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Transfusion Services

COMMONLY REQUESTED INFORMATION

SAMPLE COLLECTION PROCESS

Note: Delay of service may result from the omission of required information on the patient’s specimen label or specimen. Patients having Blood Bank testing with the possibility of receiving a transfusion must have a properly labeled (patient’s name and date of birth) Blood Bank wristband placed on them prior to the venipuncture. The Blood Bank wristband has a unique barcode with specific letters/numbers for patient/specimen identification. This special BBID wristband has extra barcode stickers for future use. One of these unique barcode stickers from the BBID wristband MUST be placed on the specimen label after collection. Specimens with handwritten information and/or BBID wristbands that are handwritten MUST be accompanied by a Certification Form or they will be rejected by the Blood Bank.

TRANSFUSION SERVICE ORDERS

Order Options

Tube to Hold: No testing performed. The specimen is held for three days (Today+3) in the event testing becomes necessary.
Type & Screen: Testing performed for ABO, Rh and antibody screen. The specimen is held for three days (Today+3).
Type and Crossmatch: Testing performed for ABO, Rh, antibody screen and Crossmatch for the specified number of units. The specimen will be held for three days (Today+3).

Pre-Admission Blood Bank Collection

If a patient is having pre-admission blood work collected and there are Transfusion Service orders (Type & Screen or Type and Crossmatch) the specimen can be collected up to thirty (30) days prior to the surgery date.

TRANSFUSION SERVICE REQUESTS

Consent Form (Form #5651)

The consent form must be dated and signed by the physician, the patient and a witness indicating that the patient received and understood the information received. The page containing blood transfusion education should be given to the patient and the signed consent must be kept on the patient’s chart.

Inpatient Orders

All inpatient Blood Bank testing will be computer generated directly to the Transfusion Service department by Order Entry. Any special blood requests (i.e., irradiated, CMV negative, etc.) must be indicated at time of order in the Comment section.

Outpatient Orders

All out-patient Blood Bank testing will be computer generated directly to the Transfusion Service department by Order Entry. Any special blood requests (i.e., irradiated, CMV negative, etc.) must be indicated at time of order in the Comment section.

SPECIAL SERVICES

Outpatient Transfusions

Adams Infusion Center (717) 339-2666, located at 40 V-Twin Drive in Gettysburg. Exceptions are weekends, holidays, weekdays after 5:00 p.m. or urgent transfusions. In these cases, a call should be placed to the WellSpan Gettysburg Hospital Blood Bank for assistance (717) 339-2317.
Apple Hill Infusion Center (717) 741-8637, located at the Apple Hill Medical Center, Suite #120. The Apple Hill Infusion Center also schedules transfusions for the York Hospital (YH) 5 Main Infusion room. Exceptions are weekends, holidays, weekdays after 5:00 p.m. or urgent transfusions. In these cases, a call should be placed to the YH 5 Main Infusion room for assistance (717) 851-4070. If assistance is needed after hours and you are unable to reach the 5 Main infusion room, a call should be made to the nursing station on 7 South (717) 851-2625.
Ephrata Cancer Center (717) 721-4840, located at 460 N. Reading Road in Ephrata.
The GSH Blood Donor Center is located at 750 Norman Drive, Lebanon, and can be reached at 270-8960. To make a donation, drop in during the hours shown below, or schedule an appointment by calling the Donor Center.
Blood Donor Hours
- Monday: 7:00 am to 2:00 pm
- Tuesday: 8:00 am to 5:00 pm
- Wednesday: 7:00 am to 4:00 pm
- Thursday: 11:00 am to 6:30 pm
- Friday: 7:00 am to 2:00 pm
Both outpatient facilities must be advised if the patient currently has or has ever had MRSA or VRE.
Pre-transfusion testing should be done the day before the scheduled transfusion. It may take longer to get the blood ready for patients with a history of an antibody, so drawing the sample in advance will provide the best customer service.

Therapeutic Apheresis

Call Dr. Gela McHedlishvili WellSpan Nephrology, at (717) 851-6040 for information or to make scheduling arrangements for Therapeutic Apheresis Services.

Special Test Requests

DAT Negative AIHA Investigation (SUPER COOMBS)

This is a referral test that will be sent to the National Testing Laboratory in Philadelphia. The specimen must be drawn on Monday or Tuesday morning only. Call the Blood Bank at (717) 851-2520 for special instructions and requirements.

PLATELET SEROLOGY TESTING/MOLECULAR PHENOTYPING OF RED BLOOD CELLS: These are referral tests that will be sent to the American Red Cross (ARC) or Grifols Reference Laboratory. Call the Blood Bank at (717) 851-2520 for special instructions and requirements.

Indirect Platelet Antibody
Platelet Crossmatch
Suspected Neonatal Thrombocytopenia or Neutropenia
HLA testing for Platelet Transfusion
Molecular Phenotyping for Red Cell Transfusion

These are referral tests that will be sent to the American Red Cross (ARC) or Grifols Reference Laboratory. Call the Blood Bank at (717) 851-2520 for special instructions and requirements.

SPECIAL PRODUCT REQUESTS

These products require prior notification for procurement. Call the Blood Bank for inquiries at (717) 851-2520.

HLA-Matched Apheresis platelets
Crossmatched Apheresis platelets
HPLA 1 Negative Apheresis platelets
Granulocytes

Blood Component Therapy for Bone Marrow Transplant Patients

Care must be taken in the selection of blood components before and after transplantation. The following information is required from the physician as soon as possible on all transplant candidates:

Patient’s name
Donor blood type
Transplant date
Tranfusion requirements (Irradiation, CMV negative, etc.)
Transplant center

It is imperative that the information listed above be communicated to the Transfusion Service department who will document all the data as well as any serological changes in the patient’s transfusion record. Documenting these items will aid in selecting the optimum blood components for transplant patients.

ADMINISTRATION OF BLOOD COMPONENTS

Positive identification of the patient and the blood unit are essential prior to transfusion.
IV solutions used during administration must be compatible to the red blood cells.

Use 0.9% Sodium Chloride for Injection, USP
Do not use 5% Dextrose solutions (may induce hemolysis)
Do not use Lactated Ringer’s (contains Ca++ which may induce clot formation in the red cell unit or in the administration set)
Do not add medications to blood or infusion set.

To avoid hemolysis, use only a temperature-monitored blood warmer.
Regulate infusion rate depending on patient condition, and type of transfusion. Set IV to a rate to infuse in desired time frame. (Transfusion Rate will be 3 ½ per unit) and the transfusion must not go longer than 4 hours.)
Transfusion Service can divide components for transfusion into smaller amounts upon request, such as for smaller sized patients or patients with history of Congestive Heart failure, Kidney Disease, Lung Disease, Transfusion Associated Circulatory Overload (TACO) or other transfusion reactions.
Leukocyte reduced blood products are used to decrease febrile transfusion reactions, decrease risk of alloimmunization to leukocyte or HLA antigens, and to reduce transmission of CMV.
The risk of Transfusion Associated – GVHD in susceptible patients is reduced using a minimum of 25 Gy of irradiation for cellular blood products. Patients who are at risk of GVHD are listed below:

Intrauterine transfusions
Premature, low birth weight ( < 1200 grams) infants (routinely until 4 months of age)
Newborns with erythroblastosis fetalis
Congenital immunodeficiencies
Lymphoma patients
Leukemia patients
Hodgkins disease
Some solid tumors: Neuroblastoma, sarcomas
Bone marrow or stem cell transplant patients
Fludarabine therapy recipients (other purine analogs: thioguanine, pentostatin, cladribine, mercaptopurine, 6-mercaptopurine,azathioprine)
Anyone receiving granulocyte components
Malignancy being treated with radiation / cytotoxic agents (or any severely neutropenic cancer patient)
Donor-recipient pairs from genetically homogeneous populations (esp. Japanese to Japanese)
Irradiate products for all infants < 4 months old.
If a patient has Sickle Cell Anemia, the patient must receive sickle negative red cells and C, E and K antigen negative units as appropriate. Notify the Transfusion Service department at (717) 851-2520.

All blood products must be infused through a filter.

Component/Products and Their Indication

Testing Requirements	Component/ Product	Composition	Indications	Turn-Around Time
Product-Order RBCs	Red Blood Cells*	RBC (approx Hct 75%); reduced plasma; WBCs; plasma	Increase red cell mass in symptomatic anemia	Crossmatched: < 45 minutes; Uncrossmatched: 15 minutes.
	Red Blood Cells* -Leukocytes reduced, prepared by filtration.	>85% of the original volume of RBC; <5x10⁶WBC; few platelets and minimal plasma	Increase red cell mass in symptomatic anemia; <5x10⁶ WBC to decrease the likelihood of febrile reactions; immunization to leukocytes (HLA Ags) or CMV transmission.
	Red Blood Cells -Washed	RBC (approx Hct 75%); <5x10⁸ WBC; no plasma	Increase red cell mass in symptomatic anemia; reduce risk of allergic reaction to plasma proteins.	Requires an additional 45 minutes for washing the unit.
Type & Rh	Platelets*	Platelets (>5.5x10¹⁰/unit); RBC’s; WBC; plasma	Bleeding due to thrombo-cytopenia or thrombo-cytopathy	Distributed as a pre-pooled platelet pool; 15 minutes.
	Platelet Pheresis*	Platelets (>3.0x10¹¹/unit); RBC’s; WBC; plasma	Bleeding due to thrombo-cytopenia or thrombo-cytopathy	15-20 minutes. Reservations preferred.
	Fresh Frozen Plasma	Source of non-labile factors	Treatment of some coagulation disorders	1-3 units/30 minutes; >4 units/45 minutes.
	Cryoprecipitate AHF	Fibrinogen, Factors VIII & XIII; Von Willebrand Factor	Deficiency in Fibrinogen, Factor XIII, Second choice in treatment of Hemophilia A, Von Willebrand Disease; can be used to make topical Fibrin Glue.	Distributed as a 5-6 unit pre-pooled cryoprecipitate pool. 30 minutes
Type & Antibody Screen	Rh Immune Globulin (RIG)	IgG Anti-D; Preparations of IM use	Prevention of Hemolytic Disease of the Newborn due to the D antigen; prevention of alloimmunization of Anti-D in an Rh negative patient who receives Rh positive red cell products.	1 vial/45 minutes

*These products can be requested as irradiated. Irradiation of the product with 25 Gy should be used to reduce the risk of Transfusion Associated-Graft versus Host Disease (TA-GVHD) in susceptible patients such as; immuno compromised recipients (Hematopoietic Progenitor Transplant patients, Congenital Immune Deficiency), a fetus receiving transfusions, recipients of donor units from relatives, recipients of HLA-matched platelets, etc.

Management of Transfusion Reactions

Steps to follow for all reactions:

Stop the Blood Component Transfusion Immediately!!!
Maintain IV access, and ensure urine output with the appropriate crystalloid or colloid solution.
Verify that the correct unit was given to the correct patient
Maintain blood pressure and pulse
Maintain adequate ventilation
Notify the Blood Bank

York Hospital Blood Bank at (717) 851-2520 or the
Gettysburg Hospital Blood Bank at (717) 339-2317)
Ephrata Community Hospital at (717) 738-6113
Good Samaritan Hospital at (717) 270-7526

Notify the provider
Obtain one (1) pink top tube labeled with a barcode readable Blood Bank ID # and a labeled urine sample for the transfusion reaction work-up.
Send the following to the Blood Bank:

Transfusion Reaction Report – Obtained from the System Transfusion Reaction Work-up Nursing Policy
Copy of vital sign records (if using downtime procedure, send a copy of the completed Blood Issue Forms)

Note: If patient has a febrile reaction during the blood transfusion, blood cultures on the patient may be required.
Instructions will be provided by the Blood Bank staff based on the patient’s vital signs.

Blood Bag and Administration Set
Be prepared to administer supportive therapy, appropriate medications, or emergency care as warranted by the clinical situation
Update the Blood Bank as to evolving symptoms and resolution of the reaction.

Note: If more than one transfusion has been given,
send as much information as you can – all vital signs related to each transfusion (if using downtime procedure, send a copy of the completed Blood Issue Forms), and each blood bag/administration set(s) from each transfusion(s).
All transfusion reactions are reviewed and interpreted by a pathologist.

TRANSFUSION REACTION INFORMATION

Assessment:

Description:

Usual Cause:

Recommendation:

Allergic Transfusion Reaction

Mild-Moderate

Any of: Hives, itching, wheezing, throat tightening, hypotension.

Antibodies to plasma proteins (fairly common).

Recommend pretreatment with an antihistamine such as diphenhydramine. Consider combined H1 and H2 blocker pretreatment or steroids for recurrent allergic reactions. Administer blood slowly, with nursing supervision.

Allergic Transfusion Reaction

Severe

Anaphylaxis, anaphylactoid shock or laryngeal edema requiring intubation and/or epinephrine administration.

Antibodies to plasma proteins (fairly common). Antibodies to IgA in IgA deficient individuals (rare).

Recommend administering washed RBC’s and pretreating with antihistamines and steroids prior to transfusions. Administer blood products slowly, under close nursing supervision. Consider testing the patient’s (pretransfusion) IgA level.

Hypotensive Transfusion Reaction

Hypotension, tachycardia, facial flushing, and abdominal pain.

Bradykinin generation, may be exacerbated by ACE inhibitors.

Recommend using pre-storage leuko-reduced products, and giving future transfusions slowly with close nursing supervision.

Stop the transfusion immediately during a hypotensive episode, place patient in the Trendelenburg position, and administer fluids.

Unrelated (Patient's symptoms are unrelated to the transfusion)

Any. May mimic a true transfusion reaction. Always is appropriate for the nurse to stop the transfusion and initiate a work-up.

Underlying disease process of patient / side effect of medication. Commonly: Neutropenia, infection, cardiac failure.

No specific recommendations at this time.

Febrile Non-hemolytic Transfusion Reaction

Within 2 hours of transfusion: Fever (temperature increase of 1 ºC or 1.8 ºF), chills, shakes, rigors.

Antibodies to leukocytes, platelets or plasma proteins stimulate endogenous pyogen release; passive cytokine infusion. Case is complicated by other reasons for fever (neutropenia or infection).

Recommend administering leukoreduced blood components and pretreating with an antipyretic such as acetaminophen.

Possible Febrile Non-hemolytic Transfusion Reaction

Within 2 hours of transfusion: Fever (temperature increase of 1 ºC or 1.8 ºF), chills, shakes, rigors.

Antibodies to leuko-cytes, platelets or plasma proteins stimulate endogenous pyogen release; passive cytokine infusion. Case is complicated by other reasons for fever (neutropenia or infection).

Consider administering leukoreduced blood components and pretreating with an antipyretic such as acetaminophen.

Probable Febrile Non-hemolytic Transfusion Reaction

Within 2 hours of transfusion: Fever (temperature increase of 1 ºC or 1.8 ºF), chills, shakes, rigors.

Antibodies to leukocytes or plasma proteins; passive cytokine infusion. Case is complicated by other reasons for fever (neutropenia or infection).

Recommend administering leukoreduced blood components and pretreating with an antipyretic such as acetaminophen.

Possible Septic Transfusion Reaction, Pending Cultures

Fever (usually a rise ≥ 2 ºC or 3.6 ºF or a rapid increase in temperature), rigors, chills, shock, potential death. May develop quickly or several hours after transfusion.

Culture transfusion bag AND patient; compare results to confirm. If clinicians culture the patient, culture the bag. If clinicians refuse to culture the patient, do NOT culture the bag. Associated products should be recalled.

Contaminated blood product, usually donor venipuncture site contamination or occult bacteremia.

Skin flora contaminants: Staph, Propionibacteria.

Gram Negative's implicated in clinical reactions and capable of causing death:

Acinetobacter, Klebsiellla, Serratia, Enterobacter, Escherichia. Less common, Gram Positive Cocci implicated in clinical reactions:Staphylococcus, Streptococcus. Likes to grow in RBCs: Yersina, Pseudomonas

Provide supportive care and appropriate antibiotic coverage. Follow patient's blood cultures.

Septic Transfusion Reaction

Provide supportive care and appropriate antibiotic coverage.

Follow patient's blood cultures.

Transfusion Related Acute Lung Injury (TRALI)

Within 6 hours of transfusion: Dyspnea, fever, hypoxia, pulmonary edema, hypotension, normal pulmonary capillary wedge pressure. "White-out" on post-transfusion chest x-ray. May require intubation. Differential diagnosis: Volume Overload. For TRALI: BNP should remain normal, no left atrial hypertension, non-responsive to diuresis.

Recipient-specific donor HLA or anti-neutrophil antibodies in the plasma component of a transfusion. Other theory - neutrophil priming lipid mediator. Less commonly, recipient antibody to donor WBCs.

Provide respiratory and blood pressure supportive care. TRALI reaction is donor specific, and therefore, the patient is at no increased risk during future transfusions if needed. However, we recommend administering leuko-reduced blood components and pretreating with an antipyretic, such as acetaminophen, and an antihistamine, such as diphenhydramine, to reduce the risk for febrile or allergic reactions.

Possible Transfusion Related Acute Lung Injury (TRALI)

Within 6 hours of transfusion: Dyspnea, fever, hypoxia, pulmonary edema, hypo-tension, normal pulmonary capillary wedge pressure. Post-transfusion chest x-ray shows edema or infiltrates. Patient has complicating factors:

myocardial infarction, cardiac failure, volume overload.

Recipient-specific donor HLA or anti-neutrophil antibodies in the plasma component of a trans-fusion. Other theory - neutrophil priming lipid mediator. Less commonly, recipient antibody to donor WBCs.

Provide respiratory and blood pressure supportive care.

TRALI reaction is donor specific, and therefore, the patient is at no increased risk during future transfusions if needed. However, we recommend administering leukoreduced blood components and pretreating with an antipyretic, such as acetaminophen, and an antihistamine, such as diphen-hydramine, to reduce the risk for febrile or allergic reactions.

Hypervolemia

“TACO”

(Transfusion Associated Circulatory Overload)

Dysnpea, headache, hyper-tension (>50 mmHg rise), pulmonary edema, congestive heart failure, cardiac arrhythmias. Severe cases: Flash pulmonary edema. Responds to diuresis.

Too rapid and/or excessive fluid and/or blood administration.

Check volumes of blood and fluid given prior to "reaction"

Induce diuresis.

Provide cardio-respiratory support as clinically indicated. If future transfusion is necessary, proceed slowly, or in divided doses (call blood bank to have units divided).

Acute Hyperhemolytic Transfusion Reaction

Hemoglobinemia (red serum), hemoglobinuria (red urine - not due to RBCs), fever, chills, anxiety, shock, DIC, dyspnea, chest pain, flank pain, oliguria.

HCT drops significantly lower than pretransfusion levels.

Rare - usually seen in chronically transfused hemoglobinopathy patients, with multiple alloantibodies (esp. beta thalassemia, sickle cell disease)

Do not transfuseadditional blood products. Provide supportive care, including fluid administration and diuresis, blood pressure and respiratory support.

Monitor the patient for DIC and shock.

Acute (Intravascular) Hemolytic Transfusion Reaction

Hemoglobinemia (red serum), hemoglobinuria (red urine - not due to RBCs), fever, chills, anxiety, shock, DIC, dyspnea, chest pain, flank pain, acute renal failure, cardiac arrest.

HCT will drop to Pretrans-fusion levels. Monitor HCT, LDH, bilirubin, haptoglobin levels, BUN, Creatinine, platelets and coags. Repeat compatibility testing.

ABO incompatibility (clerical error) or unknown/missed red blood cell alloantibody or other complement fixing red cell antibody.

Do not transfuse additional blood products, until blood bank work up is completed. Provide supportive care, including fluid administration and diuresis, blood pressure and respiratory support.

Monitor the patient for DIC and shock.

Mild (Extravascular) Delayed Hemolytic Transfusion Reaction

Asymptomatic. May see gradual HCT drop to pre-transfusion levels. May see positive DAT, increased LDH, indirect bilirubin.

IgG non-complement fixing antibody (often Rh or Kell). Coated RBC's are cleared by reticulo-endothelial system (especially spleen).

Time course: Reaction within days: anamnestic response; Reaction after 3 weeks - new antibody

Monitor the patient's hematocrit, renal and hepatic function, coagulation profile.

Acute treatment is generally not required.

Because of antibody formation, future antibody screens and cross-matches may take additional time.

Severe (Extravascular) Delayed Hemolytic Transfusion Reaction

Fever, malaise, indirect hyperbilirubinemia, increased LDH, urine urobilinogen, falling HCT.

DAT may be negative, if all coated RBCs are cleared.

IgG non-complement fixing antibody (often Rh or Kell). Coated RBC's are cleared by reticulo-endothelial system (especially spleen). Time course: Reaction within days: anamnestic response; Reaction after 3 weeks - new antibody

Monitor the patient's hematocrit, renal and hepatic function, coagulation profile, and provide supportive care if necessary.

Because of antibody formation, future antibody screens and crossmatches may take additional time.

TRANSMISSION OF INFECTIOUS DISEASES

All cases of patients who develop jaundice or unexplained liver dysfunction two weeks to six months after the transfusion and all patients suspected of having contracted a transfusion-transmitted disease should be reported to the WellSpan Blood Donor Center Manager at (717) 741-8307 or the York Hospital Blood Bank Medical Director at (717) 851-5001. For Gettysburg patients call the Gettysburg Hospital Blood Bank Manager at (717) 339-2311 or Gettysburg Laboratory Medical Director at (717) 337-4120

Transfusion Services

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