Transfusion Medicine

Brandon Thomas, CLS, MLS (ASCP) (Supervisor)

Our hospital receives blood and blood components from the BloodSource (Sacramento Medical Foundation Blood Center)(BloodSource). We are, bound by the regulations of the BloodSource, AABB, and the FDA.. We attempt to keep an adequate supply of blood on hand at all times but occasionally when blood supply is scarce, units may need to come directly from the BloodSource facility. This may cause delays beyond the laboratory's control.

Refer to AABB website, http://www.aabb.org, “Donate Blood” link for information on donating blood and “About Blood and Cellular Therapies” for general information including the safety of the blood supply.

Requests for blood components should be submitted to the Transfusion Service with tube(s) of EDTA anticoagulated blood. The label on each tube of blood must have a name and (8 digits) hospital I.D. numbers. This information can be handwritten but must be clearly legible. It is a F.D.A. regulation that each tube of blood be labeled with the identification of the phlebotomist and the date and time of the blood draw. The patient identification must be identical on tubes of blood and request slips. On one of the request slips the full name of the phlebotomist; Request slips for EMR Order Entry will have phlebotomist, time, and dated printed. The time and date is printed on the specimen labels.

If no request slip has phlebotomist's I.D., the Transfusion Service will call and obtain this information from the ward location of the patient. In cases of discrepancies between patient I.D. on tube(s) and request slip, another entire set of tubes from a new blood draw and request slips must be submitted. There will be no exceptions to this rule.

In cases of emergency, type O red cells will be issued until properly labeled tubes and request slips are available.

Do not refrigerate blood or blood components on the ward.

Do not exceed four hours when transfusing a unit of red blood cells. If blood must be transfused very slowly, request that the packed cells be ordered as a split unit. Red blood cells left unrefrigerated longer than 30 minutes (temperature exceeds 10° C) must be transfused to the patient within four hours from the time of issue. These units cannot be returned to the Transfusion Service for reissue to another patient.

All red cell components and platelet components should be filtered through a Y filter. All red cell and platelet products are prestorage leukodepleted.

Except for donor units implicated in transfusion reactions, all empty blood and blood component plastic bags, bottles, containers and immune Rh₀(D) globulin vials are to be disposed of on the ward. Blood removed from patients with hypervolemia or for partial exchange should also be disposed of on the ward.

Type O red blood cell units are always available in the Transfusion Service for emergency cases, in addition to fresh frozen plasma and other blood components.

One 4mL EDTA tube is needed for typing the adult patient and crossmatching several units of blood. Children >100 pounds are considered as adults in terms of transfusions.

When the blood of a patient is sent to the laboratory for "type and screen", it means that the patient's blood is typed for ABO and Rh, and an irregular antibody screen is performed. The specimen is held but NO DONOR BLOOD IS CROSSMATCHED AT THIS TIME. This order is appropriate when transfusion is not planned but anticipated. The specimen is held in the laboratory for 3 days from the time of collection. If sufficient sample is available, crossmatching can be performed up to 3 days. Beyond 3 days, a new specimen is required for crossmatching. If the antibody screen is negative, a crossmatch can be ordered and available for transfusion in one hour from the time of the request.

For children <100 pounds, a minimum of 2 ml blood (in a 4 mL EDTA tube) is needed for crossmatch of 3 pedipaks or one adult packed red cell. For neonates, maternal and cord blood specimens are highly desirable for confirmatory investigations. A minimum of 1 ½ mL in a 4 mL EDTA tube is needed for the initial crossmatch in the neonate, even for one single pedipack. Hemolytic disease study requires 1 ½ mL in a 4 mL EDTA tube. For platelets and red cell components, pediatric filters are available for pediatric red cells, pediatric fresh frozen plasma, and split plateletphereses. Both 30 mL and 80 mL pediatric red cells are available.

Compliance with the Gann Act (California Health and Safety Code 1645) mandates that every physician who determines that there is reasonable possibility that his/her patient may require a blood transfusion must provide the patient with the legal document "A Patient's Guide To Blood Transfusion," (see UCDMC Patient Care Standards, Volume II, IV therapy, IX, Blood Transfusion Option Advisement, Page 5). (See http://intranet.ucdmc.ucdavis.edu/policies/hosp/1411.HTM for consent form) This form legally documents that the patient has been informed of transfusion options and allows enough time for decision to exercise options. Compliance with this law is monitored by the Clinical Quality Improvement Department. See http://intranet.ucdmc.ucdavis.edu/policies/pcs/XIII-12.HTM attachments for both Pediatric and Adult Transfusion Guidelines.

Manually generated crossmatch request forms are labeled or stamped PRE-OP and the DATE OF SURGERY is indicated; EMR and Invision generated computer orders have space for computer entry of this same information. If autologous blood is requested state so as well as location of donation.

The Transfusion Service can hold the crossmatched blood for 3 days after testing is complete.

Minimum Time Required

Category for Preparation

O Packed Red Cells 5 minutes

Fast Crossmatch 45 minutes

Coombs Crossmatch (antibody present) 60 minutes

In all emergency situations when red blood cells are needed immediately, type O red cell units are dispensed.
STATs for crossmatching from the OR and ER have higher priority than from ICU or wards. Doctors for patients in ICU or wards must notify the Transfusion Service directly if an order for a regular or ASAP needs to be processed STAT due to sudden changes in the patient's condition.

STAT REQUESTS FOR BLOOD COMPONENTS MUST BE DELIVERED TO THE TRANSFUSION SERVICES BY PERSONNEL FROM THE REQUESTING UNIT. An R.N. may call the Transfusion Service and send a ward clerk to pick up the product.

It is an immediate spin crossmatch that is routinely used in patients who have a negative antibody screen and no complications. The original screen takes 35-45 minutes to complete. Additional red cell units can be obtained in 15 minutes.

Please refer to the table 1 pertaining to all components available, regarding time needed to acquire the component from BloodSource and time needed to render the components available to the patient.

Compatible packed red cells are practically always available. However, rarer blood such as B Rh-negative or AB Rh-negative may not be available in the amount needed. Notify the Transfusion Service 24-48 hours in advance if your patient has a rare blood type or has an irregular antibody. Should slow transfusion be needed to prevent congestive heart failure, request packed cells that can be split into three portions and transfuse one part at a time. Use Y filter. Whole blood units are not available except for neonatal exchange transfusion.

1. Pediatric portions: One unit of packed cells can be divided into three portions of approximately 80 mL each or eight portions of approximately 30 mL each.. All infants and small children receive O packed cells. Double or triple crossmatching of nursery infants with one unit is encouraged. Use pediatric red cell filter. All of our "O" type pedi PC are from donors that have no antibodies to cytomegalovirus and all are irradiated.
2. Washed red cells: A unit of blood crossmatched for a patient can be washed in the Transfusion Service within 2-3 hours after receipt of the request for washing. However, the unit will expire in 24 hours and should not be washed unless transfusion is imminent. Washing is not done routinely between 2300 and 0800. Washed cells are used in cases of suspected anaphylactoid reaction from foreign protein.
3. Frozen thawed washed cells: This expensive product must be ordered one day in advance and usually is ordered at the request of a Hematology consultant. Once thawed it has a shelf-life of 24 hours. Use Y filter.
4. Irradiated packed red cells: 3,000 rads of gamma irradiation or 1500rads of Xray irradiation denature nuclear DNA of lymphocytes so that they cannot divide. Graft versus Host Disease is thus prevented. The component should be given to immunocompromised patients cases, to those receiving HLA matched components or units from blood relatives, as well as the very immature neonate. Use Y filter.
5. Packed red cells from blood donors that have no antibodies to cytomegalovirus: This product is given to the immature neonate, to pregnant women, and to CMV negative potential bone marrow transplant candidates. Use pediatric red cell filter for pedipacks and Y filter for adults. CMV transmission can be prevented with component leukoreduction (already performed on UCDMC products) if seronegative products are unavailable.
6. Irradiated red blood cells from donors that have no antibodies to cytomegalovirus are also available. These products should be ordered as far in advance as possible. Use Y filter.
7. Autologous blood products: Preoperative donations by the patient for future use by that person are considered the best possible hemotherapy and should be considered in all cases in which the medical condition of the patient does not make it harmful. Such units are kept in the Transfusion Service until they expire. They are then incinerated. Please forward knowledge about autologous donations drawn in other blood centers to the UCDMC Transfusion Service. Fibrin glue can also be made from autologous donations.
8. Directed donations: Blood donations from relatives and friends for a certain patient are processed routinely by BloodSource. All directed donor units are irradiated. They are incinerated when they expire. Use Y filter.

Compatible plasma is usually available. It takes 30 to 40 minutes to thaw and prepare; Transfusion Services keeps a certain number thawed at all times. The thawed plasma should be used within four hours. "JUMBO" bags of fresh frozen plasma are available. They contain 400mL plasma from one single donor. There are 3 sizes of units available: the 400 mL, ~200 mL, and ~80 mL (pediatric units). Only the 400 mL are prethawed. Use Y filter.

If a type and antibody screen or a type and crossmatch has been performed within 72 hours, please order with either a manual B605 form, an Invision Blood Order form; with ERM Order Entry, only a demographic patient ID sticker is submitted after the order is placed. Telephone all orders for plasma products (platelets, fresh frozen plasma, cryoprecipitates) to the Transfusion Services.

Pooling 5 cryoprecipitates takes one hour to prepare. The pooled components, placed in a plastic bag, should be used within four hours. 5 prepooled (before freezing) cryoprecipitates are occasionally available. These are used for medically appropriate patients. This product takes ~30 minutes to prepare and should be used within four hours. Use a Y filter.

Are not available at this time.

This component is equivalent to eight platelet packs but is derived from one donor rather than eight different donors. It can be divided into either halves or quarters for smaller volume & platelet therapy needs. HLA matched and crossmatch compatible platelets are available for patients who are have HLA antibodies, but before ordering these special products, evaluate if fresh type specific platelets increased the patient's platelet count appropriately. A platelet count collected 1 hour post platelet transfusion is helpful for planning platelet therapy in refractory cases. Use a Y filter; product is already leukoreduced.

Factor VIII concentrate, Factor II, VII, IX, and X complex, serum albumin and minidose of immune Rh0(D) globulin are distributed by the Pharmacy. The macrodose of immune Rh(D) globulin is available in the Transfusion Service. Factor VIIa (Nova VII) is ordered from the Pharmacy.

ALL ORDERS FOR BLOOD AND BLOOD COMPONENTS MUST ORIGINATE IN THE TRANSFUSION SERVICE. DO NOT CALL DIRECTLY TO THE BLOODSOURCE. Blood is a precious commodity. Try to avoid waste.

Please report information pertaining to antibodies directly to the Transfusion Service Clinical Lab Scientists as soon as information is available. This will greatly expedite availability of blood for patients and could, in fact, prevent a serious transfusion reaction considering antibodies of low activity levels may not be detectable.

Generally, newborn babies receive irradiated components from CMV antibody-negative donors. If feasible, neonates will be placed on a limited donor exposure protocol and receive blood from the reserved unit throughout it's shelf life. They may share blood units because they generally need small amounts of blood.

All neonates will be given irradiated and CMV negative red cell, platelet and granulocyte components.

1. Any untoward or unexpected reaction of a patient to blood or blood components can be life-threatening and must be reported to the Transfusion Service immediately at ext. 4-2870. Stop the transfusion immediately and keep saline line open.

   Fill out a Transfusion Reaction Investigation Report and a Miscellaneous Laboratory Request form and send them to the laboratory with: l) unused blood still present in the plastic bag, saline bag and filter attached; 2) a 4mL EDTA tube drawn immediately following the reaction; and 3) a voided 10 ml urine sample collected as soon as possible after the reaction.

   Label all specimens and two Miscellaneous lab slips properly with the name of patient, hospital unit number, date and time of collection, block initials of the person collecting specimen, and physician requesting investigation. For infants under l0 kilograms, submit one 4 mL EDTA tube with at least 1 mL of blood. It is not medically indicated to catheterize patients to obtain the urine for an investigation. The next urination will suffice.

2. An evaluation of the results will be made by the Transfusion Service director who will report the results to the doctor caring for the patient. Transfusion reactions are worked-up depending on the individual reaction, and may include some or all of the following tests: repeat blood type, repeat crossmatch, direct Coombs test, free serum hemoglobin, total bilirubin, haptoglobin level, methemalbumin, urinalysis for occult blood as well as HLA antibody study, bacterial culture, and Gram stain of the blood component.

   Additional transfusions may be given while the transfusion reaction investigation is in progress; however, the physician should contact the resident pathologist on call at ext. 4-2870 or via the paging system for interpretation of the transfusion reaction work-up before additional blood is transfused.

Red cell units are held for 3 days from date of specimen draw for crossmatching.

If 72 hours have elapsed since the last transfusion, a fresh EDTA tube of blood should be drawn from the patient for a new crossmatch before another unit of blood is to be administered. (This is designed to minimize extravascular hemolytic transfusion reactions of a delayed nature since an antibody may have developed during the past three days.)

Administration of blood and blood components

1. Dispensing Blood and Components
2. Blood Bank Order Form (B605)
3. Physician Blood Order Form
4. Blood Bank Requisition for Exsanguination
5. UCDHS Guidelines for Adult Transfusion
6. UCDHS Guidelines for Pediatric Transfusion
7. Transfusion Reactions
8. SCN/Pediatric Admission Authorization and Blood Transfusion Option Form

1. To prevent blood shortage, early release of blood at the doctor's discretion is encouraged to free up units of blood for another patient.
2. If surgery is canceled, please notify the transfusion service ((916) 734-2870) at the time the operating room or the ward is notified of the cancellation.
3. In medical cases when the present need for blood has passed, notify the Transfusion Service ((916) 734-2870) to release the blood held for a given patient.
4. A resident and/or the attending is always on duty and available for any questions.