Shands At The University Of Florida Dept. Of Nursing And

SHANDS AT THE UNIVERSITY OF FLORIDA DEPT. OF NURSING AND PATIENT SERVICES

POLICY NUMBER: CATEGORY:

DATE: NEXT REVIEW DATE:

BA-P-004 Blood Administration – Phlebotomy April 2009 April 2010

TITLE:

BLOOD PRODUCT ADMINISTRATION PROTOCOL

PURPOSE:

To ensure safe administration of blood and blood products by delineating processes for: • Prescribing & Ordering • Administering, Patient Monitoring & Reactions • Specimen Collecting & Labeling • Transport, Handling & Satellite Storage • Dispensing & Infusion Devices • Special Requirements, Risks & Products

POLICY STATEMENTS: I. Written, informed consent is required for transfusion of blood products, except in emergency

situations. II. A physician's order is required for administration of all blood products (whole blood, packed

III. IV.

V. VI.

VII. VIII. IX.

X.

cells, platelets, plasma and cryoprecipitate). The order must include the indication(s) for use of any blood product ordered (see SUF Form #15-0373-0 Physician’s Order for Transfusion Service). Patients must have a blood identification band at the time of specimen collection for crossmatch and for blood product administration. Two clinical care providers (CCP) must verify patient identification using two patient identifiers (patient name and MR#). Verification must take place in the presence of the patient at the time the blood band is applied and the specimen is obtained. Documentation of verification must accompany specimen to Blood Bank (BB) for acceptance. The Blood Identification Band is to be completed in handwriting in the presence of the patient. Two individuals, one of whom must be the transfuser, must verify all blood products prior to transfusion. Those verifying must be comprised of at least an RN, ECMO specialist, PA or MD. If the unit has been verified and transfusion has not been immediately initiated or the verification process is interrupted, the unit verification process must be repeated. Blood products must be administered only by an RN, ECMO Specialist, PA, or MD. An LPN who has successfully completed the competency for blood administration: A. may not initiate a blood product transfusion, B. may monitor the blood product transfusion under the direction of an RN, C. may verify blood product only with an RN. Only blood bank monitored refrigerators in the ICUs can be used for the storage of blood products when a delay of emergent transfusion greater than 15 minutes would impact patient outcome. Use of medication or any other refrigerator is unacceptable.

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XI. “Satellite Refrigerator Sign-out” logs will be used by the satellite areas to assist in ensuring

tracking and quality control of refrigerated blood products in satellite refrigerators to meet compliance. XII. Quality assurance monitoring of satellite blood bank refrigerators is the responsibility of the hospital blood bank, which includes: removal of expired blood products, outdated crossmatches, overstocked blood products, monitoring the alarm systems & temperature, and cleanliness of the refrigerator. XIII. All blood will be administered using a standard blood administration set. Each administration set may be used for a maximum of 4 hours. A maximum of 2 units in a 4hour period can be used with the same blood set. SPECIAL INSTRUCTIONS: I.

Ordering (See Appendix A) A. Obtain an order from the MD. See Appendix A. B. An order for T & S or cross match should not be confused as an order for transfusion i. All orders for Blood Bank tests/blood products are to be entered into the computer via HIS/OAS Gold. C. Verify patient consent for transfusion of blood products is on record. i. Physician notification is necessary if consent is not available on the medical record. D. Verify order for transfusion is on record. Order must include: i. Type of blood component. ii. Amount of blood component to be transfused. iii. Indications for transfusion. iv. Product attributes if needed (special requirements): a. Irradiated b. Leuko-reduced c. Washed d. CMV negative v. Pre-transfusion medications, if appropriate. vi. Priority for blood product: a. STAT (45 minutes) b. Routine c. ASAP (2-4 hours) d. Timed (specified time) e. In life-threatening situations: Emergency orders for uncrossed-matched red cells are to be placed in HIS/OAS Gold.

II. Collecting & Labeling Initial Specimen for Compatibility Testing (See Appendix B) A. Initial Type & Cross or Type & Screen Process: i. Verify the patient’s identity with the patient, if possible, and patient’s hospital identification band for name and medical record number. See Core Policy CP2.51 Bloodbands, Collection of Specimen for Pre-Transfusion Compatibility Testing for Shands Healthcare policy on blood ID bands. • Addressograph labels & serum-separated tubes are not acceptable for compatibility testing. ii. In the presence of the patient, hand-write on the blood ID band, the following information: a. Patient’s full name: first and last initial. b. Medical l record number.

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c. Date & time specimen drawn. d. Initials of collector and 2nd CCP. iii. For application of blood band: a. Two CCPs shall verify the patient identification with information written on blood band. b. Both verifiers will sign the verification form and initial the blood band and initial the specimen at the time of collection. iv. Place blood ID band on the patient’s wrist and close to secure. See exemption criteria.. a. Exemption criteria for placing Blood Bank ID band on wrist: 1. ICU (Isolets). 2. Burn patients (bed). 3. Patients with severe skin conditions. 4. Patients who may disrupt the integrity of the Blood Band, such as toddlers, developmentally delayed, etc. 5. Pre-surgical outpatients requiring a disinfectant scrub before admission. 6. Outpatient areas where multiple blood products are given over several months. v. Obtain the blood specimen and mix by inverting the tube several times. a. Minimum Specimen Requirements: 1. Routine: • Adult 1, 6 mL EDTA lab tube (Pink) • Peds 1, 3-5 mL EDTA lab tube (Lavender) • Cord 1, 6 mL EDTA lab tube (Pink) 2. Liver Transplant: • Adult 2, 6 mL EDTA lab tube (Pink) • Peds 1, 6 mL EDTA lab tube (Pink) vi. Attach hand-written label from Blood bank ID band to the blood sample tube prior to leaving patient’s bedside or presence. vii. Document specimen labeling process by completing Transfusion Specimen TimeOut Verification Form with signatures and employee ID# of both CCPs. See Appendix C. viii. The white copy of the specimen verification form must be sent with the specimen to the Blood Bank for the specimen to be accepted for testing. ix. Place yellow NCR copy of the specimen verification form in the patient medical record (Transfusion tab). x. Educate the patient or guardian regarding the blood ID band or give them a copy of Appendix D. xi. Neonatal specimens are valid for four months. When the infant reaches four months, or is discharged, the specimen must be obtained every three days. xii. For non-neonatal patients, specimens are valid for three days III. Collecting & Labeling Subsequent Specimen for Compatibility Testing (after initial Banding) A. Subsequent Type & Cross or Type & Screen Process: i. Patient has current Blood Bank ID band. ii. Verify the patient’s name and medical record number on Blood Blank ID Band compared to patient armband.

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iii. At patient’s bedside hand-write the following information on the generic label or computer generated barcode label: a. Patient’s full name: last, first & middle initial. b. Medical Record Number. c. Date & time specimen drawn. d. Initials of collector. e. Blood bank ID number (sticker may be used, if available). iv. Label the appropriate tube with the completed generic blood bank specimen label or computer generated barcode label prior to leaving patient’s bedside or presence. v. Obtain the blood specimen and mix by inverting the tube several times. • Blood Bank ID band is valid for the duration of the hospitalization or until band is illegible. B. Re-banding patient: 1. Notify blood bank prior to removing multiple or illegible blood bank ID band, or if the ID band is lost. 2. Two individuals are required to verify patient and specimen identification, if re-banding is needed. 3. If the Blood Bank ID is cut off, for example during surgery, it is acceptable to re-attach the Blood ID band to a blank hospital band. The band must be placed on the patient by personnel involved in the removal of the original BBID band. 4. Check bedside rail & chart if Blood Bank ID band is not attached to patients meeting the exemption criteria above. ii. Blood Bank will notify unit if specimen cannot be accepted and redraw is needed. IV. Other Blood Bank Diagnostic Tests (see Appendix E for specifics) A. Blood Bank tests (no BBID# required): i. Type and Screen (diagnostic) a. One, 6 mL EDTA lab tube (PINK) 1. Type & Screen - Diagnostic Only - generally used for Prenatals, Pre-ops greater than 3 days in advance of surgery and for transplant evaluations - not used for transfusion purposes. ii. Direct Antiglobulin Test (DAT): a. One, 6 mL EDTA lab tube (PINK) iii. ABO/Rh confirmation a. One, 6 mL EDTA lab tube (PINK) 1. ABO & Rh Confirmation - to be used for 2nd blood type and must be drawn separately. It is generally requested by the transplant group as required by UNOS or by Blood Bank for new patients with no previous blood type on record. iv. Cord blood work-ups: a. One full 6mL EDTA lab tube (PINK) b. Cord blood must be obtained at the mother’s bedside at time of delivery. c. Attach white “cord blood” label to the specimen with the following information: 1. Mother’s full name (last, first, & middle initial). 2. Mother’s medical record number. 3. Circle male or female. 4. Baby’s medical record number, when assigned. 5. Date & time collected. 6. Collector’s initials.

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1. Cord Blood Workup - cord blood samples also require verification by two individuals, one of whom obtained the specimen. 2. If ambiguous sex, write “Baby” and notify blood bank. 3. An EDTA purple top tube may be substituted for the pink top in pediatric draws if 1.5 ml pink top not available. v. Platelet antibody test: a. Call Blood Bank to pre-schedule. b. 1, 6 mL EDTA lab tube (PINK) • Platelet Antibody Test -Specimen requirements may differ – Call Blood Bank first. V. Dispensing (See Appendix F) A. Verify that there is a physician's order to transfuse. B. Verify that informed consent for transfusion obtained and in the patient's chart. C. Verify that patient is afebrile and has adequate IV access. i. Blood should not be requested until adequate IV access is secured. D. Complete “Blood Bank Dispense Form” to initiate release of blood products (see Appendix F). Remember to include the ordering MD's number on the dispense slip. E. Send dispense slip via courier or pneumatic tube. i. http://intranet.shands.org/shandslab/shandsUF/bloodbank/dispensingbp.htm ii. Outpatient dispense slips must include the tracking # and faxed to the blood bank (fax #265-0320). See Appendix F for example. F. Release of blood products via internal courier. i. Courier verifies patient information on blood tag with dispense form. ii. Blood products released as requested, if no discrepancies noted. iii. Discrepancies are resolved prior to releasing blood products. a. One unit of blood product will be dispensed from the Blood Bank at a time, unless there is access to a monitored satellite blood bank refrigerator. G. Release of blood products via the pneumatic tube system: i. Retain white copy of dispense form to track requested products. Discard after product received. ii. Send pink & yellow copies of dispense form to Blood Bank via pneumatic tube system. iii. Blood Bank sends requested blood products (2 units maximum per dispense slip to areas with Satellite Blood Bank refrigerators) along with pink copy of dispense form. iv. Unit staff (clerical or nursing) verifies that blood tag on unit sent matches the information the retained white copy of the dispense form. v. Sign the pink form and include the date & time blood products received on floor. vi. Return pink slip to Blood Bank immediately (within 15 minutes) of receiving blood products. vii. Notify patient's RN that blood products have been received and are available for transfusion. viii. Return blood to Blood Bank immediately when the blood product will not be transfused within 30 minutes of receipt and product is still intact (not spiked). 1. Only one (1) bag of product will be dispensed at a time. 2. In a medical emergency, 2 or more units may be released in a cooler with a conditional release form to areas without a satellite refrigerator. 3. Multiple units of cryo or platelets are generally processed into one bag. 4. Syringes with needles are not dispensed via pneumatic tube.

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5. Blood infusion sets for platelets will be dispensed by the blood bank at the time platelets are released for administration. 6. Red blood cells are not to be outside of a Blood Bank monitored refrigerator (1-10°C) for more than 30 minutes. VI. Pre-transfusion Verification A. B. C. D. E.

F.

G. H.

I. J. K. L. M.

Verify that there is a physician’s order to TRANSFUSE. Check for presence of written informed consent. Check for the presence of a Blood Bank ID band on the patient. Verify the type and cross (date and time) has not expired (top right corner of blood tag on product will show specimen expiration date). Check I.V. for patency. i. Use large bore catheter to prevent lysis of RBCs: ii. no smaller than 26 gauge for peds or 22 gauge for adults. Complete pre-transfusion assessment and document vital signs prior to transfusion: i. Temperature ii. Pulse iii. B/P iv. Respirations Administer pre-medication, if ordered, prior to administration of blood products.. Two licensed professionals (RN, MD, ECMO, specialist, PA, LPN – Note: LPN may only verify with an RN), one of whom must be the transfuser, must complete the following in the presence of the patient prior to transfusion: (In the out-patient areas, clip the BBID band on the patient after verifying pt's name and MR#). i. Verify name and MR# on patient’s hospital and Blood Bank ID bands are identical to name, MR# and BBID# on blood product tag. ii. Verify that the product name, donor number, ABO blood group and Rh type on the blood product container are identical to the blood product tag. iii. Verify that the ABO blood group and Rh type on the container is compatible with the patient. *See Appendix G. iv. Verify specific attributes of blood products meet the patient’s special needs, i.e. CMV negative, irradiated, washed, leuko-reduced, autologous, direct donor, etc. v. Verify the date on the blood product container has not expired and that the product appears normal. vi. Blood Bank ID band numbers will not be present on the blood tag for the following products: a. Plasma b. Platelets c. Cryoprecipitate, and d. Group O packed cells for children under 4 months of age If a discrepancy is noted, do not administer the blood product & notify blood bank immediately. Both licensed professionals must sign the blood tag, verifying that all information is correct & accurate. See Appendix I. If the unit has been verified and transfusion has not been immediately initiated or the verification process is interrupted, the unit verification process must be repeated. Record START date and time of transfusion on blood tag. Record blood product number from blood bag on Intake and Output section of flow-sheet or computerized chart. Remove white label from back of unit if available and place on flow-sheet or computerized chart.

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N. Special Situations i. If BBID band could not be placed on an in-patient but was secured to inside front cover of blue-back chart, the blood ID band must be taken into the patient’s room for verification before blood administration ii. If an extraordinary situation exists and the blood ID bracelet is not placed on the wrist of an out-patient but given to them, they must be instructed to place the blood ID on their wrist before arriving to the hospital on the day of the transfusion or the RN is to clip the BBID band on to the patient prior to infusion. iii. In outpatient areas where blood products are given over several months, the blood band is kept in the chart. Before the patient is transfused, two CCP (one a licensed person) must verify the patient’s identity with a name and MR number or name and birthday and attach the blood band to the patient. After the transfusion, the blood band is returned to the chart. iv. If patient has received a Bone Marrow Transplant in the past year, the patient’s blood type may have changed. Please notify the Blood Bank for clarification if discrepancy is discovered. Pt’s HLA type may change sooner than blood type. See Appendix H for BMT patients. v. Expiration time will only be found on label of products that have an expiration of less than 24 hours or on products that were modified in an opensystem in the Blood Bank (ie pooled, thawed or washed). vi. If blood types do not match, Blood Bank must indicate on blood tag acceptable procedure for administration. If this is not complete, do not administer blood until Blood Bank resolves discrepancy. VII. Administration A. Blood Administration Set (tubing - see Appendix J & Infusion Devices section below for more details): i. All blood products must be administered through a standard infusion set (150-280 micron filter screen). ii. Prime blood tubing with NS only. iii. Blood tubing may be used for 2 consecutive units of red blood cells or plasma in routine use. iv. Tubing must be changed at least every 4 hours. v. Platelets should be administered via the tubing available on the unit or in clinic. vi. Blood may be administered via IV pump. a. AABB Standard 5.19.10 “With the exception of 0.9% sodium chloride (USP), drugs, or medications shall not be added to blood or components unless one of the following conditions are met: 1. They have been approved for this use by the FDA. 2. There is documentation available to show that the addition is safe and does not adversely affect the blood or component.” B. Initiating Transfusions: (Note: LPN may not initiate blood product transfusions.) i. Check the pt ID band one more time just prior to releasing the flow control clamp. ii. Begin the infusion slowly. iii. Record start date and time of transfusion on blood tag. iv. Monitor vital signs prior to blood transfusion, 15 minutes into transfusion, then after 15 minutes and observe patient for reaction. a. Transfuser must stay with the patient for the first 5 minutes to observe for reaction.

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v. If vital signs are stable and no reaction noted, increase rate of transfusion to prescribed rate. vi. Increase transfusion to prescribed rate after 15 minutes, if no reaction is observed. vii. Monitor VS every hour during transfusion and one hour after transfusion complete. (Note: LPN’s may monitor the blood product transfusion.) a. Vitals include: 1. Temperature 2. Pulse 3. Blood pressure 4. Respirations viii. All identification attached to the unit must remain attached until the transfusion is completed. C. Completed Transfusions: i. Flush IV with NS if necessary. ii. Record transfusion STOP time* and check the appropriate box to document whether or not an adverse transfusion reaction was observed**. a. See Transfusion Tag on Appendix I. b. *Mark the appropriate box if transfusions occurred during a massive transfusion (MTP) or rapid infusion (multiple units in less than 1 hour) situation. c. **Mild reaction: hives, rash, erythema, and itching disappear within 30 mins following treatment with antihistamines. iii. Place completed blood product tag (chart - top copy) in the progress notes of the patient’s chart. iv. Return the completed blood product tag (back copy) to Blood Bank immediately after transfusion. v. Record post-transfusion vital signs on the flowsheet or computerized chart one hour after transfusion. vi. Record time and volume of transfusion on I & O section of flowsheet or computerized chart. VIII.

Recognizing Signs and Symptoms of Transfusion Reactions: (see Appendix K)

A. Monitor patient for signs & symptoms of a transfusion reaction such as: i. Fever, with or without chills ii. Heat at the infusion site and along vein iii. Flushing iv. Hives, rash, erythema, itching v. Dyspnea or shortness of breath vi. Increase in blood pressure (>50mmHg) vii. Abdominal pain or nausea viii. Rigors, lumbar pain ix. Anxiety, chest pain, flank pain x. Hypotension xi. Unexplained bleeding, blood in urine B. If the patient develops signs & symptoms of a transfusion reaction: i. Stop transfusion ii. Keep IV open with NS iii. Verify correct unit was given to correct patient iv. Document patient re-verification on the back of the blood tag by checking the box and initialing the appropriate spot. v. Notify attending physician and blood bank

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vi. Request transfusion reaction investigation work-up in the HIS/OAS Gold system. C. Report ALL suspected transfusion reactions to the Blood Bank and complete a patient Patient Safety Report on-line. D. Out-patients that have been transfused should be given written instructions to include: (See Appendix L) i. signs & symptoms of an adverse reaction to transfusion ii. contact person information and phone number. E. Special Situations i. STOP transfusion immediately if product is given to the wrong patient even if no signs & symptoms of a transfusion reaction are observed. Notify MD/Service immediately and keep the line open with NS until resolved. ii. If there is a discrepancy between blood product tag and patient, DO NOT re-start transfusion. Notify Blood Bank and MD immediately. This is a life- threatening emergency! iii. BMT patients commonly experience rigors. However, rigors during or immediately following transfusions (especially platelets) must be investigated to rule out bacterial contamination as the cause for rigors. IX. Immediate Life-threatening Transfusion Reactions (See Appendix K) (back to top) A. Monitor patient for symptoms of acute hemolytic or life threatening reactions: i. Respiratory distress/arrest ii. Unexplained bleeding iii. Chills, fever, dyspnea iv. Hypotension v. Cardiac arrest vi. Flank pain vii. Chest pain viii. Shock ix. Blood in urine B. STOP transfusion C. Keep IV open with NS D. Verify correct unit was given to correct patient. E. STAT page physician(s) or activate Code Blue system depending on patient’s clinical status. F. Request transfusion reaction investigation in HIS/OAS Gold. i. See back of transfusion tag in Appendix I ii. Therapeutic Measures: a. Initiate basic resuscitation measures: airway, breathing, compressions, etc. b. Administer Epinephrine, Benadryl, and/or steroids, as ordered. c. Medical therapies to reverse shock. X. Transfusion Reaction Investigation (back to top) A. Keep blood product bag/syringe and administration set intact and place in biohazard bag. B. Collect blood and urine samples then send with blood unit and administration set to Blood Bank for all other symptoms other than hives & itching. i. Obtain specimens: a. Adults: 1, 6 mL EDTA lab tube (Pink) and 1, 7 mL (Red) lab tube (no serum separator)

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C. D. E. F. G. H.

b. Infants/Neonates: 1, 3 mL EDTA (Purple) lab tube and 1, 2 mL (Red) lab tube c. Urine specimen Checked box on front of blood tag and sign indicating adverse reaction observed. Complete information on back of blood product tag. Send hard tag copy (back copy) to Blood Bank immediately. Request transfusion reaction work-up in the Blood Bank Order Screen in the HIS/OAS Gold system. Document reaction on Daily Flow sheet or computerized chart. Call Blood Bank prior to the initiation of any further blood products.

XI. Transporting Blood Products (refer to blood transport module) (back to top) A. Transporter i. Do not transport blood while eating, drinking or smoking. ii. Follow Universal Precautions. iii. Provide patient’s Name and MR# to Blood Bank (BB) upon arrival to ensure that the right blood is transported. iv. Show ID badge to BB staff. v. Take blood product directly to the patient care-giver that dispatched you. vi. Use the shortest route to/from the BB and the patient care location. vii. Deliver blood product quickly but safely (less than 5min). viii. Do not leave blood products unattended. ix. Transport blood in the appropriate container (biohazard bag or designated blood transport box/cooler). x. Keep transport container lid tightly closed. xi. Never place Platelet or Cryo blood products in the same transport container as Red Cells and Plasma. xii. Return cooler, coolant and temperature monitor to the Blood Bank. xiii. Return blood issued in a biohazard bag if transfusion not started within 30 minutes. xiv. Return cooler for replacement coolant if cooler in use for more than 2 hours. B. Receiver i. Keep transport container lid tightly closed. ii. Never place Platelet or Cryo blood products in the same transport container as Red Cells and Plasma. iii. Return blood issued in a biohazard bag if transfusion not started within 30 minutes. iv. Return cooler for replacement coolant if cooler in use for more than 2 hours. v. Return cooler, coolant, temperature monitor and all unused blood products to the Blood Bank immediately following the crisis ¨Return cooler and its contents if the temperature monitor beads are mobile (cooler is no longer cold). C. Policy: The temperature of blood and blood components transported to customers must be maintained within the limits prescribed in the AABB standards 5.1.8. i. Proper Transport Temperatures: a. Cold – Red Cells & Plasma (1º-10ºC) b. Room Temp – Platelets & Cryo (20º-24ºC) ii. Maximum Storage Time in Transport Container: a. Cooler or Blood Box – 4 hrs b. Biohazard bag – 30 minutes XII. Transport of Blood Products via Cooler

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A. In emergent situations, multiple units will be issued to an area that does not have a monitored refrigerator in a cooler with a temperature indicator and ample ice. B. Properly Packed Transport Container for: Red Cells and Plasma i. Blood product on the bottom layer. ii. Absorbent towel or paper above the blood. iii. Coolant or chipped ice in a bag above the towel. iv. Temperature monitor beads in lower corner of transport. v. Tightly closed lid container. C. Cooler may be obtained from the Blood Bank. Replace ice packs every 2 hours. D. Prior to administering blood products from a cooler, the temperature indicator must be inspected: i. Satisfactory inspection – Indicator is solid and beads are stationary – may transfuse blood product. ii. Unsatisfactory inspection – Indicator is liquid and beads are mobile – DO NOT transfuse blood product. E. Document temperature indicator status on the blue card located in or on the cooler. F. Return the card and cooler to the Blood Bank, XIII.

Handling of Products after Leaving Blood Bank (back to top)

A. Blood products should be administered as soon as possible. B. If unable to start infusing red blood cells immediately, return the unit to the Blood Bank if unit is still intact. C. All blood products must be completely transfused within 4 hours of leaving blood bank storage and being spiked (entered). i. For aliquots placed in syringes, the syringe expires four hours form the time the syringe is prepared, not when the administration begins. D. Transfusion must cease when a blood products has not been completely infused within the 4 hr period. E. Discarded remaining product in a biohazard receptacle. F. Red blood cells and plasma should not remain at room temperature. G. Platelets and cryoprecipitate are NOT refrigerated. H. Platelets and leukocytes should not be infused with a micro-aggregate filter (less than 40 um). I. Pediatric and Neonatal blood products arriving in a syringe for administration via a syringe pump have been pre-filtered by the Blood Bank (if labeled as such) and do not require additional filtering to administer. J. Blood products spiked on the floor cannot be returned to the Blood Bank for re-issue. The unit must be transfused within 4 hours of being spiked or discarded. i. A full unit of packed red blood cells can warm to a temperature greater than 10°C in approximately 30 minutes. A partial unit in less time. K. Returned blood products can only be re-issued to the floor after determination by the blood bank that the product was maintained at the appropriate temperature and intact. L. Special Situations i. If a unit is spiked and discarded without being transfused, the Blood Bank is to be notified. ii. Blood for the days surgical cases is issued, picked up by the PST and placed in the OR refrigerator by 0700. iii. Blood not used for the surgical procedure are to be immediately returned to the blood bank at the end of the case. Blood bank would then determine if the retuned product is still suitable for use.

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XIV.

Storage of Blood Product in Satellite Refrigerator (back to top)

A. Any refrigerated blood product that has been out of a Blood Bank monitored refrigerator for greater than 30 minutes must be returned to the main blood bank for proper evaluation and disposal if necessary. B. The following blood bank monitored refrigerators may be used to store blood products: i. PICU ii. CICU iii. OR iv. SICU v. BICU vi. ER vii. Cancer Center Lab C. Nursing or clerical staff may sign-in or sign-out blood products from the satellite refrigerators. D. Record the following information on the sign-out log to place blood products in the satellite refrigerator. i. Date and time placed in refrigerator. ii. Recipient name and MR#. iii. Component type. iv. Donor number. v. Appearance of beads, in cooler, if applicable. E. To remove blood products from the satellite refrigerator for transfusion, record the following information adjacent to the corresponding documented donor number on the sign-out log: i. Date and time product removed. ii. Signature of staff removing blood product. F. Blood products may be returned to the satellite refrigerator only if the product has been out of the refrigerator less than 30 minutes, or properly stored in a cooler and maintained between 1-10ºC. G. To return unused blood products to the satellite refrigerator, record the following information adjacent to the corresponding donor number on the sign-out log: i. Signature of staff returning blood product. ii. Date and time returned. iii. Appearance of beads in cooler, if applicable. H. Blood Bank staff removes expired blood products and products assigned to patients with expired Type & Screen from the satellite refrigerators nightly. I. Additional Information i. It is the responsibility of the unit staff or PST to sign blood in on the “Satellite Refrigerator Sign-out” log designated for each refrigerator. ii. Never refrigerate Platelets, Platelet Pheresis, Cryoprecipitate or Leukocytes. iii. In cases of pediatric split products that have been entered, write the date and time entered on the unit label. iv. Return unit(s) to the Blood Bank if: a. Temperature beads are mobile. b. Unit out of refrigerator greater than 30 minutes. c. Temperature is greater than 10ºC. v. Aliquotting or repeat entry into a unit on the floor is unacceptable. Aliquotting must be performed in the blood bank under appropriate conditions. vi. All blood products expire within 4 hours of being entered on the floor.

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XV.Blood Infusion Equipment & Devices (see Appendix J) A. Blood Administration Sets i. Blood components must be infused through administration sets designed specifically for this use. ii. The set usually contains a 150-280 micron filter designed to trap fibrin clots and other debris that accumulate during blood storage. iii. Most standard filters have a four-unit maximum capacity. (Check the manufacturer’s instructions.) iv. If the first unit requires greater than 4 hours for infusion, the filter should not be reused. v. Tubing is available in two basic configurations, straight & y-type. vi. Obtain blood administration sets from Hospital Stores. B. Straight Tubing i. Usually has a medication injection site a few inches from the needle. ii. If an adverse reaction develops, a “keep-vein-open” saline drip initiated at this site will maintain IV patency but avoid exposure to the 30 to 50 mL of blood remaining in the tubing and filter. C. Y-Type Tubing i. Simplifies the process of adding normal saline to red cells. ii. Provides ready access to a saline flush if the transfusion must be interrupted D. Leukocyte Reduction Filters (bedside or lab) i. Recommended to decrease the risk of certain transfusion complications. ii. Bedside filters are not used at Shands UF. iii. Filtration is performed in the blood bank prior to release of blood product. iv. Improper use of a blood filter can significantly compromise desired results and may lead to negative patient outcome. E. Infusion Devices i. Infusion devices are used to regulate and monitor the flow of blood and intravenous solutions. a. Infusion Controllers monitor flow by gravity and may be used with all blood components if they are designed to function with opaque solutions. b. Infusion Pumps deliver solutions under pressure and may cause red cell hemolysis due to negative pressure exerted by their peristaltic or syringe-like cassette action. c. If the blood component or product contains a significant number of red cells, the manufacturer should be consulted before using an infusion pump designated for use with crystalloid and colloid solutions. d. Hemolysis caused by use of an infusion pump may be worsen by other factors such as the length of tubing; needle gauge; diameter of tubing; blood unit age; type of filter; temperature; infusion rate or viscosity. F. Manual Pressure Cuffs i. Used to increase red cell flow rate. ii. Pressure should not exceed 300 mm Hg. iii. Standard BP cuffs should not be used for this purpose because they do not exert uniform pressure against all parts of the bag. G. Blood Warmers i. Blood warmers may be used to prevent hypothermia that can be induced by rapid infusion of large volumes of cold blood.

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ii. Blood Bank assigns a special requirement for the use of a blood warmer to the transfusion record of patients with clinically significant cold reacting antibodies. iii. Blood Bank only provides blood warmers for patients with antibodies that react at temperatures under 37°C. iv. Blood warmers for all other clinical situations are provided by central supply. v. Care must be taken to use only those blood -warming devices that have been tested and approved for use with blood components. Check the manufacture's instructions vi. Clinical Situations Indicating Possible Use of a Warmer: a. Neonatal exchange transfusion b. Plasma exchange c. Surgery d. Trauma e. Cold agglutinin disease vii. Limitations of Conventional Blood Warmers a. The rate of infusion can be impeded by the additional tubing and blood warming bags required for conventional warming devices. b. Blood warmers require substantial priming volumes, making them inappropriate for small-volume transfusions. H. Special Requirements, Risks, Products (See Appendix M) a. Indications for Transfusion. b. Recommended doses for adults & peds. c. Indications for ordering Special Attributes: • CMV negative products • Irradiated products • Leuko-reduced (filtered) products • Washed products ii. Risks of Transfusion (see Appendix N). iii. Time Required to Prepare Products (see Appendix O). iv. List of Blood Products Available (see 2 pages of Appendix P). v. See Appendix M for guidelines on when filtered products are recommended. KEYWORDS: labeling, patient ID band, crossmatch, hang time, transfusion, blood component REFERENCES: American Association of Blood Banks Standards, current edition http://www.aabb.org/content http://www.jcaho.org, “Sentinel Event Alert, Blood Transfusion Errors: Preventing Future Occurrences,” (1999) Shands Laboratories Website http://intranet.shands.org/shandslab/shandsUF/bloodbank/bloodbank.htm Nettine, S. (2001) The Lippincott Manual of Nursing Practice (7th Edition). “Transfusion therapy and blood and marrow stem cell transplantation,” Pages 893-897. Wooldridge-King, M. (2001). “Blood and blood component administration,” AACN Procedure Manual for Critical Care, 4th Ed.: 757-764. W.B. Saunders Co.

SIGNATURES: _________________________________________

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_________________________________________

_________________________________________

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APPENDIX A - Blood Order Form (back to section or top)

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SHANDS AT THE UNIVERSITY OF FLORIDA DEPT. OF NURSING AND PATIENT SERVICES

APPENDIX B Proper Labeling of Blood Bank Specimen http://intranet.shands.org/shandslab/shandsUF/bloodbank/bloodbank.htm (back to section or top) Initial Type & Cross or Type & Screen Labeling Example

Cord Blood Label Sample Labeling Example

Subsequent Type & Cross or Type & Screen Labeling Example

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APPENDIX C - Blood Bank Specimen Time-Out Verification Form (back to section or top)

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APPENDIX D Out-patient Blood ID Armband Policy Card (back to section or top)

Do Not remove your blood ID bracelet! Your physician has ordered a blood test before you have surgery. When your blood sample is drawn, you will receive a blood identification bracelet that will be placed on your wrist. This blood ID bracelet has a unique number on it that will be used to identify special blood products in case you need a blood transfusion during surgery or after. Keep wearing this bracelet, even if you are not scheduled for surgery for another three days. If you remove your blood ID bracelet, we will have to re-draw your blood, give you a new bracelet and re-test your blood – all of which will be charged to you. So please do not take off your blood ID bracelet. Your cooperation with this safety measure is appreciated.

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APPENDIX E - OTHER BLOOD BANK TESTS (back to section or top)

1.

Type & Screen (Diagnostic Only) - generally used for Prenatals, Pre-ops greater than 3days in advance of surgery and for transplant evaluations. In these cases, transfusion within 3 days is not the primary goal. This test will be used to determine if there will be a problem finding units for possible future transfusions. No BBID band required. Prenatal Antibody Screen – see Type & Screen (Diagnostic Only) ABO & Rh Confirmation - to be used for 2nd type (generally requested by transplant group or Blood Bank). Phenotype/Antigen Type – generally ordered by OB and Sickle Cell Program Antibody Titer/Isohemaglutinin Titer – generally ordered by OB and transplant program

Pink Top Tube for Blood Bank (Purple acceptable if no pink available and for pediatric draws) Type & Screen (Blood ID Band required) Type & Screen with Units (Blood ID Band required) ABO & Rh Direct Coombs (DAT) Antibody Titer Isohemaglutinin Titer Neonatal Evaluation Rh Immune Globulin Evaluation (RhoGam Workup) Type & Screen (Diagnostic Only – No BBID required) Platelet Antibodies Transfusion Reaction Investigation (pink & red top – Not Serum Separator Tube)

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APPENDIX F – DISPENSE SLIP (back to section or top)

Create an out-patient tracking number by using the delivery location prefix*, the current date and the patient’s initials. Ex: #INF092605SMG for a unit going to the infusion center for patient Sally M. Gator. This number (not the patient name or MR# - for HIPAA reasons) is given to the courier or driver. When the driver arrives with the tracking number, it is compared to the tracking number on the faxed dispense slip or the already packaged transport box/cooler. *Prefixes for out-patient/non SUF locations INF – Shands Infusion Center PED – Peds Med Plaza LOH – Live Oak Hospital LSH – LakeShore Hospital SRH – Shands Rehab AGH – Shands at AGH FSC – Florida Surgical Center

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APPENDIX G. ABO & Rh Compatibility Chart for Routine Patient Population (back to section or top) Blood Type Compatibility Chart

Blood Type of Recipient O+ OA+ AB+ BAB+ AB-

Donor Can Be for…

Red Cells O+ or O-

Plasma O; A; B or AB; any Rh

Whole Blood O+ or O-

OA+; A-; O+ or OA- or OB+; B-; O+ or OB- or OAB+; AB-; A+; A-; B+; B-; O+ or OAB-; A-; B- or O-

O; A; B or AB; any Rh A or AB; any Rh A or AB; any Rh B or AB; any Rh B or AB; any Rh AB; any Rh

OA+ or AAB+ or BBAB+ or AB-

AB; any Rh

AB-

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SHANDS AT THE UNIVERSITY OF FLORIDA DEPT. OF NURSING AND PATIENT SERVICES

APPENDIX H: (back to section or top)

ABO/Rh Compatibility Chart for ABO Incompatible Bone Marrow Transplant Patient Population To be followed post transplant & until documented ABO/Rh conversion occurs. ACCEPTABLE (Listed in order of preference)

PATIENT'S ABO Donor ABO

Packed Cells

FFP & #Cryo

Platelets Pack all plasma ABO incompatible

O

A

$O

any Rh A, AB

A, *AB, !O, *!B

O

B

$O

any Rh B, AB

B, *AB, !O, *!A

O

AB

$O

any Rh AB

AB, !A, !B, !O

A

O

$O

any Rh A, AB

A, *AB, !O, *!B

A

B

$O

any RH AB

*AB, !A, !B, !O

A

AB

$A, $O

any Rh AB

AB, !A, !B, !O

B

O

$O

any Rh B, AB

B, *AB, !O, *!A

B

A

$O

any Rh AB

*AB, !B, !A, !O

B

AB

$B, $O

any Rh AB

AB, !B, !A, !O

AB

O

$O

any Rh AB

AB, !A, !B, !O

AB

A

$A, $O

any Rh AB

AB, !A, !B, !O

AB

B

$B, $O

any Rh AB

AB, !B, !A, !O

Patient's Rh

Donor's Rh

pos

pos

any Rh

any Rh

any Rh

neg

neg

neg

any Rh

1st neg 2nd *pos

pos

neg

neg

any Rh

1st neg 2nd *pos

neg

pos

neg

any Rh

1st neg 2nd pos

*Red cell free

$Washed

Patient Care – Blood Administration/Phlebotomy – BA-P-004

!Packed (low titer)

#Type specific should be given if AB not available

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SHANDS AT THE UNIVERSITY OF FLORIDA

APPENDIX I - Transfusion Tag (back to section or top) Front \

Back

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APPENDIX I - Close up of back of the Transfusion Tag (back to section or top)

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APPENDIX J – BLOOD ADMINISTRATION SOLUTIONS & DEVICES (back to section or top) ADMINISTRATION OF BLOOD PRODUCTS I. Informed Consent for Blood Transfusions on file. II. Positive Identification, at the bedside, of the Recipient and the Designated Blood Unit to be Transfused is Essential and Required. III. Compatibility of Red Blood Cells with IV Solutions: 1. Use 0.9% Sodium Chloride for Injection, USP. 2. DO NOT use 5% Dextrose solutions (may induce hemolysis) 3. DO NOT use Lactated Ringer’s (contains Ca** which may induce clot formation in the blood bag and/or administration set). 4. DO NOT add medications to blood or infusion set 5. Plasma (type compatible) or albumin (5%) are acceptable in special circumstances. IV. Blood Filters. ALL BLOOD COMPONENTS MUST BE INFUSED THROUGH A FILTER. Refer to package insert. 1. Use a standard blood filter (150-280 micron screen) for all blood components. Replace after 4 hours. 1. Leukocyte-reduction filters are used to: a. Decrease febrile transfusion reactions. b. Decrease risk of alloimmunization to leukocyte or HLA antigens. c. Reduce risk of CMV transmission

Patient Care – Blood Administration/Phlebotomy – BA-P-004

V. Blood Warming. Use only a temperatureMonitored blood warmer to avoid hemolysis. Indications for blood warming: *1. Patients with clinically active cold agglutinins. 2. Adults receiving blood over 50 mL/kg/hour. 3. Children receiving blood over 15 mL/kg/hour. 4. Rapid infusion of blood through central lines (cold blood may induct arrhythmias). * Only indication for which SUF-Blood Bank supplies blood warmer.

VI. Time Limits for Infusion. Components must be infused within 4 hours. Note: the blood bank can divide components into aliquots as needed. VII. Irradiation of Blood and Cellular Components A minimum of 25 Gy should be used to reduce the risk of transfusion associated GVHD in susceptible patients such as: selected immunocompetent or or immunocompromised recipients (ie, stem cell/ Bone marrow transplant, congenital immune deficiency, etc), a fetus receiving intrauterine transfusions, recipients of HLA-matched or crossmatched platelets.

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APPENDIX K - Adverse Reaction Recognition & Management (back to section or top) M A N A G E M E N T O F A C U T E T R A N S F U S IO N R E A C T I O N S Im m e d ia te S te p s fo r A ll R e a c tio n s : 1. S t o p T r a n s f u s io n . 3. V e r if y c o r r e c t u n i t w a s g iv e n t o c o r r e c t p a t i e n t . 2. K e e p IV O p e n w it h 0 . 9 % N a C l 4. N o t if y a t t e n d in g p h y s i c ia n a n d b lo o d b a n k . A f t e r T r a n s f u s i o n i s T e r m in a t e d ( e x c e p t m i ld a l le r g ic , s e e b e l o w ) : 5. S e n d r e q u e s t f o r r e a c t i o n w o r k u p , f r e s h l y c o ll e c t e d b l o o d a n d u r in e s a m p le s w it h b lo o d u n i t a n d a d m in is t r a t io n s e t t o b l o o d B a n k C li n ic a l A c t i o n / P r e v e n t i o n R e a c tio n T y p e S ig n s & S y m p t o m s E t io lo g y A c u te h e m o ly t ic

A n x ie t y , c h e s t p a in , fla n k p a in , d y s p n e a , c h ills , f e v e r , s h o c k , h e m o g lo b in u r ia , c a r d ia c a r r e s t , h e m o g lo b in e m ia , u n e x p la in e d b le e d in g

H e m o ly t ic t r a n s fu s io n r e a c t io n ; u s u a lly d u e t o A B O in c o m p a t ib ility o r c o m p le m e n t - f ix in g r e d c e ll a n t ib o d y

S t e p s 1 - 5 a b o v e ; t r e a t w it h v a s o p r e s s o r s , I V f lu id s , c o r t ic o s t e r io d s a s n e e d e d ; m a in t a in a ir w a y ; in c r e a s e r e n a l b lo o d f lo w ( I V f lu id s ; fu r o s e m id e ) ; m a in ta in b r is k d iu r e s is ; m o n it o r r e n a l s t a tu s f o r a c u t e r e n a l f a ilu r e . M o n it o r c o a g u la t io n s t a t u s f o r D I C ; a d m in is t e r b lo o d c o m p o n e n t s a s n e e d e d a f te r e t io lo g y is c le a r .

A c u te lu n g in ju r y ( T R A L I)

F e v e r , c h ills , d y s p n e a , r e s p ir a t o r y f a ilu r e , h y p o x ia , p u lm o n a r y e d e m a , h y p o t e n s io n

S u p p o r t iv e t h e r a p y f o r r e s p ir a t o r y f a ilu r e , o x y g e n , m e c h a n ic a l v e n t ila t io n , l e u k o c y t e - r e d u c e d b l o o d c o m p o n e n t s u n t il e tio lo g y is c le a r ( d o n o r v s r e c ip ie n t a n t ib o d y ) .

A le r g ic ( m ild )

P r u r it u s , u r t ic a r ia ( h iv e s )

A n t ib o d ie s f r o m d o n o r p a ls m a t o r e c ip ie n t 's W B C s ; le s s c o m m o n ly r e c ip ie n t a n t ib o d ie s t o W BCs A n t ib o d ie s t o p la s m a p r o t e in s

A le r g ic (m o d e ra te to

H iv e s , d y s p n e a , a b d o m in a l p a in , h y p o t e n s io n , n a u s e a ,

s e v e re )

a n a p h y la x is , t h r o a t t ig h te n in g w h e e z in g

C ir c u la t o r y o v e r lo a d

H e a d a c h e , s h o rtn e s s o f b re a th ; s y s t o lic h y p e r t e n s io n ( > 5 0 m m H g r is e ) , p u lm o n a r y e d m a , c o n g e s t iv e

F e b r ile ( m ild t o m o d e ra te )

F e v e r , c h ills , r ig o r s , a n x ie t y , m ild d y s p n e a

H y p o t e n s io n

H y p o t e n s io n , ta c h y c a r d ia

S e p t ic / t o x ic

C h ills , r ig o r s , f e v e r h y p o t e n s io n , t a c h y c a r d ia lu m b e r p a in , n a u s e a , v o m it in g , s h o r tn e s s o f b r e a t h ; c h a n g e in s y s t o lic b lo o d p r e s s u r e

E n s u r e p r o p e r s a m p l e /r e c ip i e n t i d e n t i f ic a t io n .

A n t ib o d ie s t o p la s m a p r o t e in s , in lc u d in g Ig A

T o o r a p id a n d / o r e x c e s s iv e t r a n s f u s io n

S t e p s 1 - 4 a b o v e ; a d m in is t e r a n tih is t a m in e s ( P O , I M o r I V ) ; r e s u m e tr a n s f u s io n if im p r o v e d ; if n o im p r o v e m e n t in 3 0 m in u t e s t r e a t a s b e lo w . S t e p s 1 - 5 a b o v e ; a d m in is t e r a n tih is t a m in e s , e p in e p h r in e , v a s o p r e s s o r s , a n d c o r t ic o s t e r o id s a s n e e d e d ; a v o id f u t u r e r e a c t io n s b y p r e m e d i c a t i o n a n d u s e o f w a s h e d re d c e lls . C h e c k p re tra n s fu s io n Ig A le v e l. I n d u c e d iu r e s is ; p h le b o t o m y ; s u p p o r t c a r d io r e s p ir a t o r y s y s t e m a s n e e d e d . A v o i d r a p i d o r e x c e s s iv e tra n s fu s io n .

h e a r t f a ilu r e ; c a r d ia c a r r h y t h m ia s A n t ib o d ie s t o le u k o c y t e a n tig e n s , ( m o s t ly H L A ) ; c y t o k in e s B r a d y k in in g e n e r a t io n , m a y b e e x a c e rb a te d b y A C E in h ib it o r s B a c te r ia c o n t a m in a t io n o f b lo o d p r o d u c t s

Patient Care – Blood Administration/Phlebotomy – BA-P-004

S t e p s 1 - 5 a b o v e ; m ild - a d m in is t e r a n t ip y r e tic s a s n e e d e d ; a v o id f u r t u r e r e a c t io n s b y p r e m e d ic a t io n a n d u s e o f le u k o c yte -re d u c e d re d c e lls & p la te le ts . S t e p s 1 - 3 a b o v e ; f lu id s ; T r e n d e le n b e r g p o s it io n ; d is c o n t in u e A C E in h ib it o r ; a v o i d b e d s i d e l e u k o c y t e r e d u c t io n f i l t e r s . ( L e u k o c y t e r e d u c t io n p e r f o r m e d in S U F - B lo o d B a n k . ) S t e p s 1 - 5 a b o v e ; t r e a t s h o c k w it h v a s o p r e s s o r s , I V f lu id s ; g iv e a n tib io t ic s . C u lt u r e s a m p le s f r o m p a t ie n t a n d b a g .

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APPENDIX L – POST TRANSFUSION INSTRUCTIONS FOR OUT PATIENTS (back to section or top) Nurse: Fill out form and make two photocopies. Keep one copy for medical records and give one copy to patient. This blood transfusion has been administered to you by order of your physician as part of his treatment of your condition. The blood you received is crossmatched with your blood prior to the transfusion in order to assure that the blood transfused is as safe as possible using current approved laboratory tests. The majority of blood transfusions cause no reaction; however even with the assurance of pre-transfusion testing, blood transfusions my produce some adverse reactions. Following is a list of possible reactions from infusing blood: 1. Feeling Faint (syncope) 2. Fever (with or without chills) 3. Rash or hives 4. Lower back pain 5. Dark urine 6. Difficult or labored breathing 7. Chest pain If you should develop any of these or other symptoms following transfusion therapy, call your physician or return to the hospital for evaluation and possible treatment. SHANDS at UF Emergency Department phone # is 352-265-0050. I hereby acknowledge receipt of a copy of these instructions and have had them explained to me. I understand them and agree to follow-up care, as instructed if needed.

____________________________________________________ Patient or representative signature

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Appendix M - Guidelines for Transfusion and Ordering Special Attributes APPROVED INDICATIONS FOR TRANSFUSION ORDERABLE PRODUCTS and DOSES PACKED RED BLOOD CELLS Hct less than 25% or Hgb less than 8 g Acute Blood Loss Hemodynamic Instability Symptomatic anemia in cardiovascular or lung disease Surgery (Refer to Standard Surgical Blood Order Schedule - SSBOS)

Packed Cells (250 mL/unit) Autologous Adult dose: 1 Unit will raise Hct Directed by 3% or Hgb by 1g PediSplit (80/mL/unit) Aliquot (20-60 mL in Syringe) Peds dose: 10 mL/kg

PLATELETS Platelet count less than 20,000 cu mm

Random Donor Patelets

Platelet count less than 50,000 cu mm with active bleeding Platelet count less than 50,000 cu mm with surgical procedure Platelet count less than 50,000 cu mm in pre-term infants

Adult Dose: 1 unit/10 Kg body weight (avg. 6-10 units) Child greater than or equal to 2 yr Dose: 1 unit/10 Kg Infant less than 2 yr Dose: 10 mL/Kg body wieght

Active bleeding with dysfunctional platelets

Single Donor Platelet Pheresis HLA Matched Platelet Pheresis Crossmatched Platelet Pheresis

PLASMA PT greater than or equal to 20 sec. or APTT greater than or equal to 60 sec. with active bleeding Congenital or acquired coagulation factor deficiencies for which no specific coagulation concentrates are available Thrombotic Thrombocytopenic Purpura (TTP) Rapid reversal of Warfarin with active bleeding or invasive procedure and INR greater than 1.6

Plasma (FFP or Thawed - 220 mL/Unit) Cryo-poor Plasma (220 mL/Unit) Pedi FFP (50 mL/unit) Aliquot (20-40 mL in Syringe) Dose: 10-20 mL/kg

CRYOPRECIPITATE Fibrinogen levels less than or equal to 115 mg/dL Factor XIII deficiency less than 25% of normal Uremic with active bleeding

Cryoprecipitate (CRYO 15 mL/Unit) Dose Formula:

desired increase level (mg/dl) x pt's plasma vol (mL)* 250mg/Unit for Fibrinogen * or substitute 4% body weight (kg) x 1000

Rh IMMUNE GLOBULIN Rh neg woman who delivers Rh pos infant Rh neg woman without previous sensitization at the time of 28-32 weeks gestation, abortion, amniocentesis or other indicated procedure Rh neg persons without previous sensitization who has received blood products or tissue grafts containing Rh pos red cells

Rh Immune Globulin (RhIg) Dosage is calculated using Kleihauer-Betke results 1 vial (300mcg)/15 mL Rh positive RBC exposure

VZIG Exposure to Varicella Zoster (within 72 hours of exposure)

Dose: 1 vial (2.5 mL)/10 kg - 5 vials max 125 Units of antibodies / 2.5 mL - IM use

(back to section or top)

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Appendix M - Guidelines for Transfusion and Ordering Special Attributes (back to section or top) APPROVED INDICATIONS FOR ATTRIBUTES CMV NEGATIVE LEUKOREDUCTION by FILTRATION CMV negative transplant recipient & Donor CMV negative Alternative to CMV negative products Intrauterine transfusion Recurrent febrile non-hemolytic transfusion reactions CMV negative & pregnant Reduction of primary HLA alloimmunization CMV negative AIDs patient VOLUME REDUCED Pre-term infants Prevention of volume overload Immunodeficient neonates Neonates & infants who are candidates for organ transplantation

IRRADIATION Bone Marrow Transplant Congenital Immunodeficiency Intrauterine Transfusion Blood units from blood relatives HLA matched or crossmatched platelets Aggressive Immunosuppressive Chemotherapy

Patient Care – Blood Administration/Phlebotomy – BA-P-004

WASHED Recurrent urticarial and or febrile transfusion reactions ABO incompatible bone marrow transplant Clinical conditions requiring avoidance of ammonia, K+ and or lactic acid IgA deficiency

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APPENDIX N - RISKS OF TRANSFUSION (back to section or top) ADVERSE EFFECTS & RISKS of BLOOD PRODUCT TRANSFUSION RISKS RISK / UNIT Transfuse RBC to wrong patient ^53 - 83 : 1,000,000 Infection from platelet transfusion ^66 : 1,000,000 ABO incompatible transfusion ^33 : 1,000,000 Hepatitis B (HBV) *5 : 1,000,000 Death due to ABO incompatible transfusion ^2 : 1,000,000 Hepatitis C (HCV) *1 : 2,000,000 Malaria or Syphilis ^1 : 1,000,000 Human Immunedeficiency Virus (HIV) *1 : 2,000,000 HTLV *1 : 3,000,000 West Nile Virus (WNV) Data still being collected ^ Transfusion 2001:41:1493-1499 (BaCon Study) * Transfusion 2002:42:975-979

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APPENDIX O - PREPARATION TIME FOR PRODUCTS (back to section or top) Component Transport Expiration *Prep Time Whole Blood 1-10°C 21 days CPDA - Red Cells 35 days AS - Red Cells 42 days Aliquot Red Cells 4 hrs 20 min Washed Red Cells 24 hrs 30 min Platelets 30 min 20-24°C 5 days Pooled Platelets 4 hrs 30 min Platelet Pheresis 5 days 30 min Washed platelets 24 hrs 45 min Fresh Frozen Plasma Frozen 1year FFP, Thawed 30 min - 2hrs 1-10°C 24 hrs Thawed Plasma 15 min 1-10°C 5 days Cryoprecipitate Frozen 1year Cryo, single 60 min 20-24°C 6 hrs Cryo, pooled 60 min 20-24°C 4 hrs Filtered products 40 min Irradiated products 15 min *Time needed to prepare or modify product Administer one unit at a time in non-urgent settings Infuse all blood products via standard blood infusion set (170–260 micron) ALL products must be infused within 4 hours of starting

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APPENDIX P – Blood Components and Plasma Derivative Chart BLOOD COMPONENTS AND PLASMA DERIVATIVES Component/Product Volume Composition Whole Blood RBCs (approx. Hct 40%; 500 mL plasma; WBCs; platelets

Red Blood Cells

Red Blood Cells, Adenine-Saline Added RBCs Leukocyte Reduced (prepared by filtration)

RBCs Washed

RBCs Frozen; RBCs Deglycerolized

Granulocytes Pheresis

Platelets

Platelets Pheresis

Platelets Leukocyte Reduced

RBCs (approx. Hct 75%); reduced plasma, WBCs and platelets RBCs (approx. HCT 60%); reduced plasma, WBCs and platelets; 100 mL of additive solution Greater than 85% of original volume of RBC; less than 5 x 106 WBC; few platelets; minimal plasma RBCs (approx. Hct 75%); less than 5 x 108 WBC; no platelets; no plasma RBCs (approx. Hct 75%); less than 5 x 108 WBC; no platelets; no plasma Granulocytes (greater than 1.0 x 1010 PMN/unit); lymphocytes; platelets (greater than 2.0 x 1011/unit); some RBCs Platelets (greater than 5.5 x 1010 /unit); RBCs; WBCs; plasma Platelets (greater than 3 x 1011 /unit); RBCs; WBCs; plasma Platelets (as above); less than 5 x 106 WBCs per final dose of pooled Platelets

Patient Care – Blood Administration/Phlebotomy – BA-P-004

250 mL

330 mL

225 mL

180 mL

180 mL

220 mL

Objectives Increase both red cell mass and plasma volume (WBCs and platelets not functional; plasma deficient in labile clotting Factors V and VIII) Increase red cell mass in symptomatic anemia (WBCs and platelets not functional) Increase red cell mass in symptomatic anemia (WBCs and platelets not functional) Increased red cell mass; less than 5 x 106 WBCs to decrease the likelihood of febrile reactions; immunization to leukocytes (HLA antigens) or CMV transmission Increase red cell mass; reduce risk of allergic reactions to plasma proteins. Increase red cell mass; minimize febrile or allergic transfusion reactions; use for prolonged RBC blood storage Provide granulocytes for selected patients with sepsis and severe neutropenia (less than 500 PMN/μL)

50 mL

Bleeding due to thrombocytopenia or thrombocytopathy

300 mL

Same as Platelets; sometimes HLA matched or crossmatched

300 mL

Same as Platelets; less than 5 x 106 WBCs to decrease the likelihood of febrile reactions; alloimmunization to leukocytes (HLA antigens), or CMV transmission

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APPENDIX P – Blood Components and Plasma Derivative Chart Continued

(back to section or top) BLOOD COMPONENTS AND PLASMA DERIVATIVES Component/Product Volume Composition FFP; Donor Retested FFP, Donor Retested 220 mL Plasma; Thawed Plasma; all coagulation Plasma factors; Thawed Plasma has reduced FV, VIII Cryoprecipitated AHF Fibrinogen; Factors VIII 15 mL and XIII; von Willebrand factor; 80 Units of Factor VIII per unit *Factor VIII (concentrates; recombinant human factor VIII *Factor IX (concentrates; recombinant human factor XI) *Albumin / PDF *Immune Globulin

Factor VIII; trace amount of other plasma proteins (products vary in purity)

25 mL

Factor IX; trace amount of other plasma proteins (products vary in purity)

25 mL

Albumin, some α -, Bglobulins IgG antibodies; preparations for IV and / or IM use

Rh Immune Globulin

IgG anti-D; preparations for IV* and / or IM use

*Antithrombin

Antithrombin; trace amount of other plasma proteins Activated Protein C

*Activated Protein C (recombinant)

Factor VIIa

Patient Care – Blood Administration/Phlebotomy – BA-P-004

(5%); (25%) Varies

Objectives Treatment of some coagulation disorders

Deficiency of fibrinogen; Factor XIII; second choice in treatment of Hemophilia; A, von Willebrand’s disease; (topical fibrin gluemanufactured*) Hemophilia A (Factor VIII deficiency); von Willebrand’s disease (off-label use for selected products only) Hemophilia B (Factor IX deficiency)

Volume expansion

Treatment of hypo- or agammaglobulinemia disease prophylaxis; autoimmune thrombocytopenia (IV only) 1 mL Prevention of hemolytic disease of the newborn due to D antigen; treatment of autoimmune thrombocytopenia 10 mL Treatment of antithrombin deficiency

Severe sepsis 2.2 mL (1.2 mg)/8.5 mL (4.8mg)

Bleeding episodes for Hemophilia A or B with inhibitors

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RBCs = red blood cells; Hct = hematocrit; WBCs = white blood cells; CMV = cytomegalovirus; PMN = polymorphonuclear leukocytes; FFP = fresh frozen plasma; PPF = plasma protein fraction; IV = intravenous; IM = intramuscular *Order from Pharmacy

Patient Care – Blood Administration/Phlebotomy – BA-P-004

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