Transfusion essay plans Transfusion Essay plans
Red cell transfusion
Cell salvage Introduction § Intra op v post op cell salvage § Two types of cell saver § Red blood cell washing – washes cells then centrifuges and returns to patient § Advantage of removing debris from surgery § Also removes clotting factors and platelets § Haemofiltration devices § Simply filter red cells § Don’t remove debris, clotting factors or platelets § Concerns that this may lead to unwanted circulatory or pulmonary effects § Slower processing of the devices Indications § Surgery likely to result in >20% total blood volume Contraindications § Can’t be used in operations involving infected or malignant tissue § Sickle cell disease and trait Advantages § Reduces the need for allogenic blood transfusion § Thus reducing risk of infection, alloimmunisation, § Useful in rare blood groups § Some Jehovah’s witnesses will accept § Cost effective with large volume losses § Matches transfusion to blood loss (useful if massive unexpected bleeding) Disadvantages § Operator training § Often difficult to predict intraoperative blood losses and some authors have found that they are not cost effective when used routinely for aortic surgery (cost per QALY estimated at $120,000). § Possible worsening of DIC / ARDS due to infusion of activated clotting factors, platelets and debris § Possible worsening of coagulopathy if cells washed (but can be corrected with the administration of other blood products) § Suction device not as effective and surgeons may prefer to use conventional suction especially in difficult operating conditions
Irradiated blood products Cellular blood components to prevent TaGVHD § HLA disparity § Natural killer/ T-lymphocyte mediated § 90% mortality § Target organs § Skin § Thymus § GI tract § Spleen/ liver/ bone marrow § Onset is 1-2 weeks after transfusion § Diagnosis § Skin biopsy § Confirmation of persistence of donor lymphocytes in recipient done by analysis for RFPs § Irradiation § At least 25Gy
Indications § Allo § Donors § Within 7-14 days of harvest § Recipient § Conditioning to 6 months post or immunosupression stopped (lymphocytes >1) § Auto § Within 7-14 days of harvest to 3 months post (6 months if TBI) § HD § Purine analogue (fludaribine/cladaribine) and campath § Granulocyte/ buffy coat § HLA-matched blood components § Donations from family members § IUT § Transfusions for babies that received IUT (up to 1 year) § Exchange transfusion in neonate § Congenital immunodeficiency (includes Di George) § Except mucocutaneous candidiasis
TRALI (pathophysiology / diagnosis / management) Discuss the patho-physiology of transfusion related lung injury (TRALI). Describe how you would diagnose and manage this condition and discuss the strategies for preventing TRALI. Transfusion related acute lung injury
Pathogenesis § Donor derived leucocyte antibodies § HLA (class I and II) and HNA (human neutrophil antigen) § Multiparous female donors / male donors with previous transfusion § Binding of leucocyte antibodies in the donation leads to activation of leukocytes in the patient § The reason that the lungs are targeted is not certain – may be that this is the first capillary bed that transfused leukocytes pass through. § Not all transfusions containing HLA/HNA antibodies cause TRALI (two hit hypothesis) § Less commonly, antibody is in the patient and donor derived lymphocytes are activated § Antibodies react with patient leucocytes § Pulmonary leucostasis § Complement mediated leucocyte activation § Release of proteolytic enzymes and toxic oxygen metabolites damages pulmonary capillary endothelium
Clinical features § Bilateral perihilar infiltrates and hypoxia within 6 hours of transfusion § No other readily identifiable cause § Definition of ALI PaO2/FiO2 ratio <300mmHg / ARDS <200mmHg
Predisposing factors § Haematological malignancy § Elective surgery (cardiac)
Blood components § Plasma rich – Platelets / FFP / Whole blood / Cryoprecipitate § IVIg (single case) § Red cells
Management § Prompt respiratory support § No evidence for steroids or diuretics § Mortality 5%
Investigation of cases § Clinical diagnosis – refer to hospital’s blood bank initially § Then referred to designated NBS consultant and SHOT § Collect clinical details § Identify donors to be investigated / temporarily suspended § Units in the 6 hours prior to TRALI initially females with previous pregnancies (and males with previous transfusions) § Temporarily suspend from donating § Recall other components from the same donation § Samples from patient to national granulocyte immunology laboratory § HLA and HNA antibodies in donors and patient (costs £300 for each) · Screen archived samples for HLA / HNA antibodies · Fresh donor samples required to confirm results and determine HLA and HNA antigens · May need follow up samples from patient to determine whether a weak antibody represents an immune antibody or a transferred antibody § Reporting § Highly likely if donor has specific leukocyte allo-antibodies and the patient is positive for the antigen § Likely if donor serum has non-specific antibodies which are positive when cross-matched with the patient § Possible if patient has leukocyte antibody which corresponds to leukocyte antigen in the donors (less likely mechanism since leukodepletion) or donor has leukocyte antibodies but patient is negative or weak positive pan-reactive leucocyte antibodies § Unlikely if no leukocyte antibodies in either patient or donor § Antibodies not detected in about 10%
Prevention § Implicated donors should not be used again § Exclude multiparous women as donors of whole blood / FFP / Platelet concentrates (apheresis) § Screen multiparous women for antibodies § Pool plasma which dilutes antibodies § Remove plasma from cellular blood components § Leucocyte depletion will prevent the small number
Neonatal transfusion Discuss the factors which should be taken into account when infants in a neonatal unit are transfused with blood components.
Introduction § Blood transfusion often required in neonatal patients particularly in the context of haemolytic disease of the new born. § Different triggers for transfusion compared to adults. Vary and should have local guidelines but BCSH guideline triggers are § Hb<12 in the first 24h and in unwell neonates; § Hb<11 if chronically hypoxic § Hb<7 if stable.
Specialised product § O neg but ABO matched can be used § K neg § Rh neg § CMV negative § SAG-M usually avoided especially in exchange transfusions § Plasma reduced blood in CPD anticoagulant § <5 days old – to prevent hyperkalaemia § Irradiated blood preferred for exchange transfusions / compulsory for babies who have had IUTs or babies with immunodeficiencies § HCT 0.55 § Sickle negative
Cross matching § Maternal blood typed for ABO and atypical antibodies § Neonate typed for forward ABO – reverse group likely to be due to maternal antibodies
§ Dose needs to be calculated § Product needs to be warmed carefully
Benefits of leukodepletion Discuss the potential benefits and disadvantages of pre-storage leucodepletion of all blood products. How would you manage a patient whose temperature rises to 39C following the administration of 50ml of leucodepleted red cells?
Removal of white cells from all clinical components § Usually accomplished by filtration § UK <5x106 white cells in 99% of units with 95% confidence § Compulsory since 1999 Advantages § Reduced risk of CJD transmission § Normal prion has been demonstrated on CD34+ cells, red cells, lymphocytes and monocytes § Study has demonstrated effective removal of normal prion protein § Reduces immune-related complications § HLA alloimmunisation § TRALI § Reduced refactoriness to random donor platelets § TaGVHD § Reduces non-haemolytic transfusion reactions § Caused by Abs directed towards granulocytes (HLA Abs) § Cytokines may also be implicated § Reduces transmission of cell-associated viruses § CMV in monocytes § Some consider that this is equivalanet to CMV seronegativity (reduces rate from 7% per unit to <1%) § Not considered to be robust enough to stop CMV testing § EBV and HHV8 § HTLV-I and II in T-cells Disadvantages § Retention of up to 15% of the component volume in the filter with cellular loss in proportion § Esp. if filtered after removal of buffy coat § Difficult in sickle trait blood with blockage seen in about 50% § Cost £70,000,000 annually
Management of a suspected transfusion reaction See below
Immediate and delayed haemolytic transfusion reactions (clinical features / immunological basis) Describe the clinical features and underlying immunological basis of: (ii) immediate haemolytic transfusion reactions (iii) delayed haemolytic transfusion reactions.
Immediate haemolytic transfusion reactions
Immunology § A donor into O recipient 75% deaths § B or AB donor into O recipient 20% deaths § Non-ABO § Anti K, anti Jkb, anti Fya § Pre-existing antibodies can be in the donor or the recipient § Predominantly red cells, but can be from high Ab titres in plasma
Clinical features § Differential diagnosis § Haemolytic transfusion reaction § Febrile non-haemolytic § TRALI § Bacterial contamination § Allergy § Speed of onset in this case is most suggestive of an AHTR § As little as 20mls
Assess patient § Stop the transfusion § Check patient ID and blood component § Observations and examination § Was the patient febrile prior to starting transfusion § Pain at infusion site/ loins, abdomen, chest, head § Hypotension, tachycardia § Agitation, confusion § Nausea/ vomiting § Dyspnoea § Flushing § Investigations § Urine for haemoglobinuria § Return transfusion and giving set to lab § FBC and film § Haemolysis screen § Repeat blood group of patient on pre and post samples and confirm blood group of donor § Pre and post samples for antibodies § Renal function § Coagulation § Blood cultures § Treatment § Supportive § IV fluids - may need renal support § Renal failure >30% § May need blood product support for DIC § DIC 10% § May need inotropic support § Transfer to high dependancy
Delayed haemolytic transfusion reactions § Clinical features § 5-10 days following transfusion § Fever, fall in Hb, jaundice and haemoglobinuria § Often undiagnosed as recipient may be discharged § PB shows spherocytes § Haemolysis screen § DAT becomes positive within a few days § Serological testing on pre and post samples § Ab may not be initially apparent, but can be eluted from the red cells § Immunology § Secondary immune responses following re-exposure to a given red cell antigen § Recipient has been primarily exposed during pregnancy or previous transfusion § Few days after transfusion, rapid rise in Ab and red cell destruction § Kidd > Rh > Duffy > Kell
Delayed haemolysis following organ transplantation § Passenger lymphocyte syndrome § Donor derived B lymphocytes within transplanted organ mount an anamnestic response against the recipients red cell antigens § Usually against ABO and Rh antigens § 7-10 days after transplant and last for about 1 month § Heart &lung > liver > kidney (ABO unmatched organs)
Transfusion in sickle cell disease Describe the indications for the use of red cell transfusion in sickle cell disease and discuss specifically the hazards associated with these transfusions.
Indications § Top-up transfusions § Severe anaemia § Exchange transfusions § Emergency § Chest crisis § Neurological event § Priapism § Aplastic crisis (parvovirus B19) § Splenic sequestration § Retinal bleeds § Elective § Surgery § Pregnancy if frequent pain § EBT program § Stroke prevention/ moya moya § ?leg ulcers § Pulmonary hypertension
Hazards § Frequency of alloimmunisation is dependant on the extended red cell antigen matching policy employed § All should be phenotyped § Blood should be Rh and K and C, c, E, e matched § The majority of blood donors are caucasian and so different antigen pattern eg. AC are Fya-, Fyb – (R0R0) § 40% who are alloimmunised will or have experience a DHTR § Increased rate of subsequent allo antibodies formation § Sickle pain may be intensified during a HTR § Suppression of erythropoiesis § Hyperhaemolysis § Reticulocytopenia, raised LDH, bilirubin, haemoglobinuria up to 10 days following a transfusion. § Usually DAT negative (70%) and often no allo or auto-antibodies identified § Normal G6PD levels § Mechanism poorly understood § Bystander haemolysis –patient haemolyses the transfused cells and their own cells leading to a nadir in the Hb lower than the pretransfusion Hb § Possible macrophage destruction § TTI especially if exchange transfusion due to volume of transfusion § Iron overload, may be less of a problem with exchange transfusions
Pretransfusion testing / electronic crossmatching Discuss the key elements involved in pretransfusion testing in the hospital blood bank. What are the requirements to implement electronic cross-matching and what are the potential benefits and risks of this approach?
Key elements § Blood sampling § Training of blood takers § Labelling, patient identification § Recent transfusion history § 3-14 days ago – sample within 24 hours of transfusion § 15-28 days ago – sample within 72 hours § >29 days ago – sample within 7 days § Forward and reverse grouping for ABO and RhD § Saline § 2 samples required if lab not fully automated otherwise same sample can be grouped twice unless historical sample § Antibody screen § Standard panel including the following § C,c D, E,e, M, N, S, s, K, k, Lea, Leb, Fya etc § If negative and no previous Abs, can be electronically cross-matched § If positive, further antibody testing for Ab identification and type red cells for he antigen to confirm allo-antibody § BCSH – Ab positive if confirmed in 2 cells, and has to be excluded by 2 homozygous cells § Cross-match § With each unit to be issued § IAT
Electronic cross matching § Historical record § Run group on same sample twice if fully automated lab § Reduces chance of lab admin error but accepts risk of sampling error § Ab screen negative and no history of Abs § Not on neonates § Quality control § Data from donations entered via barcode § Advantages § Reduced workload § Rapid availability § Improved stock management and reduced wastage § Reducd handling of biohazardous products § Elimination of false positives in the immediate spin cross match § Ability to issue blood at remote sites § Disadvantages § Deskill lab staff § Assumption that blood always rapidly available § Potential to miss incompatibility § Relies on blood being correctly labelled § If same sample tested twice does not prevent errors in blood taking § Does not prevent wrong patient being transfused
Reduction of blood transfusion Discuss the reasons for the need to reduce the use of blood. Critically evaluate the strategies that may be used to achieve this and identify those strategies that you believe will be effective.
What steps could a hospital take to minimise patients’ exposure to donor blood components?
§ Reduced blood availability § Population becoming less altruistic § Increased exclusions § Concern re risk of unknowns eg. vCJD § Financial implications esp with CJD screening § Transfusion related complications
Strategies § Maximum surgical blood ordering schedule § Electronic issue reduces wastage § Transfusion thresholds/ guidelines on when to transfuse § TRICC trial – transfusion in critical illness, target Hb 8.5 v Hb 10.5, no difference in mortality, but only powered to show a 10% difference because it was stopped early due to poor recruitment § Audit blood use § Empower MSLOs to question the request § Hospital transfusion practitioners for education etc § Increasing use of growth factors § Improved management of pre-op anaemia § Cell salvage and other intra-operative gizmos
Blood safety and quality regulation The Blood Safety and Quality Regulation (No 50) 2005 transposes two EU Directives (2002/98/EC and 2004/33/EC) into UK law, and comes into force from 8 November 2005. Describe the requirements on hospital blood banks contained in the Regulation(s) and / or the EU Directives. What are the necessary components of a quality system in a hospital blood bank?
§ Quality control § To detect non-conforming products or services § Checking, testing, measuring procedures § Processes in place to ensure laboratory techniques and storage of blood components comply with preset standards § Internal QC v. external QC § Internal – set standards determined by coefficient of variation (ie. daily controls with trends to identify problems early) § External QC – Neqas standards, MRHA § Quality assurance § To prevent, detect and correct variation and errors § Management procedures § Systems to ensure that all processes are working as expected § Hospital transfusion committee § Hospital transfusion team § Staff – adequate training and competency assessment § Self- inspection § Policies § SOPs § Equipment – planned maintenance § Systems review – audit, performance monitoring, root cause analysis
Blood safety Describe the principles by which the safety of blood components (red cells, platelets and fresh frozen plasma) is achieved by a blood transfusion service. Illustrate your answer with a list of the specific measures which are currently employed. What other measures are available that might affect blood component safety and what impact might these have if introduced within a national transfusion service?
§ Donor § Selection § Safety § Motivation – altruistic ie. no financial gain § Permanent exclusions § High risk behaviour · HIV + · Hep B carrier · Hep C carrier · MSM · Money or drugs for sex · IVDU includes body building drugs § Chronic infections · Incl. brucellosis, chaga’s § Risk of CJD · Previous recipient of a blood transfusion · Human pituatry hormones · Family history § Diseases of unknown or viral aetiology · UC, Crohns, malignancy § 12 month exclusion if had sex in the last year with § A partner who has high risk behaviour (as above) · + anyone who has received clotting factor concentrates or who has been sexually active in areas where HIV is common § 6 month exclusion if § Travel to malaria endemic country § Temporary exclusion § Infectious disease or contact or finished antibiotics within the last 7 days § Vaccination § Piercing, tattoo, acupuncture outside the NHS § Complicated dental work § Serious illness or major surjery § Pregnancy or delivered within last 9 months
§ Venepuncture, transport and storage § Checks of donor identity § Check for integrity of blood pack § Labelling of pack and samples § Data capture § Arm cleansing § Closed bag technique § Mixing of packs to prevent clotting § Storage and transport conditions – cold chain 4 C for red cells § Diversion pouch § Microbiology environmental testing § Platelet storage 5 days § Moves to increase to 7 days, with micro testing § Microbiology § Mandatory tests § Syphilis § Ab § HBV § HBsAg § 1 in 500 000 § HIV § Ab and Ag testing § 1 in 5 million § HCV § Ab and nucleic acid testing § 1 in 30 million § HTLVI and II § Ab and NAT § Discretionary tests § CMV (test 30%) § Malaria § If previously lived in endemic area, need to be malaria Ab negative § T cruzi § If lived or mother lived or transfused in S/C America § Anti- HBC (core) § Detects in window period § Tattoos and piercings § Mecahnisms in place to withdraw products if necessary § Appropriate transfusion § Traceability and ‘look back’ procedures § Ability to withdraw other products § Future implications § CJD – see below
Patient information leaflet Prepare a patient information leaflet about blood transfusion, intended for adult patients scheduled for elective surgery attending a pre-admission clinic approximately 1 month prior to the date of admission.
§ Indications for blood transfusion § Not always necessary – only if required § Blood loss – if the amount lost is greater than the body can tolerate § Alternatives § Cell saver § Iron § Ask your doctor § Pre-op – iron replacement, check your medications § Side effects § Wrong blood § HepB (1in 500 000), HIV (1in 5m), Hep C (1 in 30m) § vCJD – probably very low § 2m units transfused each year, only a handful of cases § How § Iv § 4 hours § Symptoms § Most asymptomatic § Regular observations § Temperature, chill or rash – paracetamol and slow transfusion § Severe reactions extremely rare § Concerns § Hospital transfusion practitioners § Contacts § NBS, national patient safety agency
CJD transmission Evaluate the risk of transmission of variant Creutzfeldt Jakob disease by blood components and plasma products and discuss strategies which have or could be used to manage that risk.
§ Sporadic § Median age 68 years, rapidly progressive dementia and death in 4-6 months § Familial § Gerstmann-Straussler-Cheinker disease, fatal familial insomnia § Acquired § Kuru, longer clinical course § Variant § Neuropsychiatric symptoms, dysaethesia and ataxia § Progressive dementia, myoclonus, choreoathetosis § Death 6 months - 2 years (median age 29) § MRI changes in the posterior thalamus § Abnormal prion accumulation in lymphoid tissue as well as CNS
§ Prion protein § 30-35kDa GP widely expressed by many cells § Encoded by a single gene PRNP § 20 different single nucleotide polymorphism have been described that presispose to the familial form § Critical polymorphism at codon 129 (M129V), results in variation of susceptibility and incubation period of human prion disease § Methionine homozygosity is much more common than would be predicted in patients with CJD § Transmissible agent induces conformational change in the prion protein (PrPc to PrPsc) § Helical structure changes to B-pleated sheet which engenders rigidty § Proteinase resistant § Aggregates in plaques in the brain and results in spongiform change § Abnormal PrP catalyses further change – cascade effect
§ Evidence of peripheral blood infectivity § Sheep studies § Donor sheep given BSE infected feed § Blood from donor sheep given to BSE free sheep § Sheep-sheep transmission confirmed § Abnormal prion accumulation detected in lymphoid tissue before it can be detected in CNS, supporting pre-clinical phase of disease § Main source thought to be plasma and white blood cells
§ Factors affecting transmissibility § No. of infected donors § Size of infectious dose § Length of incubation period § Host susceptibility
§ UK CJD surveillance unit § Transfusion medicine epidemiology review § Cases of CJD are actively investigated for history of either blood donation or transfusion § Blood donations traced through to ultimate fate § 66 recipients of blood product from infected individuals identified § 4 cases developed evidence of infection (3 clinical, 1 preclinical) § 14 patients with CJD had received blood products (1 transfused <12 months age and thus excluded) § 190 donors traced, of whom 2 developed vCJD
§ Reducing potential transmission § Donor selection § Exclude at risk family members, pituatry gonadotrophin (GH and infertility treatment pre 1985), dura mater (neurosurgery), corneal grafts, transfusion § Imported plasma for those born after 1995 § Donor screening § No serological or molecular test available § Surrogate markers – erythroid differentiation associated factor § Validation – usually requires samples from patients with the disease, not possible due to rarity § Significance of a positive result not know § Leucodepletion § Implemented in 1999 § Filtration devices – again a problem with validation ( red cell quality, 3 log reduction) § Only for red cells at the moment § Others § Increase apheresis platelets § Reduce plasma in components § Appropriate use § Early intervention therapies
Anti D Discuss current antenatal prophylaxis for haemolytic disease of the newborn. Critically evaluate methods for the quantitation of feto-maternal haemorrhage. Discuss the management of HDN due to Rh-incompatibility. See notes
Laboratory errors (reduction in) In the UK nearly 30% of serious hazards of transfusion are due to hospital laboratory errors. Discuss how these may be prevented.
§ SHOT – voluntary anonymised system to collect data on serious adverse incidents of blood transfusion and make recommendations to improve transfusion safety § Works in collobaration with MHRA, co-operating over SABRE web-based reporting system which collects data for MHRA and SHOT
2006 SHOT report § Key findings § 13% reduction in number of reports § Reduction in ABO incompatible transfusions § Increase in ICBT § Errors arisen in laboratories, with a disproportionate number out of hours § Increasing errors involving medical staff § 2 fatalities and 123 further cases § 79 special requirements not met § 46 inappropriate transfusion § Mortality and morbidity § 4 deaths § 2 incorrect prescribing § Incorrect dose of platelets to neonate § Too much blood due to dilutional Hb § Bacterial contamination § TRALI § 19 major morbidity § IBCT § 400 § ‘wrong blood’ § Lab errors 46% § Most were out of hours § Manual grouping § Computer warning over ridden § Inappropriate use of electronic issue § Different patient ID numbers – difficult historical checking § Other pre-transfusion testing errors § ABO mismatched transplants § Incorrect special requirements § Inappropriate or unnecessary § Unsafe due to handling or storage errors § Anti-D § TRALI § Reduction, probably related to preferential use of male plasma § Other immune complications § ATR § 25% increase § Mandatory reporting to BSQR § HTR § No cases of PTP, Ta-GVHD § TTI § 2 confirmed – both bacterial contamination of platelets § 1 vCJD – 4th case (from a previously identified donor) § Recommendations § Inclusion of transfusion medicine in core curriculum for junior doctors § Specialty accredited laboratory and clinical staff in all hospitals § Comprehensive reporting to SHOT by all hospitals § Requirement for CPA acrreditation
Massive blood loss § Definition § 1 blood volume within 24 hours § Adult blood volume 7% of ideal body weight ie. about 5 litres § 50% blood volume within3 hours § >150ml/minute § Goals § Maintain tissue perfusion and oxygenation § Arrest bleeding § Treat surgical bleeding § Judicious use of blood products to correct coagulopathy § Communication § Between clinical specialties (surgery, anaesthetics, haematology, ITU), lab, blood service § Interventional radiology for embolisation § Dedicated team member to co-ordinate § Early § Senior involvement § Local protocols – role of the hospital transfusion committee § Other roles include analysis of events § Contingency plan for national blood shortage and emergencies § Recommendations § Restore circulating volume § Venous access § Pre-warmed crystalloid or colloid (no benefit to 4% albumin, hypothermia increase coagulopathy) § Monitor UO/ BP § Treat acidosis § Contact key personnel § Arrest bleeding § Surgical/ obstetric § Investigations § Group and Ab screen § Baseline haem, coag and biochemistry § Consider near patient testing such as TEG § HB >8 § Assess urgency § Consider cell salvage § O neg in emergency - ABO group specific – fully cross matched § Use blood warmer, rapid infuser § HCT 0.35 may be required to sustain haemostasis in massive blood loss § 30-40% blood loss, PRCs usually required § Plts >75 (margin of safety, shouldn’t fall below 50) § Anticipate plt <50 after 2 x blood volume replacement § PTT and APTT <1.5 § FFP 12-15mls/ kg (1L in adults) § Anticipate need after 1-1.5 x blood volume § Lasts for 24 hours once thawed, therefore should start to dethaw immediately § 30 minute thaw time § Fibrinogen >1 § 2 packs for an adult, usually only needed if DIC § 30 minute thaw time § Other agents § PCC if secondary to warfarin § Not enough evidence to support antifibrinolytics § rVIIa – off license, consider if continued bleeding despite correction of other parameters § Risks § Wrong unit transfused § DIC – cardinal sign is microvascular oozing § Hypocalcaemia, hyperkalaemia, TRALI
Maximum surgical blood ordering schedule
Advantages § Reduction in crossmatching requirements (25%) § Reduced lab stress § More efficient management of blood stocks
§ Aim to have a crossmatched to transfusion ratio of 2-3:1 ideally § Occasionally higher (e.g. meningioma surgery where 4 units crossmatched but if bleeds there is very rapid blood loss § Agreed with consultant surgeons
General
IT systems in transfusion
Administration of blood
Implementation of a maximum blood transfusion order
Hospital transfusion team
New techniques for blood grouping
Platelet transfusions
FFP
Collection and storage of stem cells
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