Emergency Department Hospital Pulau Pinang

May 2011

POLICY ON ADMINISTR ATION OF BLOOD TR ANSFUSIONS IN EMERGENCY DEPARTMENT HOSPITAL PULAU PINANG
Blood is transfused in the Emergency Department (ED) area only in emergency lifesaving situations. This process needs to be clearly defined and performed consistently. This policy document is meant to address this aim. A few general principles are emphasized 1. Blood transfusions are provided at the ED in emergency situations only. In this context, many of the requirements related to consent for blood transfusion may not be able to be adhered to especially for life saving situations. This position does NOT hold for non-emergencies, where informed consent must be sought before blood transfusion is considered. 2. In emergency situations, several options are available for the ED doctor 2.1. Safe O Blood - this is meant for use only in the hypotensive exsanguinating patient in order to save life. Many of the normal requirements are not applicable in order to reduce the delay to administering blood. It is not meant to be used in any other circumstance other than that mentioned above. The request by ED-MO is done by filling up the blood product request note and getting someone to run to the Blood Bank to get the blood. Clinical audit will be performed on all usage of Safe O blood. 2.2. Type Specific Blood - occasionally referred to as Saline Cross-Matched blood. This process takes between 20 - 30 minutes. If the ED doctor needs blood urgently, a request should be made for 2 units (max) of type specific blood first, using Borang Permintaan Transfusi Darah. The time taken to transfuse these 2 units would allow time for full cross matched blood if more blood is needed (by filling up another blood request form). 2.3. Group and Cross Matched Blood - GXM blood. The process of full crossmatching takes at least 45 mins to 1 hour. In the patient going to Emergency OT, kindly indicate if you would like the Blood Bank to provide GXM blood or to perform a GSH process. (Group - Screen - Hold). GXM is used if blood is likely to be transfused; GSH only when blood may be needed at the OT or afterwards. 2.4. Fresh Whole Blood - in many patients with exsanguinating haemorrhage, fresh whole blood (preferably the most recent stocks available) should be used. This allows the replacement of RBCs as well as the plasma and stable coagulation factors that is vital in the control of continued haemorrhage. 2.5. Fresh Frozen Plasma - in many patients with exsanguinating haemorrhage, in order to support the coagulation process, the early administration of FFP may be needed. FFP request can be made without prior Blood Bank MO approval.

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Emergency Department Hospital Pulau Pinang

May 2011

2.6.

DIVC regime - this is only available in situations when there is clinical evidence of coagulopathy or high risk of coagulopathy (unstable pelvic or maxillofacial fractures in haemorrhagic shock) exists. Discussion with the Blood Bank MO is required. In emergency situations, request for 1 set first. If additional components are required, please fill up another request form.

3. In all non-life-saving situations, blood transfusions should be deferred to the concerned Ward, where the process of full cross-matching and informed consent must be carried out. 4. Whenever and wherever possible. consent should be obtained for blood transfusions. But this requirement may be waived if the process of getting this consent may delay the administration of blood to save life. 5. Procedure of determining correct patient, correct sample, correct blood 5.1. When obtaining a blood sample for cross-matching, positive patient identification is necessary to obtain the sample. It is highly recommended that the same person takes blood, labels and fills up the forms. 5.2. Prior to administering blood, at least 2 trained persons must be involved to cross-check patient identification with patients card, blood forms, blood pack and tag. Both must sign the form as well. 6. It is NOT within the scope of Emergency Care to transfuse blood in a non-emergency situation in the ED; neither is there a scope of blood transfusions to any patient on an outpatient basis, both within the ED and the Observation Wards. This practice is not allowed. 7. In the event that an unidentifiable patient is treated at the ED, the RN number can used instead. Once the patients identification has been determined, the proper identification must be informed to the Blood Bank. 8. Any deviation from these guidelines must be cleared with the ED specialist or Head of Department. 9. The algorithm of blood product transfusions in the exsanguinating hypotensive patient is listed as an Appendix in the next page. Signed and Approved for Use,

Dr Teo Aik Howe

Dr Soo Peng Yen Blood Bank HPP

Emergency Dept HPP

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Emergency Department Hospital Pulau Pinang

May 2011

Algorithm for Blood Product Transfusions in Exsanguinating Hypotensive Patients 1. Exsanguinating Hypotensive refers to a patient with severe suspected or confirmed bleeding; and have been noted to have at least one hypotensive episode; where the patient definitive surgical control of bleeding is not immediately available. 2. The algorithm to be used is as follows: 2.1. Get 2 units Safe O. Fill up the blood product request note and send a houseofficer to get the Safe O blood from the Blood Bank. 2.2. In the meantime, get 4 mls blood sample in the EDTA tube and fill up the Blood Transfusion Forms for 2 units of Type-Specific Fresh Whole Blood. Send request immediately. 2.3. Transfuse 2 units Safe O. Send back the blood bag plus segment in the plain tube, patients pre-transfusion samples and adequately filled up forms to the Blood Bank after the blood is transfused. 2.4. 2.5. Transfuse 2 units Type Specific Fresh Whole Blood once it becomes available. In the meantime, Group and Cross-Match for 2 units of Packed Cells and 2 units of FFP. (Please keep requests to 2 units max; you may fill up additional requests forms if more blood is needed). 2.6. In situations where surgical control of bleeding is limited, eg retroperitoneal bleeding from pelvic fractures, or massive maxillo-facial bleeding fractures, DIVC regime is needed urgently [even before coagulation results become available]. 2.7. In situations where there is confirmed or suspected inherent or drug induced coagulopathy, discussion about preferred blood products will be needed with the blood bank doctors. 3. Summary 2 units Safe O

Type Specific 2 units Fresh Whole Blood Further Actions (if needed) Group and Cross Match 2 units Packed Cells 2 units FFP 2 units Packed Cells 2 units FFP 1 unit DIVC

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