10⁹/L – Critical site bleeding e.g. CNS
- P4d Plt <30 x 10⁹/L – Clinically significant bleeding
Specific clinical conditions
- P5 Consumptive thrombocytopenia with bleeding or pre-procedure
- e.g DIC or ITP
Platelet dysfunction
- P6a Consider if critical bleeding on anti-platelet medication
- P6b Inherited platelet disorders directed by haemostasis specialist
Dose – 15-20 ml/kg body weight, often equivalent to 4 units in adults.
F1 Major haemorrhage
- In the trauma setting transfuse empirically in a 1:1 ratio with red cells. Other settings give FFP in at least a 1:2 unit ratio with red cells until results from coagulation monitoring are available. Once bleeding is controlled, further FFP should be guided by abnormalities in PT and APTT (keep PT/APTT ratio of < 1.5 x mean normal), or by the use of viscoelastic haemostatic assays in a near-patient setting.
F2 Bleeding (excluding chronic liver disease) with PT Ratio / INR > 1.5
- Clinically significant bleeding without major haemorrhage. FFP required only if coagulopathy not due to chronic liver disease. Aim for a PT and APTT ratio of ≤ 1.5, or local protocol range for near-patient viscoelastic assays.
F3 Pre-procedure (excluding chronic liver disease) with PT Ratio / INR > 1.5
- Prophylactic use when coagulation results are abnormal e.g. disseminated intravascular coagulation (DIC) and invasive procedure is planned.
F4 Historical indication; no longer recommended to transfuse FFP in chronic liver disease
F5 Plasma exchange
- Plasma exchange for TTP or where there is a need to replace clotting factors (in other plasmapheresis procedures, albumin would be the standard replacement fluid). Use pooled solvent-detergent treated plasma for TTP.
F6 Replacement of single coagulation factor
- Where no factor concentrate is available, under direction of a haemostasis consultant. Usually limited to factor V deficiency. Use pooled solvent-detergent treated plasma.
Cryoprecipitate
Dose – 2 pooled units will increase fibrinogen by approximately 1.0 g/l in an average-sized adult.
C1 Clinically significant bleeding and fibrinogen < 1.5 g/L (< 2.0 g/l in obstetric bleeding)
C2 Pre-procedure with a risk of bleeding and fibrinogen < 1.0 g/L
- In chronic liver disease it is uncertain whether fibrinogen levels are causally associated with bleeding risk. Some guidelines recommend a threshold fibrinogen of < 1.2 g/L in this setting; others discourage routine correction of fibrinogen deficiency.
C3 Bleeding associated with thrombolytic therapy
C4 Inherited hypofibrinogenaemia - fibrinogen concentrate not available
- Under direction of a haemostasis consultant.
- The blood group does not have to be identical but it must be compatible
- Easily accessible information on compatibility of blood components can be found at http://bloodassist.co.uk
- Please contact the transfusion laboratory or haematologist on call if you have any queries
Please see the SOP for Transfusion Reactions for further advice on investigations and management.
For a suspected moderate/severe transfusion reaction, please contact the blood transfusion laboratory and complete the ePurple referral 'Acute transfusion reaction'.
To access the ordering hub for patient information leaflets click here
Printable PDF versions of the following information leaflets:
Will I need a blood transfusion? - This leaflet forms part of the consent process and explains why patients might need a blood transfusion, and how they may feel during the process.
Information for patients who have received an unexpected blood transfusion - This leaflet is useful if a patient has received an unplanned transfusion.
Patient consent video has been kindly shared by University Hospital Birmingham NHS Foundation Trust in association with NHSBT. This is also available to all patients through hospedia.
Blood transfusion consent form - please see appendix B of the Blood transfusion policy
Fetal D screening test is available to request on. Specimen requirements are 1x6ml EDTA sample (pink top) sent to the Blood Transfusion Department at RHCH or BNNH. Please store specimens at Room Temperature.
Non Invasive Prenatal Testing using cell free fetal DNA in maternal plasma can be used to determine fetal D status, so that D Negative pregnant women can avoid receiving Anti-D prophylaxis if they are carrying a D Negative baby, as recommended by NICE guidelines.
The test involves analysing cell free fetal DNA in maternal blood and is intended for use in pregnant women who are D Negative and are not sensitised to D antigen. It is a laboratory developed test offered by the International Blood Group Reference Laboratory, NHSBT, Bristol.
Click here for NHSBT patient information.
This new test will be offered by HHFT to all D Negative women at 16 weeks gestation to identify those carrying a D Negative fetus early on in pregnancy, thus allowing D Negative women informed choice about whether to have treatment with Anti-D immunoglobulin. Results are available on EDMS via EPR. Please see attached for further information, or for any queries please contact the
Transfusion Department. BNHH 43290 or RHCH 44450
Click here to access the SHOT website.
Click here to see how we have learnt from incidents
A patient may refuse blood transfusion for a variety of reasons e.g. Jehovah’s Witness (JW). We need to ensure that individual's beliefs / preferences are acknowledged and respected and that relevant information is provided for the management of these patients.
The majority of JW’s carry a "No Blood" card which is an “Advance Directive” absolutely refusing blood, which also releases clinicians from any liability arising from this refusal.
It is the responsibility of the patient or attending relative to make sure their decision is drawn to the attention of healthcare professionals. If a patient decides to refuse blood products this should be clearly noted in the case notes. If an Advanced Decision is presented, a copy should be prominently placed in the patient's notes.
If refusal is by a non-Jehovah’s Witness is based on fear of transfusion transmitted infection, the risks should be clearly explained.
Refusal of blood transfusion should be carefully documented in the patient’s medical notes by the consultant / most senior doctor present, with the reasons given together with date, time and signature.
JW acceptance / non acceptance
The use of whole blood and its four primary components, Red Cells, White Cells, Platelets and Plasma (FFP) are refused on religious grounds.
However, there are no specific rules regarding the derivatives or fractions of primary blood components. Anti-D immunoglobulin and Cryoprecipitate may be accepted and should be offered where appropriate. Each JW must “conscientiously decide for him/herself” (Watchtower, June 2000) if treatments offered are acceptable.
Jehovah’s Witness Liaison Committee Contacts
The Jehovah’s Witness Hospital Liaison Committee (HLC) is available 24 hours to help staff and patients with advice and guidance and clarification on these matters.
Local liaison contact details:
Lee Sappleton 07887 755447 lsappleton@jw-hlc.org.uk
Sean Hayes 07799 778862 shayes@jw-hlc.org.uk
Scan the QR code for additional evidence based medical information.
