Department of Haematology, Blood Transfusion & Andrology

Introduction

The User's handbook for Haematology and Blood Transfusion provides guidance concerning the use and interpretation of diagnostic laboratory tests and gives advice on the correct collection of samples and their submission to the laboratory.

Please remember that accurate patient identification is vital; this is of exceptional importance in Blood Transfusion.

The Haematology and Blood Transfusion laboratories are staffed by Biomedical Scientists (BMS) who will be pleased to assist with any problems you may encounter. The Consultant Haematologists are available for consultation. The Haemovigilance practitioner will advise on blood transfusion practice.

We would welcome any comments that you may have concerning this Handbook - any changes can be incorporated into future editions.

Dr K Boyd MD MRCP FRCPath
Lead Consultant in Haematology
and Blood Transfusion

Mr T McFarland
Principal BMS in Haematology
and Blood Transfusion

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Location

The laboratory situated at Craigavon Area Hospital provides a comprehensive Haematology and Blood Transfusion Service. There are limited haematology and blood bank facilities at Daisy Hill Hospital.

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Craigavon Area Hospital 02838 334444

Craigavon Area Hospital direct lines: prefix extensions with 61.
e.g. Blood Transfusion 028 38 612666

Phone Numbers

Daisy Hill Hospital Tel: 028302 - 65511

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NORMAL LABORATORY HOURS

Monday to Friday - 9 am - 5 pm

Saturday & Sunday - 9 am - 1pm

Some non-urgent but essential investigations may need to be carried out after 5pm and before midnight as well as over weekends and Public Holidays. These are performed by the Biomedical Scientist (BMS) on call for emergencies. It would be appreciated if requests are confined to essential investigations only and special arrangements are made to ensure that samples are delivered to the Haematology Laboratory, CAH as early as possible.


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Emergency Service

Outside normal hours and on Public Holidays (ie 'out of hours') an emergency service is available.

Requests for an urgent report should be restricted. If you require an urgent report you should inform the appropriate laboratory by telephone and mark the request as urgent. The request will be fast tracked and the result made available on the ward laboratory results programme within one hour. Results are only telephoned to sites with no computer access.

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Out of hours telephone numbers

Monday to Friday 1700 hr to 0900hr and Saturday, Sunday and public holidays.

The duty BMS must be telephoned to arrange emergency work before the specimen is sent to the laboratory. The BMS on duty may be contacted as follows:

If any difficulties are experienced, contact switchboard at Craigavon Area Hospital.

Daisy Hill Hospital:

Internal System or contact through the hospital switchboard (according to the on-call rota)

The Consultant Haematologists may be contacted through Craigavon Area Hospital Switchboard.

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Emergency tests

Additional tests from 9am to 1pm on Saturday, Sunday and Public Holidays

REQUEST FORMS

Haematology abd Blood Bank request forms are obtained from Customer Services, CAH - Andrology request forms are obtained from the Haematology lab.
i White form with green and red shading for all Biochemistry and Haematology requests.
ii Pink form with black print for all Blood Transfusion requests.
iii White form with red print for Andrology Requests.

Please complete request forms correctly. Without full patient details computers cannot store accurate records and without full clinical details the laboratory cannot make useful comments and may perform inappropriate tests.

Please use the addressograph labels where they are available. The ward or clinic and the name of the Consultant /General Practitioner MUST be clearly written on the form.

In blood transfusion it is absolutely essential that request forms are fully and correctly completed and the information is checked either verbally with the patient or with the armband details at the time of blood sampling in order to reduce the risk of Life threatening errors. The person who has taken the sample must read and sign the declaration on the back of the form. Follow the SHSCT Blood Transfusion Policy.

Essential information on REQUEST FORM:

Desirable information on request form :

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SPECIMENS

All persons who use the laboratory service are reminded that they must comply with the legal requirements under the Health and Safety at Work Order (NI1978) and COSHH regulations (1988, revised 1995).

Request forms have a sealable plastic bag attached. All specimens must be labelled and placed in this bag and sealed according to the instructions on the Request Form.

High Risk Specimens: All specimens from suspected or known cases from blood-borne viral infection ie, Hepatitis B, HIV infection etc must be treated as "high risk" specimens and labelled with a special biohazard label "Danger of Infection - Take special care". These must be placed in a biohazard bag before sending to the laboratory.

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SPECIMEN CONTAINERS

All containers are obtained from customer services.

Please note that blood sample volume is critical in the production of accurate haematology results because the volume of anticoagulant and hence dilution of the blood is included in the automated calculation of the results.

Semen samples

For these please supply patient with a dry Universal container that has been tested and approved by the laboratory.

Paediatric samples

Containers with EDTA for FBP and ESR and containers with sodium citrate for coagulation are available; the volume of blood sample required is indicated on the container label. For special tests eg. osmotic fragility or enzyme assays please ask the haematology lab staff for the minimum blood volume required.

Bone marrow aspirate and trephine biopsies.

The sample needles, microscope slides, pathology and haematology request forms and special sample bottles are available as a 'bone marrow pack' in the haematology lab. Instructions regarding the equipement required will be provided by the haematology doctor carrying out the procedure.

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GUIDELINES FOR PROPER SPECIMEN COLLECTION AND TRANSPORT

The majority of haematological specimens are collected into vacutainers with an appropriate anticoagulant. Instruction for the safe use of the vacutainer system should form part of local operating procedures but should any difficulty arise advice is available from the Haematology laboratory.

Essential information on TRANSFUSION SAMPLE

The transfusion sample must be labelled beside the patient at the time of sampling by the person taking the sample. The details must be handwritten on the sample bottle, dated and initialled by the person taking the sample. Blood transfusion samples with addressograph labels will not be accepted for analysis.

The information must be checked either verbally with the patient, if fit, or with the details on the armband, and with the details on the transfusion request form.

Read and sign the declaration on the reverse of the request form if all is correct.
The above information applies to emergency and routine samples.

Routine samples for pre-transfusion testing must not be sent out of normal working hours.

Essential information on sample bottle for haematology and coagulation tests

Desirable information on sample bottle for haematology and coagulation tests

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Transport of sample to the laboratory

It is the requesting doctor's responsibility to arrange transport of the sample to the laboratory as soon as possible.

It is essential that samples arrive at the laboratory in a condition suitable for analysis.

Samples for the following tests must reach the laboratory within the time limits detailed below:

Further details on sample transport requirements for tests arranged in advance with the laboratory will be supplied by the BMS.


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REASONS FOR REJECTING SPECIMENS

IF ANY OF THE ABOVE OCCUR REPEAT SPECIMENS WILL BE NECESSARY IRRESPECTIVE OF THE DEGREE OF URGENCY OF THE REQUEST.

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LABORATORY TURNAROUND TIME

The majority of Haematology requests will be analysed and the results sent to the requesting medical practitioner the same day or within 24 hours.

Results requiring prompt attention in the interest of patient care will be telephoned to the requesting Medical Practitioner/House Officer.

Electronic mailing facilities are available and in use. Any general practice wishing to avail of such facilities should contact the Pathology Services Manager.

Tests referred to Reference Laboratories have a turnaround time from a few days to a few weeks depending on the type of investigation. If the results are required urgently please ring the laboratory.

Details for individual tests are listed in Tests, Samples & Turnaround Times.


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Information on tests and the interpretation of results for patients

Patients are advised to ask the Doctor requesting the blood test for an interpretation of the result and information about the test. General information about the blood testing procedure and individual laboratory tests can be accessed online from www.patient.co.uk and www.labtestonline.org.uk. The laboratory staff are not authorised to give results either written or verbally directly to patients.

Information about congenital thrombophilia and antiphosphoslipid syndrome is available from www.thrombosis-chariety.org.uk.

Warfarin packs are obtained from the hospital pharmacy these are given to all new patients who are commenced on warfarin either in the hospital wards of clinics. A DVD on warfarin is available for patients to view in hospital.

Information leaflets about blood transfusion are available in hospital clinics, day units and on the wards. These are to be offered to patients on the first occasion of blood transfusion and thereafter as needed. They are available on the SHSCT intranet site for Haemovigilence and on the CAH intranet site under blood transfusion.

Patients undergoing bone marrow biopsy are given an explanation of the reasons for performing the tests and verbal and written information about the test procedure by the Doctor performing the test. Written informed consent for the procedure is requested. Written information includes a locally produced leaflet which is available from the Mandeville Unit; in addition patients are offered printed information from www.cancerbacup.org.uk.

Information on semen ananlysis and fertility tests; patients are advised to seek an explanation for the tests and an interpretation of the results from the Doctor requesting the test. Instructions on how to obtain the semen sample are printed on the reverse side of the hospital request form. General information on Semen Analysis and fertility tests may be obtained from www.labtestsonline.org.uk.

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Information on tests and interpretation of results for users of the service.

For advice on the test required to investigate a clinical problem and for assistance with the interpretation of general haematology and coagulation and blood bank problems, please contact a Consultant Haematologist or their Deputy. Telephone and Bleep numbers of the Consultants and their secretaries are listed at the front of this Handbook. Out of hours the contact details of the Consultant Haematologist On Call are available from the hospital switchboard.

In the event of a blood transfusion reaction or a breach of the transfusion protocols please inform the Haemovigilence Officer Patricia Watt, her contact details are listed at the front of the Handbook.

For clinical advice and interpretation of Andrology results please contact a Consultant Obstetrician, Mr Noel Heasley can be contacted through his secretary, telephone no: 02838612096 or bleep number 1427.


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TEST INFORMATION

ANDROLOGY

Arrangements for semen analysis must be made in advance with the laboratory.

Investigation of fertility

Seen samples should be collected after 2-3 days of sexual abstinence, the sample must be collected by masturbation and ejaculated into a prewarmed, sterile, universal container. Condoms must not be used for semen collection because they interfer with sperm viability. Once collected the seminal fluid must be kept at body temperature and delivered to the Laboratory within 1 hour. If the patientlives more than 30 minutes travelling time from the Laboratory the sample must be collected on site, there is a room provided for sample production.

Results are sent to the requesting medical officer who will inform the patient.

Post Vasectomy

Samples of semen are required 4 and 4 ½ months post vasectomy to confirm the absence of sperm. If both samples are not clear then further samples should be sent at monthly intervals until two in sequence have an absence of sperm.

Sperm samples should be collected by masturbation in a clean sterile container (condoms may not be used) and may be left at the laboratory between 9am - 4pm, Monday to Friday.

Results of Post Vascectomy tests are sent to the Surgeon who carried out the operation. The Surgeon will write a report to the patient. The laboratory cannot give these or any other results direct to the patient.

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General Haematology

Full Blood Count

Haemoglobin concentration, red cell indices, white cell count and automated differential white cell count (DWCC) and platelet count.

Normal ranges are wide and are age and sex dependent (see Haematology reference ranges). Individuals have much tighter normal ranges so that comparison with previous results can be helpful.

Sample Required: 3 ml blood in purple topped container (EDTA)

Blood Film

Manual examination of red cell morphology, platelets and DWCC

Blood films are made only when indicated by either clinical information or by the full blood count findings. If you specifically require a film please request FILM in the large space provided on the haematology / biochemistry form and state the clinical indication eg possible glandular fever.

If malaria is suspected please request malaria examination and specify clinical reason. The clinical data is essential to ensure approproate investigation i.e. a thick blood film is needed.

Sample required: FBP sample, less than 24 hours old.

ESR Sample required: 3ml blood in purple topped container (EDTA) . A separate sample is required from that provided for the FBC.

Reticulocyte count Sample required: 3 ml blood in purple topped container (EDTA) This can be obtained from the sample used for FBC.

Infectious Mononucleosis Slide Test Sample Required: 3 ml blood in purple topped container (EDTA)

A negative result does not exclude a diagnosis of infectious mononucleosis. This can be obtained from the same sample used for FBC.

Kleihauer test. Used to detect presence of red cells containing Hb F. It is used in assessment of feto-maternal haemorrhage in Rhesus negative mothers.

For further details on use of Kleihauer and administration of human anti-D see section on 'Blood bank products'.

Sample required: 3 ml in purple topped tube (EDTA).

Leucocyte Alkaline Phosphatase Score (LAP score)

This test is performed on fresh blood films (without the addition of EDTA) which need to be fixed within 30 minutes of initial preparation. Please discuss with the laboratory when this test can be performed and arrange prompt delivery of fresh blood films to the laboratory.

Samples Required: fresh blood films (see above) . A rack of microscope slides can be requested from the lab for preparation of fresh smears at the bedside.

Plasma viscosity Sample required: 3ml in purple topped container (EDTA). A separate sample is required from that provided for the FBC because test is despatched to BCH for analysis.

Haematinics Serum ferritin, iron profile, serum folate and vitamin B12 levels are assayed in the biochemistry lab.

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Tests for haemolysis

The investigation of haemolysis is complex and the Consultant Haematologists will advise on appropriate tests for individual cases. Tests are required to confirm the presence of haemolysis and identify the cause.

Tests to demonstrate the presence of haemolysis

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Coagulation Tests

Please note: the correct volume of blood is essential for accurate coagulation results.

Coagulation screen

This consists of Prothrombin Time (PT), Activated Partial thromboplastin time (APTT), Thrombin Time (TCT) and Fibrinogen concentration .

A platelet count is required to complete the screen and so a FBP should be requested at the same time.

Abnormal tests may be investigated further. The laboratory will phone if another specimen is required.

Samples Required: 4.0 ml in blue topped tube (citrate) + 3 ml in purple topped tube (EDTA)

D-Dimers

In Venous thromboembolism (VTE), D-Dimers have a negative predictive value: i.e. a normal result in a patient with a low clinical probability score helps to rule out the diagnosis VTE.

D-Dimers are useful in confirming disseminated intravascular coagulation

Sample Required: 4.0 ml in blue topped tube (citrate).This can be performed on the sample supplied for coagulation screen

Reptilase time

This test time is not prolonged by heparin and it is used to discriminate a prolonged TCT due to unfractionated heparin from other causes.

Sample required: 4 .0 ml in blue topped tube (citrate). This can be performed on the sample supplied for coagulation screen.

Clotting Factor assays
Required to diagnose acquired or hereditary factor deficiencies such as Haemophilia A (Factor VIII deficiency) and haemophilia B (Factor IX deficiency).

Sample required: 4.0 ml in blue topped tube (citrate). Accurate filling of sample tube is essential.

These sample are transported to the Coagulation Lab, BCH for testing. Please discuss with CAH Haematology Lab in advance of testing to arrange correct time for accurate analysis.

Von Willebrand disease tests
Testing for VW Antigen, VW activity and factor VIII activity.

Sample required: 2 x 4.0 ml in blue top tube (citrate). Accurate filling of sample tubes is essential. Sample sent to BCH Coagulation Laboratory.

Platelet Aggregation
This is carried out in the Coagulation section of the Haematology Lab, BCH. It is essential that fresh samples reach the lab within 1 hour of venepuncture. Patients must attend the Haemophilia Centre, BCH for venepuncture. Please telephone the Sister in charge at the Haemophilia Centre to make an appointment for the patient to attend for testing.

Simplate Bleeding Time
This bedside test is used in the investigation of possible bleeding disorders. It is not useful in predicting surgical bleeding risk.

Please arrange with a Consultant Haematologist or Staff Grade in Haematology.

Inhibitor Screen
By mixing test plasma with normal plasma the lab can descriminate between the presence of an acquired inhibitor and clotting factor deficiency. Useful in identifying cause of isolated prolonged APPT.

Sample required: 4.0 ml in blue top tube (citrate). Can be performed on sample used for coagulation screen.

Lupus Anticoagulant

This antiphospholipid antibody is clinically associated with venous and arterial thrombosis and recurrent miscarriage. The term anticoagulant is used because of prolongation of in - vitro coagulation when the antiphospholipid antibody is present.

Diagnostic Criteria:

Sample Required: 2 x 4.0 ml in blue topped tubes (citrate) - Please arrange urgent transport to Haematology Laboratory, CAH. Please note oral anticoagulation invalidates the test for lupus anticoagulant.

DRVVT Result is reported as ratio of test time/control time. Normal Ratio <1.2

In addition a clotted sample should be sent to Immunology for Anti-cardiolipin antibodies.

Screening for inherited Thrombophilia

An increased risk of venous thromboembolism is recognised in patients with deficiencies of anti thrombin III, protein C or protein S, and resistance to activated Protein C.

Who to test Screening for inherited thrombophilia is not routinely advised but may be considered in cases where there is a strong family history, recurrent spontaneous DVT, spontaneous VTE at a young age and where unusual veins such as the axillary vein or mesenteric vein are involved. Testing women of child bearing age may be indicated to assess risk of VTE in a future pregnancy.Please discuss with a Consultant Haematologist.

When to test: samples should be collected at least 3 months after the last thrombotic event and at least 2 weeks after completion of anticoagulant therapy.

Patients should not be tested:

1. during an episode of DVT / PE

2. while on oral anticoagulant therapy

3. during heparin therapy

4. during Pregnancy or up to 3 months postpartum

5. while taking oestrogen preparations

6. under treatment with L-asparaginase

7. if they have nephrotic syndrome, liver disease, DIC or any inflammatory state.

The standard reference ranges do not apply in these situations.

Sample required: 4 x 4.0 ml in blue top tubes (citrate).

Genetic tests for Factor V Leiden (associated with APC Resistance ) and Prothrombin G20210A mutations can be arranged after discussion with a Consultant Haematologist. The tests are performed at the Haematology Lab, BCH.

To complete the thrombophilia screen for arterial or venous disease, check for fasting hyperhomocysteine. Sample required: 3 ml blood in EDTA (purple topped) tube to be sent on ice to Biochemistry for separation of plasma within 1 hour of collection.

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MONITORING HEPARIN THERAPY

All patients receiving unfractionated or LMWH should have a FBC, coagulation screen,
U & E and LFT carried out before starting therapy.

Reduce dose of LMWH in severe renal impairment i.e. creatinine clearance < 30 ml / min.

For details on therapy see Medical management guidelines on "anticoagulation in venous thromboembolism".

During treatment monitor FBC and U & E; the risk of heparin induced thrombocytopenia / thrombosis is greatest from day 5 to 10 of therapy. Hyperkalaemia has been reported with heparin therapy.

'HITT assay for Heparin associated platelet factor 4 antibodies.

Please refer to the medical unit guideline for calculation of the workention HITT score.

The Consultant Haematologist / Registrar at theHaemophilia Centre, BCH must be contacted to arrange testing. For full detail see above guideline.

Low molecular weight heparin (LMWH).

The LMWH's have a predictable therapeutic effect and monitoring of prophylactic and treatment doses is not required routinely.

In the following circumstances monitoring may be advised:
•  obese or very thin patients in whom dosing is uncertain

•  renal impairment to exclude high levels due to accumulation

•  pregnancy, a non-licensed circumstance.

The test used is anti-Xa activity

Sample required: 4.0 ml blood in blue topped tube (citrate)

Peak levels at 2-4 hr after SC injection of therapeutic dose should fall within range 0.4 - 1.0 u/ml.

Standard unfractionated heparin

Monitor APTT 6 hours after the loading dose of IV heparin or a change of infunional dose. The therapeutic range for effective anticoagulation with unfractionated heparin is APTT 1.5 - 2.5 times normal i.e. 50 - 77 secs in Craigavon Hospital.

MONITORING WARFARIN THERAPY

Consult medical management guidelines on "anticoagulation in venous thromboembolism" for the Target INR and duration of therapy in arterial and venous conditions and guidelines on reversal of warfarin therapy.

Check coagulation screen, FBP and LFT before starting therapy.

Consider tests for antiphosphlipid antibody in high risk individuals before starting warfarin.

Therapeutic warfarin doses for individual patients differ widely. Many drugs interact with warfarin. Close control is therefore essential. The prothrombin time should be checked prior to commencement of warfarin as patients with prolonged times will be very sensitive to warfarin.

Warfarin dosage is adjusted according to the INR (International Normalised Ratio) which is calculated from the test and control Prothrombin times .

Sample Required: 4.0 ml blood in blue topped tube (citrate)

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BLOOD TRANSFUSION

For full details refer to the Hospital Blood Transfusion Policy (on SHSCT Intranet). The transfusion of incompatible blood may prove fatal; errors in identification of either patient or sample are chiefly responsible and are preventable. Such errors include taking a crossmatch specimen from the wrong patient and inadvertently checking the details of crossmatched blood against those of a different patient. Please remember that it is the responsibility of the individual taking the blood sample to ensure correct identification between specimen and patient and sign the request form on the back appropriately.

First name, Surname, DOB, and Hospital Unit Number essential for cross-matched samples, or address for group and screen.
(All non-conforming samples will be rejected without exception).

Sex is essential on Infant sample.

For further information see sections on 'Request forms' and 'specimen collection'.

Reporting of Blood Transfusion Results

These will be delivered to the requesting department as early as possible. Blood Groups are not given over the telephone unless to the requesting Medical Staff concerned.

When any potentially significant red cell antibodies are detected in transfusion samples received from in-patients, the requesting doctor or, if not available, the nurse in charge of the ward will be informed of the result, as soon as possible by telephone,

Elective Surgery

A blood tariff for elective surgery has been agreed for most surgical specialties. If you are requesting more than the agreed tariff please indicate why and discuss with the laboratory if necessary. In the light of changing surgical procedures this tariff is under review.

Group and Screen or Group Screen and Crossmatch

In order to safeguard patients, the laboratory routinely requires a minimum of 2 blood grouping results to be available on the computer database before any group specific blood component can be issued. The laboratory will inform clinicians when a second sample is needed.

Sample Required: 6 mls of blood in a pink topped tube with white insert (EDTA). This should reach the laboratory by 1030 hours at the latest for an afternoon transfusion or by 1430 for transfusion the following day.

Requests in excess of 4 units of blood require 2 x 6 ml in pink topped tubes with white insert (EDTA).

Ante-natal samples

These samples are processed by the NI Blood Transfusion Service, Belfast City Hospital . For details of samples required and results, please contact directly the ante-natal department, NIBTS.

Blood for Babies less than 6 weeks old

Samples required: Group and Screen sample from mother and EDTA microtube sample from infant.

Where the mother has not been grouped and screened in the past these investigations must be carried out prior to transfusion of the infant, or issue of Anti-D to the mother whose baby is Rhesus positive.

When the mother is found to be ABO compatible with her infant and has Rhesus or Atypical antibodies as a result of her pregnancy a full crossmatch must be carried out with donor blood and maternal serum.

Exchange Transfusion

Plasma reduced whole blood from CMV negative donors is usually specially prepared. Anticipation of the need for exchange transfusion helps minimise the delay caused when suitable blood is not immediately available.

Emergency Blood Transfusion (use of uncrossmatched blood).

In an emergency a short crossmatch procedure means that compatible blood can be issued to the patient within 30 minutes of receipt of the crossmatching sample.

In the event of an emergency uncrossmatched blood of the same ABO/Rh group as the patient may be issued.

In the event of an extreme emergency uncrossmatched ORh negative blood may be transfused but this must only be at the discretion of the medical officer. Full details of any patient receiving this blood must be sent, together with the donor unit number, to the Blood Bank immediately.

Emergency Blood and its Location .

In cases of extreme emergency a limited amount of uncrossmatched blood is available at the following locations:

Craigavon Area Hospital Blood Bank (Theatre/Maternity use)

2 Units O Rh Negative blood in issue Bank. Specifically labelled:
EMERGENCY BLOOD FOR THEATRE/MATERNITY USE ONLY.

If any of these units are used in an extreme emergency the Blood Bank at Craigavon Area Hospital must be informed immediately by telephone of the DONOR UNIT NUMBER of the Blood Pack(s) and the FULL IDENTIFICATION OF PATIENT receiving the blood.

The supply of emergency units of blood will be replaced.

NB: FAILURE TO CARRY OUT THIS PROCEDURE COULD RESULT IN BLOOD NOT BEING AVAILABLE IN EMERGENCY SITUATIONS

If blood is required in an emergency telephone 02838 612666 or after hours and at weekends and Bank Holidays contact BMS on call, telephone number : 07801 458703

Transfusion Reaction

A transfusion reaction should be suspected in patients developing urticaria, fever, loin pain or bronchospasm whilst being transfused with blood.

The transfusion should be stopped. Patient identity and the blood label should be checked.

The following should be sent to the blood bank :

•  The remainder of the donor blood unit

•  2 x 6.0 ml in pink topped tubes with white insert (EDTA).

In Addition

- The first urine passed should be checked for haemoglobinuria.

- Consider checking FBP, U&E , LFT, Coagulation, Blood culture, Blood gas.

If the clinical situation necessitates continuing transfusion the advice of the Haematologist on call should be sought.

If ABO incompatible blood has been given steps must be taken to maintain blood pressure and urine output. The problem should be notified to the Consultant Haematologist and the Intensive care Anaethetist on call.

Most febrile reactions are due to white cell antibodies. The incidence of this has reduced with the introduction of leucocyte filtration of all units of donor blood. Patients with a history of more than one febrile reaction may be helped by pre-medication with paracetamol, chlorpheniramine and hydrocortisone. If there are continuing problems please discuss with a Consultant Haematologist.

All adverse events during transfusions must be reported immediately by telephone to blood bank. An adverse event form must be completed and forwarded to blood bank. The incident will be fully investigated by blood bank staff and the haemovigilance practitioner.

Massive Transfusion

Blood -all units of blood issued are leucocyte poor red cell concentrates with optimal additive solution. We are unable to supply whole blood and fresh blood.

Irradiated Blood Products

Platelets - These are not stocked in the Hospital Blood Bank but can be obtained from the Regional Blood Transfusion Service in about 1½ hours. They may be stored for 48 hours in the Hospital Blood Bank at Craigavon Area Hospital not on the ward. Please discuss with the Consultant Haematologist as accurate diagnosis of thrombocytopaenia may be required. If a platelet transfusion reaction is suspected send samples as for suspected red cell transfusion reaction.

Platelets are usually given over 30 minutes and as soon as possible after arrival. Platelets are issued as a therapeutic dose prepared from 4/5 donations. Platelets should never be kept for a prolonged period on a ward or in theatre.

Fresh Frozen Plasma

This provides useful replenishment of coagulation factors in massive transfusion and DIC. Thawing takes approximately 30 minutes. Thawed plasma can be stored for up to 24 hours but should be transfused a.s.a.p. For best clinical results, plasma should be transfused within two hours of thawing.

FRESH FROZEN PLASMA WILL ONLY BE ISSUED IN BATCHES OF 2 UNITS PER REQUEST, TO AVOID WASTAGE OF SCARCE STOCKS.

Human Anti-D

Anti-D is given to all rhesus negative women who do not already have anti-D antibodies after termination, miscarriage or antipartum haemorrhage and after delivery to rhesus negative mothers with rhesus positive babies.

Once rhesus negative mothers have delivered, a maternal specimen should be sent along with the cord blood specimen from their baby for rhesus testing. If the baby is rhesus positive and the mother rhesus negative anti-D is given to the mother. A Kleihauer test is carried out to detect significant feto maternal haemorrhage following which further anti-D may be advised.

Sample required for Kleihauer Test: 3 ml blood in purple topped tube (EDTA).

It is recommended that following events during pregnancy prior to 20 weeks gestation 250 iu of anti-D immunoglobulin is given. This is increased to 500 units for events later than 20 weeks gestation. A Kleihauer Test should also be undertaken following events later than 20 weeks gestation as a larger dose of anti-D immunoglobulin may be required.

The results of the estimation of feto maternal bleeding are given as volume of foetal bleed.

Anti-D immunoglobulin should be given to all rhesus D negative women who give birth to an infant who is shown to be rhesus D positive or if the group of the infant cannot be determined. A dose of 500 iu of anti-D immunoglobulin should be given within 72 hours of delivery.

In a small proportion of cases the Kleihauer Test will identify a requirement for a larger dose. Additional anti-D immunoglobulin is administered at a rate of 500 IU per 4ml of foetal bleed.

Follow-up of a feto maternal haemorrhage of greater than 4 mls is essential with repeat Kleihauer testing at 48 hour intervals. Adminstration of appropriate doses of additional anti-D immunoglobulin if foetal red cells persist will be required

Cryoprecipitate

Now that factor VIII concentrates are preferred in the treatment of haemophilia and Von Willebrands disease, cryoprecipitate is mainly used as a source of fibrinogen in cases of defibrination identified on coagulation screening. Thawing and pooling takes 30 minutes. Transfuse immediately over 30-60 minutes.

Novo 7

Used in cases of life threatening haemorrhage unresponsive to all other methods of controlling haemorrhage and after discussion with a Consultant Anaethetist and Haematologist, eg catastrophic post partum haemorrhage.

Dose 90 microgram / kg body weight as single treatment.

Limited stock in blood bank.

OCTAPLEX

This is the prothrombin complex concentrate held in blood bank for the rapid reversal of warfarin in the event of major haemorrhage.

It is essential to stop warfarin and give vitamin K 5 mg by slow intravenous injection.

Monitor INR and APTT immediately and at 4 hours.

Consult Medical management guidelines for full details and discuss with Consulant haematologist.

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Medical Management Guidelines

Screening for genetic haemachromatosis

Introduction

* BCSH guidelines February 2000 on Genetic Haemochromatosis

Samples needed for the tests

TESTS, SAMPLES AND TURNAROUND TIMES

In the following table EDTA refers to the purple topped tube, sodium citrate to the blue topped tube, clotted blood to the red topped tube, green topped tube to the lithium heparin. When the transfusion tube, with the pink top and white insert, is required, this is specified. Please arrange tests as required in advance with the lab. If urgent results are required please inform lab staff and they will try to accommodate your request.

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