Blood Transfusion – OSCE Guide

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This blood transfusion OSCE guide provides a step-by-step approach to safely arranging and administering a blood transfusion in an OSCE setting.


Collecting the initial blood sample

1. Wash your hands and don PPE if appropriate.

2. Ask the patient to tell you their name and date of birth and then compare this to their identify bracelet to make sure they match.

3. Perform venepuncture to collect a blood sample into an appropriate bottle for blood group analysis (typically a pink-topped blood bottle).

4. Fill out the patient’s details onto the blood bottle at the bedside immediately after taking the sample.

5. Sign the blood bottle to confirm you have personally obtained the sample.

6. Complete the associated blood transfusion form:

  • Include all relevant patient details (e.g. name, date of birth, unique identification number).
  • Document any special requirements for blood transfusion (e.g. CMV-negative blood or irradiated blood).
  • Document the number of units of blood required if a crossmatch is needed.
  • Confirm that the patient has provided valid consent for blood transfusion if relevant (see below).
  • Document your full name and sign to confirm you’ve personally obtained the blood sample and have performed the necessary checks.

7. Send the sample to the lab for analysis of blood type and cross-matching if required.

8. Dispose of the relevant equipment into a clinical waste bin and wash your hands.

Consent

Before prescribing blood, you need to make sure the patient has consented to receive a blood transfusion. For valid consent to be obtained, the patient needs to understand what the transfusion process involves, including the risks associated with blood transfusion (e.g. transfusion reactions, fluid overload and infection).


Prescribing the blood transfusion

Once the patient’s blood type is known, you will need to prescribe their blood transfusion.

Important points about prescribing blood transfusions:

  • In most cases, the prescription is written on a patient’s fluid chart in the same place that other intravenous fluids are prescribed (however this can vary between healthcare settings).
  • Each unit of blood should be prescribed separately on its own line.
  • When writing out a prescription for a blood transfusion, each unit of blood should be prescribed as “PACKED RED CELLS”.
  • The prescription should include the time and date of the infusion, as well as the indication for the transfusion.
  • In non-urgent scenarios, a unit of blood is typically transfused over a 2-3 hour period.
  • Blood needs to be administered within 30 minutes of leaving the refrigerator and it’s therefore important to only request the transport of blood to a patient when they are present and have adequate intravenous access.

Checking the blood transfusion

Once the blood transfusion arrives, you will need to check it with a colleague to ensure it is safe for administration:

1. Wash your hands and don appropriate PPE.

2. Request a colleague (nurse or doctor) to assist you with checking the blood transfusion.

3. Ask the patient to tell you their name and date of birth and then compare this to their bracelet, medical notes and blood compatibility report to ensure they all match exactly.

4. Check the blood group and serial number on the blood bag matches the compatibility report.

5. Check the expiry date and time on the unit of blood to ensure it has not expired.

6. Inspect the blood bag for:

  • Signs of tampering
  • Leaks
  • Discolouration
  • Clots

Do not administer blood if any of these are noted.


Administering the blood transfusion

Once the blood for transfusion has been checked it can be administered intravenously:

1. Wash your hands and don appropriate PPE (if not done so already).

2. Attach the giving set to the blood bag and run some blood through the tubing to expel any air.

3. Once all air has been expelled from the tubing, attach the other end of the giving set to the cannula port.

4. Set the time the blood should be transfused over (typically 2-3 hours in non-urgent scenarios).

5. Dispose of the relevant equipment into a clinical waste bin (including PPE).

6. Wash your hands.

7. Document the time and date that the transfusion was started and both you and your colleague will need to sign to confirm all checks were carried out prior to administration.


Monitoring the patient during the blood transfusion

Monitoring the patient is a crucial part of the transfusion process:

1. The patient’s baseline observations should be checked at 0, 15 and 30 minutes from the onset of the transfusion.

2. Observations can then be performed on an hourly basis and again when the transfusion has finished.

Regular observations allow early detection of transfusion reactions.


Transfusion reactions

Immediate transfusion reactions

Immediate transfusion reactions are those that occur within 24 hours of the transfusion being administered. They can be broadly categorised into immune and non-immune causes.

Immune

  • Acute haemolytic transfusion reaction (ABO incompatibility)
  • Transfusion-related acute lung injury (TRALI)
  • Anaphylaxis

Non-immune

  • Bacterial infection
  • Fluid overload

Delayed transfusion reactions

Delayed transfusion reactions are those that occur after 24 hours of the transfusion being administered. They can be broadly categorised into immune and non-immune causes.

Immune

  • Delayed haemolytic transfusion reaction (DHTR)
  • Febrile non-haemolytic transfusion reaction (FNHTR)
  • Post-transfusion purpura (PTP)
  • Graft versus host disease (GvHD)

Non-immune

  • Viral infections
  • Malaria
  • Prions

Overview of immune-mediated transfusion reactions

Acute haemolytic transfusion reaction (ABO incompatibility)

  • ABO incompatibility results in anti-A/B antibodies activating the complement pathway and triggering the release of inflammatory cytokines.
  • Early clinical features include fever, hypotension, anxiety and red-coloured urine.
  • Late clinical features include hypotension and widespread haemorrhage secondary to disseminated intravascular coagulation.

Transfusion-related acute lung injury (TRALI)

  • The pathophysiology of TRALI not fully understood but antibodies to human neutrophil antigens and human leukocyte antigens have been implicated.
  • The typical presentation of TRALI is the sudden development of dyspnoea, severe hypoxaemia, hypotension and fever that develop within 6 hours after transfusion and usually resolve with supportive care within 48 to 96 hours.

Anaphylaxis

  • Anaphylaxis occurs when the recipient is allergic to protein components present in the donor transfusion.
  • Typical clinical features include an itchy rash, angioedema, shortness of breath, vomiting, lightheadedness, and hypotension.
  • Anaphylaxis typically develops over minutes to hours and can quickly become life-threatening.

Delayed haemolytic transfusion reaction (DHTR)

  • Delayed haemolytic reactions are caused by antibodies to antigens such as Rhesus or Kidd.
  • A delayed haemolytic reaction can occur between 3 to 14 days after the transfusion.
  • Typical clinical features include a sudden drop in haemoglobin level, fever, jaundice and haemoglobinuria.

Febrile non-haemolytic transfusion reaction (FNHTR)

  • The typical clinical features of FNHTR include fever during blood transfusion with no associated haemolysis.
  • FNHTR is most commonly caused by antibodies directed against donor leukocytes and HLA antigens. This is in contrast to transfusion-associated acute lung injury, in which the donor plasma has antibodies directed against the recipient HLA antigens, mediating the characteristic lung damage.
  • FNHTR typically develops in patients who have received multiple transfusions or in women who have had multiple previous pregnancies.

Post-transfusion purpura (PTP)

  • PTP is an adverse reaction to a blood transfusion or platelet transfusion that occurs when the body produces alloantibodies to the introduced platelets’ antigens.
  • These alloantibodies destroy the patient’s platelets leading to thrombocytopenia.
  • PTP usually presents 5–12 days after transfusion.

Graft versus host disease (GvHD)

  • Graft versus host disease is a medical complication following the receipt of transplanted tissue from a genetically different individual.
  • Immune cells (white blood cells) in the donated tissue (the graft) recognize the recipient (the host) as foreign (nonself). The transplanted immune cells then attack the host’s cells.
  • GvHD can occur after a blood transfusion if the blood products used have not been irradiated or treated with an approved pathogen reduction system.

Reviewer

Dr Sandeep Potluri

Haematology Registrar


References

  1. Covin RB, Evans KS, Olshock R, Thompson HW (2001). “Acute hemolytic transfusion reaction caused by anti-Coa”. Available from: [LINK].
  2. Noizat-Pirenne F, Bachir D, Chadebech P, et al (December 2007).”Rituximab for prevention of delayed hemolytic transfusion reaction in sickle cell disease”. Available from: [LINK].
  3. Silliman C, Paterson A, Dickey W, Stroneck D, Popovsky M, Caldwell S, Ambruso D (1997). “The association of biologically active lipids with the development of transfusion-related acute lung injury: a retrospective study”. Available from: [LINK].
  4. Addas-Carvalho M, Salles TS, Saad ST (June 2006). “The association of cytokine gene polymorphisms with febrile non-hemolytic transfusion reaction in multitransfused patients”. Available from: [LINK].

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