Good evening and welcome to tonight's webinar, brought to you by Pet Blood Bank. I'm Rich Daley, head of partnerships for the webinar vet. I'm delighted to be your chair for this evening.

As you can tell from my title, I do not have a veterinary background. So when it comes to the questions at the end, and you're typing them in, please do just consider that and, any shorthand if you could just explain that for me. I've learned a bit over the last couple of years, but I'm still picking things up.

So, any questions you have, if you can just put them in as, plain or English as possible for me, I'd really appreciate it. So Pet Blood Bank is the UK's only charity that provides a canine blood bank service for all veterinary practitioners across the UK. And as I say, we're delighted that they're sponsoring tonight's webinar for you all.

Before I introduce tonight's speaker, I just thought I'd go over some housekeeping. So for those of you joined before. You know, the drill.

We work through the presentation. We ask you to put questions in the Q&A box. If you're not sure where the Q&A box is, if you go to the bottom of your screen, you should see it says Q&A.

Just click on that and then you can type in your question, and there'll be some time at the end for us to be able to post the questions to Charlotte, who's our speaker tonight. If you have any issues during the presentation with sound, or the, visual side of things, my colleague, Libby is on hand, so you can contact Libby either by once again at the bottom of the screen, clicking on the chat box and typing your query in there. Or alternatively, if you email office at the webinarvet.com, and Libby will be on hand to answer your query that way as well.

So, as I say, I'm delighted that we're joined tonight by our presenter, who is Charlotte Fennell. Charlotte is gonna be talking about the registered veterinary nurse's role in transfusion medicine. Charlotte studied at the Royal Veterinary College in 2011 till 2015 for the BSC honours in veterinary nursing.

She's worked in busy first opinion hospitals and predominantly current referral hospital. Which is the Southfield Specialist referral centre. Charlotte has spent the last two years working there as an internal medicine nurse.

Charlotte has recently passed her vet's now emergency and critical care certificate to support her work in referral and further her knowledge. Charlotte is responsible for assisting with the organisation of blood transfusions, including maintaining stock, patient transfusion, monitoring, and assisting other staff with these procedures. So without further ado, I'd like to hand over to Charlotte.

Hello, thank you. So good evening, everyone. As you can see this evening, we will be looking at the registered veterinary nurse's role in transfusion medicine.

And I'll be taking all the questions at the end of the presentation with my email address on the slide for your reference. OK, so the learning objectives of this webinar will be to look at the availability of blood products, how we collect blood, how we then store this blood that we've collected, the preparation and set up of the blood transfusions itself. The monitoring of the blood transfusion and finally we'll take a look at some of the common transfusion reactions that we may see.

OK, so before we start the webinar, I just would like to take a quick vote to establish how many of you are currently giving blood transfusions to patients in your practise. And that's whether that's whole blood or plasma. If you could just vote yes or no, that would be great.

Thank you. Without me having to say anything, they're already off voting, so that's great. Yep, the box has popped up, so please just select yes or no.

As I say, this isn't counting towards any CPD. It really is just to give Charlotte an idea of what sort of level of experience you've got in terms of blood transfusions in your practise. Anyone else can just put a couple of more?

Don't worry if the box hasn't popped up, you've got any difficulty there, . My, it just gives us that indication. OK, we'll end the poll in there.

So, 66% of people attending Charlotte have said yes, they do blood transfusions in practise. And so obviously, 34% say no, they don't currently underperform blood transfusions in their practise. OK, thank you.

So that's, that is interesting. 66% is fairly high. So we're gonna go through the webinar and hopefully those of you that are doing the transfusions, hopefully we can add to your current knowledge.

And for those of you that aren't participating in blood transfusions, perhaps it's something that with this webinar you can take forward and, and expand. And before we take a look at the products available to us, it's important to first remember why we may need to give a transfusion and which cases should trigger this thought process. So when we see patients come to the practise, there should be some triggers that, that make us think, does this, will this patient require a blood transfusion?

So first of all, we can think about the patients with a decreased red blood cell circulating volume and also patients with clotting factor deficiencies. These are our main considerations that for patients that may be requiring a blood transfusion. OK, so first thing we're gonna take a look at of our learning objectives will be the availability of blood products to us.

So there's an extensive list of canine blood products available to us in the UK for which we are very fortunate for. As you can see, there's a long list and these products are available from Pet Blood Bank, with the exception of stored whole blood. And they can be purchased for stock purposes or urgent delivery from Pet Blood Bank.

And each of these products will be discussed further throughout the presentation. Unfortunately, feline blood is much more difficult to obtain in the UK, and currently we can take the freshhold blood from our donors that we would see in practise, so whether that's the clients, other animals that they have in their household, family and friends, or sometimes even staff animals can become blood donors for us. Petlove Bank have advised me that in the early of 2020, they do plan to start their feline donor programme, which will adhere to the same guidelines and patient welfare standards as their canine programme.

So we do need to just watch this space, sit tight and, and wait and see what they can, they can offer. OK, so now we're going to take a look at each product individually and how it's obtained. I think it's really important to understand how we get each product, and then we will understand how best to use this.

So we start off with fresh whole blood. That's the, the product that we can take from our donors. So from our dogs and cats, we take the blood and we have, we have obtained fresh whole blood.

We can then store this for 8 hours and then this becomes stored whole blood. From these products at Petlo Bank, they will then spin the threshold blood. And separate the pack red blood cells.

And from that we can have just a unit of pack red blood cells that we can give to our patients. When the fresh whole blood is spun, we have separated the pack red blood cells and then from separate from that we then have our fresh frozen plasma that can be taken off. Fresh frozen plasma can again be stored for 1 year frozen, and then it can then be stored for a further 4 years after that and be named frozen plasma.

We can further spin our fresh frozen plasma products to obtain our cryoprecipitate and our cryosupernatum. Products. It's important here to remember that from one unit of threshold blood, this one unit can give us multiple uses for even fact multiple different patients.

And we can treat different patients from the one unit. OK, so first of all, we're gonna take a look at freshhold blood. And so as I said, the threshold blood is taken from our donors, that's a donor list or a do from family and friends.

So the threshold blood contains red blood cells, white blood cells, platelets, and clotting factors. The indication for using freshhold blood would include patients with anaemia, severe haemorrhage such as hypovolemic shock, and sometimes DIC. And as I've already explained, this can come from our donors or in fact pet blood bank.

Freshold blood should be stored at room temperature for a maximum of 8 hours. For these 8 hours, it can be named freshold blood. So stored hold blood is not available from Pet Blood Bank themselves, however, we can obtain stored hold blood from when we have taken blood from a donor and perhaps not used it in that instance.

We can then store that. And keep it for a later date. So stored whole blood contains red blood cells, white blood cells, the vitamin K dependent clotting factors, and non-viable platelets.

Again, similar to freshhold blood, this would be used in a, in an anaemic patient or patient with a coagulopathy. And this can be kept stored in the fridge for a maximum of 28 days. This can be stored and kept for the 28 days as long as the product has been handled correctly and aseptically at all times.

So this is a unit of pack red cells that you can obtain from pet blood bank. This contains red blood cells and white blood cells only. The indication for this again would be anaemia.

Just an important point here. I've put here to include normal volemia. So if we have a patient that we just need to give red blood cells, for oxygen carrying capacity, it would be beneficial to give red blood cells as opposed to freshhold blood.

And then we would not be at risk of overloading them with such a large volume. We can give them exactly the product they need for their condition. This product is also indicated in neonatal isoyrolysis, .

This product is obtained from Petlo Bank and can be obtained in an emergency situation or for stock. And one of the other benefits of this product is that it can be just stored for that bit longer so it can stay in our fridge for 42 days. So before looking at our plasma products, I think it's important to understand as nurses, the components in our plasma products and how they're used to treat our veterinary patients.

One of the most common cases that we would use plasma in is rodenticide toxicity. Where the vitamin K dependent clotting factors are depleted. The vitamin K dependent clotting factors are 279, and 10.

All this information can be made a little bit clearer when we take a look at the coagulation cascade. Here, so we routinely in our practise would measure the PT and the APTT on an in-house machine, and it's an increase in these times as a result of a depletion of clotting factors that we would see commonly in reddeny toxicity. With rodenticide toxicity, the first change seen in the clotting factors would be an increase in the PT.

So this is a result of factor 7 having the shortest half life. Therefore, if we had a patient that we suspected would incy toxicity based on the history and the clinical signs that they present with, an increase in PT almost confirms this as a diagnosis. As RVNs we should be aware of the common clinical signs and the main biochemical and haematological changes that we see in our patients.

In this way, we can be more prepared for these cases on their arrival, and we can treat them as effectively and efficiently as possible. So plasma can be stored as fresh frozen plasma and frozen plasma. So first we'll look at fresh frozen plasma, so fresh frozen plasma contains all clotting factors.

With minimal albumin. It's an important point to note that these products shouldn't be given just to replace albumin, as the volume of of albumin that they contain is minimal. Fresh frozen plasma would be indicated in the in the coagulopathic patient or the patient with von Willebrand's disease.

Fresh frozen pla plasma can be obtained from Petloo Bank and is kept frozen until ready for use. So frozen plasma. It's simply fresh frozen plasma that has been stored frozen for 1 year and then the expiry of the fresh frozen plasma, after 1 year, and we can keep the frozen plasma for a further 4 years.

Frozen plasma is the superior product of choice for our denticide toxicity patients and again can be sourced from Petlo bank and kept frozen until use. So our cryoprecipitate and cryos supernatant products are produced from Further spinning of the fresh frozen plasma. So our cryoprecipitate contains factor 8 from Willebrand's factor and fibrinogen.

This product is commonly used as a pre-treatment for von Willebrand's disease or haemophilia A prior to invasive procedures or active bleeding. Again, this product can be sourced from Pet Blood Bank and is kept frozen until use and will last for one year. Cryosupernatant contains albumin and the vitamin K dependent clotting factors and would be indicated in our identified toxicity cases that we see.

And again this is kept frozen for one year until we're ready to use this product. OK, so we've reviewed the blood products that are available to us. I'm aware that that was a fairly whistle stop tour.

So that all the information is readily available to yourselves on Pet Blood Bank's website about the products, what each product contains, and I think it's a great reference for us all to go back and look at, especially when we have the cases come to our practise, we can take a look at the table they have and, and see which product would be best for our patients. We're now gonna take a look at how to collect the blood from our donors. OK.

So as you can see, there's quite an extensive criteria for to meet for our donor selection. So this includes things such as being within 2 to 8 years of age. They need to have numerous blood tests performed before donation, so include PCV total protein, haematology, biochemistry and electrolytes.

And we perform an IDEX4DX snap test, which is to test for infectious diseases. And we also perform the angurombulus, so that's the lung worm snap test. They need to be of a good size, so over 25 kg, up to date with flea and worming treatment and vaccine status, and they will always have a complete health check performed by a veterinary surgeon who will deem that that patient is suitable and a full health prior to donation.

So the list for feline donors is fairly comparable to that of our canine patients and the process is also fairly similar, so they need to be again between 2 and 8 years of age with a complete health check performed by the veterinary surgeon and deemed in health. For donation. They need to have similar blood tests again and the slight difference here is that if possible and we have enough time, we would like to perform the mycoplasma PCR and we will also perform the FELV and FIV snap test in-house.

We also want to make sure that they have not had a transfusion, any transfusion history, the same as our canine patients, and again, they need to be of a good size, so at least over 4.5 kgs. It's a key consideration when we think about the blood volume that we're taking from our patients.

Another consideration actually which we need to think about is we need to make sure that they're not on any sort of long term medication for any other treatment, so that all needs to be checked, prior to donation. So before starting the blood collection, I think it's really important as RVNs that we're prepared for this procedure. So this would include a good understanding of the procedure itself and the equipment that we need, if in order for us to perform this as best as we can.

So as with any venal puncture, we would need to clip and prep the site. The person performing the venal puncture should be wearing gloves. We need at least 3 people for this procedure.

We need the phlebotomist. We need someone for restraint, and then we have the other person to agitate and weigh the collection back. So if you just want to sort of take a look at the list of equipment, I've also popped in there that we should always have emergency equipment readily available.

So that would include things like IV catheters ready if they're not already in the patient. Endotracheal tubes and emergency drugs available such as adrenaline and atropine just on standby just in case. OK, so then I've bullet pointed here the canine blood collection process.

So essentially the main things to take from this is we need to be in a separate room, away from all the noise because it's a procedure that can take. From 15 to 30 minutes depending on your patient and depending on the staff and so it's something that we need to have the time and the space to do. So we need to restrain our patients, often in lateral recumbency, .

As they prefer, and as I said, we need to have the phlebotomist and someone agitating the bag for us in addition to the person restraining the dog. So as with any venal puncture, the jugular is aseptically clipped and prepped and as you can see in this photo, With the phlebotomist is holding the gloves and we have the needle in the jugular, we need to make sure that the tubing is clamped until we confirm entry into the vessel. This ensures that it is kept as close procedure as possible for as long as possible.

We also need to make sure that the bag is lower than the patient and that someone is agitating it sort of through throughout the procedure. The bag will be filled with anticoagulant, but we just need to make sure that there is, there is mixing of the blood, and we are regularly weighing the bag so we know how much we have taken from our donor. Once we've got the correct volume that we wanted to take from our donor, we can clamp the tubing and remove the needle from the vein and apply pressure to this site.

We would then bandage place a sort of a Bandage around the neck and keep that on for 30 to 60 minutes just to prevent any hematoma forming there. We would then need to label our bag immediately with a donor ID the the donor's PCV and total protein, the date of donation, and The initials of the staff involved with this donation. So feline blood collection requires slightly different equipment and preparation as the blood is collected in 20 mL syringes rather than a closed bag collection system as we've just seen with our dogs.

So I've listed the equipment here, so we need the 320 mL syringes that are pre-filled with our CPDA. So the CPDA is our anticoagulant that we can take from, from a bag and we can prime our syringes and our extension set with the anticoagulant such that when we are in the vessel, once we draw back, the blood is not going to clot in our extension line. Again, it's really important that we have at least 3 people for this procedure.

So again, we need the person performing the venal puncture. We need at least 1 person for restraint. And then in the ideal world, we have another pair of hands for either extra restraint or assisting with.

Taking the syringes once they've been filled with the blood. So as you can see in this photo, we've got a butterfly butterfly craft being used here into the jugular. That's, that's what we most commonly use in our practise.

I believe it I think it works well, and the extension that allows you some, some room. Yeah When we take blood from our feline patients, we should always have an IV catheter in them, and sometimes they do require sedation. So if we were to sedate a feline donor in practise, we commonly use a ketamine, midazolam, and buttrophenol combination.

So we use 3 milligrammes per kilogramme of ketamine, 0.2 milligrammes per kilogramme of midazolam, and 0.2 milligrammes per kilogramme of phil.

And we find that this works quite well. We give this off an IM and then we're able to place the catheter. Prior to starting our procedure and as I said with our canine patients, we make sure that all of our emergency equipment is readily available to us.

So this picture here actually shows the venna puncture being performed in sternal recumbency in feline patients. As I said, it is obviously. Whoever is performing this procedure, they obviously need to be comfortable.

We need to make sure that our cats are comfortable. We need to do this as safe as possible for our patients and for the phlebotomist. So we fill each syringe in situ with a clamp.

So on this photo you can see a three-way tap, and so that can be turned off until we are in the vessel and then turned on once we're in, and then turned off again before we disconnect the syringe. This way we can keep the system as closed as possible and as handled as aseptically as possible. It's important again, so with our canine patients we spoke about rocking the bag and ensuring that it's, it's agitated.

With this, we just have to gently agitate our syringes just to ensure that all the blood is, is well mixed with our anticoagulant. OK, so now we've looked at how to collect the blood products from our canine and feline patients. We're just gonna take a quick look at a summary of how to store each product in our practise.

So stored whole blood should be kept in the fridge and can be kept for up to 28 days as long as it has been handled aseptically throughout. And is kept refrigerated at this temperature. Our freshhold blood, so that's the blood that we've taken immediately from our dog or cat donor, and this can be kept for up to 8 hours and is kept at room temperature.

So we would normally be taking this blood from our donor in an emergency situation, and it's normally used immediately. If anything was to change, that's when we then take our blood product. We can store it in the fridge for up to 28 days, however, it then does become stored whole blood and not fresh whole blood.

So our pack red blood cells that we obtain directly from Pet Blood Bank, these are kept refrigerated and stored for up to 42 days. Fresh frozen plasma is kept frozen for 1 year from the date of collection and is stored at -18 degrees or below. Our frozen plasma is stored for a further 4 years after the fresh frozen plasma expiry date and is again stored at -18 degrees or below.

And finally we have our cryo products again stored frozen and last one year from the date of collection. So now we're gonna take a look at the preparation and the setting up of blood transfusions. So first let's have a quick look at some general points with regard to handling our blood products that we need to consider.

So we need to ensure that they've been stored at the correct temperature. If we're storing these blood products on site, it's really important that they are kept stored correctly so that they can be used in the optimal conditions. They need to be handled aseptically at all times, so whenever handling any blood products, we should always be wearing gloves, just to keep things as clean as possible.

We need to be careful with our frozen products as they can be brittle. So we need to be careful not to knock them or drop anything when handling them. We need to keep a record of the blood products in practise and on the patient records.

So, in our practise, we have a list of all the blood products that we have in the building, and then when that blood product is taken from the fridge or the freezer, we can then record this on a hard copy in addition to it being recorded on the patient's electronic details and patient monitoring sheet. This is a drug that we are giving to our patients, so it's really important that we have a record that our patients have received this product. And as I've previously mentioned, we need to make sure that the products are clearly labelled with the date of collection, expiry, donor ID, blood type, volume, and donor.

PCB and total protein, that's if we've taken that ourselves. OK, so before starting a blood transfusion, there are some pre-transfusion monitoring and tests that need to be performed and considered before we can start. So we would need to take the patient's vital parameters, so that's the temperature, pulse, and respiration and the blood pressure, and assess theiration just so that we have a baseline before we start so that if the patient's status changes, we have something to compare this to.

All patients should ideally be blood type before receiving any blood product. Cross matching should be performed if they have a transfusion history of greater than 3 to 5 days. We should take a baseline PCV in total protein so that again we can compare once we've given the transfusion where we are at, and this can help assess our patient's status.

We do need to consider all blood products available to us, as I previously mentioned. If we do only need to give red blood cells, we can, we should be considering our pat red cells so that we do not overload our patients with larger volumes of products than we need to, so we can keep this as safe as possible for our patients. We need to have somebody assigned to monitor the transfusion.

It's really ideal if we can have one person assigned to that patient so they can keep a close eye and they'll be the first to notice any change in that patient. And we need to make sure we have a designated and patent IV catheter. In these patients.

So this is a blood typing kit that we're using in-house for dogs and there's a similar one for cats. So basically we use the EDTA blood, we use our test strip, we pop that into our blood. There's a nice set of instructions here that you can see.

We use 3 drops of the buffer and then we pop our card in. The blood is drawn up the card and it will then nicely tell us whether our patient is DAA DEA1, positive or negative. So as RVNs I think it's important that we should be aware of why we perform blood type in in our patients.

So a patient's blood type is determined on the surface cell proteins that the antigen. And some patients will have circulating antibodies to these antigens. So if incompatible blood is given, this may result in a transfusion reaction.

Which is what us as RVNs will be looking out for. So in dogs, there are many blood types documented, however, the most antigenic type is the DEA1, and the universal donor of our dogs is negative. There are other blood types that we can send to the lab and have tested.

However, this is not gonna be done in an emergency, so routinely in practise, we are testing for DEA1 positive or negative only. So the cat's blood types are again completely different to those of our canine patients. They will have type A, B, or AB.

The major difference is that cats have naturally occurring allo antibodies, therefore they must, must, must receive type specific blood. I think that's something that we all need to remember. So cross matching, as I previously mentioned, is a test that's performed.

We can perform it in-house or we can send them off to the lab. Often if we have an emergency, we would be performing this test in-house. And this should be done in any patient that has had a transfusion that has a transfusion history of greater than 3 to 5 days.

It can be quite a long procedure. It's something to definitely familiarise yourself with if you do have the kits in-house and there are step by step instructions and then we can check whether there is likely to be a. Compatibility between our donor and re recipient.

So here is just some images of a blood transfusion in our practise. We can see that the blood is hung on the drip sand and is being given through the drip pump. And we can see on our patient that we don't have any bandage on our catheter, so we can clearly determine that the catheter is patent and that the blood is being administered correctly.

OK, so I've just included a checklist here that we use for our record in practise, just to make sure that we have everything ready for our transfusion. I think it's important we need to be as prepared as we can so that the transfusion will run as smooth as possible. So when we prepare the transfusion before starting the transfusion itself, we need to calculate the volume that our patients need to receive.

There are a couple of different calculations that we can use. Although this is predominantly the veterinary surgeon's responsibility to inform us of the volume that we need to be given. I don't see any harm or any reason as to why RVNs should not be aware of these calculations, and we should always be double checking each other's calculations and making sure we understand how much we're giving and why we are giving this volume.

So first of all, we can take a look at the blood volume. So that's the meals per kilo, so roughly. 60 to 90 mL per kilo for.

Dogs and cats, we multiply that by our desired PCV. Minus our actual PCV and divide that over the donor's PCV. This calculation works effectively when we have all this information.

So however, when we don't have this information, we can use this calculation here, which is 1 mL per kilo of pat red cells, is required to increase the patient's PCV by 1%. If we were using fresh whole blood, we would need 2 mL per kilo of the threshold blood to increase the patient's PCV by 1%. So as you can see, we need twice the volume of threshold blood to raise the PCV by the same percentage in comparison to that of pack red blood cells.

When preparing the transfusion, the entire process should be treated with strict asepsis and an appropriate philtre needs to be attached. That's either through the given set that's going straight into the bag or an extension set with a philtre attached to the end. We need to make sure there's no air in the line or any contamination, and as I've previously said, we need to always be wearing gloves for this.

So the feline blood administration differs slightly compared to viral canine patients where the product is given through a syringe driver. This will allow a better accuracy of the rate that we're infusing and the volume to be infused. So our blood will be given, whether we've collected it from the feline patient or we take.

The pack red cells and we separate them out of the syringe, it will always still be given on a syringe driver with an extension set. The syringe in the syringe driver should be clearly labelled and again we still need to have that separate IV labelled for this process. So I'd just like to make a quick point that we just need to know there's not enough recent evidence to suggest that drip pumps damage the red blood cells on delivery.

Therefore, in our practise, we are currently giving the blood with a Baxterg set with a philtre already in that line, and the drip pump is calibrated with this given set and this is working well in our practise. Just for, to make you all aware. So when we look at the rates, we need to first start off at a slower rate.

So we're gonna start off at 0.5 to 1 mal per kg per hour for the 1st 15 to 30 minutes with close observation of our patients for any signs of transfusion reactions. If the patient remains stable without a sign of a reaction, this rate can be increased to 4 to 6 mL per kg per hour, such that the whole volume to be given is given within 4 to 6 hours.

However, the emergency haemorrhaging patient may well receive the blood faster as directed by the veterinary surgeon to treat hypothalemic shock, for example, as a result of large volume blood loss. But this should be communicated within the team. So now we're just gonna take a brief look at the monitoring of our patients when they receive a blood transfusion.

So before we give the blood transfusion, we've already got our baseline vital parameters, our temperature pulse, respiratory rate, blood pressure, mentation, and then this monitoring is then repeated regularly throughout our transfusion. And it's changes and it's changes in these parameters that will alert us that something is perhaps not quite right with our patients and that's when we then need to intervene. So we have our baseline parameters.

We initially start our monitoring every 15 minutes, and if the patient remains stable with this blood product, we can then increase our monitoring to every 30 minutes. And as I've previously mentioned, we need to record everything onto the monitoring sheet and the electronic records. So here I've just included a picture of the blood transfusion monitoring sheet that we're using in our practise.

So on the left we can see a space to record donor information. So that's here and the volume that's going to be transfused, so that should be clearly written before the before the blood transfusion is started. And on the right we have a reminder of the rate at which the transfusion can be given.

I think this is important to have all of this information on one page because when we're given blood transfusions in practise, it's commonly for an emergency, so I think it's good that we have everything in front of us just so we can have a reminder. In the middle at the bottom there we have the clinical signs of transfusion reaction again to remind us and we'll be taking a look at this shortly. So here I've just got a reminder of some important considerations when we're giving blood transfusions.

So we need that sole use for the IV catheter and we cannot co-administer heart and solution. This is because the Hartman's contains calcium and the calcium will precipitate with the anticoagulant in our blood products. And we should never be giving cars through this line.

The catheter should be labelled blood so that it's clear that only blood is being administered through this catheter at this moment in time. And when we're flushing these catheters, we should be flushing them only with saline well before and and after administration of the blood. We should remove all bandaging from the catheter and ideally have a 1 to 1 patient monitoring system if we can.

OK, so now we're aware of what we're going to monitor during the blood transfusion. We're gonna take a final brief look at the main transfusion reactions that may occur, and the clinical signs of them and what we're going to do after we have seen these. OK, so an immunologic reaction is where the immune system of the recipient has a reaction to the donated blood.

This can be of an acute or delayed onset reaction. Acute immunological reactions include hemolytic. Bearial and for brow non-hemolytic.

Delayed immunologic reactions can be delayed hemolytic or post-transfusion puripura, where the body has produced allo antibodies to the allergenic transfused platelet antigens. As a result, the patient's platelets are destroyed and this will lead to thrombocytopenia and a decreased platelet count. So our non-immunologic reactions are simply a reaction that does not involve the patient's immune system.

Again, this can be an acute or delayed onset. So our acute non-immunologic reactions include an anaphylactic reaction. So hypocalcemia as a result of citrate toxicity, so that's in our anticoagulant.

Circulatory overload. And hypothermia. And a delayed reaction would be as a result of infectious disease transmission and is seen slightly later on.

As RVNs, it's important to be aware of the possible transfusions to look out for, so that the earliest intervention is possible. It's really important because it's most commonly gonna be the RVN monitoring these transfusions. So we do need to know what clinical signs to look out for and what might be happening with our patients with this drug that we are administering.

So there are numerous clinical signs unfortunately making our job a little bit more difficult that can be observed during blood product transfusion. So we've got here fever, tachycardia, dyspnea, vomiting, hemoglobinemia or haemoglobin urea. Urticaria, erythema, muscle tremors, and ECG changes.

So that's why we always need to have our baseline vital parameter assessment first so that we can identify changes. Some patients may present pyrexic already and then the temperature increases, or we may start with a normal thermic patient, which needs to be monitored closely. So what's the next steps?

Once we've observed that the patient, there has been a change in the patient's status in the clinical signs, we we need to be aware of our next steps. So first things first, we need to stop the transfusion immediately. If there is any concern that this patient has change in mentation, its vital parameters have changed, there's vomiting, any changes at all that we're concerned about, we need to stop this transfusion.

Then we need to obviously alert the veterinary surgeon responsible for this case so that we can communicate our concerns, report the changes that we've seen. We will have been recording the vitals throughout the transfusion and it's, it's often a change in this that will alert us that there is a problem. We should record whether the patient has vomited past urine or faeces.

So that we can give all this information to the veterinary surgeon and they can then make a decision for subsequential treatment. The following treatment might include to stop the transfusion, give fluid therapy, steroid or antihistamine therapy in the case of an anaphylaxis reaction, for example, and sometimes we may end up administering calcium gluconate in the event of hypocalcemia. So we would first monitor for our hypocalcemic clinical signs.

And then we would obviously have to take a blood sample to measure our calcium and then we can go from there. The most important thing we need to do here and remember is if we have any concern, we need to stop the transfusion and alert veterinary surgeon responsible. So in summary, I just wanted to recap on the RVN's role in transfusion medicine.

So we are heavily involved in transfusion medicine and I think it's something that we can play a vital role in. So we will start by monitoring the patient, administering the blood product, alerting the veterinary surgeon of any transfusion reactions. So yeah, we're really heavily involved with this, and I think therefore we need to have a good understanding.

Of this so that we can nurse our patients effectively. So we're also heavily involved in our practise of storing the blood and our donor access. It will often be the RVN to obtain the blood product, whether that's from PET blood bank or trying to obtain a donor.

So as RVNs again, we need to be aware of our donor criteria, for example, and the tests that we will be performing in these patients to ensure that we have the best donor possible. As I've also previously mentioned, it's often the RVN that will be monitoring these transfusions for the duration. So we need to be aware of the clinical signs that may change and what we need to be looking out for.

And finally, it's, it's not that we give the blood transfusion and it stops there. It's not, that's not how it will be. So we will continue to monitor our patients for the next day and the next day after, and whether they then need another blood transfusion or they have responded well to our treatment.

The treatment continues and the monitoring continues. So I think it's really important that the RVN has sound understanding of, of the process from start to finish and understands about how heavily involved we can be with them. So I've just included for you, just to finish up some references that I have found useful whilst working with our transfusions at Southfields.

So we've got the BSAVA ECC menu. We've also got this manual here of the veterinary transfusion medicine and blood bank. It's really useful.

And of course, we have the Petlo Bank website that has got some nice flow diagrams and some charts to let you know which product contains what and when they would be indicated and best used for different cases. OK, so I'd just like to say thank you for listening. If you have got any questions that you would like to email me, my email is at the bottom, so it's Charlotte.

Fennell at Southfields.co.uk.

I'll be happy to get back to you if you have anything at a later date or if you have any questions now. Fantastic. Thank you very much, Charlotte.

That was a brilliant, talk and I gave lots of detailed information there that I'm sure people will take away and put back into their practise. And hopefully, some of you who don't currently perform blood transfusions in practise may feel a bit more comfortable in terms of the process and may want to look at then how you actually do offer that in terms of in your practise going forward. So, really well done.

Thank you very much, Charlotte. We have had questions coming through, while the presentation has been going on. So, we will get to them shortly.

Just, a little bit of housekeeping at the end of the webinar, a little pop-up box will appear in your web browser, asking you to complete a couple of questions for the feedback. So that's both to feedback about the presentation, but also there's a couple of questions there. From Pet Blood Bank as well.

And as they've kindly sponsored tonight's webinar, please do take some time to complete that questionnaire, as it will really be, useful for Pet Blood Bank and our programme as a whole. So, on to some of the questions. Sophie's asked, does the sedation not alter the blood pressure when you're performing transfusions?

OK, yes, so obviously we do sedate sometimes our feline patients most commonly as opposed to our canine patients. And yes, blood pressure is something that can be altered with sedative medications. So it's something that is monitored during our donation process, so we would keep an eye on our patient's blood pressure and if that was to drop, we would obviously need to intervene with appropriate treatment.

As directed by the veterinary surgeon, commonly that would be treatment with doing therapy, but yes, absolutely it's something that we need to keep a really close eye on, in our, in our patients. Thank you. And then sort of follow on from that, Diane's just asked if you could, repeat the suggested sedation and dosage for felines.

Yes, sure. Bear with me. So we're currently using ketamine, midazolam, and burophenol.

As an IM sedation and that's most commonly given just in one syringe IM. So the doses that we're using is 3 mix per kg of ketamine. 0.2 milligrammes per kilogramme of midazolam.

And 0.2 milligrammes per kilogramme of phil. As I said, that's what we're using in our practise, and we see, we find that that works well.

Obviously, each patient is an individual, not all of them will react the same to that sedation, and we would obviously treat everyone as an individual basis and see, how it went. Fantastic. Thank you very much.

Hopefully you've got that then, Diane. And as I say, if you do miss any of that, this webinar is recorded and it will be available on the webinar website within the next 48 hours. So please feel free to visit back to the website.

You can watch this webinar again, with the whole thing or whether you want to just move to a couple of the key elements. So keep an eye out for that. Jo from Portugal has been asking, do you give fluids, crystalloids after blood collection in cats?

We do after they've donated blood in our practise, yes, we are giving fluid therapy to our feline patients for a couple of hours just so once we've had a cat in and we've taken blood from them, we will keep them hospitalised, whether that's for a couple of hours, depending on the time of the day, a couple of hours or until the next day with fluid therapy. Normally at about 3 mL per kg per hour again that depends on the individual patient, the blood volume we've taken their vital parameters, but that's, that's just roughly, we would keep them on fluids until they're sort of eating and drinking unless sort of directed otherwise from the vet in charge, but yes, we do, we do put our feline patients on fluids after taking blood volume from them. Fantastic.

Thank you very much. Question, from Jose, asking, do all Siamese cats have the same blood type? Don't know whether you know that one.

OK, so that is a good question. I, I wouldn't be able to say whether all Siamese cats have the same blood type. However, there is, there is room for debate that exotic cats are common, more commonly presented with, a type B blood.

However, we cannot say that every Siamese cat will be type B, so we would obviously always have to blood type and we could never assume. If they wanted, if you would like to email me, for sort of a further discussion on that, I'd be more than happy to, but yes, more commonly exotic cats type B, however, That's not a hard and fast rule. No problem.

Thank you. There you are, Jose. So Charlotte's details are there.

So if you want to pick that one up, then please feel free to email charlotte. [email protected].

. Question here about Amy's asking, they've got extension lines for the syringe driver and narrower than the normal IV line for blood transfusions. Is this OK, stroke safe to use for feline blood transfusions? Yes, so we're using our our narrow bore extension sets in practise.

So we attach that to our syringe and we would then attach our extension set. We then have the philtre, and this would also then get attached to the patient's T connector and we have not had problems, using this to administer, even threshold blood or just the red cells to our feline patients. Thank you.

I'm not sure if you'll know the answer to this next one because I know that you actually work in Southfields and you're not actually employed by pet club bank, but you might be able to direct, questions to someone relevant or at least take it and then ask the question. Someone's asking saying, why, why is there no feline blood in the pet blood bank? Is it due to an ethical issue?

As a cat can develop some condition during donation, such as a oculus, cardiac disease. So yeah, just a query really about, obviously pet blood bank is canine, but, you know, is there any reason why they haven't gone down the feline route? So that is a good question.

That question is probably better directed towards Pet Blood Bank directly. I'm happy to contact them and ask for further information. However, when I did ask about their feline blood donation, they advised me that they will be looking into it in the early 2020.

So if you can leave that one with me, I will, I will be able to get back to you, but it is a slightly different, ball game with feline blood donation, because sometimes they would have to be sedated, for example, and we need to keep the system as close as possible. So there are numerous factors that will influence feline blood donation that would need to be considered. And it's a slightly more difficult, process that we would need to consider a lot of things for, but if you, if you leave it with me, I can contact Petlo bank and see if I can get any further information from them regarding their feline blood donors programme.

No worries. I did think that might be the case. So no, don't worry about that.

But as I say, you know, the Peplo Bank website is there as well, and all their contact details are on that website. So you once again, you, you can contact them directly as well if you have any questions along those lines. .

Couple of just couple of last questions before we let you go, Charlotte. Fans asked what signs would there be to indicate circulatory overload other than increased respiration? OK, have we stated if it was a dog or a cat?

So, and then said what volume of blood is blood is sufficient or weight. What's what was the last part what volume of blood is sufficient or do you go by weight of blood? So the blood volume is the mils per kilo that we spoke about in the previous slide.

The signs of circulatory overload, yes will include sort of tachynia or dyspnea, so changes in respiratory rate, respiratory pattern. We could also perform if we was, very concerned, we could perhaps perform, chest thoracic radiographs, we could perform an LAAO check, to measure the left atrium if we was concerned about volume overload, we could be measuring patients' blood pressure. There's there's a number of different things that we would be looking at with volume overload in our patients, but one of the earliest indicators would be changes in respiration.

Right, and things like that. Fantastic. Thank you very much.

Last two questions. One, is, do you keep transfused pets muzzled during the transfusion? No, we don't.

Unfortunately, on that occasion with the photo used in the webinar, the patient, despite being a little bit unwell, was not the most friendly towards us at the time. So no, it's not something that we routinely do at all. It's just in that instance, the patient was slightly, uncooperative.

And in fact, actually the last slide here that you can see now is that patient much healthier and happier. Fantastic. Always good to see the after photo.

Yeah. And last question, how do you rewarm frozen or refrigerated blood products? So there is a big debate on whether we should warm the blood products before administering them.

Obviously the frozen products need to be defrosted, so they're thawed, so. Ideally, as soon as we know that we need to be given a a frozen product, we would take it out of the freezer as soon as possible and get it wrapped or placed in a warm area to start the defrosting process. You can use warm water baths, and we don't currently have one of those in practise.

As long as the bag of plasma is kept perhaps within a sealed, another sealed bag so that there is not any contamination of the product, and there is, the ability to control the temperature of that water bath so that we don't then damage the. The product, but alternatively we can just try and thaw out the product as quickly as possible, by getting it out of the freezer as soon as possible. With the refrigerated products, there's not too much evidence to suggest that warming, for example, the pat red cells, if we take them out of the fridge, by the time that the, the product is actually administered and The patient received this product, it will have warmed to at least room temperature, so it's not like we would be giving it cold by the time it actually gets into the patient's circulating volume, it wouldn't be as cold as it was before.

Fantastic. No, that's great. And, thank you very much for taking time to answer all those questions.

So, fully and succinctly, it's, absolutely brilliant. So that brings us to the end of tonight's webinar. All it leaves us to do is to obviously thank Pet Blood Bank for sponsoring tonight's webinar and making it available to yourselves.

Hopefully, it's giving you some really good food for thought, for those of you who, Do you currently, perform blood transfusion in practise. Hopefully, it's helped with your systems and procedures, giving you some giving you insights on how to develop your processes. And as I say, for those who don't currently perform them, yeah, hopefully it'll give you the confidence now to look at how you could then maybe develop this going forward in the future.

Thank you to all of you for attending. I hope you, I say, you've enjoyed it. Please do take time to fill out the survey at the end.

We have also done a, webinar for vets as well by Pet Blood Bank, which was held earlier this month. So if you are interested in finding out more, once again, go to the webinar vet website, go to sponsors, look for Pet Blood Bank, and you will find it there. Oh, just had a couple of people coming through saying, thank you very much.

Thank you very much for this interesting webinar. Well done, sir. You did Southfields proud, and that's from Ken.

So, you said you might have a couple of colleagues listening tonight, Charlotte, so we'll to hear that. Thank you. My colleague, Libby has just put in a link to the, previous webinar as well.

So that's in there for you now. That's in the chat box. Gavin said, thank you for an excellent webinar, some, some, really lovely feedback there for you, Charlotte.

And I hope you don't mind me saying, this is Charlotte's first webinar and I think she's done absolutely fantastically well and all from all the webinar that we hope that, we have you back doing our webinars in the future as well, Charlotte. Yeah, thank you very much. So thank you very much, Charlotte.

Wishing you all a pleasant evening and we wish you, welcome you on a webinar soon. Good night.