Blood Center Services

Adverse Reactions to Transfusion
Autologous Donor Blood Program
Bacteria Detection Tests
Blood Administration
Blood and Blood Components
Blood Center Requisition and Specimen Collection
Circular of Information - Blood
Circular of Information - Cellular Therapy
Emergency Issue of Blood
Guidelines for Therapeutic Phlebotomy
Guidelines for Transfusion

Hematopoietic Progenitor Cells
Hold Guidelines for Pretransfusion Compatibility Testing
Informed Consent
Location and Service Hours
Massive Transfusion Protocol
Maximum Surgical Blood Order Schedule
Patient Services
Pretransfusion Compatibility Testing
Surgical Tissue
Transfusing Incompatible Red Blood Cells
Transfusion Order Requirements

LOCATION AND SERVICE HOURS

Function	Location	Phone	Scheduled Hours
Blood Bank	C271 GH	6-2561	24 hours
Blood Donor Center: Blood Donation	C250 GH	6-2058	Call for current hours of operation
Blood Donor Center: Patient Services	C250 GH	6-3710	0800-1700 weekdays
Consultation	Pathology Resident	Pager 3404	24/7
Tissue and Cellular Therapies: Hematopoietic Progenitor Cell (HPC) Lab	C271 GH	4-5292	0800-1630 weekdays
Tissue and Cellular Therapies: Tissue Bank	C271 GH	6-3709	24 hours

BLOOD AND BLOOD COMPONENTS

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

Crossmatch

If a Type and Screen has been ordered, and blood is subsequently needed, it may be requested by placing an order in Epic or sending an A-1a Blood Center request. If the patient's current and previous antibody screens are negative, an electronic crossmatch is performed to detect ABO incompatibility only. The Red Blood Cell unit is then 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: Hold - 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 placed in Epic for each transfusion event. The only exception is during surgery when the order may be written on the anesthesiology record.

Each order must include the name of the product, special instructions (e.g., irradiated, washed, autologous), 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 <7 gm/dL, transfuse two units red blood cells over six hours"). However, each transfusion treatment requires a separate order.

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 AABB, and The Joint Commission, note the need for informed consent prior to blood transfusions in their accreditation manuals. Members of the Transfusion Subcommittee have approved four 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 923463).

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 922373).

3. Form G-2d₁₃ - "Consent for Therapeutic Apheresis" 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.

4. Form G-2d₂ - "Consent to Collect Lymphocytes and/or Peripheral Blood Progenitor (Stem) Cells by Automated or Manual Methods", include statements regarding potential for red blood cell prime of the circuit in small pediatric patients and is only used 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 transfusion consents are scanned into Epic and are available in the Chart Review Media tab.

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 and All Blood Bank Samples

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 collection date/time. Indicate the tests and/or or blood components needed, and the date/time needed. Special requirements (such as irradiated, washed or autologous) should be noted, as well as additional information for obstetric and pediatric patients.

EMERGENCY ISSUE OF BLOOD

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

Patients whose ABO group (for females) is unknown will receive group O red blood cells. Four units of group O Rh negative red blood cells and 4 units of group O Rh positive red blood cells (for males) are stored in the Emergency Treatment Center (ETC) and 4 units of group O Rh negative blood are also stored in the Critical Care Laboratory (CCL: 5802 JPP). These units are available for life threatening emergencies in which transfusion cannot be delayed. As soon as possible a properly labeled sample and an Epic order or A-1a Blood Center Request should be sent to the Blood Bank. If the A1-a requisition is used, the physician must also sign the section authorizing release of blood components before pretransfusion testing is completed. If units are removed from the ETC or CCL blood refrigerator, the physician must complete an order for ETC/CCL Floor Stock Blood in Epic.

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 Center 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 an Epic order or 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.

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	RBC Clumping 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 Blood Center physician will inform the patient's physician when a new incompatibility is identified. 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

If patient condition permits, start the transfusion slowly at one ml per minute for the first 15 minutes.
Observe the patient constantly for symptoms and signs of a reaction.
Take vital signs prior to starting transfusion, whenever a reaction is suspected or, in the absence of a reaction, after the first 15 minutes, after 30 minutes, and after completion of transfusion.

If there is evidence of a transfusion reaction

See Adverse Reactions to Transfusion.
If patient condition warrants immediate transfusion:

Begin another unit of Red Blood Cells per physician order. The new unit also is likely to test as incompatible, but may be tolerated better.
If further transfusions can be delayed, follow the transfusion reaction policy and resume transfusion after evaluation is complete.
Page the Blood Center resident (pager 3404) to discuss options.

If no symptoms or signs of transfusion reaction are noted after 30 minutes

Proceed with the transfusion and monitor the patient per usual transfusion practices.
Repeat the entire process for each incompatible Red Blood Cell unit transfused.

ADVERSE REACTIONS TO TRANSFUSION

Symptoms include fever, pain, apprehension, chills, sweating, tachycardia, or fall in blood pressure.
STOP the transfusion immediately, maintaining the IV with 0.9% saline.
Refer to Nursing policy 07.070 Blood and Blood Components using Scanned/Barcode Technology, Administration of.
DeGowin Blood Center Transfusion policy BC-445.1: Investigating Suspected Transfusion Reactions

BACTERIA DETECTION TESTS

Apheresis platelets are cultured for evidence of bacterial contamination. Transfusing physicians are advised to evaluate patients who have signs or symptoms consistent with bacteremia or sepsis after transfusion, and notify the Blood Center resident (pager 3404).

PATIENT SERVICES

The services listed below are available in the DeGowin Blood Center Patient Services area for both in-patients and out-patients by consultation with medical staff. Contact the Blood Center/Pathology resident (pager 3404) to arrange for consultation, and complete the appropriate DeGowin Blood Center Consult Form in Epic. Patients must be scheduled at least 24 hours in advance unless arrangements are made with DeGowin Blood Center physicians to treat sooner in emergency circumstances. PROCEDURES CANNOT BE PERFORMED WITHOUT A COMPLETED, DEGOWIN BLOOD CENTER CONSULT IN EPIC.

1. Plasma exchange (plasmapheresis) is the removal of plasma with replacement by other fluids, usually a combination of normal saline and hetastarch or albumin.

2. Cytapheresis is the removal of cells from the patient's blood (RBCs, platelets, leukocytes) when they are suspected of causing symptoms or signs of hyperviscosity.

3. Photopheresis is the treatment of WBC with psoralen and UV light for the treatment of Sezary syndrome, GVHD, and some forms of solid organ transplant rejection.

4. Therapeutic phlebotomy is available for treatment of polycythemia vera, hemochromatosis, etc. This service is available Monday-Friday 0800-1700 only. If the clinical service decides to perform phlebotomy outside of these hours, refer to the Guidelines for Therapeutic Phlebotomy.

5. Peripheral blood stem cell collection.

AUTOLOGOUS DONOR BLOOD PROGRAM

The autologous blood program is primarily for patients who are anticipating surgery that is likely to require blood transfusions. Patients must be referred to the Blood Center by their surgeon. Additional printed information can be obtained from the Blood Center.

This program may be considered for all patients for whom crossmatched units of Red Blood Cells are planned. Patients undergoing procedures for which blood is made available by type and screen, rather than crossmatch, are usually not candidates because the risks, expense and inconvenience of predeposit are not justified.

Patients must be in satisfactory health to easily tolerate whole blood donation. Refer only patients considered able to withstand repeated blood donations.

Hemoglobin requirement: > 11 g/dl
Hematocrit requirement: > 33%

There are no age limitations. Elderly patients are eligible. Children with adequate veins who are cooperative usually tolerate phlebotomy. Generally, it is difficult to enroll patients smaller than 35 kg (<10 yrs. of age).

Guidelines for the number of units to be collected for a particular procedure can be found in the Maximum Surgical Blood Order Schedule. Up to six units can be collected, providing the patient is referred six weeks prior to date of surgery. Therapeutic doses of ferrous sulfate can be started at the time or up to two weeks before the first donation. The dose of elemental iron is 3-6 mg/kg/day with the maximum being 200 mg elemental iron/day. The maximum dose of elemental iron corresponds to 320 mg FeSO4 tid. Iron must be prescribed by the referring surgeon; the Blood Center will not prescribe iron.

If possible, refer the patient to the Blood Center six weeks prior to surgery so that optimal scheduling of phlebotomies can occur. If scheduled later, allow one week per unit of blood requested. Generally, units of blood will not be drawn the final week before surgery. Do not refer patients with only one week until surgery.

Certain donors referred to the DeGowin Blood Center may be eligible for 2 unit red cell apheresis, depending on body size and hematocrit.

The referral and first visit must be to the DeGowin Blood Center. Subsequent donations can occur at other blood centers, and all arrangements will be made by the DeGowin Blood Center during the initial visit.

Autologous units will not be tested for infectious disease markers. Units collected at DeGowin Blood Center cannot be transferred to another hospital.

To refer a patient for this program, the referring physician’s clinic must contact the DeGowin Blood Center at 356-2058 or to schedule an appointment. Complete a "Consult DeGowin Blood Center Blood Donation, Autologous" in Epic.

Guidelines for Transfusion

HEMATOPOIETIC PROGENITOR CELLS

The Circular of Information for the use of Cellular Therapy Products is considered an extension of container labels as the space on those labels is limited. The Circular of Information contains sections on general information, side effects and hazards, hematopoietic progenitor cell sources and products, and manipulated products. The circular was prepared jointly by the AABB, America’s Blood Centers, American Association of Tissue Banks, American Red Cross, American Society for Apheresis, American Society for Blood and Marrow Transplantation, Foundation for the Accreditation of Cellular Therapy, International Council for Commonality in Blood Bank Automation, International Society for Cellular Therapy, and National Marrow Donor Program.

Tissue and Cellular Therapies staff prepare hematopoietic cells for infusion. For a list of procedures performed, please go to Tissue and Cellular Therapies on the DeGowin Blood Center website.

SURGICAL TISSUE

DeGowin Tissue Bank dispenses all human autologous and allogeneic tissue implanted at UIHC, except sperm and oocytes. For a list of available tissue types, see the Epic Tissue: Master Order. To order tissue, please refer to the Surgical Services policy SS-10.006, Tissue Bank: Ordering, Receiving, and Returning Human Tissue. It is appropriate to order tissue in advance for cases where there is a significant (>25%) chance that it will be needed.

If an unusual tissue request is being made, please complete the O.R./ASC Staff Product Request Form referred to in Section "F" of the Surgical Services policy SS-10.006, Tissue Bank: Ordering, Receiving, and Returning Human Tissue.