Ordering Blood Products

  • Every patient receiving a fresh blood product needs valid pretransfusion compatibility testing/blood group and antibody screen performed at the RCH prior to blood transfusion.

    Pretransfusion testing

    Correctly identifying the patient during collection of the pretransfusion sample is vital in avoiding 'wrong blood to wrong patient' episodes. 

    All specimen collection and labeling must be done in accordance with The Royal Children's Hospital  specimen collection procedure and  blood product transfusion procedure.

    Pretransfusion compatibility testing prior to transfusion involves the following;

    Blood group and antibody screen:

    1. Determines the ABO and Rh(D) group of the recipient
    2. Performs a red cell antibody screen to detect red cell antibodies
      1. For patients who have "no red cell antibodies detected", compatible units are selected and issued electronically
      2. For patients who have "red cell antibodies detected", further laboratory work is required to identify the specificity of the antibody, to type the patient and donor units in order to provide specific antigen negative blood and to perform a full serological crossmatch. For patients with multiple antibodies this work can take several hours to complete.
    3. Checking for previous transfusion and blood group records.
      The patient's current blood group must agree with any previous record of the patients group. Patient's who have previously had clinically significant red cell antibodies detected require antigen negative blood and full serological crossmatching.

    If a patient is having a planned surgery where blood loss is expected, or a planned RBC transfusion, an order for blood group and antibody screen can be made. The date and type of surgery or expected date of transfusion can be outlined in the clinical notes field of the order. Blood bank will then be aware of the potential requirements for blood products and can make provisions as necessary. If you know your patient has special transfusion requirements, a conversation can still be had with the blood bank to discuss individual transfusion requirements.   

    72 hour rule

    A blood group and antibody screen expires 72 hours after collection.  A fresh blood group and antibody screen will be required for any units not commenced within the 72 hour period.  The time and date of collection of the cross match specimen is indicated in EMR. If a unit of red cells is ordered in EMR without a current blood group and antibody screen, a prompt will appear with the option to order a blood group and antibody screen at the time of ordering the red cells. 

    The 72 hour rule also applies whenever a patient has been transfused or is/has been pregnant within the last 3 months. This internationally accepted safeguard is used to prevent a transfusion reaction in patients who form antibodies to foreign red cell antigens in response to pregnancy or transfusion. 

    The only exceptions to the 72 hour rule are some neonates and infants during the first four months of postnatal life (neonatal extended expiry) or those patients who have extended expiry crossmatching completed prior to having planned surgery (extended expiry)

    Extended expiry

    Extended expiry allows patients having a planned admission for spinal, craniofacial or cardiac surgery to have a blood group and antibody screen performed and remain valid for 30 days before their planned date of surgery.

    For the the extended expiry blood group antibody screen to remain valid, certain conditions must be met prior to sampling and maintained throughout the 30 day period.

    The following conditions must be met:

    • No transfusions in the past three months
    • No pregnancy in the past three months .
    • The blood bank must receive a signed declaration from the parent/guardian/patient in order to validate the sample.
    • Negative antibody screen. 

    If any of these conditions change in the lead up to surgery, the parents/guardians/patient will have instructions to contact the blood bank to inform them of these changes. Another blood test will be required to ensure to confirm the blood group and antibody screen.  

    Forms are located here: 

    1. English as a first language or primary language spoken at home
    2. Interpreter service used.

    Prepare and transfuse order (Prescription)

    Refer to the EMR tip sheet for further information.

    The ‘prepare’ and ‘transfuse’ orders are the responsibility of the medical practitioner. It is the authorisation for blood bank to prepare the blood product and for clinical staff to administer it.

    In EMR, complete the ‘transfuse and prepare’ orders only if there is an intention to transfuse.

    The ‘prepare’ order automatically prints in blood bank. It must include:

    • Relevant clinical notes
    • Type of blood product
    • Dose
      • In a patient < 20kg, the order should be in mls
      • If patient >20kg, typically 1 unit and reassess
        • (Higher doses allowed in MTP/ red cell exchange/chronic transfusion programmes/cardiopulmonary bypass)
    • Indication for transfusion
    • Any special requirements
      • RBC (CMV negative/irradiated/other – please specify e.g. phenotype matched)
      • FFP ( Cryodepleted/IgA deficient)
      • Platelets(CMV negative/washed/HLA matched) – should have apheresis
    • Clinical notes – can specify any special needs including the need for pre-medication
    • date and time transfusion required

    The ‘transfuse’ order is electronically sent to ‘flowsheets’ and will include

    • Dose (mls/units) - populated from prepare order
    • Transfusion duration per unit must be specified
    • Confirmation of transfusion consent

    The prescriber is responsible for ensuring:

    • Transfusion is clinically appropriate and the indication documented
    • Expected benefits outweigh potential hazards
    • Clinical staff have been informed of the prescription

    Dosing recommendations:

    Red blood cells:

    Neonate: A typical dose for transfusion in neonates is 10 – 20 mL/kg  (where the upper end of the range applies to severe anaemia, expected ongoing risk factors or concurrent bleeding)

    • Indications for neonatal red cell transfusion
      • Bleeding (or the term used for the RBC transfusion)
      • Preterm or term neonate with no respiratory support, Week 1, Hb 100-120 g/L
      • Preterm or term neonate with no respiratory support, Week 2 , Hb 85 -100 g/L
      • Preterm or term neonate with no respiratory support, > Week 3, Hb 70-100 g/L
      • Preterm neonate with respiratory support, Week 1, Hb 110-130 g/L
      • Preterm neonate with respiratory support , Week 2, Hb 100 -125 g/L
      • Preterm neonate with respiratory support, > Week 3, Hb 85-110 g/L

    Patients < 20 kg: Volume to be transfused = 0.5 x patient weight x (desired Hb – patients current Hb).

    • Indications for red cell transfusion in patients <20kg
      • Hb <70g/L where other specific therapy is not appropriate
      • Hb 70-90g/L AND clinical signs and symptoms of anaemia
      • Hb <70-90g/L with disease or therapy related marrow failure
      • Hb <80-100g/L and ECLS
      • Hb <90-100g/L and Beta-thalassaemia major
      • Sickle cell disease
      • Blood prime for circuit
      • Red Cell exchange
      • Haemolysis

    Patients > 20 kg: Volume to be transfused = 0.5 x patient weight x (desired Hb – patients current Hb) however no more than 1 unit should be transfused before re-testing the patient Hb to assess for rise.

    Typically RBC units are 200 – 300 mL in volume.

    • Indications for red cell transfusion in patients >20kg
      • Hb <70g/L where other specific therapy is not appropriate
      • Hb 70-90g/L AND clinical signs and symptoms of anaemia
      • Hb <70-90g/L with disease or therapy related marrow failure
      • Hb <80-100g/L and ECLS
      • Hb <90-100g/L and Beta-thalassaemia major
      • Sickle cell disease
      • Blood prime for circuit
      • Red Cell exchange
      • Haemolysis

    Platelets

    Platelet dose is normally 5 mL/kg however usual dose in an adult is 1 unit.

    • Indications for platelet transfusion
      • Platelet count <10 x 10^9/L – Chemotherapy, haemopoetic stem cell transplant
      • Platelet count <20 x 10^9 – With risk factors E.g. Fever, minor bleeding
      • Platelet count <50 x 10^9 – Patient undergoing invasive procedure
      • Platelet count <100 x 10^9 – ECLS
      • Platelet count <10 x 10^9 – Critically ill patient – Stable without bleeding
      • Platelet count <20 x 10^9 – Critically ill patient – Non bleeding patient with risk factors. E.g. Sepsis, renal failure medications
      • Platelet count <50 x 10^9 – Active bleeding

    Fresh Frozen Plasma (FFP) 

    FFP dose is normally 10 – 15 ml/kg for all patients

    • Indications for FFP transfusion
      • Significant coagulopathy
      • INR >/= 2.0 and invasive procedure
      • Plasma exchange for TTP
      • In addition to Prothrombinex in warfarin reversal in high risk patients
      • Specific factor deficiencies where a factor concentrate is not available

    Cryoprecipitate

    Cryoprecipitate dosing is normally 5 – 10 ml/kg for all patients

    • Indications for cryoprecipitate transfusion
      • Fibrinogen <1.5 g/kg and active bleeding
      • Significant bleeding in context of DIC

    For elective transfusions, prescribe one unit/transfusion episode at a time and re-evaluate the need for further transfusion. 

    For indications not listed, "other" can be selected. In this instance, the clinical notes section must be completed with an alternate transfusion indication. Consider a discussion with a haematologist if transfusing outside of the listed parameters.