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SA: Hello, and welcome to Master the MRCPCH. In this series, we tap into the expertise here at Great Ormond Street Hospital to give you an overview of a topic on the RCPCH exam curriculum. So whether you're revising for an exam or just brushing up on a need to know topic hopefully this podcast can give you the information that you need.
I'm Dr. Sarah Ahmed, a paediatric registrar and the current digital learning education fellow here at GOSH.
Today, we're talking to Dr. Anne Kelly about blood transfusion. Dr. Kelly is a consultant haematologist at Great Ormond Street Hospital and holds a number of national roles in blood safety, including working as an expert in paediatric and neonatal transfusion for NHS Blood and Transplant. We're going to be talking about blood transfusions, which maps to learning outcomes in the haematology and oncology section of the exam curriculum.
This episode will be split into two parts. In part one, we're going to cover patient blood management, including safe prescribing and transfusion thresholds. In part two, we're going to discuss major complications, risk management and rules around taking consent.
This is part two. Part one is already live and can be found wherever you get your podcasts.
SA: Can we talk a little bit about some of the complications that arise from blood transfusion? So what are the common complications that you need to be aware of as a paediatric trainee?
AK: Okay, excellent. So, suppose what I'd like to talk first of all, all about generally is adverse events from transfusion. And I think we can split these into errors and complications. So, errors. I think the key thing is around our previous podcast on transfusion is talking about getting it right in terms of the volume because one of the big things that we know with transfusion is if we can prevent the errors clearly that is one of the main things.
In terms of reactions, these are things that we potentially can't prevent in a child, but we just need to be aware of. Probably the commonest thing you might see would be a febrile, allergic or hypotensive reaction in a child. So I think if you are called to assess for a transfusion reaction, probably a temperature increase would be one of the commonest things that one comes across. And these are a form of acute transfusion reactions. That's one way of splitting transfusion reactions is into acute and chronic. And then also you can split it by the different types of reactions. So this is an example of an acute transfusion reaction.
And in fact the management and how we identify that should be directed by the symptoms and signs. So sometimes it might be a febrile transfusion reaction. Sometimes it might be more of an allergic type transfusion reaction with rash or lip swelling etc. Sometimes we might see a drop in or change in blood pressure following transfusion. We might see a whole range of different symptoms. And exactly how we're going to manage those will depend on what symptoms we're seeing. And all of your trusts should have a policy in place for how you manage acute transfusion reactions. If a patient develops a new symptom, then one of the first things to do is, to stop the transfusion temporarily and check the identification of the whatever's running, the unit that's running and the patients, the nurses will generally have done all that for you. Check the identity band, the compatibility label on the product, check that the product looks okay. And with mild reactions so whether you, for example, you've got a temperature rise of just one to two degrees, or a mild rash. You might, for example, be able to give just a dose of paracetamol and restart the transfusion at a slower rate. All your units will have policies about that.
Mild isolated allergic reactions can generally be treated with an antihistamine, for example. And generally we wouldn't recommend routinely using steroids unless, corticosteroids, unless you’ve got, you know, a more significant reaction. And most units will have a flow sheet to help you work out how to, how to, manage the reaction.
For severe reactions, one of the key things is to follow your local anaphylaxis policy. So essentially you'd be giving adrenaline you know, early use of adrenaline if you think you've got a severe reaction.
The other thing that we, we don't want to miss as well is a potential bacterial contamination, which is more common with a platelet product because it's kept at a warmer temperature in the laboratory. So, again, not common, but, you know, something to think about.
And then the other thing would be an acute haemolytic transfusion reaction. So that's, you know, one reason why we're checking that product matches the patient's risk and then making sure that that's all appropriate. And the exact management of the reaction depends on what's happening to your, your patient.
SA: So that's acute transfusion reactions. How do you go about managing a delayed reaction?
AK: So I think a delayed reaction, so this might be, for example, a patient that's had a transfusion and then gone home and then comes back in with, dark, dark urine or a drop in haemoglobin from the baseline, and I think this is really where you need to involve your local transfusion uh, laboratory and your transfusion practitioners. So transfusion practitioners are experts who will help you navigate what to do, and your haematologists as well. So you'll be looking at investigations in terms of the blood count, liver function, bilirubin, et cetera, reticulocyte count, and exactly what you do will depend on your investigations. You might be looking for the development of new antibodies in the patient. So very much being guided by what your transfusion laboratory is telling you.
There are also a number of other acute transfusion reactions that we need to think about. So we've spoken about febrile reactions. We've spoken about a bit about haemolytic transfusion reaction. One other big group that we see are respiratory complications of transfusion, so pulmonary reactions with transfusion. So these are broadly split into TACO, which stands for Transfusion Associated Circulatory Overload, and then non TACO. So, I think the exact classification doesn't really matter, but I think the key thing is if you think a child's developing a respiratory problem following transfusion, this is something that your transfusion laboratory, your haematologist and your transfusion practitioners want to know about.
So transfusion associated circulator overload is probably under-recognized in neonates and children. So generally what we see is onset of respiratory symptoms generally within the first 24 hours after transfusion. And often children have risk factors for this, so they've got other fluids running. They might have other problems like low albumin, abnormal renal function. Maybe preterm babies. Sometimes it might be that they've had a large volume, but sometimes it can also happen with a small volume. The pathophysiology is largely around increased hydrostatic pressure in the capillaries and the lungs, but also there may be some inflammatory element and endothelial element to it as well, but essentially the end result is a child who has symptoms and signs of fluid overload following the transfusion. And you might manage with furosemide or supportive care, etc.
In terms of non TACO respiratory complications there's also something called Transfusion Related acute lung Injury or TRI, very rare. But again, I think the key message is if you suspect respiratory problems following transfusion is to communicate with your transfusion laboratory and your haematologist or your transfusion practitioners.
Other potential complications of transfusion, which fortunately are very rare, are transfusion transmitted infections. So, you know, uncommon complication, but historically we know prior to a lot of changes in the blood service, you will have all heard about the infective blood inquiry. So I think, you know, blood is very safe, but it's not 100 percent safe. So when you're consenting for transfusion, you need to be aware that that there is still a very low, very, very low risk of transfusion transmitted infection. So, that's another potential thing.
And then there are very rare complications of transfusion. And one example for this where the actual pathophysiology is poorly understood and the kind of causation is poorly understood would be transfusion associated necrotizing enterocolitis. So this is necrotizing enterocolitis that's temporally associated with transfusion. So I guess the key message is that anything that a patient develops that's temporally associated with transfusion, then, your transfusion laboratory or transfusion practitioner will be interested in that.
SA: Which I think leads us on quite nicely to talking about SHOT. S H O T. Can you tell us what SHOT is and why it's important?
AK: SHOT stands for Serious Hazards of Transfusion and it is the UK's haemovigilance or Blood Safety Organisation. It's the independent organisation, it's affiliated with the blood service, for example, but it's the way that we collect information from all of the trusts in the UK around both errors and reactions with related to transfusion. And it produces an annual report summarizing these errors and reactions and pulls out learning points every year to feedback to trusts about potential things that can be changed and things that can be improved in terms of blood safety.
SA: So if someone has a reaction, does that go to SHOT?
AK: So what happens is that if somebody has a reaction, it should get reported via your local trust reporting policy. So many trusts, they would, if you have a transfusion reaction, there'll be either a form that you fill in, or there will be a process within your trust about how you report a transfusion reaction. And then it will be escalated through to your transfusion practitioner or your transfusion laboratory, and they do the reporting for you to SHOT. So they may come back to you to ask for further information. But you yourself, you don't need, you don't report to SHOT. It happens automatically. And it's essentially, it's a, it's a voluntary scheme, but it's professionally mandated. So laboratories report any and all of these through to SHOT, the reports all get analysed and an annual report has been published. And it's been running now for over 25 years. We've got a lot of data around transfusion safety and, you know, improvement over time in terms of transfusion safety.
SA: Amazing. I'll make sure to put the the website in the description where people can go to find out more.
AK: The other thing I think is really important, particularly in paediatrics and neonates, is correct identifications of patients. So, we know, based on error reports to the blood safety organisation, we know that there are situations where we have, for example, the wrong blood in the tube, where the wrong patient's been bled, or the wristband's not been on the patient or a mix up of twins, or mix up between cord blood and maternal bloods at delivery. So, I think the other thing, particularly important for transfusion, but actually for everything, for giving medications, for looking at blood, taking blood samples, like a full blood count or a U&E in a patient, we need to make sure that we've got the right patient. So I think correct patient identification, correct use of wristbands, labelling of samples next to patients. You know, number of times we pick up areas where we've got two group and save samples and we pick up and the laboratory saves a child from having an incorrect transfusion because of a historical blood group. And all of this is really, really important for transfusion.
SA: Yeah, absolutely. You mentioned consent earlier, and I just want to round off by talking a little bit about consent. Should we be taking written consent for all transfusions?
AK: So the current recommendations which actually were published in 2020 come from SABTO, which stands for the Safety of Blood, Tissues and Organs. And they published an opinion on the position on consent for blood transfusion. So, at present based on that guidance document formal written as in signed by the patient consent is not required for blood transfusion. However, it is required that you take your patients through a process of informed consent for transfusion. So you need to explain to them why the child or the young person's having a transfusion. You need to explain, so the rationale for it, you need to explain to them the risks and benefits, the alternatives and you need to document that. So some trusts may have that documentation as part of their prescribing process. For regularly transfused patients on trust may just have a reaffirmation of consent, but it's recommended that consent is recorded somewhere. And I think in the light of the Infected Blood Inquiry, I think it's even more important that we make a record that families have consented for their child to receive a blood transfusion.
SA: Yeah, absolutely. And most trusts will have a patient information leaflet that you can give to families as well.
AK: Exactly. There is actually a national patient information leaflet which the NHS Blood and Transplant have developed. And this is applicable, it is designed to be applicable to all ages. So it's got language that will apply to adults and also to parents of children.
SA: Anne, thank you so much for what's been actually a really comprehensive overview of blood transfusion. We've mentioned resources a couple of times. Are there any useful resources that you would recommend?
AK: Yeah, there are some excellent resources. So the first one I'd like to highlight to you is the Blood Components App. This is an excellent resource. It was created by NHS BT patient blood management team. And it was developed with input from the National Blood Transfusion Committee and the British Committee for Standards in Haematology, and it goes through for neonates, for infants and children, and for adults, all of the things we spoke about in terms of thresholds and volumes for red cells, platelets, FFP, cryo, and it's an excellent on the spot resource for things. Again, just check that it aligns with what your local trust guidelines are, but, it's based on the British Society of Haematology Transfusion Guidelines for Children. These are the ones that are currently being revised and so when they're revised the app will be updated to reflect the new guidance because as I said there's a little bit of change particularly and there will be a little bit of change in some areas because there's been some key trials coming out in, particularly in neonates since the last guideline. So that's the first thing, Blood Components App.
The second useful thing are the actual guidelines. They're quite long, but if you want some detail and you're particularly interested in transfusion, the British Society of Haematology website has links to the guidelines and it summarizes everything about transfusion in this age group.
There is also on the British Society of Haematology website, there is irradiation guideline, which summarizes who needs irradiated products.
And if you're interested in safety of blood products, the SABTO website, the Safety of Blood, Tissues and Organs website has some links in terms position statement on CMV negative products, position statement on consent. And it's really very useful.
And in terms of other websites and so that the SHOT, the Serious Hazards Of Transfusion website is also really useful. So on there, you can see the annual reports, you can look at the paediatric chapters, so you can read about case studies, you can see where things have gone wrong from people and what we can learn about from errors and particularly I think near misses, it collects data on near misses so you can see where things nearly went wrong. And it also has a whole separate paediatric section, so in there there's something called a SHOT bite which is a very short thing about key messages for paediatrics. it has some information it has a paediatric video summarizing some of the key learning points from SHOT paediatrics over the last 10 years So, I think that's a really useful resource.
NHSBT patient blood management website has some very useful resources around patient blood management. There are also resources on the National Blood Transfusion Committee, and there is some links to some educational resources from that website as well.
SA: A veritable plethora of resources and I will make sure everything is linked down below.
AK: Excellent, brilliant.
SA: So finally, to wrap us up, what would be your three takeaway learning points?
AK: I think my key takeaway learning point, number 1, would be prescribe in mls for children and make sure that you are adhering to your local and national guidelines for transfusion thresholds.
Number two would be, optimize your patient and use patient blood management strategies to actually try to avoid transfusing children and babies where you don't need to.
And my third key point I think really would be, I guess, appropriate use of tranexamic acid. This is more relevant for surgical patients, but we know for patients who are going to have significant chance of receiving blood products during surgery, that tranexamic acid can significantly reduce the risk of bleeding.
SA: Anne, thank you so very much for talking with us today. This has been so very informative. Thank you.
AK: No problem.
SA: Thank you for listening to this episode of Master the MRCPCH. We would love to get your feedback on the podcast and any ideas you may have for future episodes. You can find link to the feedback page in the episode description, or email us at
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