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Fresh frozen plasma, blood component transfusion

This guideline outlines the types of fresh frozen plasma (FFP) available for transfusion as well as the preparation of the child and family, prescription and transfusion processes. 

It includes identity checking, administration, observations and reaction management and the safe completion of the procedure.  

Note: While this guideline refers to the ‘child’ throughout, all activities are applicable to young people. 

Available products

Available in the following size packs:

  • neonatal packs 55-75ml
  • standard sized packs up to 300ml
The unit size issued depends on volume required.

All donations are from single donors.

Methylene blue treated Non UK sourced FFP is supplied for all children under 16 years (Rationales 1 and 2).

FFP should only be used when appropriate (Rationale 3).

It is used to correct abnormal coagulation (Rationale 4), ie:

  • to replace single coagulation factor deficiencies 
  • to reverse the effect of warfarin
  • acute disseminated intravascular coagulation (DIC)
  • thrombotic thrombocytopenic purpura (TTP)
It may also be indicted if there is bleeding and abnormal coagulation due to (Rationale 5):

  • massive red cell transfusion
  • liver disease
  • cardiopulmonary bypass surgery

Preparation child and family

Inform child and family of the following (Rationale 6):

  • that a blood component transfusion is necessary
  • the reason for the transfusion
  • what it entails
  • the likely duration of the procedure
  • document ‘consent’ using the tick box on the consent form or by an entry in the medical notes (Rationale 7)

Supply child and their parents with the appropriate information leaflet obtainable from all wards and the Family Resource Centre (Rationale 8).

Ensure the child is wearing an identity wristband containing the child's Great Ormond Street Hospital (GOSH) hospital number (Rationale 9).

Ensure the following pre-infusion observations of the child are known (Rationale 10, 11, 12):

  • temperature
  • respiration rate
  • heart rate
  • blood pressure

Ensure venous access has been established (Rationale 13). 

This should be according to intravenous infusion guidelines.

Preparation: Prescription

Blood components must not be administered unless prescribed on the child’s Blood Transfusion Prescription Chart (pink transfusion chart).  Completion of special requirements and consent boxes is mandatory (Rationale 14).

A medical officer, or non medical prescriber, must prescribe blood products (Rationale 15).

FFP is normally prescribed as follows (Rationale 16):

  • a child weighing less than 30kg: 10mls/kg
  • a child weighing 30kg and over: one standard pack
The prescription must include (Rationale 17 and 18):

  • a suitable infusion rate for the size of child 
  • an infusion time of four hours or less from time of thawing 

Ensure there is sufficient FFP supplied to meet the prescription requirements (Rationale 19).

Ensure you have a prescription or instructions for what should happen after the infusion (Rationale 20).

If administering an intravenous pre-medication of an anti-histamine and steroid do so prior to commencing infusion (Rationale 21).

Preparation: Transfusion

The Blood tracking System should be used for the collection and administration of all blood components.  In the event of the Blood Tracking System being unavailable, or if you have not been trained in the use of the system, the downtime procedure should be used.  Details on how to use the system can be found in Section 9: Using the Blood Tracking System in the Blood Transfusion Policy and Information Folder, available in all wards and departments and online on GOSWeb (Great Ormond Street Hospital Intranet).

Arrange for the collection of the required FFP from the tray in Blood Bank.  This should be just before it is needed. The FFP must be transported using the box provided (Rationale 22).

The person collecting the component must (Rationale 23 and 24):

  • Use a collection slip generated from the Blood Tracking System, containing a barcode and eye readable patient demographics.
  • The FFP must be located, checked and scanned out following the process on the kiosk screen.  Instruction sheets are available next to the kiosks.

On receipt of the FFP on the ward (Rationale 23 and 24):

  • The unit(s) must be 'arrived' on the Blood Tracking System using the handheld PDA or the collection slip must be signed, staing date/time of arrival.
  • The collection slip must then be returned to Blood Transfusion via the porter delivering the product or the air tube system.

Check child’s details are the same on the blood component bag, prescription and report form ie (Rationale 25):

  • first name and family name
  • hospital number
  • date of birth

Gather the equipment required for intravenous infusions.

An appropriate blood component administration set (Appendix), which has an integral 200mm micro-aggregate filter, should be used (Rationale 26).

Blood components of less than 100mls administered using a giving set with an integral 3 way tap via a syringe driver carry an inherent risk. When using a giving set of this type:

  • The component bag must remain attached throughout the procedure to ensure positive patient identification. 
  • The 3 way tap must be checked prior to transfusion to ensure that the component is administered from the syringe and not allowed to flow freely from the component bag (Rationale 27). 

When preparing the transfusion:

  • Check child’s details are the same on the blood component bag, prescription and blood component form (Rationale 25):

    • first name and family name
    • hospital number
    • date of birth
  • Check unit number on label and blood component bag are the same and match the details on the blood component form (Rationale 28).
  • Check the Blood Group (ABO and Rhesus) on the blood component bag are compatible with those of the child (Rationale 29).
  • Check the expiry date/time of the component (Rationale 30).

Check the blood component bag is intact (Rationale 31).

Prime Blood Product Administration set using standard (universal) precautions and an aseptic non-touch technique (ANTT) (Rationale 32, 33, 34).

If the transfusion is cancelled at this point (Rationale 35):

  • inform Blood Bank
  • discard blood component in a yellow bag for incineration
  • record in child’s health care records

Infuse component: identity check and administration

Check the child’s identity band and prescription (Rationale 36).

If you are using the Blood Tracking System follow the prompts on the screen to complete all the pre-transfusion checks.  Otherwise, manually check the child's details on the blood component bag.

Check the child’s details on blood component bag, Blood Transfusion Prescription Chart and blood component form for (Rationale 37):

  • first name and family name
  • hospital number
  • date of birth

Recheck the child’s identity using the wristband.

Connect prepared blood component to the child according to relevant intravenous therapy guidelines using an aseptic non-touch technique (Rationale 38, 39).

Set infusion rate according to prescription but ensure infusion is completed within four hours of product being thawed (Rationale 40, 41).

Give diuretic if prescribed at the required time according to the Drug Policy (Rationale 42, 43).

Infuse component: observations, recordings and traceability

Do not leave the child unattended for the first thirty minutes of the transfusion (Rationale 44).

This should be negotiated with any family members in attendance.

Record the following in the child’s health care records:

  • Date and time of starting transfusion (Rationale 45).  
  • Sign that you are responsible for its administration (Rationale 46).
  • Sign the transfusion report form, ensuring date and start time are recorded and stick the label from the Blood Tracking System on the reverse of the form.
  • If you are not using the Blood Tracking System, once the transfusion has commenced the person administering the transfusion must (Rationale 47, 48, 49):

    • detach the red part of the label
    • sign, print their name and add date/time given
    • return label to Blood Transfusion Laboratory

Observations must be undertaken and clearly documented for every unit transfused.  Minimum monitoring of the child must include (Rationale 50):

  • Pulse rate, blood pressure, temperature and respiration rate:

    • no more than 60 minutes before the start of the transfusion
    • 15 minutes after the start of the transfusion
    • no more than 60 minutes after the completion of the transfusion
  • If the child becomes unwell or shows signs or symptoms of a transfusion reaction further observations must be undertaken and recorded, and appropriate action taken.
  • Routine patient observations, as defined by each clinical area, should also be continued during the transfusion period.

Check peripheral transfusion access site half hourly for (Rationale 51):

  • redness
  • swelling/inflammation
  • pallor
  • leakage/oozing
  • skin temperature change
  • tenderness

If ANY appear STOP transfusion.

Check all the infusion system is intact at least half hourly (Rationale 52, 53, 54).

Record the following hourly (Rationale 55, 56, 57, 58):

  • transfusion rate
  • transfusion pressures
  • volume infused
  • total volume infused
Observe child for minor reactions to blood component (Rationale 59) eg:

  • sweating
  • mottled appearance
  • dizziness
  • rash
  • redness on chest
  • flushing
  • fever
  • tachycardia
  • nausea
  • chills
Observe child for major reactions to blood component (Rationale 59) eg:

  • rigor
  • laboured breathing/wheezing
  • chest pain
  • back or loin pain/darkened urine
  • loss of consciousness
  • sudden collapse

Infuse component: reaction management

If the reaction is unexpected:

  • Stop transfusion (Rationale 60).
  • Infuse 0.9% sodium chloride for infusion (Rationale 61).  
  • Obtain medical assistance (Rationale 62).
  • Record vital signs (temperature, pulse, respiration and blood pressure).  
  • Continue transfusion when possible. Remember the thawing time.
  • Record incident in child’s health care record (Rationale 63).
  • Inform Blood Transfusion Laboratory (ext 8527) or bleep Biomedical Scientist on call out-of-hours (bleep 0590).
  • Complete an incident report form.
If child had potential for a reaction:

  • Stop transfusion (Rationale 60).
  • Infuse 0.9% sodium chloride for infusion (Rationale 61).
  • Inform the doctor.
  • Record vital signs (temperature, pulse, respiration and blood pressure).
  • Record in child’s health care records (Rationale 63).
  • Give prescribed steroid and anti-histamine.
  • Continue transfusion when child has recovered. Remember the thawing time.
  • Inform Blood Transfusion Laboratory (ext 8527) or bleep Biomedical Scientist on call out-of-hours (bleep 0590).
  • Complete an incident report form.
If a severe reaction occurs:

  • Stop transfusion immediately (Rationale 64).
  • Infuse 0.9% sodium chloride for infusion (Rationale 61).
  • Seek urgent medical assistance.
  • Give steroid and anti-histamine if prescribed (Rationale 60).
  • Record vital signs (temperature, pulse, respiration and blood pressure).
  • Record incident in child’s records (Rationale 65).

Do not recommence transfusion.

  • Inform Blood Transfusion Laboratory (ext 8527) or bleep Biomedical Scientist on call out-of-hours (bleep 0590).
  • Complete an incident report form (Rationale 63).

Completing transfusion

If using the Blood Tracking System:

  • end the transfison on the system
  • stick the label generated on the reverse of the pink form and file in the patient notes

If the prescription is complete:

  • Remove administration set using standard (universal) precautions and continue with planned treatment (Rationale 66, 67).

  • The needle/spike should be placed in the yellow sharps box. The blood component bag should be placed in an orange clinical waste bag, sealed and placed in the clinical waste bin.  Do not put into sewage/water system (Rationale 68).

    If large volumes of FFP are required this should be planned with Blood Bank (Rationale 69).

Appendix

Blood component giving set flowchart (PDF, 9KB)

Rationale

Rationale 1: To reduce the possible risk of vCJD (variant Creutzfeldt-Jakob Disease).
Rationale 2: To reduce the incidence of TRALI (Transfusion Related Acute Lung Injury).
Rationale 3: There is an increased risk of viral transmission from plasma products.
Rationale 4: To give the child clotting factors to correct their coagulation.
Rationale 5: To replace clotting factors.
Rationale 6: To obtain "consent".
Rationale 7: To document written agreement to transfusion.
Rationale 8: To address any information requirements.
Rationale 9: To enable positive patient identification and the wristband to be used by the Blood Tracking System.
Rationale 10: To establish the normal parameters for a child.
Rationale 11: To rule out pre-existing disease processes if a reaction is suspected.
Rationale 12: Alterations in these could indicate a reaction.
Rationale 13: To enable infusion to commence.
Rationale 14: To maintain Hospital Policy.
Rationale 15: To meet the recommendations of the British Committee for Haematology Standards in Blood Transfusion Task Force.
Rationale 16: To meet the needs of the child.
Rationale 17: To reduce the risk of infection.
Rationale 18: To ensure given within four hours of thawing by Blood Bank to maintain product viability.
Rationale 19: To enable Blood Bank and clinical area to plan adequately.
Rationale 20: To ensure planning takes place.
Rationale 21: To prevent a reaction to the blood component in children who have suffered reactions in the past.
Rationale 22: Clotting factors are thermo labile so it needs to be kept at room temperature once thawed.
Rationale 23: To enable blood component tracing to take place, eg audit trail.
Rationale 24: To know whom to contact if a problem occurs.
Rationale 25: To ensure the correct component is given to the correct child.
Rationale 26: To remove particulate matter including fibrin.
Rationale 27: To ensure patient safety by administering the prescribed amount of blood component at the correct rate.
Rationale 28: To ensure correct labelling.
Rationale 29: To prevent incompatibility.
Rationale 30: To prevent administration of an out of date component.
Rationale 31: To prevent infection.
Rationale 32: To prevent air embolism.
Rationale 33: To ensure administration set is patent.
Rationale 34: To minimise risk of infection.
Rationale 35: To ensure Blood Bank records are accurate.
Rationale 36: To ensure the blood product is being connected to the correct child.
Rationale 37: To increase reliability of the checks.
Rationale 38: To maintain Hospital Policy.
Rationale 39: To minimise the risk of infection.
Rationale 40: To maintain the effectiveness of the component.
Rationale 41: To minimise the risk of infection.
Rationale 42: To meet Hospital Policy.
Rationale 43: To prevent fluid overload especially if fluids are being restricted.
Rationale 44: This is when reactions are most likely to occur.
Rationale 45: To ensure accuracy of records.
Rationale 46: To determine accountability for the transfusion.
Rationale 47: To comply with legislation.
Rationale 48: To provide positive traceability.
Rationale 49: To ensure inclusion of recipients in any 'lookback' programme.
Rationale 50: To monitor for potential complications as indicated in the British Committee for Standards in Haematology guideline.
Rationale 51: To monitor for extravasation and phlebitis.
Rationale 52: To ensure the product is being infused.
Rationale 53: To prevent wastage.
Rationale 54: To prevent accidental spillage.
Rationale 55: To ensure rate remains correct.
Rationale 56: To detect for signs of extravasation.
Rationale 57: To prevent over-transfusion.
Rationale 58: To ensure transfusion pump is working correctly.
Rationale 59: To ensure safety of child.
Rationale 60: To stop reaction.
Rationale 61: To maintain patency of IV access device.
Rationale 62: To obtain prescription for steroid and antihistamine.
Rationale 63: To maintain accurate records.
Rationale 64: To minimise impact from reaction.
Rationale 65: To assist investigation of incident.
Rationale 66: To conclude treatment.
Rationale 67: To minimise risk of infection to handler.
Rationale 68: To reduce risk of infection by safe disposal.
Rationale 69: To ensure adequate stocks are available.

References

Reference 1:
Bradbury M, Cruickshank JP (1995) Blood and blood transfusion reactions: 2. Br J Nurs 4 (15): 861-8.  

Reference 2:
British Committee for Standards in Haematology (2004) Guidelines for the use of Fresh Frozen Plasma, Cryoprecipitate and Cryospernatant. British Journal of Haematology 126: 11-28.  

Reference 3:
British Committee for Standards in Haematology (2004) Transfusion Guidelines for Neonates and Older Children. British Journal of Haematology 124: 433-453.  

Reference 4:
British Committee for Standards in Haematology (2004) Guidelines for compatibility procedures in blood transfusion laboratory. Transfusion Medicine 14: 59-73.  

Reference 5:
McCelland DBL (2007) Handbook of Transfusion Medicine (4th edition). London, HMSO  

Reference 6:
Cohen H et al (2009) SHOT Annual Report 2008. London, Serious Hazards of Transfusion.  

Reference 7:
British Committee for Standards in Haematology (2009) Guideline for the Administration of Blood components. www.bcshguidelines.com. Viewed on: 08/10/2012.

Document control information

Lead author
Sylvia Hennem, Specialist Practitioner of Transfusion, Blood Transfusion

Additional authors
Helen Nulty, Lead BMS Blood Transfusion, Blood Transfusion

Document owner
Sylvia Hennem, Specialist Practitioner of Transfusion, Blood Transfusion

Approved by
Clinical Practice Committee

First introduced: 30 June 2005
Date approved:
8 October 2012
Review schedule: Two years
Next review:
8 October 2014                                                                                     

Document version: 4.0
Replaces version:
3.0