INTERPROFESSIONAL PROTOCOL - MUHC

Transcription

1 INTERPROFESSIONAL PROTOCOL - MUHC Medication included No Medication included THIS IS NOT A MEDICAL ORDER Title: This interprofessional protocol is attached to: Definition Administration of Labile Blood Products Pediatric Patients Only Positive Patient Identification and Specimen Identification in Transfusion Medicine Procedure for Transfusion Reaction Labile blood products are perishable blood components that are stored under controlled temperatures to maintain their integrity. The labile products include the following: RBC (red blood cells), plasma, platelets, granulocytes, cryoprecipitate and cryo-poor plasma (cryosupernatant). 1. PURPOSE The purpose of this protocol is to provide standard procedures for professionals involved in the clinical aspects of labile blood product transfusions. All transfusions of labile blood products must be carried out according to this protocol. This protocol is not intended for exchange transfusion, intrauterine transfusion nor massive transfusion. 2. PROFESSIONALS AND PATIENT POPULATION Professionals: This protocol is intended for all professionals who may transfuse labile blood products. These professionals include: Registered Nurses, Physicians, Perfusionists, Anesthesia and Respiratory Therapists (Anesthesia). These professionals must review this document. Nursing Assistants (NAs) may only verify the product with a Registered Nurse (RN). Candidates to the Profession of Nursing (CPN) may verify transfusion with a RN or physician and may initiate transfusion, in the presence of a RN. Patient Population: All pediatric patients who require a transfusion of labile blood products (see definition above). Patient population definition: Population 1: patients from birth up to four (4) months of age Population 2: patients aged four (4) months and older 1

2 3. ELEMENTS OF CLINICAL ACTIVITY Professionals are responsible to know the limits and extent of their practice as related to the particular protocol. Do not administer products using B Braun Infusomat Space Pump IV tubing with Burette, because it contains a 15 micron in-line filter. Equipment needed: Blood product with accompanying blood product distribution voucher Blood administration set with micron filter IV administration set(s) Normal saline 0.9% Alcohol swabs IV access with largest possible catheter, as per patient s venous access (see point #5) Non sterile gloves, face shield, protective wear, as per MUHC Infection control policy Syringe driver/volumetric pump Additional equipment as medically requested (i.e. blood warmer, rapid infusion device) 2

3 Procedure: a) Assessment: 1. Ascertain that there is a valid medical order and consent. The following information must be included: 1.1. patient s full name, 1.2. Medical Record Number (MRN), 1.3. type & quantity of blood product, 1.4. medication related to transfusion (pre, per, post) if needed, 1.5. rate/time of blood administration, 1.6. order of product administration if more than one kind of blood products were requested, and 1.7. directive(s) if needed (ex. Cytomegalo virus (CMV) negative, irradiated, etc ). 2. Communicate with Transfusion Services (Blood Bank) or verify in TraceLine to determine if a new blood sample for Type & Screen testing is needed For Red Blood Cell (RBC) transfusions, the Blood Bank sample is valid as following: Patient: Patients less than 4 months old regardless of transfusion history (population 1) MCH / Shriner s patients older than 4 months who have not, in the last 3 months, been transfused, nor pregnant All other patients: older than 4 months and who have a history of transfusions and/or pregnancy Blood Bank Sample: Sample valid until patient is 4 months old Sample valid for 28 days Sample valid 96 hours 2.2 For other labile products, the sample is valid throughout the patient s admission Note: Be certain a new sample is needed. Lab testing is a significant cause of anemia. 3. Refer to the following protocol if a Blood Bank sample is needed: Positive Patient Identification and Specimen Identification in Transfusion Medicine. 4. Verify patient s baseline vital signs (Blood Pressure, Heart Rate, Respiration Rate, Oxygen Saturation and Temperature) If the decision is made to transfuse a blood product, communicate with Blood Bank. A pick-up slip/form is necessary to get blood products from Blood Bank For Red Blood Cells, the unit can be aliquoted (divided, i.e. Pedipak) upon request. Specify quantity in ml as needed. The mother bag used will be reserved for that patient, thereby decreasing the patient s exposure to multiple donors For Platelets and Plasma, pedipaks can also be requested. Specify quantity in ml if less than one unit is needed If pre-medications related to a transfusion are prescribed, administer as per physician s order. 3

4 5. The largest possible venous access should be used to allow appropriate flow rate and prevent cell damage to the infusing product (i.e. the smaller the needle access, the slower the infusion rate). Red Blood Cells (RBCs) can be safely administered through a 22, 24 or 26 gauge catheter; however, if using a smaller gauge, care should be taken to prevent lysis of cells, i.e. use maximum allowable time to transfuse Labile blood products can only be infused through an IV lumen with normal saline. Ensure primary IV is NS. Blood should be connected to proximal port Labile blood products cannot be infused through an IV lumen with TPN, colloids or crystalloid solutions containing calcium (i.e. Ringer s Lactate) or solutions containing glucose (i.e. D5W). Solutions containing calcium neutralize anticoagulants in blood products which may lead to blood clotting. Solutions containing glucose may lead to hemolysis Labile blood products cannot be infused via a Hemodialysis or Plasmapheresis catheter unless the treating medical specialty team is aware and an order is written When drawing up blood with a syringe to administer using a syringe pump, the blood must be drawn through the blood filter. 6. Prepare all equipment needed for transfusion. Be ready so that the transfusion may be started as soon as possible upon product s arrival on unit Wash hands and don gloves as per MUHC protocol 6.2. Prime blood administration set 4

5 b) Intervention: No medications or solutions should be added to the blood product or infused through the same tubing during the transfusion. Medication can be administered between two blood products. The IV line must be flushed with NS 0.9% before and after the added medication administration. 1. When blood product is received: 1.1. Visually inspect the product and its container. If questionable, send it back to Transfusion Services with its voucher Examples (photos) of adequate and inadequate blood products are found on the MUHC Intranet, Departments & Services, Transfusion Safety, Policies & Procedures, Log of images of Blood Components for Inspection Refer to the following table for product inspection guidelines: RBC: The colour inside the bag should be uniform. o Abnormal colours: purple, brown, black PLASMA, CRYOPRECIPITATE, CRYO-POOR PLASMA: The colour and aspect should be uniform. o Normal colours of plasma: clear, pale yellow, light green, orange tint o Normal aspect of cryoprecipitate: slightly turbid PLATELETS: The colour can be pale yellow, pink or peach, due to the presence of red blood cells. DO NOT ADMINISTER IF CLOTS OR FLOATING MATERIAL VISIBLE/PRESENT 2. Only one blood product should be transfused at any one given time, exception is during massive transfusion (refer to massive transfusion protocol). 3. The infusion of labile blood products MUST be completed within four (4) hours from removal of a controlled environment. NOTE: Product expiration date & time can happen to be before the 4 hours limit. Refer to the blood product distribution voucher for distribution time and expiration time of product If unable to begin transfusion within thirty (30) minutes, product must be returned to Transfusion Services without delay 3.2. DO NOT store any product in unit s refrigerator, unless it is one regulated by Blood Bank 3.3. All products connected to a patient are considered transfused even if no blood was transfused. In this case, the distribution voucher must be completed with reason given under motif de retour 4. At bedside ONLY, verify concordance between the blood product label information (including the label with patient s name & MRN), the distribution voucher and the patient s hospital identification bracelet. This verification MUST be performed by two (2) healthcare professionals. The professional initiating the transfusion must be one of the verifiers. NAs may verify but are not allowed to start the transfusion. ** Once product/patient verification is complete, product should not be removed from patient s presence. If so, verifications have to be reconfirmed as per procedure If alert, oriented and able to reply appropriately, the patient/responsible adult must be asked by the two healthcare professionals to state the patient s name and date of birth during verification of blood product. 5

6 4.2. The verification of the patient, blood product and the issue voucher consists of eight (8) checks: Patient s full name and hospital MRN Name/type of product Blood group and Rh (if applicable) of product vs patient Product s donation/lot number Expiration date/time of the product Special requirements related to the patient s directives (i.e. CMV negative, irradiated) Aspect of product and container Patient s hospital identification bracelet 4.3. On the blood product distribution voucher, the section Directives must be carefully verified. Ensure that all directives written on the voucher appear on the label of the blood product issued (ex. Directive: sang K neg, the following information K- must be seen on the product label or on label attached to the bag and on the Phenotype section of the voucher). If there is no information on the Directives section, disregard the attribute or phenotype information, if any If there is any discrepancy during verification, DO NOT TRANSFUSE until clarification with treating physician and/or Transfusion Services Refer to compatibility poster for ABO compatibility between donor & recipient s blood groups 5. The blood product must be gently agitated before use. 6. Ascertain all connections of administration set are secure in order to maintain an adequate flow rate. 7. If more than one hour since vital signs were taken, they must be taken again prior transfusion. 8. Start the blood product infusion at a low rate, i.e. ¼ prescribed rate to a maximum of 50 ml/h. Refer to the following table if rate was not prescribed. Product Volume Rate: Population 1 (birth to 4 months of age) RBC (Red Blood Cells) ml/kg 0-15 min: 2 ml/kg/h Platelets Plasma Cryoprecipitates 5 10 ml/kg ml/kg 5 ml/kg 15 min to end: 3.5 ml/kg/h MAXIMUM transfusion time; 4 hours from distribution time Rate: Population 2 (4 months and older) Start at 15 ml/h (or ¼ final rate, max 50 ml/hr) for 15 min, then increase to complete transfusion within 4 hours from distribution time 8.1. Health care professional must stay with the patient for the initial fifteen (15) minutes. A major transfusion reaction can occur immediately and rapid intervention must be initiated (see Procedure for Transfusion Reactions protocol). 9. The product must be infused within four (4) hours of distribution (see voucher for time of distribution) or removal from a controlled and monitored environment. Verify expiration date & time or product (voucher). 10. At the end of the transfusion, disconnect blood product, cap administration set and store the empty bag with the administration set tubing in an empty plastic bag (supplied by Blood Bank) for 24 hours in a designated area. Then, discard as per MUHC protocol. 11. If a different blood product is to be transfused, the administration set must be changed. 12. If a second product of the same type (i.e. red cells) is transfused, the administration set can be reused as it is good for four hours. 6

7 Using a new administration set for a second (same) blood product may not apply to the Operating Room. c. Monitoring: 1. Vital signs (BP, HR, RR, O 2 sat, T) must be monitored at the minimum: before the transfusion, fifteen (15) minutes into transfusion and at the completion of transfusion If VS (as above) are stable after 15 minutes, increase the rate of infusion as per medical order 1.2. The patient s condition should be monitored every thirty (30) minutes 1.3. If patient develops any signs or symptoms of a transfusion reaction, follow the protocol Procedure for Transfusion Reactions 1.4. Neonates, young infants, and children with cardiac or renal issues are at risk of volume overload 2. If a situation arises whereby the patient must be transported while a transfusion is in progress, a health care professional (RN, physician) MUST accompany the patient. This person must be present to intervene if any problem occurs If a health care professional CANNOT accompany the patient during transportation, the blood transfusion must be stopped. Tubing should be flushed. Record time the transfusion was stopped 2.2. Transfusion can be restarted providing a health care professional is present and the four (4) hour time limit is respected 3. At change of shift, the replacing nurse must be informed of the transfusion. 4. Inpatients should be monitored for 24 hours after the transfusion, as the potential for a transfusion reaction exists (VS, lab values, patient s status). 5. Outpatients should be monitored for at least 30 minutes from the end of transfusion. Upon discharge, signs and symptoms of possible delayed reactions should be explained to patients/responsible adult, with instructions to present to the Emergency Department as needed. 6. Blood Transfusion: Answers to your Questions handouts are available on every unit. If none is available, Transfusion Safety Services will provide upon request. 7

8 d) Documentation: 1. All documentation in the chart related to the transfusion must be written in RED. 2. Premedication (if any), vital signs (as above), explanation to patient/caregiver/responsible adult, rate of administration, patient s tolerance to the procedure, ingesta/excreta, transfusion reaction (if applicable), interventions and follow up must be written in the patient s hospital or electronic chart. 3. Confirm completion of transfusion within 24 hours, to Transfusion Services by one of the following methods: 3.1. Via TraceLine 3.2. If TraceLine cannot be used, by sending the completed bottom part of the blood product distribution voucher to Blood Bank 4. The completed upper part of the blood product distribution voucher must be kept in the patient s chart indefinitely or until chart is scanned. Medications: Under no circumstances can any medication be administered in the same access line as an infusing blood product. Also, no medications or air are to be introduced into any container housing a blood product. Main Authors: Monica Howard RN BSc(N), Brigitte Morin TM Consultants: Martine Chagnon RN MCH 9C N.B. Whittemore MD FRCPC MCH NPDQM committee 8

9 4. APPROVAL PROCESS Institutional and professional approval Committees Pharmacy and Therapeutics Pediatrics (if applicable) Adult Pharmacy and Therapeutics (if applicable) MUHC Adult Site Medication Administration Policy (MASMAP) (if applicable) MUHC Pediatric Medication Administration Policy (PMAP) (if applicable) Date [yyyy-mm-dd] Clinical Practice Review Committee (if applicable) Nursing Executive Committee and Council of Nurses (NEC and CN) (if applicable) Multidisciplinary Council (if applicable) MUHC Central Executive Committee of Council of Physicians Dentists and Pharmacists Committee (ECPDP) (Obligatory if attached to a collective order) Final approval Signature of Chairperson: 5. REVIEW DATE To be updated in maximum of 5 years (2019) or sooner if presence of new evidence or need for practice change. 6. REFERENCES London Health Sciences Centre, Blood Transfusion Resource Manual, 2014 AQESSS: Administration de produits sanguins labiles en néonatologie et pédiatrie, Insertion, care, maintenance of Nexiva peripheral intravenous (PIV) catheters in the Adult population 9