Blood Transfusion Procedure

PRINCESS ALEXANDRA HOSPITAL
PROCEDURE MANUAL

Section: Clinical Procedure No. 01552/v13/07/2012
Procedure Title: Blood and Blood Product Transfusions

Purpose:
To ensure the safe administration of blood and blood products and
the management of transfused patients based on current clinical
guidelines.

Authorised to Undertake the Procedure:
Medical Officers,
Nurse Practitioners (endorsed),
Registered Nurses,
Enrolled Nurses (without restrictions),
Princess Alexandra Hospital Transfusion Service (Blood Bank).

Indications for Use:
A decision to transfuse a patient is made from a medical
assessment of an individual patients clinical need which complies
with clinical transfusion guidelines.

National Health and Medical Research Council (NHMRC) Clinical
Practice Guidelines (2001) are available for all commonly used blood components.

HYPERLINK TO: Australian Red Cross Blood Service Website
Australian Red Cross Blood Service: Blood Component Information
National Health and Medical Research Council Website Blood and Blood Products
Queensland Blood Management Program Website
Metro South Transfusion Resources Website

Education:
Australian Council on Healthcare Standards require that training in blood policy and procedures occurs for
new staff and all staff involved in blood transfusion are required to complete specific training and education
in relation to blood transfusion. This should be completed every 2 (two) years, and/or as new guidelines or
procedures are advised.
1
For online training see the Blood Safe E-Learning program: http://www.bloodsafelearning.org.au/
This e-learning program has been designed to provide you with an opportunity to develop your knowledge of
blood and to encourage safe transfusion practice and the appropriate use of blood components. Completion
of this course attracts 2 RCNA CNE points.

Medical
Biennial completion (every two years) of Blood Safe E-Learning It is recommended that interns and house
officers review this training at least every two years.

Nursing Staff
Biennial (two years) completion of Blood Safe E-Learning for registered nurses and enrolled nurses involved
in the transport, checking , administration and monitoring of blood transfusions is a mandatory requirement
at Princess Alexandra Hospital.

HYPERLINK TO: Quick Transfusion Administration Checklist
Initiator: Metro South Transfusion
Committee

Review Officer: Chairman, Transfusion
Committee

Review Summary: 13
th
Version

Applicable To: All Staff

Last Review Date: 04 2011

Next Review Date: 04 2013

Authority: Transfusion Committee

..
Signature of Authorising Officer

Replaces: 01552/v12

Key Words: Blood Transfusions

References: Refer to end of document
Printed version is an uncontrolled copy 1

Table of Contents

Section A: Venous Access and Equipment for Transfusion.............................................................................. 4
Venous Access .............................................................................................................................................. 4
Blood Administration Sets.............................................................................................................................. 5
Leucodepletion (also refer to: Appendix 2: Administration of Fresh Blood Components)............................. 6
Blood Warmers .............................................................................................................................................. 7
Infusion Devices............................................................................................................................................. 8
Section B: Concurrent Fluids and Medications ................................................................................................. 9
Concurrent Fluids........................................................................................................................................... 9
Medications.................................................................................................................................................. 10
Section C: Related Medical and Nursing Issues ............................................................................................. 11
Prescription of Blood and Blood Products ................................................................................................... 11
Informed Consent......................................................................................................................................... 12
Pre-Transfusion Blood Sample Collection................................................................................................... 15
Transfusion Requests and Use of Transfusion Department Request Form................................................ 16
Care and Monitoring of Transfused Patient (also refer to: Appendix 2: Administration of Fresh Blood
Components)................................................................................................................................................ 17
Documentation of Transfusions ................................................................................................................... 18
Staff Responsibility for Blood Transfusions and Handling of Products........................................................ 19
Section D: Administering Blood and Blood Products ...................................................................................... 21
Administration of Blood Products................................................................................................................. 21
Collection of Blood Products from the Blood Bank and Delivery to Ward or Operating Room................... 22
Inspection of Blood and Blood Products...................................................................................................... 23
Identity Check of Patient and Blood Product............................................................................................... 24
Completing the Transfusion......................................................................................................................... 28
Section E: Management and Reporting of Adverse Reactions....................................................................... 29
Haemovigilance............................................................................................................................................ 30
Section F: References..................................................................................................................................... 32
Section G: Glossary of Terms ......................................................................................................................... 34
Section H: Appendices .................................................................................................................................... 35
Appendix 1: Queensland Incidents in Transfusion Reaction Chart............................................................. 35
Appendix 2: Administration of Fresh Blood Components............................................................................ 36
Appendix 3: Special Requirements.............................................................................................................. 37
Appendix 4: Administration of Intravenous Immunoglobulin........................................................................ 38
Appendix 5: Administration of Albumin........................................................................................................ 40
Appendix 6: Coagulation Factors................................................................................................................. 41
Appendix 7: Transfusion Administration Checklist....................................................................................... 42
Appendix 8: Pre-transfusion Sample Collection Flow Chart........................................................................ 44
Appendix 9: Administration of Blood Component Flow Chart...................................................................... 45
Appendix 10: Informed Consent Quick Reference Guide for staff............................................................... 46
Appendix 11: Princess Alexandra Hospital Massive Transfusion Guidelines.............................................. 47
Appendix 12: Transfer of Blood Components
16
........................................................................................... 48


Blood Management:

Blood management refers to appropriate use of blood components and derivatives. Wherever possible,
utilise strategies to avoid or reduce the need for blood transfusion. Optimal patient blood management will
result in improved patient outcomes by reducing exposure to infectious and non-infectious complications of
blood transfusion. Identification and investigation of pre-operative anaemia may allow timely correction of
anaemia, thereby avoiding patient deferral or precipitous measures necessitated by immediate pre-operative
recognition of this problem. Utilise techniques and technology which will aim to conserve the patients own
blood. The following alternatives are available:
Treat preoperative anaemia wherever possible. The following factors are needed for effective red cell
production; iron replacement, vitamin B12, folic acid and Vitamin C. Erythropoietin analogues can also
be effectively employed in some cases. Timely and appropriate use of these therapies can assist in
ensuring the patient enters surgery in the best condition.
Reduction in surgical blood loss, utilising techniques which conserve the patients blood supply.
Minimally invasive surgical technique, surgical instruments that prevent blood loss, medications which
may assist in control of bleeding.
Recycling the patients own blood during surgery through intra operative cell salvage.

Not all of these options as suitable for all patients. Blood management requires a team approach to develop
a plan of care aimed at reducing blood loss.


Section A: Venous Access and Equipment for Transfusion

Venous Access

Peripheral intravenous access should be sufficient to maintain an adequate rate for transfusion without
causing a risk of haemolysis.

The size of cannula chosen depends on the size and integrity of the vein.
The recommended cannula size is a standard 18-20 gauge for adults.
Smaller gauges can be used, but this may restrict the flow rate leading to a much longer transfusion time.
2

Central venous access devices can be used to safely administer blood and blood products.

Some Peripherally Inserted Central Catheters (PICC) with small tubing diameters may pose problems
with blood or platelet administration leading to slow flow rates and clogging.

Recommended Intravenous Access Set Up for Blood Transfusion Administration

During transfusion reactions it is necessary to attach a N/Saline line to keep the vein open, without removing
the transfusion giving set. Flushing the existing blood administration set during a transfusion reaction is not
recommended
3
(Section E: Management and Reporting of Adverse Reactions).

Assess whether the patient has alternative IV access prior to commencing the transfusion, and if there is no
available alternative, the following can be attached to the existing venous access prior to commencement:
A Smartsite2 way extension set, primed with 0.9% Sodium Chloride may be attached directly to the
PIVC or single lumen of CVAD device to provide additional IV access point.

Alternatively, if patient already has a single extension set attached, a 3 way tap may be utilised on the
end of the blood administration set. Ensure the tap is primed with 0.9% Sodium Chloride and a bung is
attached to the side of the 3 way tap which is not in use.
+
Either of these devices would allow attachment of a N/saline line as close as possible to the patient in the
event of a transfusion reaction. Following the completion of all prescribed blood components, the extension
set and/or 3 way tap must be removed along with the IV blood giving set and a new extension set/IV line
added if there is to be additional fluid replacement following transfusion.


Blood Administration Sets

All blood products must be transfused through an IV blood administration set incorporating a standard
in-situ 170-200 micron filter, which removes clots and cellular debris
3
(micro-aggregates) that may
form during collection and storage.
IV Blood administration sets must not be piggy-backed into other lines.
Medications shall not be added to any blood component prior to its transfusion.

Priming:
Prime the standard blood administration set only with 0.9% Sodium Chloride or the blood product.
DO NOT prime the blood administration set with Dextrose.

IV Set Changes:
One (1) standard blood administration set may be used for the administration of 2 4 units of red blood
cells (provided the flow rate remains adequate).
All IV blood administration sets must be changed on completion of the transfusion or with lengthy
transfusions, every 8 hours
2
to reduce the risk of bacterial contamination.
In an emergency or theatre situation 8 10 units may be transfused before the set is changed,
provided the set is changed every 8 hours.
Extension set tubing and or 3 way tap attachments should also be changed, if attached to the
blood administration set. See Princess Alexandra Hospital Procedure 01585 Peripheral Intravenous
Cannulation (PIVC) Insertion and Care or 01505 CVC Procedure for procedure to follow for changing
of extension sets and IV giving sets following blood transfusion.
If a platelet transfusion is required following a red cell transfusion a new IV blood administration set is
required, as red cell clots and cellular debris trapped in the micron filter would subsequently trap the
platelets.

Central Venous Access Devices:
A standard gravity-flow IV blood administration set with an in-line 170 200 micron filter should be
used with intravenous access devices which guarantee the maintenance of an adequate flow rate.

Picture 2. Gravity Blood
Administration set: with inline
170-200 micron filter in drip
chamber.
Picture 1. Standard IV Fluid
Administration set.
Not for use with Red cells,
platelets, FFP, Cryoprecipitate
Can be used with plasma
derived blood products: Intragam
P, Flebogamma, Albumex.
Picture 3. Infusion Pump Blood
Administration set with inline
170-200 micron filter.

Leucodepletion (also refer to: Appendix 2: Administration of Fresh Blood Components)

Purpose:
To remove most of the white blood cells from either red cell or platelets.

Indications:
To reduce the risk of Cytomegalovirus (CMV) transmission in the immunosuppressed patient (CMV
seronegative products may be indicated in certain patients).
To reduce the risk of platelet refractoriness from alloimmunisation to leucocyte antigens especially in
patients with malignant haematological disease.
To reduce the rate of alloimmunisation in non-hepatic solid organ transplant candidates.
2-3

Pre-storage leucodepleted platelets and Red Cells are provided by the Australian Red Cross Blood Service.
These products DO NOT require a Leucocyte Depletion Filter.


Blood Warmers

Red Cells should only be warmed by using a commercial device fitted with an external thermometer and
audible warning. Blood warming should not be improvised by putting the bag in hot water, into a microwave
oven or on a radiator.
2,4

Indications for use (medical order required):
Massive transfusions.
When transfusing patients with cold haemo-agglutinins who are at risk of haemolysis.
Apheresis procedures.

Precautions:
Blood and blood products should not be warmed above 41C.
5

Prior to use blood warmer consumables must be primed as for other blood infusion sets.

Quality/Infection Control:
Water bath warmers must be emptied and cleaned after use, as per hospital equipment cleaning
procedure. They are to be stored dry.


Infusion Devices

The use of a gravity line is preferred when administering transfusions of fresh blood components
such as red cells, platelets, FFP via peripheral intravenous cannulas.

Electronic Volumetric Pumps
Infusion pumps may be used provided the manufacturer has certified that they are safe to infuse blood
components.
Specific blood administration sets are available for use with IV pumps and must be used when
administering transfusions, these have a 170-200 micron filter in-situ.
Infusion Pumps are not necessary to deliver transfusion of fresh blood components but they can assist
in administering solutions at a controlled rate and measurement. Utilisation of an infusion pump for
fresh blood components may be indicated if a patient is at particular risk of fluid overload.
Ideally, when using an infusion pump, 18-20 gauge cannulas should be used to decrease the risk of
haemolysis of cells through a small gauge cannula.

Monitoring and Checking of Infusion Pump
Include pump settings, flow rates and volume of blood component in the standard checking procedure.
Both the pump setting and volume delivered shall be monitored hourly throughout the infusion to ensure
that expected volume is delivered and to monitor the patient for signs/symptoms of transfusion reactions.

Use with Central Venous Access Devices
Infusion pumps may be of use during the transfusion of blood products where a satisfactory gravity flow
rate cannot be guaranteed (e.g. Peripheral Inserted Central Line PICC or Implanted Port POC).
2

Ensure largest lumen of CVAD is used when administering blood products.

Plasma Derived Blood Products
Infusion pumps are recommended for use with some plasma derived blood products such as intravenous
Intragam P, Albumex, and Octagam. See Appendix 4 Administration of Plasma Derived Blood Products

External pressure devices SHOULD NEVER BE USED IN ROUTINE TRANSFUSIONS
5

Purpose:
To administer a unit of red cell within a few minutes.

Precautions:
Should only be used in an emergency situation.
Ensure a large gauge venous access/cannula.
Exert pressure evenly over the entire bag.
Have a gauge to measure the pressure.
Never exceed 300mm Hg of pressure.
Be monitored at all times when in use.


Section B: Concurrent Fluids and Medications

Concurrent Fluids

Only isotonic 0.9% Sodium Chloride can be added to a blood product intravenous (IV) line.

Incompatible Fluids:
Infusates containing Calcium (e.g. Ringers Lactate, Haemaccel, Gelofusine) are incompatible with
blood products collected in an anticoagulant containing Citrate, as calcium-containing solutions will
reverse the anti-coagulant effect of citrate resulting in clotting.
Dextrose 5% in water and hypotonic/hypertonic saline solutions may cause red cell haemolysis.


Medications

Do not add medications to blood and blood products on the same IV line, as there may be a direct
incompatibility with the blood or the anti-coagulants or preservatives added to the product.

It is recommended that medications be administered via a 3 way tap or 2 way extension set if attached,
rather than the side port of the blood administration set.

In exceptional circumstances when there is a need for IV medications to be administered via the same IV
line as a transfusion and where no alternative venous access is available.

Procedure:
STOP the transfusion.
Flush the IV line with 0.9% Sodium Chloride via the y-connector.
Administer the IV medication in accordance with the manufacturers or Pharmacy directives.
Flush the IV medication with 0.9% Sodium Chloride.
Resume the transfusion.

This must not result in the time for transfusion of red cells exceeding 4 hours from the original despatch time
from blood storage.

Co-administration of morphine, pethidine and/or ketamine diluted in 0.9% Sodium Chloride (as for patient
controlled analgesia or continuous side arm infusion) via a non reflux valve has been shown not to
adversely affect red cells.
7


Section C: Related Medical and Nursing Issues

Prescription of Blood and Blood Products

Medical Officers and endorsed Nurse Practitioners (licensed to prescribe blood and blood products) are
solely responsible for prescribing blood and blood products on the appropriate form Queensland Health
Intravenous and Subcutaneous Fluid Order Form.

In addition to the patient identification details (name, date of birth, gender and UR number) the
prescription should also specify:
Date for transfusion,
Type of blood or blood product to be transfused,
Volume or quantity to be given,
The duration of the transfusion,
Any special instructions (diuretics, pre-medications, CMV anti-body negative products, gamma-irradiated
products, or blood warming).

Medical Officers and endorsed Nurse Practitioners (licensed to prescribe blood and blood products) are
responsible for ordering blood and blood products from the Princess Alexandra Hospital Blood Bank with a
signed written request or a telephone order followed by a signed written request.

Where possible Medical Officers and endorsed Nurse Practitioners are also responsible for explaining
the significant risks, benefits and alternatives to the transfusion and giving the patient an opportunity to ask
questions.
Hyperlink to: Consent Information Patient Copy Blood and Blood Products Transfusion Consent

Registered Nurses in some circumstances may verbally request blood and blood products
2
but a medical
order/prescription is required for their administration.


Informed Consent

Informed Consent:
Informed consent for transfusion means a dialogue has occurred between the patient and the doctor. The
significant risks, benefits and alternatives to transfusion including the patients right to refuse the transfusion
should be discussed.

Documentation of informed consent for blood and blood product transfusion has now been recommended
by:
Australian Red Cross Blood Service (ARCBS).
Australian and New Zealand Society of Blood Transfusion (ANZSBT) and Royal College of Nursing
Australia Guidelines for the Administration of Blood Components (2004).
The National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines on the Use of
Blood Components (2004).

These documents support the Australian Council of Healthcare Standards (ACHS) Safety Standard 1.5,
Criterion 1.5.5 within The EQuIP4 Guide Part 1 (2007)
1
, which includes the following:
A procedure exists for ensuring written consent.
The consumer is made aware the risks associated with blood component therapy.

Informed Consent must be obtained and is to be documented by a consent form or by documenting the
discussed information in the Patient Medical Record by the Medical Officer, in accordance with PAH
Procedure 01542 Consent and Queensland Health Policy Statement Informed Consent for Invasive
Procedures (14025).

Informed Consent Discussion:
As a result of this discussion the patient should:
Understand what medical action is recommended.
Be aware of the risks and benefits associated with the transfusion.
Appreciate the risks and possible consequences of not receiving the recommended therapy.
Be given an opportunity to ask questions.
Give informed consent for the transfusion.
The medical officer obtaining the blood transfusion consent may discuss the current information detailed in
Appendix 8: Informed Consent Quick Reference Guide with the patient prior to signing the consent form.

In the event that the patient lacks capacity to give consent, consent should be obtained from the first in order
of the following:
1. The Advanced Health Directive of the patient if one exists;
2. A Guardian appointed by the Guardianship and Administration Tribunal;
3. A Health Attorney appointed by the patient;
4. A Statutory Health Attorney; or
5. The Adult Guardian as the decision maker of last resort.

The Statutory Health Attorney is the first in the order of the following:
1. A spouse provided the relationships close and continuing;
2. A person 18 years or over that is the patients carer (not paid carer);
3. A person 18 years or over, whom is a close friend or relative of the patient.

See Princess Alexandra Hospital Procedure 01305 Substitute Decision Making for Adults who Lack Capacity

Which forms will need to be completed?
In order to standardise the consent process for blood and blood product transfusion Queensland Health has
developed a state-wide Blood and Blood Product Transfusion specific consent form and accompanying
patient information sheet is available from the Queensland Health Informed Consent website.
Surgical Procedures: Queensland Health's procedure specific consent forms have a statement
included within the patient's consent should a blood transfusion be required. This statement covers
consent for blood transfusions for that specific procedure only. The Blood and Blood Products
Transfusion Consent Patient Information Sheet should be given to the patient, next of kin or guardian
and explain as per the above procedure for obtaining blood transfusion consent.
Transfusions in Emergency Situations and Critically Ill Patients: In the event that a critically ill
patient is unable to give consent or in an emergency situation the Medical Officer may determine that the

transfusion is in the patients best interest. Document in medical notes reason why consent could not be
obtained. For further details regarding patients who are unable to provide consent, refer to: 01305
Substitute Decision Making for Adults who Lack Capacity.
For Patients who are unable to consent in Non-Urgent situations Next-of-kin, Living will or Adult
Guardian may be approached to give consent which includes documentation and provision of the
informed consent patient information Consent Information Patient Copy Blood and Blood Products
Transfusion Consent.

Order of File:
The Queensland Health Blood and Blood Product Transfusion Consent will be located in alphabetical
order at front of chart.

Patient Information:
Patients/significant others should be provided with the Consent Information Patient Copy Blood and Blood
Products Transfusion Consent outlining the risks and benefits of blood transfusion prior to commencement of
blood transfusions. NB: These brochures do not take the place of providing verbal discussion.
The information can be provided to patients:
When the patient is required to have a pre transfusion blood sample;
Prior to a blood component transfusion administration; or
Prior to a blood component transfusion treatment regime; or
As soon as possible after a transfusion when the transfusion has been administered in an emergency
situation.

An interpreter and a translated brochure must be used for non-English speaking people.
The Consent Information Patient Copy Blood and Blood Products Transfusion Consent contains links to
further information including English and multicultural information brochures from the Australian Red Cross
Blood Service.

Validity of Blood and Blood Product Transfusion Consent:
Consent may be obtained to cover a specific period/course of treatment of up to 12 months using the
Queensland Health Blood and Blood Product Transfusion Consent Form for those patients who may
require numerous transfusions over an extended length of time/course of treatment.
For a specific time period or group of procedures covered by one informed consent, the consent needs
to be person, product and procedure specific.
The specified period for which the consent is obtained must be clearly documented and flagged for
review in the patients medical record.
If there are any changes within the specified period/course of treatment (i.e. change in clinical indications
for transfusion, capacity of the person, change in patients condition, change in blood product used etc.)
for which the consent was obtained, the consent must be reviewed by a medical officer with
responsibility for the care of the patient.

Documenting Verbal Consent:
If the Blood and Blood Product Consent Form is unavailable, consent for blood transfusion may be
documented as a note in the medical record. This documentation should include the elements of the
informed consent discussion and a statement that the patient has agreed to the transfusion. Please note
verbal consent is not valid for 12 months but must be ascertained each transfusion episode.

Responsibilities:
Medical:
Medical responsibility to obtain informed consent and ensure correct documentation is completed.
Provision of written information.
In all cases where consent is undertaken for a course of treatment/specific period of time, consent
must only be obtained by the attending registrar or consultant with responsibility for the care of the
patient.
The attending registrar or consultant may delegate the responsibility of providing information and
obtaining consent to another doctor provided they are satisfied that the doctor has the necessary skills
and experience.

Nursing:
Provision of written information.

Nursing responsibility to check that all relevant documentation is completed by the medical officer, at the
time of ordering the transfusion or prior to the collection any fresh blood component for transfusion from
blood bank in non-emergency situations.

NB: Any Princess Alexandra Hospital employee who becomes aware that a patient does not have sufficient
information to make an informed consent should notify the Attending Medical Officer, delegated doctor.

For Refusal of Blood and Blood Product Transfusion see Princess Alexandra Hospital Procedure
01128 Refusal of or Limited Consent to Blood and Blood Product Transfusion.

Informed Consent Summary

Emergency/Critical Ill patients Medical Surgical
In an emergency situation or
critically ill patient, where the
patient is unable to give consent
and the blood product transfusion
is required immediately:
(i) to save the persons life; or
(ii) to prevent serious injury to a
persons health;
the blood product transfusion may
be carried out in the absence of
consent.
Separate Blood and Blood
Product Transfusion Consent
Form is required. This is valid for
one transfusion episode or
multiple transfusions up to a
period of 12 months provided
there are no changes to type of
blood products required,
indications, patient condition.
More than one type of blood
component may be consented for
at the same time with the one
form, provided it is clearly
documented.
Dates of treatment course should
be clearly documented in the
space provided.
A separate Blood and Blood
product Transfusion Consent
Form will not be required. The
Queensland Health procedure
specific consent forms have a
statement regarding blood
transfusion should this be
necessary. This statement covers
consent for blood transfusions for
that specific procedure provided it
has been discussed with the
patient. The consent will only be
valid if the indication for the blood
transfusion is directly related to
the procedure for which the
patient has consented.
Consent form will not be required
for urgent transfusions of blood
products when a guardian or a
parent or a responsible person or
the Guardianship Tribunal is not
available.
A new blood transfusion consent
form may be required if indication,
type of blood component, patient
condition or patient capacity
changes.
A separate blood transfusion
consent form may be required if
indication, type of blood
component, patient condition or
patient capacity changes.
The reason for being unable to
obtain consent and the indication
should be documented in the
patient medical record as soon as
possible following the event.

The indication of each transfusion
episode needs to be clearly
documented within the medical
record.
The indication in relation to the
associated surgical procedure
needs to be clearly documented,
as with all transfusions, within the
medical record if a transfusion is
required postoperatively.
Patients next of kin or guardian
should be informed as soon as
possible after the transfusion of
blood and blood products. Blood
and Blood Products
Transfusion Consent Patient
Information Sheet can be provided
The Blood and Blood Products
Information Sheet should be given
to the patient, next of kin or
guardian and explain as per the
above procedure for obtaining
blood transfusion consent.
The Blood and Blood Products
Information Sheet should be given
to the patient, next of kin or
guardian and explain as per the
above procedure for obtaining
blood transfusion consent.


Pre-Transfusion Blood Sample Collection

Experience has shown that many errors occur in documentation when labelling samples and completing
forms.
It is recommended that verbal verification be sought with the patient or a second person verifies that the
patient is correctly identified and that the patient details have been correctly written on both the sample tube
and Clinical and Statewide Services (CaSS) Pathology Queensland Request Form (Form A/3879).

ENSURE IN LEGIBLE HANDWRITTING

Only Phlebotomists, Medical Officers and Registered Nurses deemed competent in venipuncture should
collect blood samples for pre-transfusion compatibility testing.

Authorisation for pre-transfusion testing is with a legibly written Clinical and State-wide Services
Pathology Queensland Request Form (Form A/3879) and includes:
Patient surname, given name, date of birth and UR number,
Location of the patient,
Date and time of collection,
Name of requesting medical officer and signature,
Reason for the request (e.g. group and hold),
Date required,
Name and signature of the collector in the ALL collectors must complete section to confirm the
correct labelling and time of collection of the sample.

The patient is asked to state their surname, given name, date of birth and is checked against the patient
identification band and Clinical and Statewide Services Pathology Queensland Request Form (Form
A/3879).

Outpatients must be asked for evidence of identity.

Only one patient is to be bled at a time. After blood collection, the pathology sample tube must be legibly
labelled immediately before leaving the patient with the following:
Patient surname, given name, date of birth, gender, location and UR number.
Time and date of collection.
Signature of the collector confirming the patients identity.

Blood tubes must NOT be pre-labelled.
DO NOT use printed labels for labelling the blood tubes.
2

Both the Clinical and State-wide Services Pathology Queensland Request form (Form A/3879) and
pathology cross-match tube must have identical patient identification information.
Hyperlink: Pathology Queensland Blood Bank: Specimen Collection

Princess Alexandra Hospital Blood Bank will discard any incorrectly labelled tubes and the
procedure will need to be repeated.


Transfusion Requests and Use of Transfusion Department Request Form

A correctly completed State-wide Transfusion Department Request Form will be required for the
issue of any blood products from the blood bank
(includes Red Blood Cells (RBC), Fresh Frozen Plasma (FFP), Platelets (PLT), Cryoprecipitate (CRYO),
Cryo-Depleted Plasma (CDP), Prothrombinex (PTX), anti-D Ig, Hep B IG, Tetanus Ig, Zoster Ig, Biostate and
Albumin).
N.B. Zoster Ig and Biostate are Restricted Products. The requesting Medical Officer is still responsible
for obtaining ARCBS Medical Officer approval.

The purpose of the transfusion department request form is to:
- Improve provision of patient clinical information for the request of red blood cells and specialised
products.
- To highlight the National Health and Research Medical Council Practice Guidelines on the Use of
Blood Components and collect accurate information on the laboratory parameters related to the
request.
- Improvements in safety and quality of blood transfusion practice across Queensland including
appropriate blood use and haemovigilance.
- A higher standard of safety and care for patients.

Mandatory fields are clearly marked with a red asterisk ( * ), and includes Haemovigilance information
(relevant test results (Hb, Plt, Count, and/or INR/Fib) and Clinical Indication Code).
Test results and Clinical Indication Code (IC) (Indication for Use detailed on the back of the request
form) are only required for the relevant blood product, i.e. Hb and IC for RBC; Plt Count and IC for
Platelets; INR/Fib for FFP or Cryoprecipitate.
Incomplete or incorrect Transfusion request forms will be NOT TESTED until correctly completed, this
may result in delays in processing transfusion request UNLESS the situation is clinically urgent, where
Emergency procedures will be activated uncross matched products issued in most circumstances
(except for IVIg which has a separate procedure).
Pathology request forms should be used for all Transfusion Department blood test requests, e.g. Group
& Hold, antenatal tests, cord blood testing, DAT, transfusion reaction investigations. Transfusion request
form is only to be used for requesting blood products.
PLEASE NOTE no other Pathology requests, e.g. FBC, U&E, BHCG etc are to be made on the
transfusion request form.
All phone requests for blood products must be followed Transfusion Department request Form (only the
Massive Transfusion Protocol is exempt after the initial transfusion request form (or phone call); clinical
information will be obtained by direct contact with the Clinicians).
Follow this link for further information on how to complete the Transfusion Department Transfusion Request
form http://qheps.health.qld.gov.au/pathology/tests/blood-bank/how-to-order/request-form.htm


Care and Monitoring of Transfused Patient (also refer to: Appendix 2: Administration of Fresh
Blood Components)

The most basic principle of patient care during transfusion is to ensure patient safety.

Patients receiving transfusions shall be monitored for signs of the potential complications of transfusion and
any suspected problems dealt with swiftly and efficiently. There is wide variation in the frequency of nursing
observations during transfusion
8
and it is not clear what is the optimum type and frequency of observations.

Whenever possible avoid overnight transfusion.
2

Blood product transfusion between 2000 0700hrs is not recommended for stable patients due to
reduced overnight staffing and medical cover on the wards. Direct observation of patients and ability to
recognise and respond to transfusion reactions is reduced.
Check urgency with Medical Officer.
If there is doubt, do not delay transfusion.

Severe reactions are most likely to occur within the first 15 minutes of the start of each blood product,
and patients should be most closely observed during this period.

Instruct the patient to immediately report any signs of a transfusion reaction, e.g. fever, chills, pruritus,
urticaria, chest or lower back pain, headache, nausea, bleeding, tachycardia or dyspnoea.

Observation and monitoring of transfusions (refer to Appendices)
It is recommended
2-4
that a patients temperature, pulse, respirations and blood pressure be recorded with
the administration of each unit of blood and blood product as follows:
Immediately before starting the transfusion.
Repeated 15 minutes after the start, during which time the patient is closely monitored for any adverse
reactions.
At the end of each unit.
Flow rate and cannula site must be monitored hourly.
Frequent visual observations are to be maintained throughout the transfusion for signs of transfusion
reactions or fluid overload.

Frequency of observations during a transfusion depends on the patients condition before the
transfusion, or if the patient becomes unwell, or shows signs of a transfusion reaction.

Observations of patient vital signs, the date and the time are to be recorded on the Form: PA 216 Acute
Observation Chart.

Unconscious or Anaesthetised Patients
5
It is more difficult to monitor for signs of transfusion reactions unconscious or anaesthetised patients. During
the first 15-20min following the start of a unit of blood or blood component, transfusion reactions should be
considered when assessing a change or deterioration in the patients condition.
Closer observation patients who are unable to verbalise symptoms or use the call bell due to mental or
physical limitations.

Hypotension, uncontrolled bleeding or generalised oozing during surgical procedures may indicate a
coagulopathy, e.g. disseminated intravascular coagulation. However, these symptoms may suggest the
possibility of an acute haemolytic reaction due to an incompatible red cell transfusion.

Haemoglobinuria or oliguria may also be an early sign of an acute haemolytic transfusion reaction due to an
incompatible red cell transfusion.

Medical Officer Approval must be obtained for the transfusion of blood and blood products to febrile
patients.


Documentation of Transfusions

Complete documentation of transfusions is essential so that the cause of serious adverse effects can be
adequately investigated, which can entail a retrospective look back. It also facilitates auditing of all aspects
of the transfusion process.
9

Patient Medical Record:
A permanent record of the transfusion of blood and blood components and the administration of blood
products must be kept in the Patient Medical Record including:
Blood transfusion compatibility report with date, time and signatures denoting that correct checking
procedures have been followed.
Prescription of blood products on the Queensland Health Intravenous and Subcutaneous Fluid
Order Form.
Including:
- Name and signature of prescriber,
- Date, time, route of administration, transfusion rate, special requirements,
- Signatures of staff checking and administering blood product,
- Volume, start and finish times,
- A complete record of the blood product or donation numbers transfused (yellow sticker).
Nursing observations during the transfusion PA 216 Acute Observation Chart.
- Minimum observations, baseline/at 15mins/post transfusion. Observations may be more frequent
dependant on patient condition.

Transfusions are to be documented by both medical and nursing staff to include:
5
Indication for the use of blood product.
Outcome of the transfusion including whether or not it achieved the desired effect.
Occurrence and management of any adverse effects.


Staff Responsibility for Blood Transfusions and Handling of Products

Many groups of staff are involved in one or more aspects of blood transfusion. Some procedures are
specific to one staff group, but many can be carried out by more than one.

Medical Staff and Endorsed Nurse Practitioners (licensed to prescribe blood and blood products) are
solely responsible for prescribing blood and blood products and for ensuring adequate documentation of
blood transfusion in the patient medical record PA Patient Progress Notes, including documenting
consent.

Registered Nurses can perform the following actions and be responsible for:
Follow-up/arranging the venepuncture for the pre-transfusion blood samples for compatibility testing
Collection of blood and blood products from the Princess Alexandra Hospital Blood Bank.
Provision of patient information brochures relating to blood transfusion to patients.
Ensuring consent for blood transfusion is appropriately documented by a medical officer prior to
commencing transfusions. Explanation to the patient of the signs and symptoms of possible blood
transfusion reactions and procedures to follow in the event of this occurrence.
Safely carrying out the procedure for the administration of blood and blood products.
Monitoring patients during transfusion, and carrying out the appropriate actions in the event of adverse
effects.
Reporting of transfusion reactions or other incidents related to the transfusion to the Medical Officers, to
the service provider (Princess Alexandra Hospital Blood Bank) and PRIME incident reporting system.
Documentation of the procedure in the medical record.

Enrolled Nurses (Medication Endorsed), when delegated by a Registered Nurse can perform the
following actions and be responsible for:
Checking order for blood and blood products, calculating administration rate, priming IV lines, connecting
blood product to line, except via Central Venous Access Lines.
Monitoring patients during transfusion, and carrying out the appropriate actions in the event of adverse
effects, including notification of delegating Registered Nurse.

Phlebotomists responsibilities are restricted to:
Venepuncture of blood samples for compatibility testing.

Ancillary staff responsibilities are restricted to:
The collection of blood and blood products from the Princess Alexandra Hospital Blood Bank or blood
storage refrigerator.
It is emphasised that this is a vital role, and errors in blood collection have been identified as an
important cause of administration of the wrong blood.
10

Staff of Princess Alexandra Hospital Transfusion Service (Blood Bank) are responsible for:
Ensuring that the labelling of request forms and blood samples comply with best practice guidelines.
Blood grouping and compatibility testing.
Checking whether there are any special requirements whenever blood or blood products are requested.
Ensuring that blood and blood components are properly labelled, and the identification details of the
patient and the blood to be transfused are the same on the compatibility label attached to the component
and the blood transfusion report form.
Investigation and reporting of transfusion reactions or other incidents related to transfusion.

Clinical Governance:
The Princess Alexandra Hospital Clinical Executive is responsible for ensuring that all health care
professionals are informed of, and follow, policies on blood transfusion through its arrangements for clinical
governance with an established Transfusion Committee.

Princess Alexandra Hospital Transfusion Committee is responsible for:
Reviewing transfusion policies and procedures.
Reviewing the arrangements for training of staff in transfusion policies and procedures.
Reviewing adverse transfusion events including near misses.
Reviewing the appropriateness of blood transfusion, and making recommendations about the proper use
of blood and blood products.

Recommending corrective action in transfusion practice, where indicated.
Promoting continuing education in transfusion medicine for all relevant members of staff.
Investigating the use of Information Technology (or other technology) to improve transfusion safety.

Current Representation on the Princess Alexandra Hospital Transfusion Committee:
Division of Medicine,
Division of Surgery,
Division of Cancer Services,
Division of Nursing,
Pathology Queensland: Laboratory/Blood Bank,
Australian Red Cross Blood Service,
Anaesthesia,
Intensive Care,
Transfusion Clinical Nurse Consultant.

Scheduled Meetings:
Every three four months.

Report to:
Princess Alexandra Hospital Safety and Quality Committee.

Transfusion Clinical Nurse Consultant is responsible for:
Working in conjunction with Metro South Transfusion Committee, Blood Bank and Clinicians to:
Promote safe and appropriate blood transfusion practice.
Promote the continuing education of best practices in blood transfusion for hospital medical and nursing
staff.
As a clinical resource for staff, answer questions regarding blood component and blood product
administration.
Ensure blood transfusion procedures and guidelines reflect the available national and international
standard practice.
Provide assistance in the reporting and follow up of adverse transfusion events including near misses
and transfusion reactions.
When required, recommend corrective action in transfusion practice.
Increase staff awareness of the availability of patient information materials and encourage provision of
these materials to all patients receiving blood products.
Liaise between laboratory and clinical areas.
Ensure quality improvement in transfusion practice:
- Auditing of transfusion practice to make certain key performance indicators are identified,
attainable and monitored to continuously improve our service.
- Audit adherence to transfusion related guidelines and disseminate data effectively.
- Effectively manage/coordinate improvement initiatives and changes within the organisation across
all domains of transfusion practice.
- Report to the District Safety and Quality Committee through the Quality Department.


Section D: Administering Blood and Blood Products

Administration of Blood Products

Errors at the time of administration of blood or blood products are the most frequent documented site of error
culminating in the transfusion of the wrong blood.
11-12

However, preceding errors in blood sampling, laboratory procedures and especially in withdrawal of
blood components from storage refrigerators were found to be an important contributory factor in many of the
incidents.
13

Two (2) members of nursing or medical staff, one of whom must spike and hang the bag, shall be
responsible for carrying out the final identity check of the patient and blood/blood product.
5

Checking of blood and blood products at the patients bedside must be audible to the patient.
Checking of blood and blood products in the operating theatre must be audible to the attending
clinical staff.

The following checks are to be carried out at the patients bedside to ensure the right patient receives the
right blood/blood products:
The bag is inspected for any leaks, discolouration or the presence of large clots.
Identify the patient by asking them to state their name and date of birth, UR Number and/or Address and
check this against the patients identity band. NO WRISTBAND = NO TRANSFUSION
Check that the patients name, date of birth and UR number on the blood transfusion compatibility report
form matches the patients identity band.
Check that the blood product number on the compatibility report matches the label/tag number on the
product bag or bottle.
Check that the patients Blood Group and Rh D status on the compatibility report matches the label/tag
on the product bag.
Check that any special requirements on the medical order match the compatibility form and product
bag(s) (e.g. CMV status and/or irradiation).
Check the expiry date on the bag(s) or bottle.
Check the medical orders for type of blood product, special requirements, number or quantity of blood
product required, rate of administration and indication for pre-medications or diuretic.
The compatibility report and prescription forms are to be signed by both staff members.
The staff member who administered the blood product is also required to enter the time and date on both
forms.
If using an infusion pump: pump settings, flow rates and volume of blood component should be included
in the checking procedure.

Infusion Rates (Refer to: Appendices)
All individual units of blood and blood product transfusions must be completed within 4 hours of removal
from designated blood storage.
2,5

If there has been a delay in starting the transfusion, and the blood has been out of the fridge for more than
30mins, it may still be used for that patient provided transfusion of the unit will been completed within 4
hours of the original despatch time.

Princess Alexandra Hospital Blood Bank staff or the Haematology Registrar should be consulted if it appears
that the hang time may exceed the 4 hour timeframe.


Collection of Blood Products from the Blood Bank and Delivery to Ward or Operating Room

Removal of blood and blood products from the storage location was identified as a major source of error in
the transfusion of the wrong blood in the 1996/97 SHOT report.
10

Multiple errors were found to contribute to two-thirds of such incidents, and collection of the wrong blood was
the most frequent cause of the first error. Most errors at the time of collection occurred because the blood
was not checked for identity with the patient, but there were some even when it was personally handed from
blood bank staff to ancillary staff or a member of the clinical team.

Pre-Transfusion Administration Checklist (Refer to: Appendices)
The patient should have appropriate IV access before blood is collected from Princess Alexandra
Hospital Blood Bank to avoid unnecessary delays in the transfusion process.
The designated staff member collecting blood products must have some documented evidence of the
patients identity (e.g. a printed patient ID label or IV fluid order form), checked against the patient.
The blood transfusion compatibility report form showing product and patient ID details is held in
Princess Alexandra Hospital Blood Bank and is issued with the first unit of blood or single issue blood
product.
All withdrawals of blood products from the Princess Alexandra Hospital Blood Bank and from any
approved blood refrigerators are to be documented either electronically in Auslab or in the appropriate
register book. The relevant details include product description details, blood group product number or
batch number, the name of the staff member and the time of removal from storage.
Except in an emergency, only one bag of red blood cells is to be taken from the Princess Alexandra
Hospital Blood Bank at a time.
Prior to removal from the Princess Alexandra Hospital Blood Bank and any approved blood
refrigerator, the details recorded on the compatibility report must be checked against both:
- The adhesive Australian Red Cross Blood Service label on the blood component; and
- The Transfusion Medicine compatibility tag attached to the blood product.
- Batch numbers of bottled blood product are to be checked against the adhesive label on the
bottle.

There is no variation in procedure for the collection or identification of Autologous Blood.

Refrigeration of Blood and Blood Products:
Blood and certain other blood products are only stored in specialised temperature controlled blood
transfusion refrigerators in the Princess Alexandra Hospital Blood Bank and Ward 2E and never in Ward
domestic refrigerators.
8
Red cells and Plasma which is stored within the 2E satellite blood fridge must be signed into and out of the
Princess Alexandra Hospital/2E Fridge Blood and Blood Product Sign out Sheet.

Fresh Frozen Plasma and Cryoprecipitate are stored in a freezer at minus 25C and Princess Alexandra
Hospital Blood Bank staff need 20 30 minutes to thaw FFP to room temperature.
Other non-refrigerated blood products are stored in designated areas in the Princess Alexandra Hospital
Blood Bank.
Platelets are stored at 20 24C on a shaker in Princess Alexandra Hospital Blood Bank (or Ward 2E for
short periods only) to prevent aggregation or clumping.
3
DO NOT store platelets in a refrigerator or put on ice.


Inspection of Blood and Blood Products

Princess Alexandra Hospital Blood Bank staff checks the expiry date and inspect blood product before issue
with particular attention to:
Integrity of the pack by checking for leaks at the ports and the seams.
Evidence of haemolysis in the plasma or at the interface between red cells and plasma (check interface
in attached donor segments).
Evidence of unusual discolouration or turbidity.
Presence of large clots.

If there is evidence of any of the above, the blood product should not be used and should be returned to
the issuing blood service (Princess Alexandra Hospital Blood Bank, Australian Red Cross Blood Services,
CSL or other manufacturer).

It is best practice for the staff administering blood products to inspect each blood product in a similar way
before its transfusion and to return the blood product to the Princess Alexandra Hospital Blood Bank if any
defects are found.


Identity Check of Patient and Blood Product

The bedside check is a vital step in preventing transfusion error, and ALL staff shall be vigilant in the
checking procedure to ensure that the right blood product is given to the right patient.

Two (2) members of staff shall be responsible for carrying out the identity check of the patient and the blood
product at the patient bedside. The members of staff shall be doctors or nurses holding current registration.

The patient shall be positively identified by asking the patient to state their surname, given name and
date of birth (whenever possible) and make sure that the surname and first name are the same as on the
patient identification bracelet. NO WRISTBAND = NO TRANSFUSION

Special care should be taken for those patients who cannot state their name for whatever reason.

ALL Princess Alexandra patients having a blood transfusion must have at least one securely
fastened Patient Identification Bracelet indicating the patient surname, given name, date of birth and
Unique Record (UR) number.

Exceptions to this rule:
Emergency retrieval: where an emergency UR number has been allocated to an unknown patient

Issue of blood products to patients with an Unknown Identity
Blood and blood products are issued to the patient details as specified on the cross-match request form and
blood specimen tube. When a cross match specimen is labelled with an Unidentified Patient Identity is
processed by the laboratory, blood products will be issued to the Unidentified Patient only. To pick up
blood products from the blood bank take the Unidentified Patient ID label.

Issue of blood products when the patients identity has changed
Once a patients identity has changed, a new blood sample must be taken if the patient requires blood
products.
When a group and hold or cross-match has been taken from a patient in DEM whos identity is unknown, if
any details for that patient are changed in HBCIS than a new sample MUST be taken. Blood Bank cannot
release crossmatched blood for any other patient details but they can release MEDEVAC,
uncrossedmatched Type O negative. This ensures the Blood Bank release the right blood product to the
right patient, preventing transfusion errors.

See Princess Alexandra Hospital Procedure: 01915 Unidentified Patients in Emergency Department
Administrative and HBCIS Management of

Verification of patient identity should be checked with parent/carer/spouse if the patient is unable to state
his/her name.

The staff member spiking/hanging the component shall be one of the two (2) persons who have
undertaken the component and patient identity check.

The following details (patient surname, given name, date of birth, patient UR number) shall be checked
and found to be identical on:
The patients identification band,
The compatibility label attached to the blood/blood product,
The prescription,
The blood transfusion compatibility report form.

In addition the following checks are to be made:
Blood group and donation/batch number on the blood product bag/bottle shall be checked and found to be
identical to the information on the label attached by the laboratory.

Blood group on the blood product shall be compatible with the blood group of the patient as indicated on the
compatibility label attached to the blood product. If the blood group of the blood product and the patient are
not identical, the Princess Alexandra Hospital Blood Bank will make a specific comment to indicate that the
blood is compatible (or most suitable available).


Blood product shall be checked for compliance with any special requirements on the prescription sheet
(gamma-irradiated, CMV-seronegative).

Blood product shall be checked to ensure it has not passed its expiry date, or expiry time in the case of blood
products with a short shelf-life (washed red cell and platelet concentrates).

Check for consent documented in medical record (except during emergency transfusions) and any pre-
medications required.

If a DISCREPANCY IS FOUND during the bedside identity checking procedure and is not covered by a
comment by the issuing Princess Alexandra Hospital Blood Bank, the blood or blood product shall not be
transfused until the discrepancy is resolved with Princess Alexandra Hospital Blood Bank.


Red Cell

26

Unique identifier
Collection
date
Expiry date and
time
Component
Specific details
(Inc. Modifications)
e.g. CMV Negative,
Irradiated
Blood Group

Red Cell (phenotyped)

Unique identifier
Component
Specific details
Expiry date and
time
Collection
date
Blood Group
Red cell
phenotype

Printed version is an uncontrolled copy

Platelet

Blood Group
Specific details
Unique identifier
Component
Expiry date and
time
Preparation
date

Irradiated Blood Labels

If Irradiated blood components are required irradiated labels are attached to the bag prior to gamma
irradiation to ensure that the correct dose was received. Once the correct dose is received the NOT on the
label turns opaque so that it cannot be seen. Please note: Plasma blood components and plasma derived
blood products do not require irradiation.


Completing the Transfusion

All blood individual units of blood should be infused within 4 hours of removal from designated blood
storage (with exception of Factor VIII or IX prepared for continuous infusion).

Ensure the blood transfusion compatibility report form is filed in the Patient Medical Chart.

Ensure documentation is completed (see Section C: Documentation of Transfusions).

Ensure empty transfusion bags/blood product bottles are disposed into clinical waste plastic (glass bottles
are not suitable for recycling).

Retention of empty blood bags for a period of 48hrs after transfusion has been previously
recommended
4
so that they are available if a severe transfusion reaction occurs some hours after
discontinuation of the transfusion. This can be considered to be good practice, but it is cumbersome to
implement and the benefits are uncertain.

Blood bags need only be retained and sent to back to blood bank in the event of an acute transfusion
reaction occurring.


Section E: Management and Reporting of Adverse Reactions

Many of the serious adverse events following blood transfusion are unpredictable. The most important are
acute and delayed haemolytic transfusion reactions, febrile (nonhaemolytic) transfusion reactions, urticaria
and anaphylaxis (including IgA/anti-IgA reactions), transfusion-related acute lung injury (TRALI), post-
transfusion purpura (PTP), transfusion-associated graft-vs.-host disease (TA-GvHD)
4
and transmission of
infection.
(Refer to: Section H Appendices)

If a transfusion reaction is suspected remember, a second patient may be at risk and other blood
products collected from the same donor may be implicated.

Transfusion reactions are unpredictable and may vary from mild to life threatening.

Any change in a patients vital signs or complaints of symptoms must be acted upon immediately.

In the event of a transfusion reaction (See Appendix 1 Queensland Incidents in Transfusion Reaction
Chart):
STOP the transfusion and leave the giving set attached until situation has been discussed or a medical
officer has reviewed the patient.
Keep the vein (KVO) open with saline using a new giving set.
Check and record the patients vital signs: monitor: temperature, blood pressure, pulse and respirations
every 15mins.
Repeat checks of all labels, forms and patient identity, including the patient wristband, to determine
whether the right blood component was given to the right patient.
Notify Medical Staff.
- Management of the patient will depend on the severity of the transfusion reaction. In the case of a
mild transfusion reaction, the Medical Officer may recommend the transfusion be recommenced
after the administration of the appropriate medications, e.g. anti-pyretic or anti-histamine.
Notify Princess Alexandra Hospital Blood Bank, who may request the return of the blood product and the
collection of appropriate blood samples for further investigations.
Collect other pathology specimens, e.g. blood cultures or urine, as requested.
Continue to closely monitor the patients vital signs every 15mins until reaction resolves.
If requested, return the blood product with the administration set attached and appropriate specimens to
the Princess Alexandra Hospital Blood Bank; the blood product/administration set combination without
sharps should be double plastic bagged and tightly sealed for transport. Care must be taken not to
contaminate the blood product and administration set, as this may confound any microbiology tests.
Document the reaction and all interventions in the patients medical record.
Complete a PRIME Incident Report The QiiT Transfusion Reaction Chart can assist staff in selecting
the appropriate category for the transfusion reaction in PRIME as possible aetiologies are listed with
corresponding signs and symptoms. Some mild reactions may not require a report see Appendix 1: QiiT
Transfusion Reaction Chart.
Hyperlink to: Prime.

Refer ALL enquiries to:
Princess Alexandra Hospital Blood Bank (ext. 2727 or pager 496) ALL HOURS;
OR
Haematology Registrar during normal working hours.

Bacterial Contamination of Platelets
It has been recognised that bacterial contamination is a significant residual infectious risk; bacterial
contamination is the second most common cause of death related to transfusion. Australian Red Cross
Blood Service now screen all platelet components for bacterial contamination.
3

Platelet components are sampled at 24 hours after collection and will be available for issue from Australian
Red Cross Blood Service with bacterial contamination screening status as negative to date. The culture will
be incubated during the full shelf life of the platelet components. Due to the short shelf life of platelets, there
may be instances where contaminated platelets may have already been transfused. In the event of this
occurring, blood bank will notify the treating clinician and prophylaxis with antibiotics must commence
immediately. See Queensland Blood Management Program information sheets, Bacterial Contamination
Screening Clinician Advisory or Bacterial Contamination of Platelets: Patient Information.

Haemovigilance

Haemovigilance consists of the detection, gathering and analysis of information regarding untoward and
unexpected effects of blood transfusion.
14

Queensland has a state-wide, haemovigilance program, Queensland Incidents in Transfusion (QiiT),
established by the Queensland Blood Management Program to fulfil Queensland Health's obligations to
promote safe use of blood products under the National Blood Agreement.

Hyperlink to: Queensland Incidents in Transfusion Website

QiiT will contribute to a national Haemovigilance system currently being developed by the National Blood
Authority as well as defining the degree of risks associated with current transfusion practice in Queensland.
The QiiT system is designed to extract information from the PRIME system. Hyperlink to: PRIME

The QiiT haemovigilance system will only be collecting information from events related to fresh blood and
blood components:
Red cells,
Platelets,
Fresh frozen plasma,
Cryoprecipitate,
Cryo-depleted plasma,
Whole blood.

Any event related to incident, near miss or reaction to a plasma derived blood product should be
documented within PRIME but these will not be forwarded to QiiT.

Information to Assist PRIME Reporting
The QiiT Reaction Chart can assist staff in selecting the appropriate category for the transfusion reaction as
possible aetiologies are listed with corresponding signs and symptoms.
The categories for Patient Reactions for the incident Type, Blood Products, Transfusion and
Haemovigilance, within PRIME are listed below. Multiple items may be selected if required.

None: This option is always displayed, as completion of the Patient Reaction field is mandatory.

Febrile Non Haemolytic Transfusion Reaction (FNHTR): Select when the transfusion of a blood product
has caused a febrile non haemolytic transfusion reaction defined as one or more of following within 4 hours
of transfusion without any other cause (e.g. haemolytic transfusion reaction or infection) rise in temperature
during transfusion of 1
O
C or temp. =38.0
O
C; chills; sensation of cold; rigors.

Transfusion Associated Cardiac Overload (TACO): Select when volume overload led to congestive
cardiac failure within 24 hours of transfusion.

Severe Allergic Reaction: Severe allergic reaction (one or more of rash, wheezing, dyspnoea, stridor,
angioedema, generalised pruritus, and/or urticaria) during or within 24 hours of a transfusion of a blood
component or a plasma component that requires pharmacological treatment.

Anaphylaxis: Allergic reaction (one or more of rash, wheezing, dyspnoea, stridor, angioedema, generalised
pruritus, and/or urticaria) with hypotension (drop in systolic blood pressure of equal to or more than 30
mmHg) during or within 24 hours of a transfusion of a blood component or plasma component.

Transfusion Related Acute Lung Injury: Occurrence of acute respiratory distress and bilateral pulmonary
infiltrates on CXR with no evidence of circulatory overload or other potential cause within 6 hours of
transfusion of a blood component or plasma component.

Post Transfusion Purpura: An acute episode of thrombocytopenia occurring within 12 days of a transfusion
(red cells or plasma) and confirmed by the presence of platelet specific alloantibodies (usually anti-HPA1a)
in recipients blood and presence of the antithetical antigen on donor platelets, or by positive platelet cross
match.

Delayed Haemolytic Transfusion Reaction: Haemolytic transfusion reaction occurring more than 24 hours
after the transfusion.

Acute Non-ABO Haemolytic Transfusion Reaction: Haemolytic transfusion reaction (not due to ABO
incompatibility) occurring within 24 hours of a transfusion.

Transfusion Associated Acute Graft versus Host Disease: Development of symptoms and signs (fever,
erythematous skin rash, hepatic dysfunction, diarrhoea and bone marrow hypoplasia/pancytopenia) 1-6
weeks following transfusion with no other apparent cause. The diagnosis is confirmed by skin and/or bone
marrow biopsy appearances and/or the demonstration of genetic chimerism in the recipients peripheral
blood lymphocytes.

Transfusion Transmitted Infection (including Bacterial Contamination of Blood Component): A post-
transfusion infection (viral, bacterial or parasitic) not present in the recipient before transfusion of a blood
component or plasma component and present in either one of the components transfused or the donor of
one of the transfused components. Includes Bacterial Contamination of blood component detection and
confirmation of bacteria in a blood component or plasma component, which has either not been transfused to
the intended patient or was transfused but no bacteria was detected in cultures of the recipients blood.

ABO Haemolytic Transfusion Reaction: Haemolytic transfusion reaction (due to ABO incompatibility)
occurring within 24 hours of a transfusion.
The reporter is able to define the nature of the problem further with the following additional categories.
Multiple items may be selected as required.

Incorrect Blood Component Transfused (IBCT) wrong patient: Select when a blood component or
plasma component was administered to the wrong patient and there was no harm to the patient.
Incorrect blood component transfused (IBCT) not suitable: Inappropriate product/requirement not met, i.e.
Select when a blood component or plasma component ordered or administered did not meet the appropriate
requirements (expired, non irradiated, CMV negative, leucodepleted, etc.) for the intended recipient.

Transfusion time outside of prescribed rate, without circulatory overload: This category should be
selected when, as per best practice, transfusion of a blood product bag was either not completed in 4 hours,
or was significantly different from the prescribed rate and without evidence of circulatory overload. If the
incident results in circulatory overload, reporter should select the corresponding entry under the "Patient
Reaction" section.

Wrong dose/volume: This category should be selected when either the dose or volume transfused is
outside the prescribed dose or volume and without evidence of circulatory overload. If the incident results in
circulatory overload, reporter should select the corresponding entry under the "Patient Reaction" section.

Administered with contraindicated substance: Administration of an incompatible substance through the
same intravenous route as the blood component.


Section F: References

1. Australian Council on Healthcare Standards. The ACHS EQuIP 4 Guide, Part 1 Accreditation,
Standards, and Guidelines. [Online]. 2007 [cited 2010 May 11th]. Available from: URL:
http://www.achs.org.au

2. Australian and New Zealand Society of Blood Transfusion Inc. Guidelines for the administration of blood
components. [Online]. 2004 [cited 2010 May 11th]. Available from: URL:
http://www.anzsbt.org.au/publications

3. Australian Red Cross Blood Service [Online]. 2010 [cited 2010 May11th]. Available from: URL:
http://www.transfusion.com.au

4. British Committee for Standards in Haematology. Guidelines for the administration of blood and blood
components. [Online]. 2009 [cited 2010 May 11th]. Available from: URL: http://www.bcshguidelines.com

5. Australian and New Zealand Society of Blood Transfusion Inc. Guidelines for the Gamma Irradiation of
Blood Components. [Online]. 2003 [cited 2010 May 11th]. Available from: URL:
http://www.anzsbt.org.au/publications

6. South Australian Dept of Health funded Blood Safe Program. Flippin blood. [Online]. 2006 [cited 2010
May 11th]. Available from: URL: http://www.health.sa.gov.au/bloodsafe

7. Birch C, Hogan C, Mahoney. Co-Administration of drugs and blood products. Anaesthesia & Intensive
Care 2001; 29: 137140.

8. Standards Australia. Medical refrigeration equipment for the storage of blood/blood components, AS
3864. [Online].1997 [cited 2010 May 11th]. Available from: URL: http://infostore.saiglobal.com.store

9. Queensland Blood Safety Management Program. Ordering receipting blood system (ORBS). [Online].
2009 [cited 2010 May 11th]. Available from: URL: http://www.health.qld.gov.au/qhcss/qbmp.orbs

10. Williamson LM, Lowe S, Love E et al. Serious Hazards of Transfusion Annual Report 1996/97. [Online].
1998 [cited 2010 May 11th]. Available from: URL: http://www.shotuk.org/shot-reports/reports-and-
summaries-19967

11. McClelland DBL, Phillips P. Errors in blood transfusion in Britain: survey of hospital haematology
departments. British Medical Journal 1994; 308:1205-1206.

12. Sazama K. Reports of 355 transfusion associated deaths: 1976 through 1985. Transfusion 1994; 30:
583-590.

13. Waters AH, Skace P, Murphy MF, Wilkinson J , Hartigan G. National audit of the clinical blood transfusion
process. Research Unit of the Royal College of Physicians; 1998.

14. Council of Europe. Guide on the preparation, use and quality assurance of blood components. No. R
(95)15. [Online]. 2003 [cited 2010 May11th]. Available from: URL:
http://www.coe.int/t/dg3/health/publications_en.asp

15. Hussain MA, Fletcher R, Long T, Zuccaro K, Bolwel, BB, Hoeltge G. Transfusion of platelets 2h after the
completion of amphotericin-B decreases its detrimental effect of transfused platelet recovery.
Transfusion Medicine 1998; 8: 43-47.

16. Royal Brisbane and Womens Hospital Health Service District Safety and Quality Unit. 06603/CPP:
Blood and blood components, administration of (excluding Anti D) [Online]. 2008 [cited 2010 May 11th].
Available from: URL: http://hi.bns.health.qld.gov.au/rbh/policies/06603cpp.pdf

Appendix 1: Queensland Incidents in Transfusion Reaction Chart
Appendix 2: Administration of Fresh Blood Components
Appendix 3: Special Requirements
Appendix 4: Administration of Intravenous Immunoglobulin
Appendix 5: Administration of Albumin

Appendix 6: Coagulation Factors
Appendix 7: Transfusion Administration Checklist
Appendix 8: Pre-transfusion Sample Collection Flow Chart
Appendix 9: Administration of Blood Component Flow Chart
Appendix 10: Informed Consent Quick Reference Guide for staff
Appendix 11: Princess Alexandra Hospital Massive Transfusion Guidelines
Appendix 12: Transfer of Blood Components


Section G: Glossary of Terms

TERM DESCRIPTION

AABB American Association of Blood Banks
AIMS Australian Incident Monitoring System
Ancillary staff Patient care assistants, orderlies
ARCBS Australian Red Cross Blood Service
ANZSBT Australian & New Zealand Society of Blood Transfusion

BMT Bone Marrow Transplant

CMV Cytomegalovirus
Component Used throughout these guidelines to describe all components and products,
including such terms as units, packs, bottles, etc.
CSL CSL Limited

Factor VIII Antihaemophilic factor used to treat Haemophilia A
Factor IX Antihaemophilic factor used to treat Haemophilia B
FNHTR Febrile non-haemolytic transfusion reaction

HLA Human leucocyte antigen
HTC Hospital transfusion committee

ISO International Standards Organisation

NHMRC National Health Medical Research Council [Australia]
NPAAC National Pathology Accreditation Advisory Council
NZBS New Zealand Blood Service

PBSC Progenitor (Peripheral) Blood Stem Cell
PICC Peripherally inserted central catheter
PTP Post transfusion purpura

QBMP Queensland Blood Management Program
QiiT Queensland Incidents in Transfusion [Qld] Haemovigilance reporting system

RCNA Royal College of Nursing Australia

SHOT Serious Hazards of Transfusion [UK] adverse event reporting system

TA-GvHD Transfusion associated graft versus host disease
TRALI Transfusion related acute lung injury


Section H: Appendices

Appendix 1: Queensland Incidents in Transfusion Reaction Chart

T T

Appendix 2: Administration of Fresh Blood Components

Blood Component Clinical Indication Observations Special Considerations
Packed Red Blood
Cells
For routine administration, there is extensive experience of safely administering a red cell unit over
60-120 minutes per unit.P
4
P
Patients less tolerant of increased blood volume should be transfused more slowly with careful
haemodynamic monitoring.P
4
P
For some patients it may be appropriate to give a diuretic (e.g. furosemide 20 to 40mg orally),
though this is not necessary as a routine. Diuretics may be ordered between or post transfusion of
units.P
4
P
During major haemorrhage, rapid infusion (1 unit over 5-10 minutes) may be required (with
appropriate clinical and haemodynamic monitoring).P
4
P
Blood transfusion must be commenced within 30 minutes of the removal of the unit from
refrigeration.
All red cell units should be transfused within 4 hours of removal from designated temperature
controlled storage.
CMV status: Hyperlink to: HTUQHPS Blood Bank CMV Negative BloodUTH.
All Haematology patients must receive irradiated blood to prevent Transfusion Associated Graft
versus Host Disease.
Platelets Transfuse over 20 30 minutesP
2
P (10mls/min) to provide maximum benefit for the control or
prevention of bleeding.P
14
P
Administer as soon as possible after removal from continuous agitation.
Gently agitate during transport and prior to administration.
Do not refrigerate.
Criteria for CMV negative platelets: are as for red blood cells.
Criteria for Irradiated platelets: are as for red blood cells.
Patients, who have a history of febrile reactions to platelets, should be considered for pre-
medication with antipyretics, antihistamines and/or hydrocortisone.
Platelets should be given two hours after completion of Amphotericin B. This antifungal adversely
affects recovery and survival of transfused platelets.P
15
P
Fresh Frozen Plasma
and
Cryo-depleted
Plasma (CPD)
Transfuse over 20 30 minutesP

Pto provide maximum benefit for the control or prevention of
bleeding.P
14
P
A unit of FFP contains all coagulation factors: CPD has the cryoprecipitate component removed.
Transfusion of each unit of FFP/CPD must be completed within 4 hours of thawing.
Component is stored at -25C and needs to be thawed by Blood Bank before use. Thawing usually
takes approximately 30 minutes.
Once thawed, components should be transfused immediately.
Thawed components can be stored in a temperature controlled blood refrigerator at 2-6C (in a
designated temperature controlled refrigerator) but the transfusion must be completed within 24
hours of thawing.
Cryoprecipitate
Hyperlink to:
HTUMetro South
Transfusion
Resources:
Product InformationUTH

HTUMetro South
Transfusion
Resources:
Decision to
TransfuseUTH
Vital signs temperature, pulse,
blood pressure, respirations and
oxygen saturation are to be taken
and recorded:
- Before the start of the
transfusion.
- 15 minutes after the start of
the transfusion, during which
time the patient should be
closely monitored for any
adverse event (refer to:
HTUAppendix 1 Queensland
Incidents in Transfusion
Reaction ChartUTH).
- At the end of each unit of
blood.
- More frequent observations
may be necessary if the
patient becomes unwell,
shows signs of a transfusion
reaction or they are clinically
unstable.P
2
P
Transfuse as fast as tolerated.
Component contains most of factor VIII, fibrinogen, factor XIII, von Willebrand factor and
fibronectin.P
3
P
Components are stored at -25C and needs to be thawed in Blood Bank before use.
Once thawed, cryoprecipitate must not be re-frozen and should be used immediately. If delay is
unavoidable, the component must be stored at ambient temperature and used within 4 hours.P
4
P

Appendix 3: Special Requirements

Special
Requirements
Clinical Indications
Irradiated
Blood
Products
Hyperlink to:
HTUQHPS Blood Bank
Irradiated BloodUTH
Very Immunocompromised patients are at risk of developing transfusion associated graft versus host disease (TA-GVHD), which in most
cases is rapidly fatal.P
3
P
Main indications:
THaematopoietic progenitor cell transplants (Tallogeneic or autologous).
During and for a week prior to stem cell harvest.
During and for 90 days post autologous transplant.
Hodgkin's disease or Aplastic Anaemia.
Dedicated transfusion (from 1st or 2nd degree relatives).
Congenital cell mediated immunodeficiency.
Current or prior treatment with purine analogue drugs (fludarabine, cladribine or deoxycoformycin).
Transfusion of HLA matched platelets.
Products not requiring irradiation:
FFP,
Cryoprecipitate,
Fractionated products.
CMV Negative
Blood
Hyperlink to:
HTUQHPS Blood Bank
THUCMV Negative BloodUTH
Very immunosuppressed patients are at risk of developing CMV disease (as opposed to simple seroconversion) from blood transfusion and
should be given CMV negative blood.
Main indications:
CMV seronegative recipients of allogeneic Thaematopoietic progenitor cell transplants.
CMV seronegative recipients of highly immunosuppressive chemotherapy (<70 years with AML, Aplastic Anaemia).
Neonates and transfusion during pregnancy (because of foetal exposure).
Solid organ transplant.
Hodgkin's disease (but the risk is probably not as great).
If CMV serology unknown in any of the above main indications:
Use CMV negative blood products.
If CMV negative blood cannot be supplied by ARCBS (Princess Alexandra Hospital Blood Bank):
It is reasonable to give leucocyte depleted CMV untested red blood cell or platelets.
Leucocyte
Depletion/
Filtration
Hyperlink to:
HTUARCBS: FAQ:
Leucodepletion of platelets
and red blood cellsUTH
Pre storage leucodepleted platelets and Red Cells are supplied by ARCBS, and do not require bedside leucodepletion filtration.
Renal Dialysis/
Transplant
Patients
Hyperlink to:
HTUNephrology Department
ProceduresUTH

a) If a patient is on renal transplant list or may be considered as a candidate for renal transplant and requires transfusion, cyclosporin or
mycophenolate is required for 12 days. This should commence at least 2 days prior to elective transfusion or as early as clinically
appropriate. Transfusions for these patients are prescribed by renal consultant or registrar only as future renal transplantation may be
negated by development of HLA antibodies following blood transfusion. It is NO LONGER ROUTINE to transfuse patients prior to renal
transplant.
b) Blood transfusions pose an increased potassium and fluid load to patients with renal failure therefore it is ideal to administer transfusions
during dialysis, where treatment can be adjusted, i.e. changing of dialysate bath to lower potassium and inclusion of volume into
ultrafiltration goal. Transfusions are usually administered via an infusion pump, after the dialysis filter into the venous chamber to
minimise the risk of clotting.

Appendix 4: Administration of Intravenous Immunoglobulin

Dosage of IVIg products is dependent on patient weight (kg). Administration rates may differ from product information (PI) for increased patient safety with approval by Transfusion Committee.
Clinical Indications: Intravenous immunoglobulin (IVIg) is allocated in accordance with the HTUCriteria for the Clinical Use of Intravenous Immunoglobulin in Australia (2008)UTH.
Forms for requesting IVIg can be accessed at: HTUMetro South Transfusion Website, Product InformationUTH.
Storage and Transport:
When refrigerated, should be stored in a monitored blood
fridge in blood bank or Ward 2E Satellite Fridge.
Must not be stored in a domestic/ward refrigerator.
Protect from light.
Immunoglobulin products do not contain antimicrobial
agents.
The products must therefore be used immediately after
opening.
Any unused bottles must be returned to the blood bank.

Visually Inspect Product:
Do not use if product is turbid or cloudy, or contains any
sediment or particles, return to blood bank.
Should be clear or slightly opalescent.

Contraindications and cautions:
Always refer to the full product information.
Patients with rare total IgA deficiency should have the IVIg
product with the lowest IgA content INTRAGAMP is the
preferred product.
Infusion of IVIg may lead to a relative increase in blood
viscosity. Patients should be adequately hydrated prior to
commencement of the infusion.
IVIg should NOT be infused rapidly to patients at increased
risk of thromboembolic and renal adverse events,
particularly when using higher concentration IVIg products.

Infusion Equipment:
Use of an IV pump is recommended to ensure accurate
delivery of infusion rates.
Standard IV giving set or a new IV blood line (incorporating
a 170-200 micron filter) may be used.
Addition of a 3 way tap/2 way extension set when setting
up infusion line can be of use in the event of a transfusion
reaction if patient does not have alternative IV access.
Administration from glass bottles requires a vented IV line
system.
Medications/Compatible Intravenous Fluids:
Flush with 0.9% Sodium Chloride.
Do not mix any immunoglobulin with any other fluids,
medications or blood products.
Premedication may be prescribed if patient has a history of
reaction.
Before commencing the IVIg infusion ENSURE that:
Medical order/prescription including the brand and strength
of IVIg is documented.
Medical staff have discussed use of the blood product with
the patient/carer. Qld Health does not require written
consent process for plasma derived blood products as they
carry lower risks than fresh blood components.
Procedure has been explained to patient, including
possible reactions. Manufacturers patient information
brochure may be given.
Intravenous access is patent.
Baseline TPR and BP have been assessed and
documented.
The product information contained in the box has been
reviewed.
The product is allowed to reach room temperature.
Resuscitation equipment, including oxygen and adrenaline
is available and in working order.
Patients should be adequately hydrated prior to
commencement of the infusion as dehydration can be a
risk factor for adverse reactions.
RIGHT PATIENT/RIGHT PRODUCT
HTUIdentity Check of Patient and Blood Product as per
procedure 01552UTH

Infusion rates:
See table on next page for product specific infusion rates.
Start slowly and increase rate only if tolerated.
Avoid out of hours infusion of IVIg where possible.
Patients with pre existing risk factors, e.g. >65years,
diabetes, obese, cardiac disease, renal failure,
arterial/venous thromboembolic events, hyperviscosity,
paraprotein, dehydration, slower infusion rates are
recommended.
Each bottle should be completed within 4 hours.
All doses of IVIg are capped by ARCBS at a weight of
100kg.
Infusion rate calculations should be based on patients
ideal body weight in obese patients. Link to QH HTUIdeal body
weight calculatorUTH.
Monitoring Infusion
Baseline TPR/BP pre infusion.
5 minutes after commencement.
5 minutes after every increment until a maximal infusion
rate is achieved.
Every 30 minutes at maximal infusion rate.
Completion of infusion.
Patients who have not previously had IVIg infusions,
switching to an alternative IVIg type and long intervals
between IVIg infusions must be closely monitored for the
first infusion and first hour following the first infusion.
Subsequent infusions in patients without previous
reactions, observation of the patient is recommended for
20 minutes following the infusion.
Additional vital sign monitoring may be required if there are
any rate changes or if the patient becomes unwell or
exhibits signs of reaction.
Reactions
Reactions are more common in certain patient groups and
tend to be related to rate of infusion.
Allow the product to reach room temperature before
infusing.
Symptoms/signs may include: wheezing, dyspnoea, chest
tightness, coughing, change in blood pressure,
tachycardia, flushing, rigors, urticaria/rash, headache,
vomiting, nausea, abdominal/back pain.
If a reaction does occur stop administration immediately,
assess vital signs, notify the medical officer, and provide
emergency care as required.
Inform Blood Bank (must be reported to manufacturer).
Serious reactions will need to be documented in PRIME.
Minor reactions (a common minor reaction is headache)
the infusion can often be restarted cautiously at a slower
rate after the patient has improved clinically.
Always record batch number administered. Remove batch label from bottle and place onto the IV/Fluid Subcutaneous Fluid Order Form.

Immunoglobulins: Intragam P 6%/Octagam 5%/Octagam 10%/Kiovig 10% HTUProduct Comparison InformationUTH
CAUTION! The different IVIg products have different concentrations and infusion rates and some adverse reactions may be infusion rate dependent. It is, therefore, imperati ve to
ensure that the correct product-specific administration protocol is used for every infusion. Administration rates may differ slightly from PI as per the Transfusion Committee.
Intragram P 6% Octagam 5% Octagam 10% Kiovig 10%
Manufacturers
Information:
CSL: HTUProduct InformationUTH
Patient Information
Available: 3g/50ml, 12g/200ml
Octapharma: HTUProduct InformationUTH
Patient Information
Available: 2.5g/50ml; 5g/100ml
10g/200ml
Octapharma: HTUProduct InformationUTH
Patient Information
Available: 5g/50ml,10g/100ml,
20g/200ml
Baxter: HTUProduct InformationUTH
Patient Information
Available: 5g/50ml,10g/100ml, 20g/200ml
UAll Doses:U
0.5ml/kg/hr for 30mins (minimum)
then
1.0ml/kg/hr 30mins
2.0ml/kg/hr 30mins
3.0ml/kg/hr 30mins
4.0ml/kg/hr 30mins
5.0ml/kg/hr 30mins
6.0ml/kg/hr 30mins
7.0ml/kg/hr is the maximum infusion
rate
Maximum rate in PI 864ml/hr
It is recommended that
subsequent infusions are give via
the same protocol.
HTUOctapharma Adverse Event FormUTH
UAll Doses:
0.5ml/kg/hr for 30mins (minimum) then
1.0ml/kg/hr 30mins
2.0ml/kg/hr 30mins
3.0ml/kg/hr 30mins
4.0ml/kg/hr 30mins
5.0ml/kg/hr (maximum)

It is recommended that subsequent infusions
are gi ven via the same protocol

HTUBaxter Adverse Event FormUTH
Rates of Infusion

Note Infusion of any
smaller volume vials
first is recommended to
decrease waste in the
event of an adverse
reaction.

Note Rapid infusion
of IVIg is not
recommended for in
setting of renal failure.
UFirst Dose
60ml/hr 15mins (minimum) then
120ml/hr 15mins
180ml/hr 15mins
240ml/hr (maximum)

USubsequent doses:
If the patient has had no adverse
events during the initial infusion,
subsequent infusions may:
Increment as above at 5min
intervals;
This will depend on patient risk
factors and condition.

HTUCSL Adverse Event FormUTH
UAll Doses
1.0ml/kg/hr 30mins
2.0ml/kg/hr 30mins
3.0ml/kg/hr 30mins
4.0ml/kg/hr 30mins
5.0ml/kg/hr (maximum)
(If a patient weighed 60kg the rate
would be set at 60ml/hr)
Maximum rate in PI 600ml/hr

It is recommended that
subsequent infusions are give via
the same protocol.

HTUOctapharma Adverse Event FormUTH
10% concentrate immunoglobulin products must start at 0.5ml/kg/hr for 30mins
Patients with pre existing risk factors, e.g. >65years, diabetes, obese, cardiac disease,
renal failure, arterial/venous thromboembolic events, hyperviscosity, paraprotein,
dehydration, a maximum rate of less than 2/ml/kg (200ml/hr) is recommended.
Monitoring
All Products the same
Baseline TPR/BP pre infusion.
5 minutes after commencement.
5 minutes after every increment until a maximal infusion rate is achieved.
Every 30 minutes at maximal infusion rate.
Patients who have not previously had IVIg infusions, switching to an alternative IVIg type and long intervals between IVIg infusions must be closely monitored for the
first infusion and first hour following the first infusion.
Subsequent infusions in patients without previous reactions, observation of the patient is recommended for 20 minutes following the infusion.
Blood Glucose
Monitoring
Intragam P and Octagam 5% and 10% contain maltose as stabiliser. Reported falsely elevated glucose readings in presence of maltose. PAH blood glucose test strips
are not affected by this. Kiovig 10% Contains Glycerol as stabiliser, will not effect blood glucose testing.
Patients Weight (Kg) (Round patient weight down to nearest weight on table). All doses are capped by ARCBS at 100kg.
Infusion rate calculations should be based on patients ideal body weight in obese patients. Link to QH HTUIdeal body weight calculatorUTH.
Infusion
mL/kg/hr
Pump
Rate
ml/hr 40 45 50 55 60 65 70 75 80 85 90 95 100
0.5 mL/kg/hr ml/hr 20 22.5 25 27.5 30 32.5 35 37.5 40 42.5 45 47.5 50
1.0 mL/kg/hr ml/hr 40 45 50 55 60 65 70 75 80 85 90 95 100
2.0 mL/kg/hr ml/hr 80 90 100 110 120 130 140 150 160 170 180 190 200
3.0 mL/kg/hr ml/hr 120 135 150 165 180 195 210 225 240 255 270 285 300
4.0 mL/kg/hr ml/hr 160 80 200 220 240 260 280 300 320 340 360 380 400
5.0 mL/kg/hr ml/hr 200 225 250 275 300 325 350 375 400 425 450 475 500

Appendix 5: Administration of Albumin

Albumex 4% & 20%P
13
P
Clinical Indications: HTUQHPS Blood Bank Blood Product UtilisationUTH, HTUARCBS: AlbuminUTH,
Manufacturers Information: HTUAlbumex 4% Product and Patient informationUTH, HTUAlbumex 20% Product and Patient informationUTH
Available in different concentrations and bottle sizes.
Albumex 4% containing 40g/L of human albumin in
500mL glass bottles.
Albumex 20%containing 200g/L human albumin in
100mL glass bottles, total of 20g human albumin.

Storage:
Stored below 30P
o
PC. Protect from light.
Must not be stored in a domestic/ward refrigerator.

Visually Inspect Product:
Do not use if product is turbid or cloudy, or contains
any sediment or particles.

Infusion Equipment:
Use of a IV pump may be utilised to ensure accurate
delivery of infusion rates.
Standard IV giving set or a new IV blood line
(incorporating a 170-200 micron filter) may be used.
Administration from glass bottles requires a vented
system. Open air vent on IV line, if line is not vented,
an air inlet needle maybe required.

Compatible Intravenous Fluids:
Normal Saline (0.9% NaCl Solution) or 5% Glucose.
Do not mix with any other fluids, medications.
Care should be taken with patients who are also
receiving drugs that bind to albumin, e.g. calcium
channel blockers. Refer to product information.
Before commencing the IVIg infusion ENSURE that:
Medical order.
Medical staff have discussed use of the blood
product with the patient/carer. Qld Health does not
require written consent process for plasma derived
blood products as they carry lower risks than fresh
blood components
Explain procedure to patient, including possible
reactions. Manufacturers patient information
brochure may be given.
Ensure intravenous access patent.
Ensure patient adequately hydrated.
Take baseline TPR and BP.
Read the product information contained in the box.
Allow the product to reach room temperature before
infusing.
Check resuscitation equipment, including oxygen and
adrenaline are available and in working order.

RIGHT PATIENT/RIGHT PRODUCT
HTUIdentity Check of Patient and Blood Product

Adverse Reactions:
Adverse reactions to albumin solution are uncommon
and are usually mild and transient.
Symptoms of adverse reactions may include:
chills, fever, allergic reactions (hypotension, urticaria,
skin rash, anaphylaxis), nausea, vomiting and
increased salivation.
Refer to Appendices 1 HTUQueensland Incidents in
Transfusion Reaction ChartUTH.
Observations:
The patients clinical condition will dictate the
frequency of observation.
Usually TPR and BP are taken before
commencement, half hourly throughout the infusion
and on completion.
Patients should be monitored for circulatory overload
and hypersensitivity to the product.
Accurate fluid balance documentation is important.

Administration:
Rates of infusion are determined by the clinical
condition of the patient.

Albumex 4%
Administer each 500mL bottle over 2-4 hours.

Albumex 20% Administration rate should not exceed
2mL per minute.
Infusion rate as per medical officer. If questions
regarding appropriate infusion times consult product
information.
Each bottle should usually be completed within 4
hours.

Albumexproducts do not contain an antimicrobial
preservative. It must be used immediately after opening
the bottle. Any unused solution should be discarded
appropriately. Use in one patient on one occasion only.

**More detailed information within manufacturers
instructions.
Always record batch number administered. Remove batch label from bottle and place onto the IV/Fluid Subcutaneous Fluid Order Form.

UAlways ensure the correct concentration is
collected and administered.U
If Albumex 20% instead of 4% is administered the
patient may be at risk of SEVERE circulatory
overload.
Appendix 6: Coagulation Factors

Plasma Derived & Recombinant Coagulation Factors
Clinical Indication: HTUQHPS Blood Bank: Recombinant Clotting FactorsUTH
HTUARCBS Factor ConcentratesUTH
Refer to individual product information for reconstitution and administration instructions
Plasma Derived
Factor VIII
Biostate:
HTUManufacturers
InformationUTH

Recombinant FVIII
Kogenate
Xyntha

Plasma derived
Factor IX
MonoFIX VF
HTUManufacturers
InformationUTH

Recombinant Factor
IX
Benefix

Warfarin Reversal
HTUProthrombinex VF:
Use and
Administration (02201)UTH
(previously known as
Prothrombinex HT)
Medical staff have discussed use of the blood product with the
patient/carer. Qld Health does not require written consent
process for plasma derived blood products Tas they carrying lower
risks than fresh blood componentsT.

Reconstitution for CSL Plasma derived clotting factors
Important: Reconstitute as per HTUmanufacturers instructions with
plastic Mix2VialUTH filter transfer set; dissolve the powder by gentle
agitation to avoid frothing. The product vial must always be on a
level surface, do not insert at an angle or the vacuum may be
released from the product vial and water for injection will not
transfer into product vial.

Products are stored at 2-6C and must be brought to room temperature before
reconstitution.
Administer within 3 hours of reconstitution.
Administered by the intravenous bolus as per manufacturers instructions.

Recombinant Factor
VIIa (Novoseven)

HTUNovoSeven RT Information Booklet FULLUTH (PDF 1.1MB)
HTUNovoSeven RT Information Booklet Part AUTH (PDF 366kB)
HTUNovoSeven RT Information Booklet Part BUTH (PDF 345kB)
HTUNovoSeven RT Information Booklet Part CUTH (PDF 474kB)
Presentation A single pack containing a vial of sterile freeze-dried powder,
water for injection and a filter needle.
Product is stored at 2-6C and must be brought to room temperature before
reconstitution.
Reconstitute and administer as per manufacturers instructions:
Dissolve the powder by gentle agitation to prevent frothing.
Reconstituted solution can be stored for 3 hours at 2-8C.
Administer by intravenous bolus injection.
Always record batch number administered. Remove batch label from bottle and place onto the IV/Fluid Subcutaneous Fluid Order Form

Appendix 7: Transfusion Administration Checklist

Know your hospital transfusion protocols before you proceed.
Follow standard (universal) precautions.
Ensure the right blood product is given to the right patient at the right time.
Whenever possible avoid overnight transfusion in stable patients.
- Check urgency with Medical Officer.
- If there is doubt, do not delay transfusion.

UBEFORE THE BLOOD PRODUCT IS COLLECTED

Medical order for blood product prescribed on the Intravenous and Subcutaneous Fluid Order form.
Blood collection/Transfusion request form
Current cross match specimen available in Princess Alexandra Hospital Blood Bank and blood
component requested on QHPS Transfusion Request form.
Special requirements? Check for pre-medication, diuretic, CMV negative, Irradiated, blood warmer: As
per medical order or unit policy for specific patient groups.
IV access patent and sufficient to allow adequate flow rates. Check if patient has alternate access, if
not attach a Smartsite 2 way extension set.
Informed consent obtained and documented by medical officer (where time and circumstances allow).
Consumer information provided
Is the blood product ready in Princess Alexandra Hospital Blood Bank?
Procedure explained to the patient.
IV Blood Administration set (approved for blood administration) prepared:
Change at least every eight (8) hours,
Baseline observations recorded on the PA216 Acute Observation Chart (T,P,R and BP)
UBLOOD PRODUCT COLLECTION ALWAYS TAKE WRITTEN PATIENT DETAILS

Full Name, Date of Birth and/or Patient Identification UR Number of the right patient!
Applies to collection from all areas including blood refrigerators/blood shippers.
Check details and complete documentation log book.
UONCE THE BLOOD COMPONENT IS DELIVERED/COLLECTED

Commence red cell transfusions within 30 minutes of issue and complete each unit within 4hrs.
Checking A final patient identity check must be undertaken at the bedside by two (2) appropriate staff, one
(1) of whom must then connect and spike the blood product.
Check blood compatibility label/paperwork are all identical/compatible and correct.
Blood product and patient details are identical and correct.
Patient identification band(s) details are identical and correct ask the patient if able to state/spell their
full name and date of birth.
Correct type of blood product including special requirements.
Check expiry date (and time) of blood product.
Visual inspection of the blood product (remember to mix gently before use):
- Intact no leaks or evidence of bag tampering.
- No unusual discolouration or turbidity or haemolysis (and no significant colour change in the bag
compared with tubing segments).
- No clots.
If any checks fail contact Princess Alexandra Hospital Blood Bank immediately.
Observations as per Princess Alexandra Hospital Transfusion Procedure and observe the patient closely
during the first 15 minutes.
Ensure documentation is complete.
Fluid balance chart.
Administration times (start and finish).
Two (2) checking signatures and printed names.
Blood product donation number/label (yellow sticker to be placed on PA 226 Intravenous and
Subcutaneous Fluid Order form)
Patient transfusion observations.
Outcome of transfusion documented in the Patient Medical Record/Chart.


Based on ARCBS & Government of South Australia (2008) Blood Safe Transfusion Administration Checklist,
version TP-L3-402 5.1, viewed 24/03/2010.
USAFE BLOOD TRANSFUSION STARTS WITH ME

Make sure the RIGHT PATIENT gets the RIGHT BLOOD at the RIGHT TIME.
Verify patient identity at all steps.
NEVER put blood in a ward refrigerator.
NEVER warm blood except with an approved blood warmer device.
Mix gently before transfusion BUT NEVER shake a blood pack or product.
If YOU have any doubt contact the Princess Alexandra Hospital Blood Bank.
UIF A BLOOD TRANSFUSION REACTION OCCURS
UFollow QiiT Transfusion Reaction Chart

STOP the blood transfusion immediately leaving giving set attached:
Keep vein open (KVO) with saline using a new giving set.
Check vital signs monitor respiration, pulse, BP and temperature every 15 minutes.
Recheck patient identity (including wristband) with product details on the label.
Notify Medical staff.
Contact Princess Alexandra Hospital Blood Bank or Haematology Registrar.
Save Urine passed by patient.
Complete a Prime Incident Report.
Document in Patient Medical record/chart.
If requested by Princess Alexandra Hospital Blood Bank or Haematology Registrar:
Return blood product and IV administration set to Princess Alexandra Hospital Blood Bank.
Collect blood/urine samples.
Monitor the patient closely.
COMPATIBLE ABO GROUPS FOR URED CELLU CONCENTRATES ONLY
(Other rules apply for products containing plasma such as platelets, fresh frozen plasma, cryoprecipitate and
whole blood, check with blood bank if unsure of compatibility).

Patient ABO Group ABO Group of red cells that can be given
O O ONLY
A A or O
B B or O
AB AB or A
There are many other aspects to ensuring compatible red blood cells for a patient. If ever in doubt
contact the transfusion service provider
UINFORMED CONSENT FOR BLOOD TRANSFUSION

In the event of the patient being unable to give consent or in an emergency situation the medical officer may
determine that the transfusion is in the patients best interest to be transfused. Medical officer should
document why consent could not be obtained and patient or next of kin informed as soon as possible
following transfusion.
In all other transfusion episodes, informed consent for transfusion must be checked prior to the
administration of blood and blood components.
Blood transfusion is include in procedure specific consent forms, check that patient has discussed
transfusion with their doctor, offer written information to patient.
- Consent will only be valid if the blood transfusion is related to the procedure they have been
consented for, a new consent may be required if there is a change in clinical indication, type of blood
component, patient capacity, patient condition.
Patients requiring single or multiple transfusions over extended period of time will need to provide consent
on the Queensland Health Blood and Blood Product Transfusion Consent Form. Dates for which consent is
valid needs to be documented in the space provided. More than one type of blood component may be
documented on one form.
For more information, visit Princess Alexandra Hospital Blood Bank website:
HTUhttp://paweb.sth.health.qld.gov.au/medicine/bloodbank/consent.aspUTH

Appendix 8: Pre-transfusion Sample Collection Flow Chart


Appendix 9: Administration of Blood Component Flow Chart


Appendix 10: Informed Consent Quick Reference Guide for staff

Hyperlink: HTUhttp://paweb.sth.health.qld.gov.au/transfusion/documents/consent_guide.pdf


Appendix 11: Princess Alexandra Hospital Massive Transfusion Guidelines

Massive Transfusion Guidelines were developed to assist in the provision of blood products in an efficient
and sustained manner while maintaining appropriate proportions of Red Cells, Fresh Frozen Plasma and
platelets in a 1:1:1 ratio.

This should be activated by a senior clinician when a patient is suffering from hypovolemic shock due to
massive exsanguination where the patient is non-responsive and prolonged resuscitation using blood
components is required.

Hyperlink to: HTUMetro South Transfusion ResourcesUTH Intranet Site for further information


Appendix 12: Transfer of Blood ComponentsP
16
P

Blood will be discarded (wasted) if any of the following parameters are not followed:

RULES PROCESS
SIGN OUT RULE Signing out of blood/blood components must be undertaken either
by access to the Blood Bank Auslab computer or by using the sign
out log.
Patient ID must be supplied to sign out blood products.
30 MINUTE RULE
(No Esky/Shipper)
Take only the amount of blood that is immediately required.
Note: Use an esky/shipper if more than one bag is taken from the
fridge).
Return blood/blood components to the Blood Bank if not used
within 30 (thirty) minutes.
If there has been a delay in starting the transfusion, and the blood
has been out of the fridge for more than 30min, it may still be used
for that patient provided transfusion of the unit will been
completed within 4 hours of the original despatch time.
4 HOUR RULE
(Administration)
Completion of transfusion of all blood/blood components must be
within 4 (four) hours of removal from esky/shipper.
TEMPORARY STORAGE

UNo PlateletsU
Storage of blood/blood components in an esky/shipper may be
undertaken if warranted by the patients clinical condition.
2 (two) frozen bricks must be used.
Place a piece of cardboard on top of the bricks to separate blood
from bricks.
Place blood on top of the cardboard.
Lid must remain in place.
2 units of Red Cells are validated for 2 hours with this
configuration.
TRANSFERRING BETWEEN
DEPARTMENTS
Transferring of blood/blood components must not be undertaken
between departments (e.g. operating theatre to ward/department)
unless the blood or blood component is to be administered
immediately upon arrival.
If the blood is to be administered immediately upon arrival in the
receiving ward, one of the checking persons, prior to that
administration of the blood/blood component must be one of the
transferring clinicians.
Any remaining product must be returned to the Blood Bank.
SIGN IN RULE Inform Blood Bank staff of all blood/blood components returned to
Blood Bank.

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