2 PROVIDING BLOOD COMPONENTS FOR PERIOPERATIVE PATIENTS

It is the responsibility of the surgical team to submit preoperative blood samples to the Blood Bank for surgical patients. The Preadmission Type and Screen Program is encouraged to ensure adequate processing time. Sufficient time must be allowed for procurement of compatible units for patients with an unusual blood type, antibody problems, or for those undergoing procedures associated with a large anticipated blood loss.

Preadmission Type and Screen

In order to avoid delay or cancellation of "Admission Day of Procedure" operations, most patients may have a pretransfusion blood sample collected up to one month prior to the surgery date. A sample collected up to three days in advance of surgery is needed for patients with clinically significant blood group antibodies and those who have been previously transfused. See Chapter 1 for a description of the process.

Patients who do not have preadmission testing performed must have a blood sample submitted as soon as possible after admission.

Initial Order for Blood Components

• The initial order for blood components is taken from the Surgery Schedule.
• To prevent duplication and waste, do not order blood components intended for use in the Operating Room as if it was an order for blood components on the patient care unit.
• Red Blood Cells will be crossmatched for elective surgical cases if the patient's name appears on the published OR schedule.
• Red Blood Cells will be crossmatched for unscheduled and emergency patients who have been added officially to the schedule.

MSBOS

The Maximum Surgical Blood Order Schedule (MSBOS) has been developed from an analysis of Red Blood Cell utilization by procedure. It has been approved by the surgical section heads and is printed at the end of this booklet in Appendix A. The amount of Red Blood Cells ordered by the surgeon should be an approximation of the anticipated need based on the specific patient's condition. If the order will exceed the quantity stated on the MSBOS, the surgeon must consult with the Blood Bank medical or supervisory staff to arrange for an increase over the MSBOS. If a surgeon orders fewer units than listed in the MSBOS, the lesser number will be prepared.

Type and screen (TS) on the OR Posting Schedule or on the MSBOS represents a maximum preoperative order for those patients who will probably not require intraoperative blood transfusion. If a TS is ordered preoperatively and the patient subsequently requires transfusion, the surgeon or anesthesiologist need only notify the Blood Bank that blood components are required immediately.

If PTS or PTSI are noted on the OR schedule, the blood components requested on the OR schedule may be released from the Blood Bank when the patient arrives provided the patient has the required identification form and the Pre-Admission Type & Screen (PTS) Identification form has been received by the Blood Bank.

Provision of blood components for operations not included in the MSBOS will be based on the blood component order of the surgeon scheduling the procedure on the OR Posting Schedule.

If use of a large quantity of platelets or cryoprecipitated antihemophilic globulin (CRYO) is anticipated during or after an operation, notify the Blood Bank well in advance of the operation so that special arrangements can be made.

The Surgical Blood Status Sheet is delivered to the OR early each weekday. This sheet documents patients with:

* Red Blood Cell orders reduced according to the MSBOS

* Unresolved blood group antibody problems

* Unsigned autologous consent formspatients who require special consent forms for the release of Autologous units and forms have not been completed

* No blood sample available for crossmatch or PTS sample not valid

ADDITIONAL ORDERS

If additional blood components are required intraoperatively, the circulating nurse (or Core manager) is responsible for requesting additional components.

The person ordering the blood component is also responsible for determining the need for an additional blood sample the approximate time the blood components will be available and submitting a written order confirming the verbal orders.

The following information must be provided to the Blood Bank:

* patient's name and medical record number

* components required

* quantity

* name of the physician requesting the order

* location of patient (Mott or UH OR)

DOCUMENTATION OF INTRAOPERATIVE BLOOD COMPONENT ORDERS

The Blood Bank Requisition Form should be used to document the total number of intraoperative verbal orders. The Box "Summary of Intraoperative Orders" should be checked so that unneeded blood components will not be prepared. The nurse will notify the OR desk clerk of the additional blood component order and the approximate time they will be available.

Mott Operating Room – Blood Loss Notification

The circulating nurse will verbally notify the anesthesiologist when the blood loss reaches 5cc per kilogram of body weight.

DELIVERY OF BLOOD

Autologous and Directed Donor Units

To prevent errors, if both autologous and directed donor Red Blood Cells are available for a patient, the autologous units will be sent first. Unless specifically requested because of patient need, directed donor units will be sent only after the autologous units have been used. Allogeneic (bank stock) units will be sent only after the autologous and/or directed donor units have been used.

OR Personnel Pickup

It may be necessary to send an OR staff member to pick up the blood components for cases with a large blood component use if the pneumatic tube system is not functioning.

Pneumatic Tube

When blood is delivered using the pneumatic tube system, the person opening the tube at the receiving location must verify that the product is designated for a patient in the receiving location, and the time the blood component was received.

The person removing the blood component from the pneumatic tube should record the date and time that the blood was removed from the pneumatic tube and sign the form. The signed and dated Blood Delivery Form should be returned to the Blood Bank using hospital mail.

The OR desk clerk is responsible for monitoring the tube station and for immediate delivery of components to the Core area.

If Red Blood Cells or Plasma are not received in a timely manner

• A unit of Red Blood Cells or plasma that is out of controlled refrigeration for greater than 30 minutes cannot be stored for subsequent transfusion to the assigned patient nor can it be reissued to another patient.
• If more than 30 minutes have elapsed since the time stamp on the Blood Delivery Form, and the Red Blood Cells or plasma will be used for immediate transfusion that will be completed within 4 hours of the time stamp, transfuse the component.
• If the blood component is not needed for immediate transfusion, return the Red Blood Cells or plasma to the blood bank for proper disposal. Do not store Red Blood Cells and plasma that has been out of refrigeration for more than 30 minutes in patient care unit Blood Refrigerators.
• Any units that have not been properly stored must be tagged so that staff will know that they are not suitable for issue to any patient.

Storage of Blood Components

USE OF COMPONENTS IN THE OPERATING ROOM

Once the patient is under the care of the anesthesiologist or perfusionist, the administration of blood components shall result only from an agreement between the surgeon and the anesthesiologist that their use is necessary.

It is the responsibility of the Core manager or circulating nurse to confirm, in a timely fashion, the arrival of the blood components ordered. The Core manager or circulating nurse is responsible for:

• Confirmation of the arrival of blood components ordered.
• Appropriate storage of components
• Immediate return of units no longer required.
• Prompt notification to the anesthesiologist of the arrival of the blood.
• Management of components in the Core area.
• Units that outdate first should be transfused first

Because they outdate soon after preparation, Cryoprecipitated Antihemophilic Globulin (CRYO), Platelets and Fresh Frozen Plasma should be used immediately, or returned to the Blood Bank for possible use by another patient.

PATIENT IDENTIFICATION IN THE OPERATING ROOM

The patient is to be identified before the procedure by the anesthesiologist or CRNA (certified registered nurse anesthetist) by asking the patient to identify him/herself and by checking positive patient identifier (PPI). The identification or reconfirmation must take place in the operating room.

In the Operating Room, the circulating nurse shall identify the patient by asking the patient to identify him/herself and by checking the PPI to verify that the

• name,
• birth date and
• registration number

on the patient’s printed labels corresponds with the information on the patient’s PPI. 
The patient’s printed labels become the means of identifying the patient when the PPI is covered and impossible to use as a PPI without contaminating the sterile field or disrupting surgery. (Revised 9/23/09)

BLOOD ADMINISTRATION GUIDELINES

In the operating room, transfusion may be the responsibility of a physician, a CRNA or perfusionist. Non-physician transfusionists and anyone who assists in double checking the units (nurses, physician assistants, perfusion technicians and anesthesia allied health technicians) should have completed the "Blood Transfusion Policies" course and examination.

Immediately before transfusion verify the identification label, blood bag label and the following information on the Transfusion Record Form (TRF):

• patient name and registration number with patient PPI
• donor (unit) number
• component name
• blood type of patient and component
• compatibility (see chart on back inside cover)
• outdate of component

If the identifying information matches, sign the TRF. If the identifying information does not match the patient, remove the unit from the room immediately.

The person who initiates the transfusion is responsible for recording the donor unit number and the indications for transfusion on the anesthesia or perfusion record.

Enter the date and time the transfusion was initiated on the TRF. Indicate where the vital signs will be recorded.

Once the transfusion has been initiated, observe the patient for signs and symptoms of a transfusion reaction.

At the termination of each transfusion, complete the TRF with the amount of component administered, the date and time the infusion was completed and whether or not a transfusion reaction is suspected.

If there was no transfusion reaction, the empty bag should be discarded in a biohazard waste container. If a reaction is suspected, refer to chapter 7, Adverse Reactions to Transfusions, for additional information.

Checking in Anticipation of Massive Transfusion

Blood products may be check in anticipation of emergent rapid transfusion. However, the blood product should remain available in the patient care area for transfusion. The following proecures should occur to ensure that the blood is either used or retruned to the blood refrigerator in a timely fashion.

The Transfusion Data worksheet may be used by the Department of Anesthesiology for tracking blood utilization in high use cases such as liver transplants. However, this form is not a part of the patient's medical record and its use does not obviate the need for the TRF, which must be completed for each unit transfused.

The Anesthesiologist/CRNA is responsible for completion of the TRF and for bringing the completed forms to the PACU or ICU nurse who will be in charge of the patient. As with other patient care records, the nursing unit clerk will place these records in the proper location in the patient's chart and return the Blood Bank copies to the Blood Bank.

SPECIAL CONSIDERATIONS FOR BIOHAZARD AUTOLOGOUS UNITS

Autologous donor units that test positive for infectious diseases will be labeled with a biohazard sticker. Michigan law requires that autologous units testing positive for antibody to HIV be transfused only after written consent has been obtained from both the patient and the transfusionist. Federal regulations require that units testing positive for Hepatitis B surface antigen, and or positive for tests for HIV be labeled with a biohazard sticker and that consent of the transfusing physician be obtained prior to transfusion. Autologous units that require special consent forms will be labeled "FORMS REQUIRED" or "FORMS COMPLETED". When completed request forms have been returned to the Blood Bank, the unit will be labeled "FORMS COMPLETED". A copy of the completed request form is placed on the patient's chart, the second copy is retained by the Blood Bank.

Consent is not required for other "biohazard" autologous units and these units will have the notation "OK" on the biohazard sticker.

BLOOD WARMERS, INTRAOPERATIVE and POST-TRAUMATIC INJURY BLOOD SALVAGE DEVICES

Blood may be collected from the patient immediately preoperatively, salvaged intraoperatively from the operative site, recovered from an extracorporeal circuit or salvaged from the site of injury. The actual procedure may vary from collection of anticoagulated blood to more complex processing of salvaged blood through mechanical washing, concentrating and filtering devices.

• Devices must be used according to the manufacturer's instructions.
• Methods for intraoperative blood salvage shall be safe, aseptic, and ensure accurate identification of all blood collected. The equipment used must include a filter capable of retaining particles potentially harmful to the recipient, and must preclude air embolism.
• Devices must be tested periodically for appropriate function and safety. Equipment must not be used unless it has a current Biomedical Engineering tag.
• Only trained personnel shall operate these devices.
• Blood collected using these devices shall be transfused only to the patient from whom it was collected and must be labeled with the phrase "FOR AUTOLOGOUS USE ONLY" and with the following information:
• name and hospital medical record number of the patient
• source of collection (autologous or salvaged blood)
• time collection started
• outdate of the blood: 6 hours after collection initiated if stored at room temperature
•  

ENTERED BLOOD COMPONENT BAGS AND SYRINGES OF COMPONENTS

If a blood component bag has been entered and/or any portion has been placed into a syringe, the component must not be used more than four hours after the original entry into the bag. The bag or syringe must be labeled with the following information:

• patient's name
• patient's hospital registration number
• donor unit number
• time of entry into the original unit
• outdate (4 hours after entry into the original unit)
•  

The blood component must be filtered using a filter suitable for blood components.

The patient's medical record must document the date, time and volume of each portion of the component transfused.

RETURN OF UNUSED COMPONENTS

When the patient leaves the OR, all blood components must be returned immediately to the Blood Bank with the possible exception that up to two units of Red Blood Cells may be delivered to the PACU or ICU blood storage refrigerator.

It is the responsibility of the OR desk clerk to return blood to the Blood Bank. Red Blood Cells and plasma removed from a Core refrigerator must reach the Blood Bank or patient care unit blood storage refrigerator within 30 (revised 8/1/02) minutes of their removal from the Core refrigerator.

Any units that have not been properly stored must be tagged so that staff will know that they are not suitable for issue to any patient.

GUIDELINES FOR THE MANAGEMENT OF THE SURGICAL SCHEDULE DURING BLOOD SHORTAGES

No elective surgical procedure will be canceled on the basis of blood shortage until 10:00 p.m. on the evening prior to the day of the procedure. To prevent false rumors regarding the blood supply, no conclusive statement regarding availability of blood for an elective procedure will be made by Blood Bank personnel until the evening before the operation, although advisory information may be provided to the Medical Director of the Operating Rooms, or designee.

Just before 10:00 p.m. on the evening before the day of operation during times of short supply, Blood Bank supervisory personnel will compare the need for crossmatched units for elective surgical cases as defined in the Maximum Surgical Blood Order Schedule (MSBOS), or the preoperative physician's order for those procedures not listed in MSBOS, with available units of blood above minimal inventory levels. In an effort to provide blood for the maximum number of patients, group and type compatible, rather than group and type specific, blood may be used. Under no circumstances will group O, Rh-positive or group O, Rh-negative units be crossmatched for elective surgery if the inventory of group O, Rh-positive or group O, Rh-negative units is equal to or less than 35 and 8 units, respectively. The Blood Bank will perform routine pretransfusion processing of blood for scheduled patients whose blood type is not in short supply.

After notification that the demand for blood, as described above, exceeds supply, the Blood Bank Medical Director, or designee, will consult with the Medical Director of the Operating Rooms, or designee, as to management of the schedule of cases. The Operating Room Head Nurse and the Faculty Anesthesiologist on-call also must be notified of the blood shortage. Consideration should be given to the potential blood needs of those cases that might be substituted for canceled cases.

Cancellation of cases is the responsibility of the Chairman or Associate Chairman of the Department of Surgery, or designee, in consultation with appropriate department or section heads. The patient's surgeon must be notified as quickly as possible of any schedule modifications. "Admission Day of Procedure" patients will be notified by the appropriate surgical service if it is necessary to cancel their operations.

After the operative schedule has been modified through cancellation of cases, Blood Bank personnel will crossmatch blood for the first cases to be done. If the first scheduled patient's blood requirements are less than anticipated, previously canceled cases may be rescheduled.