Page1/2 DOCTOR TO COMPLETE THIS FORM WHEN MNCMS IS DOWN Refer to Management & Investigation of Adverse Transfusion Reactions PP-CS-HV-2 Available in Q Pulse __________________________________________________________________________________________ Patient’s First Name_______________Surname___________DOB__________Hospital Number___________ Gender Female/ Male_______ Ward/clinical area __________ Patient Diagnosis___________________ Component/Product transfused Pleast tick appropriate box and complete all sections Red cells Pre transfusion Hb________ Plasma Platelets Pre Transfusion Platelet count____________ Other product specify_____________ Volume transfused at time of reaction __________________ Volume in Bag_________________________ Donor number/Batch number _________________________ Special requirements_________________ Date & Time transfusion started _______________________ Time of reaction______________________ Blood Warmer used? Yes No Was prophylactic medication administered? No if Yes specify_________________________________ Was anything injected into the pack or giving set? No if Yes specify___________________________ Was a blood administration set used? Yes No Reason for transfusion ________________________________Any previous transfusions Yes No Any previous reactions No Yes If yes specify_________________________________________________ Any pregnancies No Yes if yes specify parity__________________ Pre transfusion observations: Observations at onset of reaction
Temp: ______ Pulse: ________B/P: _______Respirations: ________ Temp: ______ Pulse: ________B/P: _______ Respirations: ________
Clinical signs and symptoms tick BOX as appropriate Apprehension/feeling of doom Raised Temp ≥2o above baseline Chills Rigor Increased pulse rate Backache Pain at infusion site Chest pain Nausea/Vomiting Hypotension Hypertension Breathlessness/dyspnoea Itching Urticaria Anaphylaxis Lip/Tongue Swelling Jaundice Decreased urinary output Dark or red urine Diffuse bleeding/petechiae Other specify_____________________________________________________ Type of reaction suspected ___________________________________________________________________ If the reaction has implications for the safety of associated blood components (eg Transfusion Transmitted Bacterial infection, Viral infection, Parasitical infection, Transfusion Related Acute Lung Injury) YOU must inform the medical scientist on duty immediately so that a RAPID ALERT can be instigated. Name of medical scientist contacted________________________ Date/Time contacted__________________
Reaction reported by Dr_____________________MCRN :________Date______ Time______Bleep No_______ PLEASE MAKE A COPY OF COMPLETED PAGE 1 AND 2 BEFORE DISPATCH TO LABORATORY AND SCAN TO PATIENT ELECTRONIC CHART IN REACTION ENCOUNTER WHEN BACK ON LINE
RF-CS-HV-1 Ver. 2
RF-CS-HV-1 Version 2
Page 2/2
Patient’s First Name_______________Surname___________DOB__________Hospital Number___________
Suggested action in all transfusion reactions Stop the transfusion and perform Clerical check, Verify that the identity of Patient, ABO RhD Group of patient and donor pack and documentation match. Inform Blood Transfusion Department immediately if discrepancy is found as another patient may also be at risk of receiving the wrong blood.
Mild Urticarial or Mild Pyrexial reaction only Stop Transfusion but do not discontinue and Notify Doctor Following review +/- treatment, the Doctor may decide to recommence the transfusion under close observation. If any new signs or symptoms, the transfusion must be discontinued and investigations undertaken.
Acute Haemolytic, Bacteraemic, Severe Allergic/ Anaphylactic, Severe Febrile /Other reaction Stop the transfusion and discontinue. Notify the Doctor immediately Using a new giving set keep line open with 0.9% NACL Management is dictated by presenting signs and symptoms
In all reactions where blood transfusion is discontinued investigations must be carried out and the laboratory informed immediately Ensure that you send all blood packs (used & unused) to lab with attached giving set (sealed to prevent spillage) with completed reaction form and all samples and request forms as required
Note re: NEONATES all suspected reactions IN NEONATES should be investigated as per Paediatric instructions. The volumes of samples collected from neonates will be decided by the paediatrician
INVESTIGATION CHECK LIST (tick appropriate box and complete all pertinent sections) 1. 2. 3.
Clerical check carried out? No error detected Error detected specify______________________________ Inform Blood Transfusion Department/Medical scientist on call? Yes No Include SUSPECTED TRANSFUSION REACTION on forms when ordering investigations
4. 5.
Tests required for Adult patient transfusion reaction investigation BELOW see note re NEONATES ABOVE IgA Levels should be checked for all moderate & severe allergic reactions (7ml serum sample gold top)
Department
SpecimenType
Test request/Tick box for sample collected
Blood Transfusion
1. EDTA samples purple top 9ml
Group & Antibodies
Haematology
1. 3ml EDTA, purple top 3ml
FBC Coagulation screen Haptoglobins
Trisodium Citrate Solution blue top 3mls Serum sample gold top 7ml 1. Lithium heparin green top 4ml Biochemistry Microbiology Blood culture set
U&E Creatinine Bilirubin LDH Blood Cultures Patient
LFT’s
Blood cultures ( Adult blood culture set ) 1. Urine sample Sterile 50ml MSU container Sterile 50ml MSU container (first voided if possible) for MCS MSU for MCS 1. Serum sample gold top 7ml Samples Tryptase (only indicated if patient has Biochemistry should be collected up to 1 hr, 3 hr, 12 hrs signs of anaphylactic shock) & pre and 24hrs post event. transfusion sample if available IgA Levels Anti-IgA Antibodies HLA Antibodies Anti-platelet Antibodies B Naturietic Peptide BNP Chest x ray OTHER SAMPLES/TESTS (see PP-CS-LM-4 Primary sample manual for sample type) MAY BE REQUIRED TO OUTRULE OTHER CAUSES SWABS e.g. HVS/Wound Specify ________________________________________________________________________________