The primary purpose of this department is the provision of safe, compatible blood and blood components for transfusion.
The preferred product supplied for adult transfusion is packed red cells in a CPD anticoagulant additive solution (volume approx. 250-300 ml per unit). This replaces whole blood or concentrated cells, which are no longer routinely available. The laboratory stocks all blood groups with the exception of Group AB RH D Positive, the volume of each group corresponding to the prevalence of the blood group in the regional population; AB Rh D Positive Patients are provided with AB Rh D Negative blood, this is to reduce stock wastage. The shelf life of a standard bag of red cells is approximately 30 days.
Blood for neonatal and paediatric transfusion is also kept in stock however, blood for exchange purposes is not. This is available on request but there will be a short delay before issue as it will need to be delivered from the National Blood Service Centre in Birmingham. Only blood group O RhD Negative is kept in stock for neonates due to low demand, though this is suitable for all groups. All units are also irradiated in case of intra-uterine transfusion history.
A stock of fresh frozen plasma is held in the department, stored at -25°C. The laboratory stocks all blood groups , the volume of each group corresponding to the prevalence of the blood group in the regional population. The stock is kept frozen to improve the shelf life of the product, which can be up to two years. Once thawed, the shelf life reduces dramatically to 24 hours (refridgerated) and 4 hours (un-refridgerated) respectively. There will be an inevitable delay between request and supply while the plasma is thawed, which is approximately 30 minutes.
Plasma for neonatal and paediatric patients is available on site. Plasma for these patient groups is now sourced from the USA and is treated with methylene blue as part of a vCJD risk reduction strategy.
For patients born after 01/01/1996, Octaplas will be issued instead of standard FFP. Octaplas is a solvent-detergent treated FFP (SD-FFP) and is also used as a precaution to reduce transfusion transmission of prion-associated diseases. SD-FFP is recommended for plasma exchange in patients with thrombotic thrombocytopenic purpura (TTP).
Plasma is no longer the preferred therapy for treating warfarin reversal, please see Octaplex.
A small stock of pooled cryoprecipitate (volume approx. 150-200ml per unit) is held in the department, stored at -25°C. Cryoprecipitate is available in all blood groups. The stock is kept frozen to improve the shelf life of the product, which can be up to two years. Once thawed, the shelf life reduces dramatically to 24 hours (refrigerated) and 4 hours (un-refrigerated) respectively. There will be an inevitable delay between request and supply while the cryoprecipitate is thawed, which is approximately 30 minutes.
The life span of platelets is short and therefore no stock is maintained by the department, appropriate units are ordered in as required for individual patients on a day to day basis. The department receives regular routine deliveries from the NHS Blood and Transplant Centre in Birmingham, so all routine requests will arrive via this route (see times below). Urgent requests for platelets will still need to be delivered from Birmingham, so there will be an inevitable delay between request and supply. Requests for multiple bags of platelets must be made through the Consultant Haematologist.
Stocks of 20% (100ml volume) and 5% (100ml volume) human albumin are maintained by the department. This will only be issued on receipt of a written or order-comms request (X-Match form).
Anti-D immunoglobulin is used to prevent RhD negative women of child-bearing age becoming sensitised to RhD positive red blood cells. This is to protect a RhD baby’s red blood cells either during the current or future pregnancies. Stocks of 1500IU are maintained in the department and are available on request.
Haemate is used to prevent or to stop bleeding caused by the lack of von Willebrand factor and factor VIII (Haemophilia). Haemate is not stocked in the department but is available on request from the Haemophilia Centre, Birmingham. Haemate can also be used in the management of acquired factor VIII deficiency and for treatment of patients with antibodies against factor VIII.
FEIBA (Factor VIII inhibitor bypassing activity) is another product that can be used to control bleeding in haemophilic patients who have developed inhibitory antibodies against factor VIII or IX.
Octaplex is made from human plasma and contains human coagulation factors II, VII, IX and X. It is used for the prevention (during surgery) and treatment of bleeding caused by the acquired or congenital lack of vitamin K-dependent coagulation factors, particularly those caused by warfarin overdose. Stocks of 250IU and 500IU are kept in the department and are available on request. All issues of Octaplex will be referred to the Consultant Haematologist for approval. An Octaplex dose calculator is available on the ICE ordering system and administration advice can be obtained from the laboratory.
Recombinant activated factor VII (Novoseven) is indicated for the prevention of bleeding in surgical interventions or treatment of bleeding episodes in haemophilia A or B patients with inhibitors to FVIII or FIX, patients with acquired haemophilia or patient with congenital FVII deficiency. A small stock is held on site which is available on request. All issues of Novoseven will be referred to the Consultant Haematologist for approval.
The blood transfusion department operates a strict sample acceptance criteria in line with current BCSH guidelines.
The Blood Transfusion Department will accept either order comms request forms or standard pink blood transfusion request forms. Order comms request forms must be printed off and signed by the requesting clinician. Standard pink request forms must be completed in full and signed by the requesting Doctor or Nurse. The following patient information must be completed:
(a) Surname (correctly spelt)
(b) First name (correctly spelt)
(c) Date of birth
(e) Hospital identification number/NHS number
(h) Ward or department
(i) Date and signature of person taking the sample
Pre-printed labels may be used on the request form but must be present on all three copies. Full demographics are required to minimise the risk of patients with the same or similar names being given the incorrect blood component. Any incomplete or incorrectly labelled forms or specimens will not be accepted. Details on the request form must match the enclosed blood sample.
The following clinical information is required on the request form:
(a) Diagnosis/ Reason for request; this should include details of any surgical procedure
(b) Number and type of components requested
(d) Any special requirements, such as irradiated, CMV negative or HbS negative
(e) If group and screen only
(f) Date and time required
Requests for infant cross-matching (four months or younger), should ideally be made on a paediatric cross-match form, as they carry infant and maternal details. If requested on order comms, please place a request for the infant and a group and screen request for the mother. Please state the volume of any product required.
For AAE requests for patients whose details are unknown or incomplete, the following data is required at minimum:
- Casualty number (111….)
- The words ‘UNKNOWN MALE’ or ‘UNKNOWN FEMALE’
- Date and signature of person taking the sample
This information must be present on both the specimen and form.
All requests for blood transfusion should be sent directly to the laboratory and not left at specimen collection points.
All samples for the Blood Transfusion Department should be completed in full by hand, signed and dated at the bedside by the person collecting the sample.
PRE PRINTED LABELS MUST NOT BE USED ON BLOOD SAMPLES FOR BLOOD TRANSFUSION.
|Group and screen / crossmatch||1 x 6ml EDTA (pink)
|Ante-natal Kleihauer||1 x 6ml EDTA (pink)|
|Delivery Kleihauer||Mother – 1 x 6 ml EDTA (pink)
Infant cord – 1 x 6 ml EDTA (pink)
|Cold agglutinin screen||1 x 4 ml EDTA (purple) completed by hand, signed and dated.|
|DAT||1 x 4 ml EDTA (purple)|
|Transfusion Reaction Investigation||1 x 6ml EDTA (pink) post transfusion. Also take samples for FBC, PT/APTT, U&E, LFT and urine sample.|
|Red cell antibodies||2 x 6ml EDTA (pink)|
|HLA B27||2 x 4 ml EDTA (purple)|
|Heparin-induced thrombocytopenia (HIT) test||6ml EDTA (purple) and 6 ml clot (red)|
|Neonatal alloimmune thrombocytopenia (NAIT)||Maternal: 3 x 6ml EDTA and 6ml clot
Paternal: 3 x 6ml EDTA
Neonate or cord blood, if possible: 1 ml EDTA
Investigations for white cell or platelet antibodies will only be referred to the National Blood Service after discussion with the Consultant Haematologist. For individual tests not listed here, please contact the blood transfusion laboratory for specimen requirements.
Wherever possible, requests should arrive in the department allowing at least one full working day for the work to be carried out in case any irregularities are found. If it is planned to admit a patient for routine surgery then specimens should be sent to the department well in advance of admission if possible e.g. on the day the patient is seen in pre-assessment clinic.
In line with current BCSH guidelines, two samples will be required to determine the blood group of a patient before a crossmatch is released.
- If a patient has a historical blood group on record, just one sample for the current request is required.
- If a patient has no blood group on record, two samples (with two request forms) are required. These samples should be taken by two different people, or if bled by the same person must be taken 30 minutes apart.
- In life-threatening cases where there is insufficient time to take a second sample, only O RhD Negative (females under 60 years) or O RhD Positive (males and females over 60 years) blood will be issued until a second blood group sample is received.
The validity of a sample for use in transfusion depends on the history of the patient. If a patient is pregnant or has received a transfusion recently, the patient may have developed clinically significant antibodies. We therefore need a sample much closer to the transfusion date to ensure we have the most up to date information for cross-matching.
- For patients transfused or pregnant within the previous 3 months, a fresh sample must be taken within 72 hours of the next transfusion.
- For all other patients, a fresh sample is required up to 7 days before the next transfusion.
Samples for all routine group and screens will be stored for 7 days before discard.
For all urgent requests or requests where a full working day’s notice cannot be given, the requesting Medical Officer must telephone the department to explain the degree of urgency in order that other routine matching can be re-scheduled.
Matched blood will be found in one of the following places:
- In the Pathology Laboratory Issue Blood Bank prior to removal to satellite issue banks, on route 021.
- West Wing satellite blood bank on the hospital corridor, level 2 of the West Wing. For AAE, West Wing and Modular Block patients.
- Maternity satellite blood bank located on Delivery Suite. For Maternity and NNU patients.
Locations 2 and 3 each contain 2 units of O RhD negative ‘Flying Squad’ blood for emergency use.
A group and screen (previously known as group and save) is performed if a patient is at risk of bleeding. The sample is tested for blood group and a general antibody screen, and held in the department for use in the event that blood is required.
The majority of red cells issued from the department are cross-matched. This involves taking a sample of blood from the donor bag and incubating it with the patient sample, to ensure each donor bag is a perfect match. When a cross-match is requested, a blood group and antibody screen are also performed.
In an emergency scenario, type specific blood can be issued from the department in 10-15 minutes. A sample must be sent to the laboratory immediately, and a blood group will be performed. Donor bags of the patient blood group will then be released, and cross-matched retrospectively. Type-specific blood is still unmatched, but should be switched to once the patient blood group is determined.
Flying squad blood is unmatched O RhD negative blood which is held around the hospital site in the satellite blood banks. Flying Squad blood should only be used when there is insufficient time to determine the blood group of the patient. Once the blood group of the patient is known ‘type specific’ unmatched blood can be issued. When units of flying squad are removed from the blood bank, the staff in the Blood Transfusion department MUST be informed immediately. Fresh units will be issued and placed in the appropriate blood bank as soon as possible to replace the removed units.
Flying squad blood is located:
- 2 adult units in West Wing satellite blood bank on the hospital corridor, level 2 of the West Wing.
- 2 adult units in Maternity satellite blood bank located on Delivery Suite.
The administration of blood and blood components is the responsibility of the medical and nursing staff. Before commencing blood transfusion, ALL details on the bag label must be confirmed with the patient wristband to ensure that they are correct and pertain to the patient concerned. This must be performed by a member of staff who has completed their blood transfusion administraton training.
ANY DISCREPANCIES MUST BE RESOLVED BEFORE TRANSFUSION COMMENCES
The kleihauer test is an acid elution technique used to quantitate feto-maternal haemorrhage. Is is performed on RhD negative mothers for potentially sensitising episodes, and at delivery, to determine if prophylactic anti-D is required.
The department offers a polyspecific and a monospecific direct antiglobulin test. The direct antiglobulin test (also known as the direct Coombs test) is used to detect if antibodies orcomplement system factors have bound to red blood cell surface antigens in vivo. The DAT is used primarily to help diagnose haemolytic anaemia, a condition in which red blood cells (RBCs) are being destroyed more quickly than they can be replaced, due to antibodiesattached to RBCs. The cause may be an autoimmune disorders such as systemic lupus erythematosus, malignant diseases such as lymphoma and chronic lymphocytic leukemia, and infections such as mycoplasma pneumonia and mononucleosis. It can also occur in some people with the use of certain medications, such as penicillin.
A DAT is used to help diagnose haemolytic disease of the newborn (HDN) due to an incompatibility between the blood types of a mother and baby, and is also used to investigate a suspected transfusion reaction.
The department offers a test to screen for cold agglutinin disease. Cold agglutinin disease is an autoimmune disease characterized by the presence of high concentrations of circulatingantibodies, usually IgM, directed against red blood cells. It is a form of autoimmune haemolytic anaemia, specifically one in which antibodies only bind red blood cells at low body temperatures, typically 28-31°C. Specimens received for cold agglutinin analysis will be subjected to an investigation of haemolysis, samples with a positive DAT will be forwarded to the RCI Laboratory at Birmingham NBS, where antibody titre levels are also performed.
Patients can develop red cell antibodies through transfusion or pregnancy. These red cell antibodies need to be identified to enable the issue of compatible blood.
Neonatal allo-immune thrombocytopenia (NAIT) is caused when there are genetic differences between the foetal and maternal platelet antigens, and the mother has developed platelet antibodies, resulting in thrombocytopenia in the neonate.
HLA B27 is a blood test to look for a specific protein found on the surface of white blood cells. The HLA-B27 test is primarily ordered to help strengthen or confirm a suspected diagnosis of ankylosing spondylitis, reactive arthritis, juvenile rheumatoid arthritis, or sometimes anterioruveitis.
All specimens for donor HLA typing are referred to NHS Blood and Transplant, Birmingham. Specimen requirements vary and should be discussed with the laboratory when HLA typing is being arranged.
The department has two routine deliveries every day, Monday to Friday. The deliveries arrive at 12 pm (orders must be in by 9 am), and 4:30 pm (orders must be in by 1 pm). There is a facility for ad-hoc orders, but this will result in additional cost to the Trust, and should be avoided for non-urgent cases.
Most blood transfusions go very smoothly. However, mild problems and, very rarely, serious problems can occur.
Acute immune haemolytic reaction is very serious, but also very rare. It occurs if there is a mismatch between the patient blood group and that of the donor. The transfused red blood cells will be haemolysed in vivo, and the by-products damage the kidneys.
The symptoms include chills, fever, nausea, pain in the chest or back, and dark urine. The transfusion must be stopped at the first sign of this reaction.
Allergic reactions to the blood given during transfusions can happen even when the blood given is the right blood group.
Allergic reactions can be mild or severe. Symptoms can include:
- Chest and/or back pain
- Trouble breathing
- Fever, chills, flushing, and clammy skin
- A quick pulse or low blood pressure
- Nausea (feeling sick to the stomach)
The transfusion should be stopped at the first signs of an allergic reaction. The health care team should determine how mild or severe the reaction is, what treatments are needed, and whether the transfusion can safely be restarted.
This is a haemolytic reaction occurring more than 24 hours after transfusion. It may be caused by an antibody which is undetectable to routine blood bank screening. Symptoms occur usually within 1-14 days of transfusion
Additional information on different types of transfusion reaction and Transfusion transmitted infections
On suspecting a blood transfusion reaction, contact the blood bank immediately. You will be required to send to the laboratory:
- The remnants of all bags of blood or products given to the patient, spigotted in a sterile manner and giving times of administration.
- Venous samples for full blood count, PT/APTT, LFT, U&E taken away from the site of transfusion.
- The first urine voided by the patient after the incident.
- Completed transfusion reaction investigation form.
For advice on the clinical management of the patient, please contact the Consultant Haematologist.
Acute Transfusion Reaction Management FlowCharthttp://www.transfusionguidelines.org/docs/pdfs/htm_edition-4_all-pages.pdf p74
Information on different types of transfusion reaction and Transfusion transmitted infections
All transfusion reactions must be reported to the Blood Bank for haemovigilance monitoring. The Blood Bank is responsible for alerting the MHRA SABRE (Serious Adverse Blood Reactions and Events) and SHOT (Serious Hazards of Transfusion) of all incidents relating to the blood transfusion, from the initial sample being taken to the administration of the blood product.
As with all treatments, a blood transfusion should only be prescribed when really necessary. The risks of having a transfusion need to be balanced against the risk of not receiving one. The clinician should discuss treatment options with the patient before reaching a decision to prescribe blood components. You should give the patient information on the benefits and risks of transfusion as well as any alternatives. Consent and the reason for transfusion should be documented in the patient record.
Patient information leaflets are available from the National Blood Service website
Clinical Practitioners must be aware of Jehovah’s Witness patients’ beliefs in relation to receiving blood or blood products and of the non-blood, medical alternatives to transfusion that may be applicable.
Jehovah’s Witnesses are encouraged to carry a document at all times which details their wishes about medical care. Please forward a copy of this directive to the blood bank to ensure the patient’s wishes are strictly honoured.
Please see Trust policy for Patients refusing blood products.
For further details on the alternatives to transfusion, including cell salvage, please contact the Transfusion Laboratory or the Transfusion Practitioner who will be happy to discuss any individual cases.