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Lab Manual for Moffitt-Long and Mount Zion

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Transfusion Service (x31313) and Blood Center (x31809)

A. Blood Donation

Encourage friends and relatives to donate blood so that adequate supplies will be available for our patients.

Blood Center: Our Blood Center is located in Millberry Union MU-09 I Level and is open 0800-1915 Monday-Friday and 0900-1615 Saturday. Potential donors may drop in to make a donation. The Blood Center collects volunteer donations not directed to a particular recipient, directed-donor blood for a specific patient, and autologous blood donated by the patient for his or her own use. The Center also performs plateletpheresis to obtain large numbers of platelets at one session. Whole blood donations can remain as whole blood or can be processed into packed red blood cells and fresh frozen plasma. Orders for the collection of blood donations from friends or family members of our patients or from Medical Center employees can be transmitted by calling 353-1809 or by fax (353-8605).

In-patient autologous blood collection can be arranged during Blood Center hours following approval of the Blood Bank Attending Physician. Therapeutic phlebotomy is performed by arrangement with the Hematology/Oncology Clinic (353-2421).

B. Infection Transmitted by Blood Transfusion

The AIDS crisis has helped all of us remember that the safest blood is our own blood. Although blood units are tested for HIV/HCV by NAT, West Nile Virus by NAT, anti-HIV-1 & -2, anti-HTLV-I/II, anti-HCV, anti-HBc, HBsAg and syphilis, a small but definite risk of transfusion-acquired infection remains. Current estimates of the risk of transmitting viral infections per unit administered (Busch, JAMA 2003; 289: 959):

Hepatitis B 1 in 220,000
Hepatitis C 1 in 1.6 million
HIV 1 in 1.8 million
HTLV-I/II 1 in 641,000
The risks for other infections - babesiosis, malaria, syphilis, trypanosomiasis, and yersiniosis - <1:1,000,000.

C. Autologous and Directed Donation

Whenever indicated, the patient should donate autologous blood once a date has been selected for elective surgery. Although there is evidence that directed-donor blood is no safer for transfusion than volunteer donor blood, many patients and their families currently prefer this source of blood. TO ARRANGE FOR THE COLLECTION OF AUTOLOGOUS OR DIRECTED-DONOR BLOOD, PLEASE PRE-REGISTER THE PATIENT, OBTAIN A BLOOD TYPE AND ANTIBODY SCREEN, AND CALL THE BLOOD CENTER (353-1809). Potential blood recipients must be registered and given a hospital unit number because our Blood Bank often receives autologous and/or directed-donor units before the intended recipient arrives in the hospital, and the name of a patient is not a sufficiently unique identifier. The difficulty in connecting an unregistered patient to these units can result in the patient receiving volunteer instead of autologous or directed-donor blood products. It is important to contact our Blood Center even if the donation will be made elsewhere, so that the patient will be entered into our tracking system.

Please remember that directed-donor units are NOT cross-matched prior to the blood being ordered. Physicians who anticipate a need for cross-matched blood must request it in advance from our Blood Bank in the routine manner, exactly as for the usual volunteer units.

If it is anticipated that blood will be collected at a blood center other than our Blood Center, please fill out the appropriate order form and forward it to our Blood Center; we will retain a copy on file and fax a copy to the designated alternative blood collection site.

  1. Autologous Donation

    A patient's own stored blood does not require cross-matching. When the need for transfusion is known, the patient should be referred to the Blood Center (353-1809, MU09), ideally 4-5 weeks preoperatively, for donation at intervals of 3-7 days, but not within 72 hours of surgery. Autologous blood can be stored in the liquid state for 35 days (blood collected from family members is irradiated; the shelf life for these products is only 28 days). In clinically compelling situations, blood can be collected and stored in the frozen state for a longer period. Please note that our fees for these services are far lower than those of many other blood donor centers.

    To request autologous blood collection, a physician or his/her representative must do one of the following:

    1. complete a UCSF "Autologous and Directed Donation Request" and forward it to "Blood Center, Box 0100" (fax: 353-8605), or
    2. call the Blood Center office (353-1809) and request autologous blood.
    The patient should then be referred to the Blood Center at MU-09. As noted above, autologous blood collection from in-patients can be arranged during Blood Center hours following approval of the Blood Bank Attending Physician.

    Prospective autologous donors should weigh at least 110 lbs (50 kg) [half-units can be drawn from those weighing 65-110 lbs (29-50 kg)], have a hemoglobin of at least 11 g/dL prior to each donation, and not have received antibiotics within the 48 hours prior to donation. Pregnant females may donate autologous units, and children 6 and older may do so with written physician and parental consent.

    If the autologous donor has a history of cardiac disease, a physician who is familiar with the patient's general health and cardiac status must evaluate the patient's ability to withstand phlebotomy for autologous donations. Patients with a history of coronary artery disease, prior myocardial infarction or bypass surgery are acceptable donors if they are not subject to severe arrhythymias, are not experiencing active angina within the 24 hrs prior to donation, and are not known to have left main coronary artery stenosis, aortic stenosis, or idiopathic hypertrophic subaortic stenosis.

    Autologous units are reserved for the donor-patient until each unit's expiration date, even after the date of discharge from the hospital. The Blood Bank does not release unused autologous blood for administration to other patients.

    Autologous units can be frozen for later use if surgery is cancelled or the blood is not needed by the patient within 35 days of its collection. A physician who wishes this to be done must notify the UCSF Blood Bank, which will make the necessary arrangements. THIS SPECIAL PROCESSING INCURS SUBSTANTIAL ADDITIONAL CHARGES.

  2. Directed Donation

    Directed donor blood is more expensive and no safer than volunteer blood. The Paul Gann Act does not require that physicians encourage directed donors; the Act requires that patients be informed of the option.

    1. Potential Recipients
      1. Physicians or their office staff must fill out an "Autologous and Directed Donation Request" and send or fax (353-8605) it to "Blood Center, Box 0100" or call 353-1809 to place an order for the specific patient. The patient must register and - if the patient's blood type, Rh group and antibody status are not already known - these tests must be ordered. Patient can register at the Admitting Office, M~140, or the Registration Desk in the lobby of the Ambulatory Care Center.
      2. Patients' specimens for blood typing, Rh grouping and antibody screening (lavender top tube) can be drawn at the ACC, A~122, 353-2736, Monday-Friday, 0730-1830.
      3. Autologous and Directed Donation Request forms and patient specimens, properly labeled and signed by the blood drawer, may be delivered to the Blood Bank by the patient, a relative or a friend.
      4. Directed-donor units, if not utilized during the admission, are AUTOMATICALLY RELEASED TO GENERAL USE AT UCSF WHEN THE PATIENT IS DISCHARGED, unless the laboratory is notified by the ordering physician that the units should be held. If units are due to expire before the patient is discharged, the Blood Bank will contact the physician by fax for permission to release the units for general use. The current dating on packed RBCs and whole blood can be either 35 or 42 days from collection, depending upon the type of preservative used.
    2. Potential Donors
      1. Blood donations should be made at least 3 working days before the intended date of transfusion, which will allow adequate time for testing and processing the blood. Directed donations should be completed by 1700, Monday-Friday and by 1700 on Saturday. Potential plateletpheresis donors should donate blood at the Blood Center prior to scheduling an appointment for apheresis. The Blood Center is open 0800-1915, Monday-Friday, and 0900-1615, Saturday.
      2. Donors who do not know their blood type may call the Donor Center 2 days following their donation to obtain this information. No blood typing is done at the time of donation.
      3. Alternatively, prospective donors can be typed for a fee without donating (for hours of blood drawing service, see information above under "Potential Recipients"). After the donor obtains a receipt from the Cashier's office for the amount of the test (from the Admitting Office when the Cashier's office is closed), a blood specimen will be collected as described above for recipients. Donor testing in this circumstance is NOT covered by health insurance and cannot be charged to a UC patient account card.
      4. NOTE: A husband should NOT donate blood to a wife of childbearing age because of the potential risk of maternal sensitization, which could result in hemolytic disease of the newborn.
      5. Because of recent reports of fatal graft vs. host disease in recipients of blood from relatives, whole blood, RBCs and platelets from any blood relative will be irradiated prior to transfusion. The process of irradiation shortens the shelf life of donated whole blood and RBCs to 28 days.
  3. Voluntary Non-directed Donation

    The Blood Center gladly accepts voluntary non-directed donations, as well. Volunteers may give blood as often as every 8 weeks, provided that their hematocrit exceeds the minimum level of 38% (hemoglobin 12.5 g/dL).

D. Blood Bank (Transfusion Service) Hours

The Blood Bank provides blood product support twenty-four hours a day, seven days a week. The Blood Bank is located at M 501, 353-1313.

E. Specimens for Crossmatch and Check Sample

For Type and Screen or Type and Crossmatch, submit 6 mL of EDTA-anticoagulated blood (lavender top tube) from an adult patient or 2-3 mL from a pediatric patient. In addition to the patient's full name, medical record number and date of birth, the label must show the date drawn and the legible name of the phlebotomist/nurse who drew the specimen.

Additionally, for patients with no prior UCSF Blood Bank record, a second "check" specimen, should be obtained and sent to the Blood Bank. The "check" specimen is an important safeguard against transfusion errors resulting from incorrectly labeled patient specimens. The ABO group and Rh type of this "check" sample must agree with that of the initial specimen before the Blood Bank issues red cell or plasma products.

The "check" specimen should be separately collected (another phlebotomy). In addition to the patient's full name, medical record number and date of birth, the label must show the date drawn and the legible name of the phlebotomist/nurse who drew the specimen. The "check" specimen does not incur an additional charge.

F. Requests for Blood Products and Automatic Blood Orders

  1. Blood Bank Requisitions:

    Each clinical service orders blood directly from the UCSF/UCSF Mt. Zion Blood Bank on requisition form 701-04, available at all nursing stations. Incomplete forms will not be accepted. The minimum information required is:

    Patient's full name
    Hospital medical record number or date of birth
    Amount and blood component wanted
    Anticipated date of transfusion
    Name of requesting physician

    When the patient is ready for transfusion, a Blood Product Pickup form (#602-063) must be faxed to the UCSF Blood Bank at x31316 or UCSF Mt. Zion Blood Bank at x57780, or sent with the person dispatched to pickup blood from the UCSF Blood Bank (M501) or UCSF Mt. Zion Blood Bank (B210).

  2. Emergency Requests for uncrossmatched blood:

    If type-specific blood or O negative blood is required before crossmatch, a physician must sign as accepting responsibility in the "Emergency Request" section of the Blood Bank requisition. Alert Blood Bank personnel either by telephone or in person to all emergency requests. A Blood Bank Requisition, filled out completely as described under section F.1 above and signed by the physician, must be presented at the M 501 UCSF Blood Bank or B210 UCSF Mt. Zion Blood Bank.

  3. Automatic Blood Ordering System for Elective Surgical Patients:

    The Departments of Surgery, Anesthesiology, and Laboratory Medicine (Blood Bank) have coordinated a system for automatically ordering blood for patients scheduled for elective surgery. The Blood Bank generates Type and Screen or Type and Crossmatch orders for these patients in accordance with "Guidelines for Automatic Blood Ordering for Elective Surgery" in Blood Bank, which have been agreed upon by the chiefs of all surgical services. This system ensures that Blood Bank processing is completed on the day prior to elective surgery.

    The automatic ordering procedure covers only those surgical procedures listed on the OR schedule finalized at 1600 on the day before surgery. Essentials of the system are as follows:

    1. The OR will issue a tentative surgery schedule at approximately 1230 on the day prior to surgery.
    2. From the surgery schedule and the Guidelines, the Blood Bank will determine which surgical cases require Type and Screen or Type and Crossmatch and will issue requisitions to the Blood Drawing Team for specimen collection.
    3. The OR will issue a final schedule at approximately 1600 and Blood Bank will initiate requisitions and specimen collection to cover any changes.
    EXCEPTIONS: Patients and procedures NOT covered by the system for automatic ordering include:
    1. Emergency procedures and any cases added to the schedule after 1600. It is the responsibility of the physician to order the blood necessary for these cases.
    2. Pediatric surgery other than pump cases, thoracotomy, PDA repair or some neurosurgical procedures. Guidelines for other pediatric cases have not been established.
    3. Surgical procedures that are not listed in the Guidelines.

GUIDELINES FOR AUTOMATIC BLOOD ORDERING FOR ELECTIVE SURGERY

Orders for a BILATERAL procedure will be filled as if for a single procedure of that kind.

Orders for MULTIPLE procedures on the same patient will be filled in accordance with the guidelines for the procedure requiring the greatest number of units.

Orders for STANDBY procedures will be filled as if regularly scheduled.

Only packed red blood cells are routinely set up. Whole blood may be provided for patients who commonly bleed massively and transfusion of one blood volume is common, e.g., complex spine surgery.

All requests from the OR for FFP, cryoprecipitate or platelets will be honored automatically and reviewed retrospectively.

The patients' physicians should call the UCSF Blood Bank (3-1313) for exceptional orders.

Legend
H = Hold patient specimen in Blood Bank
T&S = Type and Screen for Unusual Antibodies
0 = No specimen needed in Blood Bank

G. CMV-Seronegative Blood Products

Profound immunosuppression, whether therapeutically induced to facilitate organ transplantation, secondary to cancer chemotherapy, or inherent in certain malignancies or congenital defects, is being seen with increasing frequency at our hospital. These patients are highly susceptible to transfusion-transmitted CMV infection. Guidelines for the appropriate use of CMV-seronegative blood have been developed to ensure a sufficient supply of blood, which is safe for recipients who are at risk of developing severe clinical CMV disease. These guidelines are based primarily upon knowledge of the patient's CMV antibody status. If the patient's CMV antibody status is unknown continue to issue CMV negative products until the test result is available.

The risk of CMV infection associated with transfusion is relatively small. Although 50% of blood donors are seropositive, only 1-8% of recipients develop CMV infection. CMV disease develops weeks after transfusion. Symptoms and signs are those of infectious mononucleosis: fever, hepatosplenomegaly, and adenopathy. Less frequent complications are pneumonia, thrombocytopenia, hemolysis, chorioretinitis, and secondary bacterial or fungal infection. Congenital infection may result in deafness. Immunocompromised persons often develop symptomatic disease.

CMV-seronegative blood is indicated for the following patients:

  1. Pregnant women
    1. All pregnant women at the request of the clinician.
    2. Any woman whose fetus is undergoing intra-uterine surgery.
    3. All intra-uterine transfusions
  2. Infants
    1. Infants < 4 months of age, regardless of birth weight or CMV antibody status (passive transfer of maternal antibody does not necessarily imply CMV infection of the infant)
    2. Infants < 1year, regardless of CMV antibody status, who are awaiting bone marrow or solid organ transplantation.
    3. Infants < 1 year receiving a solid organ/marrow transplant from a donor who is also < 1 year of age, regardless of CMV antibody status of donor.
    4. Infants with immunodeficiency disorders like SCIDS, Wiskott-Aldrich syndrome, thymic aplasia, etc.
    5. Potentially immunocompromised infants, e.g. those with DiGeorge syndrome or with cardiac lesions like truncus arteriosus/interrupted aortic arch, which are strongly associated with the DiGeorge syndrome.
    6. Infants < 1 year, regardless of CMV antibody status, who are being treated with ECMO or ECLS.
    7. Infants < 1 year, regardless of CMV antibody status, who are receiving exchange transfusions. For children > 1 year, only CMV-seronegative patients receive CMV-seronegative blood for exchange transfusions.
    8. Infants and children (up to 2 years) undergoing complex cardiac procedures like unifocalization.
  3. Solid organ transplants
    1. CMV-seronegative heart and/or lung transplant candidates: If the organ donor is CMV-seronegative, all patients (regardless of age) receive both CMV-seronegative and leukodepleted blood products.
    2. CMV-seronegative children (1-18 yrs) receiving liver, kidney or pancreas transplants from CMV-seronegative donors receive CMV-seronegative products.
    3. CMV-seronegative adult patients (> 18 years) receiving liver, kidney or pancreas transplants from CMV-seronegative donors are supported with leukodepleted products. See I. Policy for the use of leukocyte-reduced blood products.
  4. Bone marrow/ stem cell transplants
    1. CMV-seronegative bone marrow/peripheral blood stem cell transplant candidates, when the donor is CMV-seronegative.
    2. CMV-seronegative bone marrow/peripheral blood stem cell transplant candidates receiving T-cell depleted transplants, even if the donor is CMV-seropositive.
    3. CMV-seropositive bone marrow/peripheral blood stem cell transplant candidates receiving T- cell depleted haploidentical transplants from CMV-seropositive/CMV-seronegative donor.
    4. CMV-seropositive bone marrow/peripheral blood stem cell transplant candidates for whom seropositivity is not a definitive indication of prior CMV infection, e.g. prior therapy with intravenous immune globulin (IVIG).
  5. Other immunosuppressed patients
    1. CMV-seronegative patients with HIV infection.
    2. CMV-seronegative patients undergoing myelosuppressive chemotherapy and/or radiation therapy, e.g. for hematologic malignancies like leukemia, lymphoma, multiple myeloma, Waldenstrom’s macroglobulinemia, etc.
    3. CMV-seronegative patients undergoing high dose chemotherapy for osteogenic sarcoma /rhabdomyosarcoma /Ewing’s tumor /Wilm’s tumor /glioblastoma /neuroblastoma, etc. who are candidates for a bone marrow/stem cell transplant.
    4. CMV-seronegative patients with diseases like aplastic anemia for which bone marrow/stem cell transplant is a treatment option.
    5. All HIV positive patients with hemophilia, regardless of CMV antibody status.
    6. All patients with inherited severe immunodeficiency syndromes.

Note: When CMV-seronegative blood products are not available, leukodepleted products will be provided.

Conditions for which screened blood is unnecessary

Transfusion-transmitted CMV has not been reported with previously frozen plasma components. Components such as cryoprecipitate and fresh frozen plasma do not require prior CMV testing, regardless of the recipient's CMV status. However, these products as well as IVIG may contain antibodies to CMV, and recipient CMV testing performed on sera collected after transfusion of any of these components may be falsely positive for CMV antibody.
CMV infection in immunocompetent individuals rarely causes clinically significant disease. In immunosuppressed patients who are CMV-seropositive, CMV infection is almost always the result of reactivation of endogenous CMV. Infection by another strain of CMV is possible but rare compared with endogenous reactivation. CMV-seronegative blood is a limited resource, and even in immunosuppressed patients, the routine provision of CMV-seronegative blood to CMV-seropositive patients would be of low benefit.
CMV-seronegative blood is not indicated for the following patients:
    1. CMV-seropositive patients (with exceptions, as noted in the previous section).
    2. CMV-seronegative immunocompetent patients (with exceptions, as noted in the previous section).
If an order does not fall within the above guidelines:
Contact the resident (353-1721, beeper 719-8296 or, after hours, call UCSF Blood Bank at 353-1313 or UCSF Mt. Zion Blood Bank at 5-7791).

H. Irradiation of Blood Components

Graft versus host disease (GVHD) may occur whenever immunologically competent allogeneic lymphocytes are transfused into a severely immunocompromised recipient. Prophylactic irradiation of blood products prior to transfusion inhibits the ability of transfused lymphocytes to proliferate and is the most efficient way to prevent post-transfusion GVHD. Irradiation of blood components does not prevent the transmission of viruses.

Patients for whom irradiation of cellular blood components is indicated include:

  1. Infants <4 months of age.
  2. Patients with cellular immunodeficiency syndromes (SCIDS, Wiskott-Aldrich syndrome, thymic hypoplasia, DiGeorge syndrome, AIDS).
  3. Patients undergoing treatment for:
    1. Hodgkin's disease or non-Hodgkin’s lymphoma.
    2. Acute or chronic leukemia, multiple myeloma, Waldenstrom’s macroglobulinemia
    3. Neuroblastoma or glioblastoma, Wilm’s tumor.
    4. Ewing’s tumor, osteogenic sarcoma and rhabdomyosarcoma.
    5. Aplastic anemia.
  4. Individuals undergoing bone marrow transplantation (until the time of engraftment).
  5. Due to isolated reports of fatal GVHD caused by blood from any blood relative, directed donations of whole blood, RBCs and platelets which have been so identified will be irradiated prior to release from the Blood Bank. The irradiation of whole blood and RBCs shortens the period of their availability to 28 days.
  6. Patients who are taking or have taken fludarabine (Fludara)

There is currently no evidence for the need to irradiate blood products for patients undergoing transplantation of a solid organ or treatment for solid tumors unless they are receiving high-dose chemotherapy or radiation. If an order does not fall within the above guidelines, the physician will be asked to seek approval by contacting the Blood Bank resident (x31721 or 719-8296; after hours, UCSF Blood Bank 3-1313 or UCSF Mt. Zion Blood Bank 5-7791).

I. Policy for the Use of Leukocyte-Reduced Blood Products

All allogeneic blood products issued by the blood bank are leukoreduced. Directed-donor units collected at our Center are also leukoreduced; rare units that fail leukoreduction may be available for issue to the recipient, provided all other requirements are met. Autologous blood products collected at our donor center do not undergo leukoreduction.

J. Policy for the Use of Hemoglobin S Negative Blood

Criteria for selecting HgbS negative blood:

  1. Intra-uterine transfusions
  2. Fetus in fetal surgery
  3. Infant exchange transfusions
  4. Patients diagnosed with Sickle Cell Disease

K. Platelets

Platelets are available in the Blood Bank at all times. Platelets are our most limited resource and are also the blood component which carries the greatest risk of transmitting infection.

  1. If no platelet count has been ordered since the last platelet transfusion or during the last 24 hours, a platelet count must be obtained.
  2. Only apheresis platelets are available at our blood bank. The standard dose for adults is one apheresis product, which is equivalent to a 6-pack of platelet concentrates. Pedi- (1/2) and quad (1/4) - apheresis units are also available.
  3. If Rh-positive platelets are given to an Rh-negative female recipient (up to 50 yrs), administration of Rh immune globulin (RhIg) should be considered. One dose does of RhIg (300µg or 1500 IU) adequately cover 5 units of Rh-positive apheresis platelets given over a 3-week period. In general, Rh-positive platelets from Directed Donations should not be given to Rh-negative recipients, if Rh-negative random platelets from volunteer donors are available.
  4. Volume reduced platelets are indicated
    1. for neonates and children with fluid overload problems and patients with repeated severe allergic reactions.
    2. for patients that have experienced hemolysis from the transfusion of ABO incompatible platelets.
  5. Orders under the following conditions can be filled without approval (all platelet counts are x109/L, equivalent to x103/µL):
    1. Regardless of platelet Count
      1. Post-cardiopulmonary bypass - one dose
      2. Patients with platelet dysfunction
        1. Patients who have received acetylsalicylic acid (ASA, aspirin) within the previous 72 hours, and who’s bleeding cannot be surgically corrected.
        2. Within 72 hrs of treatment with abciximab (Reopro), if the patient is experiencing uncontrolled bleeding or requires surgery.
        3. Within 5 days of treatment with clopidogrel (Plavix) if the patient is experiencing uncontrolled bleeding or requires surgery.
        4. Patients with inherited platelet function disorders like Glanzmann’s thrombasthenia/ Bernard-Soulier syndrome, who are actively bleeding
    2. Platelet Count <150 k
      1. Infant on an extracorporeal membrane oxygenator (ECMO)
    3. Platelet Count <100 k
      1. Patients with head bleed or bleeding into the eye or orbit
      2. Patients with an intracranial pressure monitor (ICPM)
      3. Postoperative period in patients with surgery of the brain, spine, eye or airway
      4. Postoperative period in cardiac surgery patients (for up to 24 hours after coming off the bypass pump)
      5. Patients with DIC who are bleeding
      6. Infants with sepsis
      7. Infant weight ≤ 1500 g
      8. Infants on ECLS
    4. Platelet Count <75 k
      1. Bleeding in the first 24 hrs post-liver transplantation
      2. Bleeding in patients with renal failure
      3. Infants getting a transthoracic intracardiac line removed
      4. Massive transfusion
      5. Prior to and up to two days after an invasive procedure to avoid arterial bleeding from a blind site, e.g. ERCP with sphincterotomy
      6. Removal of epidural catheters
    5. Platelet Count <50
      1. Prior to an invasive procedure
      2. Patients with significant active bleeding
      3. Patients receiving heparin
      4. Within 72 hrs of treatment with the Fab fragment of antibody to GPIIb/IIIa (Reopro®), whether or not actively bleeding
    6. Platelet Count <20
      1. Presence of mucositis or fever
    7. Platelet Count <10
      1. Prophylaxis

Platelet transfusions are generally not used in the treatment of patients with ITP, except when complicated by significant bleeding. Platelets are relatively contraindicated in patients with TTP (prior to the initiation of plasma exchange), or HIT.

For VWD type 2B patients with major bleeds and surgery, VWF–containing concentrates should be given first; platelets may be indicated for severe thrombocytopenia. For patients with platelet-type VWD, platelet transfusions are indicated for treatment of hemorrhages.

When considering platelet transfusions in the above situations, a hematology consult is strongly recommended.

In general, the following uses for platelets are inappropriate:

  1. Prophylactic platelets for non-bleeding patients with platelet counts >10.
  2. Bleeding uremic patients with platelet counts >75.
  3. Cardiac surgery patients with platelet counts >=100 and who have already received one post-pump "dose" of platelets.

For any orders which do not fall within the above guidelines, contact the Blood Bank medical staff for approval

Contact the resident, x31721 or 719-8296 (after hours call UCSF Blood Bank at 3-1313 or UCSF Mt. Zion Blood Bank at 5-7791).

L. Cross-Matched or HLA-Matched Platelets

One-third to 3/4 of leukemic patients become alloimmunized to platelet antigens. Lack of appropriate increments following transfusion of random platelets is the best indicator of alloimmunization if non-immune causes (most frequently hypersplenism, fever and infection, DIC, and liver disease) and other immune causes (ITP, post-transfusion purpura) have been excluded.

Platelet alloimmunization can be due to antibodies directed against HLA and/or platelet-specific antigens. Testing a refractory patient's plasma against the platelets of several donors (platelet crossmatch) may identify donors whose platelets will survive in the sensitized individual's circulation for a longer period of time.

If refractoriness to transfusion with random platelets has been documented on TWO occasions by a 15 minute - one hour post-transfusion corrected count increment of <7.5, the patient's physician can arrange for a platelet crossmatch. The physician should contact the Blood Bank resident, 353-1721 or 719-3649(b). [Platelet crossmatching is done at the Blood Centers of the Pacific, and can only be arranged weekdays from 0830-1630 (0830-1100 on Friday). PLATELET CROSSMATCHING IS UNAVAILABLE AT NIGHT, AND IS NOT USUALLY AVAILABLE ON WEEKENDS.]

  1. Please describe the clinical diagnosis and status of the patient, including current drug treatment, bleeding manifestations, body surface area (or height and weight), need for CMV antibody-negative products, and the presence of any non-immune causes of platelet consumption.
  2. Once crossmatching has been approved, the clinician should send a Blood Bank requisition for crossmatched platelets along with two lavender top tubes of blood from the patient.
  3. The UCSF Blood Bank will arrange for crossmatched platelets. Anticipate a 1-2 day delay, as the products have to undergo bacterial testing.
  4. The Blood Bank will notify the nursing unit when crossmatched platelets become available.

HLA-matched platelets will be arranged for a patient by the Blood Bank if the patient is refractory to crossmatched platelets.

  1. HLA typing of the patient and HLA antibody screen must be done prior to requesting HLA-matched platelets, and can be arranged through Immunogenetics, 476-3883.
  2. Once the HLA typing results are available, a 2- to 4-day delay in availability for the HLA-matched platelets can be anticipated.
  3. The Blood Bank will notify the nursing unit when HLA-matched platelets become available.

M. Fresh Frozen Plasma (FFP)

The inappropriate use of FFP has been the focus of national concern. In addition to wasting a valuable biologic resource and unnecessary expense, it exposes the patient to all the risks of homologous transfusion except HTLV-I and CMV infection.

These guidelines for the appropriate use of this important product are adapted for the Medical Center from the efforts of the UCSF Transfusion Committee.

  1. Before FFP is ordered:
    1. Obtain a PT (since the last FFP infusion or within the past 24 hours), PTT, platelet count and fibrinogen. Use of FFP is generally appropriate with a PT >19.0 seconds or INR > 1.5, as long as the platelet count is >50 x109/L) and the fibrinogen >100 mg/dL. Other requests will require approval by the Blood Bank resident or attending physician.
    2. Draw blood for CMV serology prior to administering FFP to patients awaiting organ transplantation.
    3. Inform the Blood Bank whenever a patient is undergoing plasmapheresis to lower pre-transplantation isoagglutinin titers, so that type-specific FFP will be provided.
    4. The cause of the prolonged PT or PTT must be identified!
  2. Dose and Timing:

    The dose of FFP should be adequate for replacement of the coagulation factors. Generally, 10-15 mL/kg body weight should be given; each unit of FFP contains about 200 mL. FFP should be administered rapidly through a blood filter at the time of bleeding or within an hour of anticipated bleeding. Maximal effect declines 2-4 hrs after transfusion.

  3. Monitoring:

    The patient's PT should be determined immediately before and immediately after the transfusion of FFP. Laboratory monitoring is necessary before and after each infusion of FFP. Administration of FFP should not be continued if bleeding does not decrease when the PT is corrected to ≤ 1.3 times normal.

  4. Use of FFP in Adult and Pediatric Patients:
    1. Appropriate Indications:
      1. Correcting Multiple Coagulation Factor Deficiency:

        Multiple coagulation factor deficiency should be suspected in a patient with a prolonged Prothrombin Time (PT) and activated partial thromboplastin time (PTT), if the prolongations are not due to a single coagulation factor deficiency, heparin or other inhibitor. The most common causes of multiple coagulation factor deficiency include:

        oral anticoagulants liver disease
        massive transfusion disseminated intravascular coagulation
        plasmapheresis vitamin K deficiency
      2. In patients with clinical bleeding or oozing, or in patients prior to an invasive procedure, use of FFP is generally appropriate with a PT > 19 seconds or INR > 1.5, as long as the platelet count is >50 x 109/L and the fibrinogen is >100 mg/dL.
      3. FFP may be indicated to prevent dilutional coagulopathy in patients with elevations in PT < 19 seconds or INR < 1.5, if administration of substantial amounts of intravenous fluid is required or anticipated. Other requests will require approval by the Blood Bank physician.
      4. Intraoperatively, when there is generalized bleeding which cannot be controlled by sutures or cautery, the PT is prolonged to >1.3x the mid-range of normal in the absence of heparin or a pathological circulating anticoagulant, and the platelet count is >50 x109/L.
      5. Congenital Deficiences of Clotting Factors II, V, VII, X, XI or XIII:

        Hematology consultation should be obtained. FFP should not be used to treat Factor IX deficiency, for which purified Factor IX concentrates are available from Pharmacy.

      6. Correction of Warfarin Overdosage:

        If bleeding must be controlled, patients should receive injectable Vitamin K1. FFP should only be given if life-threatening bleeding must be controlled and the 8-12 hrs necessary for Vitamin K1 to be effective cannot be tolerated.

        Correction may not be necessary for emergency surgery. Fully anticoagulated patients can undergo major surgery such as mitral commissurotomy, pneumonectomy, cholecystectomy or gastric resection for peptic ulcer without uncontrollable bleeding.

      7. Treatment of symptoms other than bleeding which are due to deficiencies of plasma factors: thrombotic thrombocytopenic purpura (TTP) and hereditary C1-esterase inhibitor deficiency with life-threatening angioedema.
      8. Support for patients with acute fulminant hepatic failure (pre-liver transplant) and for 48 hours post-liver transplant until adequate graft function is assured. PT should be measured every 6 hours; if the PT is >1.3 times normal, an initial bolus of 15 mL FFP/kg body weight should be administered, followed by an FFP drip at 2 mL/min. If the patient is bleeding and an invasive procedure has been performed and/or is planned within 8 hours, additional FFP should be given. If the patient is not bleeding and no procedure is planned, the FFP drip should be adjusted as follows:
        PT >18.0 seconds continue drip at same rate
        PT 16.0-18.0 seconds decrease FFP drip by 50%
        PT <16.0 seconds stop FFP drip
      9. If RBC transfusion is needed in bleeding patients whose PT is prolonged to <1.3 times normal, FFP is indicated to prevent further dilutional coagulopathy. Alternatively, whole blood can be used, if available, rather than RBCs and FFP.
      10. FFP is indicated in patients who have received or will receive one or more blood volumes of packed RBCs and/or cell-saver units (10 units for an adult) within 24 hours.
    2. Uses of Unknown Benefit:
      1. Control of bleeding in patients with disseminated intravascular coagulation (DIC). Cryoprecipitate is the product of choice in patients with DIC, bleeding and hypofibrinogenemia.
      2. Correction of a PT which is prolonged to <1.3x normal in patients with bleeding or prior to an interventional procedure in a critical area (brain, eye, airway).
      3. Control of bleeding due to thrombolytic agent overdose.
      4. Replacement of plasma factors during plasmapheresis for hemolytic uremic syndrome.
      5. Treatment of recurrent venous thrombosis due to Protein C or S deficiency.
      6. FFP within 48 hours of liver transplantation in patients who are bleeding.
    3. Inappropriate Uses:
      1. Volume expansion.
      2. Prophylaxis of patients with massive bleeding who do not have significantly abnormal coagulation tests. FFP should not be given prophylactically to massively transfused patients treated with primarily whole blood.
      3. Treatment of non-bleeding patients who have prolonged coagulation times and who are not anticipating an invasive procedure.
      4. Treatment of immunoglobulin deficiency. These patients should be given intravenous gamma globulin preparations which do not impose the risk of AIDS.
      5. Treatment of patients with uremia and bleeding (see chart below).
      6. Treatment of Factor VIII, Factor IX or Antithrombin III deficiency, for which purified, therapeutically superior components are available from Pharmacy.

        Please note that the PTT is relatively insensitive to deficiencies of Factor IX; levels must decrease to 10% of normal for this measurement to reliably be prolonged. Factor IX levels should be specifically measured to determine the need for purified Factor IX concentrates prior to surgery or in the bleeding patient with Factor IX deficiency.

    4. Uses in Neonatal Patients:
      1. Appropriate Indications:
        1. Vitamin K Deficiency. The primary treatment is vitamin K1. FFP should be given concomitantly with vitamin K1 only when the patient has life-threatening bleeding.
        2. Congenital deficiencies of factors II, V, VII, X, XI, XIII. Hematology consultation is advised.
      2. Uses of Unknown Benefit:
        1. Treatment of bleeding in patients who have DIC.
        2. Treatment of Protein C or S deficiency (neonatal purpura fulminans).
      3. Inappropriate Uses:
        1. Treatment of non-bleeding patients who have prolonged coagulation times but who are not anticipating an invasive procedure.
        2. Treatment of patients with immunoglobulin deficiency.
        3. Replacement fluid during therapeutic phlebotomy of polycythemic infants.
        4. Volume expansion.
    5. Citations from which these guidelines are derived may be obtained from the Blood Bank.

N. Cryoprecipitate

Each unit contains approximately 80 units of Factor VIII and 250 mg of fibrinogen. Appropriate indications include:

  1. Patients with fibrinogen levels <=100 mg/dL who are bleeding or who are at high risk for bleeding (one unit of cryoprecipitate/10 kg).
  2. Factor XIII deficiency
  3. Dysfibrinogenemia

Purified factors are safer and are preferred over cryoprecipitate for the treatment of bleeding patients with hemophilia or von Willebrand's disease. Obtain hematology consultation.

One uncontrolled and unconfirmed study has suggested that uremic patients who are bleeding may respond to cryoprecipitate. A trial of cryoprecipitate may be undertaken after proven interventions have failed (see chart below).

 

ALGORITHM OF MEDICAL TREATMENTS
WHICH CAN BE CONSIDERED IN BLEEDING UREMIC PATIENTS
(from the Medical Center at UCSF Transfusion Committee, 4/92)

If:

  1. the PT/PTT are normal
  2. bleeding is not from anatomic defect

N.B.: NONE OF THE FOLLOWING TREATMENTS ARE PROVEN

Treatment Rationale Reference
1. Dialysis Improve platelet function Watson AJ, Whelton A. J Clin Pharmacol 1985;25:315-7. .br Remuzzi G. Lancet 1988;i:1205-8. .br                
2. Keep hematocrit >24% Bleeding time increases when the hematocrit is below 24%; maintain RBC reserves in a bleeding patient. Fernandez F et al. Brit J Haematol 1985;59:139-48. .br Moia M et al. Lancet 1987;ii:1227-9.
3. Keep platelet count >75 x109/L Increase concentration of partially functional platelets None, but has some rationale
4. Give conjugated equine estrogens 0.6 mg/kg iv qd for 5 days Maximal correction in 5 days; lasts 14 days Livio M et al. New Engl J Med 1986;315:731-5. .br Shemin D et al. Amer J Med 1990;89:436-40.
5. Give DDAVP 0.3 µg/kg iv q12-24 hrs for 2 days Releases von Willebrand Factor from endothelium; effective in 30-60 minutes. May not be effective with repeated doses (tachyphylaxis). Mannucci PM et al. New Engl J Med 1983;308:8-12.
6. Give a one-time trial of cryoprecipitate (one concentrate/7kg) for acute bleeding unresponsive to steps 1-5 Increases von Willebrand Factor concentration Janson PA et al. New Engl J Med 1980;303:1318-22.

Other references:

  1. Bolan CD, Alving BM. Pharmacologic agents in the management of bleeding disorders. Transfusion 1990;30:541-551.
  2. Woolley AC. Platelet dysfunction in uremia. The Kidney 1987;19:15-20.

O. Washed RBCs

RBCs may be washed with sterile saline to remove all but traces of plasma, plasma proteins, and potassium. Appropriate indications include:

  1. Infants (<1 year of age) with single-ventricle physiology.
  2. Infants (<1 year of age) with two-ventricle physiology during a 72 hour post-op period.
  3. Infants (<1 year of age) undergoing a complex pump procedure.
  4. Pediatric cardiac patients with renal insufficiency and/or hyperkalemia.
  5. IgA deficient patients at risk for an anaphylactic transfusion reaction (2 L saline wash is recommended).
  6. Patients with a history of severe transfusion reactions after a consultation with a Blood Bank Physician.
  7. Patient with a diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH) when group specific red cells are not available for transfusion.

For removal of potassium (indications 1-4), even relatively fresh (<5 day old red cells) should be washed because potassium levels can still be high. Because potassium continues to leak out of red cells stored after washing, washing should be performed (within 5 hours). WHEN IRRADIATION IS REQUIRED, RED CELLS MUST BE IRRADIATED PRIOR TO WASHING.

P. Granulocytes

The usefulness of granulocyte transfusion for treatment of life threatening bacterial or fungal infection remains controversial. A handful of past controlled clinical trials of granulocyte transfusion therapy in neutropenic patients have yielded mixed results. A multicenter clinical trial is currently under consideration, by the new Transfusion and Hemostasis Clinical Network funded by the National Institutes of Health, to evaluate the effectiveness of the therapy and the safety of medicating donors for granulocyte mobilization. Granulocyte transfusion may be indicated in neutropenic patients with bacterial or fungal infection unresponsive to antimicrobial therapy whose bone marrow hematopoietic capacity is expected to recover. Since a unit of granulocytes outdates in 24 hours, there is not enough time to perform routine infectious disease screening. Therefore, potential donors must make a blood donation for testing prior to donating granulocytes (pre-donation).

  1. The ordering physician must contact the Blood Bank Resident (353-1721) or the Blood Bank Attending (353-1313) on service for an approval.

    Designated Donors

  2. Potential donors need to be recruited. The physicians on the clinical service should approach the family members and friends. Please note that there may be a 5 day delay between the time a potential donor is identified and when a unit of granulocytes will be available (3 days for donor testing, 1 day for granulocyte mobilization, and 1 day for granulocyte pheresis).
  3. Potential donors must make a whole blood donation to ensure compatibility and suitability. The donors should be ABO-compatible. If D-negative donors are not available for a D-negative recipient, the administration of RhIG will be considered. For appropriateness of CMV-seronegative and/or irradiated units, refer to indications for CMV-seronegative and irradiated units.
  4. An appointment for granulocyte apheresis needs to be made with the Special Donations Coordinator at the Blood Centers of the Pacific-Irwin Center (415-749-6657). The UCSF Blood Bank Resident should be involved in coordinating donors’ schedule.
  5. The ordering physician should decide whether or not to stimulate the donors for granulocyte mobilization on a case by case basis. An optimal regimen based on information available in the literature is the administration of 480 µg G-CSF (s.c.) and 8 mg dexamethasone (oral) to be given approximately 12 hours before the start of the collection. The ordering physician should obtain the consent for mobilization. Some risks of G-CSF administration include bone pain, hyperviscosity, thrombocytopenia, thrombosis, ophthalmologic problems, and exacerbation of autoimmunity. Also, long-term side effects have not been fully evaluated. A complete medical evaluation of a potential granulocyte donor is recommended.

    Community Donors

  6. Community donors may be available through the Blood Centers of the Pacific. If needed, the Blood Bank Resident should contact the physician on call at the Blood Centers of the Pacific (415-749-6657) to ask for the availability of their community donors. The following information will be required: (1) the patient’s diagnosis, ABO/Rh type, height, and weight, (2) the name of the attending physician on the clinical service, (3) indication for granulocyte transfusion, (4) and expected duration of therapy. Community donors are not available for stimulation using G-CSF.

    Administering Granulocytes

  7. The granulocytes must be infused within 24 hours of collection. Therefore, the Blood Bank Attending must authorize the release of untested units. The ordering physician must sign emergency release forms (both UCSF and the Blood Centers of the Pacific forms).
  8. Routine premedication of the recipient is not recommended.
  9. DO NOT USE A BED-SIDE LEUKOCYTE DEPLETION FILTER OR A MICROAGGREGATE FILTER. Avoid granulocyte infusion during and within 4 hours of last Amphotericin infusion since incidents of severe pulmonary reactions have been reported.
  10. The granulocyte transfusion should be given daily or QOD during the period of neutropenia depending on donor availability. The yield of granulocytes in each unit should be a minimum of 10 x 109 cells.

References

  1. Hübel et al., Current Status of Granulocyte (Neutrophil) Transfusion Therapy of Infectious Diseases, The Journal of Infectious Diseases; 2001; 183:321-8.
  2. Standards for Blood Banks and Transfusion Services, 20th Edition, AABB.
  3. Dutcher et al., Granulocyte transfusion therapy and amphotericin B: adverse reactions? American Journal of Hematology; 1989; 31:102-8.
  4. Dale et al., Return of granulocyte transfusions Current Opinions in Pediatrics; 2000; 12:18-22.
  5. Anderlini et al., Allogeneic Blood Stem Cell Transplantation: Considerations for Donors, Blood; 1997; 90: 903-8.

Q. Blood Components Available

  1. Blood Components available at Moffitt Blood Bank
    1. Packed red cells: Average hematocrit-70%. Administer through a filter.
    2. Whole Blood (limited quantity available): ): Indicated if massive hemorrhage is anticipated or encountered. Administer through a filter.
    3. Fresh Frozen Plasma: Crossmatch is not required. Blood Bank personnel need 20-30 minutes to thaw. Administer through a filter. See Guidelines for the Use of Fresh Frozen Plasma (FFP) in previous section.
    4. Apheresis Platelets: Crossmatch is not required. Store at room temperature until infused. Administer through a platelet transfusion filter. See Guidelines for the Release of Platelets above.
    5. Cryoprecipitate: Crossmatch is not required. Blood Bank personnel will thaw and pool (allow 30-40 minutes). Store at room temperature until infusion. Administer through a filter within four hours of thawing. Factor VIII concentrate is available through the Pharmacy.
    6. Rh Immune Globulin: Prevents Rh-D sensitization in Rh-D negative women. Administer within 72 hours following abortion, miscarriage, ectopic pregnancy or amniocentesis in a Rh negative woman, or following the delivery of an Rh-positive infant by an Rh-D negative women.

      Dosage is determined by the amount of fetal-maternal bleeding; one vial will suppress the immunization potential of 15 mL of fetal red cells.

      Rh immune globulin should also be considered for Rh-negative patients who have received Rh-positive platelets (see section on platelets).

      Requests for Win Rho for the treatment of patients with ITP should be referred to the Pharmacy.

  2. By Special Order from UCSF Blood Bank
    1. Pediatric Units: Available as packed cells in 75 mL packs (quad pack RBC) or in syringes for smaller volumes.
    2. SEND BOTH MATERNAL AND INFANT SPECIMENS WHEN REQUESTING TRANSFUSION FOR NEWBORN.

R. Issuing Blood

  1. Crossmatched blood is available for issue until 12:00 midnight of the second day following the draw date of recipient's blood specimen.
  2. A Blood Bank pick-up form with the patient's name and medical record number must be presented to the UCSF or UCSF Mt. Zion Blood Bank at the time blood is issued to confirm patient identification. The unit of blood or blood component is issued with the Transfusion Form. Administration (filter) sets appropriate for general transfusion are available in the Operating Room and on the nursing units.
  3. Only one unit of Red Cells or Whole Blood may be taken from the Blood Bank at any one time for any one patient (exceptions: ED, ICUs, Labor and Delivery, OR, PACU). Blood cannot be returned for credit more than 30 minutes after removal from controlled temperature storage in the Blood Banks. Ward refrigerators are not suitable for blood storage.

S. Administering Blood

  1. Responsibilities of the Transfusionist
    1. By policy of the Executive Medical Board, the person administering a transfusion must be either a physician or a specially-trained and certified nurse.
    2. Before starting the transfusion, the transfusionist must:
      1. Compare the name and hospital medical record number on the patient's wristband with the name and hospital medical record number on the blood bag. These must be identical.
      2. Compare the donor's ABO, Rh and number on the labels attached to both front and back of the blood bag. These must be identical.
      3. Request that another physician or nurse independently check the above items and record the time of the check and of the start of the transfusion in the Nursing Notes.
      4. Sign the Transfusion Record, which is issued with each unit of blood.
      5. Verify that a valid signed "Blood Transfusion Consent" is in the patient's chart.
    3. After administration of the unit of blood, the transfusionist is responsible for completing the "Physician" section of Transfusion Record, indicating the volume of blood given and the reaction, if any. The Transfusion Record must be placed in the patient's chart.
  2. Responsibilities of the Nurse

    In addition to assisting in accurately identifying the recipient and checking the consistency of the donor identification on the blood bag as noted above, the nurse must enter the volume of blood given on the patient's parenteral fluid flow sheet and in the Nursing Notes in the patient's chart.

T. Transfusion Reactions

  1. Stop the transfusion and notify the physician. Check the patient's vital signs and symptoms.
  2. Fill out the "Report of Possible Transfusion Reaction" (Form 705-033), and send it to the Blood Bank together with:
    1. All blood bags and IV solutions and administration set(s) from this transfusion series (dispose of the needles on the nursing unit - transporting the sets with the needles attached could cause injury).
    2. Specimen of the patient's blood (a 6cc EDTA lavender top), carefully collected so as to avoid hemolysis - remove the needle from the syringe before expelling the blood into the tubes. The sample must be labeled with the patients full first and last names; the hospital medical record number or date of birth; the date drawn; and the full, legible signature of the person who drew the specimen. The sample should also be marked "post-transfusion reaction".
    3. The first post-transfusion urine specimen if a hemolytic reaction is suspected.

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