The Circular of Information for the use of Human Blood and Blood Components is considered an extension of blood and blood component container labels as the space on those labels is limited. The Circular of Information contains sections on general information, side effects and hazards of transfusion, blood components descriptions, actions, indications, contraindications, dosage and administration. The circular was prepared jointly by the AABB, America’s Blood Centers and the American Red Cross, and is recognized as acceptable by the Food and Drug Administration.

Please refer to the UI Hospitals and Clinics Policies and Procedures web site for DeGowin Blood Center Transfusion Protocols.

PRETRANSFUSION COMPATIBILITY TESTING

Type and Screen

Type and Screen only is appropriate for all patients who are unlikely (<25% chance) to actually need a transfusion, but may need blood to be available promptly if a need arises. A blood type (ABO and Rh) and antibody screen will be performed. The antibody screen detects the presence of clinically significant red blood cell alloantibodies in the recipient's plasma. The sample is stored in the blood bank and is valid for crossmatching three days after collection. (e.g., the date the sample is drawn + three days. A sample collected on Monday is good until midnight on Thursday.) If a Type and Screen has been ordered, and blood is subsequently needed, it may be requested by calling the Blood Bank (356-2561) and/or sending a Blood Center Request (Form A-1a).

Crossmatch

If the patient's current and previous antibody screens are negative, an electronic crossmatch is performed to detect ABO incompatibility only. When the health care provider is ready to transfuse, a call should be made to the Blood Bank. The electronic crossmatch is then performed and the Red Blood Cell unit is available within 10 minutes.. When a patient has a clinically significant antibody, an antiglobulin crossmatch is performed and the donor’s cells are tested for the corresponding antigen. This takes 45 minutes or greater. Crossmatched units of blood are held for a given patient until the sample has expired (three days after the day of collection).

HOLD GUIDELINES FOR PRETRANSFUSION COMPATIBILITY TESTING

DeGowin Blood Center Transfusion policy BC-475.11: Emergency Treatment Center and Clinical Cancer Center Pretransfusion Compatibility Testing Specimen Guidelines


TRANSFUSION ORDER REQUIREMENTS

A transfusion treatment is defined as the infusion of blood product(s) to fulfill a single clinical indication. One or more units may be needed to provide the correct dose for each single event. It is against hospital policy to write standing orders for transfusion. The patient should be evaluated at least once daily, and new transfusion orders written as needed. A physician's order must be written on the "Doctors' Orders" (Form A-1a) for each transfusion event. The only exception is during surgery when the order may be written on the anesthesiology record. The order for transfusion must be written no more than 24 hours prior to the administration of the transfusion.

Each order must include the complete name of the product (e.g., leukoreduced, irradiated platelets), either the volume or the number of units, and the total administration time or rate of infusion.

An order for transfusion may be based on specific objective parameters, and may be written for more than one unit of a blood product (e.g., "If hemoglobin is <8, transfuse two units red blood cells over six hours"). However, each transfusion treatment requires a separate order.

If additional (reflex) testing is necessary to provide ordered blood components, the testing WILL BE performed unless a signature is present on the Blood Center Request form A-1a to prohibit it.

The DeGowin Blood Center may issue a blood component different than that ordered when indicated by patient needs or University of Iowa Hospitals and Clinics policies.

INFORMED CONSENT

It is University of Iowa Hospitals and Clinics policy to obtain informed consent before transfusing blood components in nonemergency settings. Two of our accrediting agencies, the American Association of Blood Banks, and the Joint Commission on Accreditation of Healthcare Organizations, note the need for informed consent prior to blood transfusions in their accreditation manuals. Members of the Transfusion Subcommittee have approved two methods to facilitate obtaining informed consent before blood transfusions. They are as follows:

1. Form G-2d₂ - "Consent for Blood Transfusion" can be completed and placed in the patient's medical record. This form is available in Hospital Stores (stock number MHO7796).

2. Form G-2d₂ - "Consent for Operation or Procedure" includes a brief statement regarding transfusion of blood products. This form is available in Hospital Stores (stock number MHO1575).

3. Form G-2d₂ - "Therapeutic Apheresis and Plasma Exchange Informed Consent" includes statements regarding transfusion of blood products when needed as replacement for blood components removed by apheresis procedures. This form is used exclusively by the DeGowin Blood Center.

Consent does not have to be obtained before each individual transfusion of blood or blood products but should be obtained when management decisions are made (e.g. at the time of the initial decision to transfuse and at the time of any change in the patient's condition and treatment plan that changes risks, benefits, or indications for transfusion). For inpatient transfusions, consent will be valid no longer than that hospitalization. For outpatient transfusions, the consent may be valid for up to one year.

BLOOD CENTER REQUISITION AND SPECIMEN COLLECTION

Refer to the following policies

Surgical Services policy SS-10.005: Blood Specimen Collection and Administration in the Operating Room

Nursing policy N-07.069: Blood Specimen Collection for Type and Screen, Type and Crossmatch, Pre-Solid Organ Transplant ABO Evaluation and Rh Factor

Nursing policy N-07.070: Blood and Blood Components using Scanned/Barcode Technology, Administration of

Nursing policy N-07.072: DOWNTIME PROCESS: Blood Product Tracking

Patient identification on the specimen label and the requisition must be legible and complete.  The date of collection should be on the specimen label.  The patient identification on the specimen and the requisition must match.  Specimens that are not collected as specified in the above UIHC policies cannot be accepted.  Specimens that are unlabeled, illegible or incomplete, or specimens that do not match the requisition cannot be accepted.  Unacceptable samples must be discarded and will need to be recollected.

The requisition must include the physician's name and code number, and patient's diagnosis or surgical procedure. Indicate the tests and/or or blood components needed, and the date/time needed. Provide an ICD-9-CM code for each test or blood component ordered.  Special requirements (such as irradiated/leukocyte reduced or autologous) should be noted, as well as additional information for obstetric and pediatric patients. 

In cases of Emergency Release, the physician should also sign the section authorizing release of blood components before pretransfusion testing is completed.

EMERGENCY ISSUE OF BLOOD

Use of group O red blood cells for patients of unknown ABO group:

Patients whose ABO group is unknown will receive group O red blood cells. Four units of group O Rh negative red blood cells are stored in the Emergency Treatment Center (ETC) and 4 units are also stored in the Blood Bank Satellite Laboratory (5892 JPP). These units are available for life threatening emergencies in which transfusion cannot be delayed. As soon as possible a properly labeled sample and Blood Center Request form A-1a should be sent to the Blood Bank to request additional units.

If additional units are requested before the sample arrives, Blood Bank personnel will: (a) issue the number of red cell units requested as group O Rh positive cells; (b) inform the requesting physician that only group O Rh positive cells will be issued until the ABO group can be determined and a sample is required; (c) alert the Blood Bank resident if the blood sample is not forthcoming.

Use of ABO type-specific blood for patients of known ABO group:

When time permits to allow testing for ABO and Rh type (5-10 minutes after patient sample arrives at the Blood Center) the patient will receive ABO type-specific red blood cells.

ABO type-specific RBCs can be released 5-10 minutes after both a patient blood sample AND a requisition (A-1a Blood Center Request) with the "emergency" box checked and the signature of the responsible physician in the "emergency release" section are received by the Blood Bank. The telephone number to be called when the blood is ready must be included on the requisition (A-1a Blood Center Request) for all urgent blood requests.

This blood is released solely on the basis of ABO and Rh(D) type(i.e., before the antibody screen and other pretransfusion tests, as needed, are completed). Thus, its use is appropriate for massive blood loss where delay due to complete compatibility testing would significantly endanger the patient's life.

Complete compatibility testing (blood type, antibody screen and immediate-spin crossmatch) can be completed in 45 minutes under optimal conditions for emergency patients. Requests for large quantities of blood, delays due to other emergency work simultaneously in progress or the detection of unexpected antibodies may increase this time.


BLOOD ADMINISTRATION

Before sending for blood, the transfusionist should ensure that venous access has been established. 

Refer to the following policies

Nursing policy N-07.070: Blood and Blood Components using Scanned/Barcode Technology, Administration of

Surgical Services policy SS-10.005: Blood Specimen Collection and Administration in the Operating Room

Nursing policy N-07.072: DOWNTIME PROCESS: Blood Product Tracking

Acceptable for use with transfusion	Comment
0.9% saline	Only solution approved for direct mixing with blood
5% dextrose in 0.9% saline	Approved for rinsing I.V. tubing
5% dextrose in 0.45% saline	Approved for rinsing I.V. tubing

Unacceptable with transfusion	Reason
5% dextrose in water	RBC Clumping and hemolysis
5% dextrose in 0.2% saline	RBC Clumping and hemolysis
Lactated Ringer's solution	Clotting
Any other solutions	Agglutination and hemolysis

Immediately before starting the blood transfusion, gently mix the blood unit by gentle inversion. Administration instructions are printed on the label of each unit. Note: Do not mix containers of blood components together prior to transfusion.

Use of blood filters:

Refer to the Nursing policy N-07.070: Blood and Blood Components using Scanned/Barcode Technology, Administration of


TRANSFUSING INCOMPATIBLE RED BLOOD CELLS

On rare occasions it may not be possible for the Blood Bank to provide Red Blood Cells that are serologically compatible with the recipient. The patient’s physician will always be informed of the decision by the Blood Center. Accompanying each unit of RBCs will be a copy of the Information for Patient Care Staff Transfusing Incompatible Red Blood Cells form for reference.

Start the transfusion slowly