Hello everyone, it's Anthony Chadwick from the webinarest. Welcoming you to our monthly nurse webinar where we will be talking. There will be blood and perhaps some plasma too.

We're, we're very fortunate to have Natasha Summerfield today who's gonna be speaking to us about this topic of transfusions and and products and how to do it. So really looking forward to that. Natasha is a registered veterinary nurse based at the University of Zurich in the.

Animal Hospital there, the Zurich Animal Hospital. Natasha qualified in 2011 and has had a varied career, including working abroad with charities all over the world, including countries like Indonesia, Thailand, Sri Lanka, Nepal, and of course, Battersea. She was really found her passion for emergency and intensive care medicine whilst working at the Royal Veterinary College at their ECC unit in the UK.

But then in 2014, she moved to Zurich, learned a new language, and has really helped to develop the University of Zurich's intensive care unit. She's currently the head nurse of the university's new emergency unit. Where she also plays an integral part in the education of nurses at the university as well, so really looking forward to the talk, Natasha, and it's over to you.

Great, thank you so much for the lovely introduction. So again, I just, thank you all for joining me this evening. This talk is called There Will Be Blood and Perhaps some Plasma 2.

So we'll be talking about blood products, indications, administration, and a little bit about coagulation disturbances as well. And just a little recap. So my name's Natasha Summerfield.

RVN, BTS ECC, kind of qualified in the UK and now based in Switzerland in Zurich. So let's get started with our learning outcomes for today's lecture. So what I want you to take away from this lecture today will be to be able to identify the different blood types in dogs and cats.

Be able to list the current products available, describe the indications for administration of blood products, and, list some of the common coagulation disturbances. There's quite a few, so it carries on. So, understand the process of administering blood products and to be able to recognise the different types of reactions and when we should report them to the vet.

So first up, identify the blood types in dogs and cats. So just a little bit to start off with, kind of a little bit of vocabulary. So we have antigens and antibodies, and I just thought I'd go into this before I go, kind of deeper into the blood types, as to what these things are.

So we have our antigens, and antigen is a substance that causes your immune system to produce antibodies against it. And then we have our antibodies. So this is a blood protein produced in response to and counteracting a specific antigen.

And then we have alloe antibodies as well. And these are antibodies formed against the blood type antigen that they're lacking, and these can actually be acquired, so post-sensitization, post transfusion, or they can be naturally occurring. So, blood types, canine blood types, what types do they have and what do we test for?

So we have different blood types in dogs, and these are generally known as DEA something, and that all that stands for is dog erythrocyte antigen. And dogs really have many different types of blood, so blood types, but what we commonly test for in practise is DEA 1.1, and they'll be even negative or positive to that blood type.

And the reason we test for this 1.1 is because it's the most antigenic blood type. That means it's the most likely to cause a reaction.

And as we, we know that dogs do not have naturally occurring antibodies to DEA 1.1. And so as I said, dogs really do have many different types, have many different types of blood types, blood groups, so this can go through DEA 1 to 8, and then we have also dull and chi 1 and 2, but really in practise, all we're looking at is DEA 1.1.

And then we have our cats, so cats have a different blood typing system, they have an AB blood typing system. And the difference with cats compared to dogs is that they do have naturally occurring antibodies. So a cat will this AB typing system, what this means is that a cat will be either type A, which is the most common, or they'll be type B or rarely they'll actually be type AB.

And cats, it's really important that they receive the correct blood type on their first transfusion. So an AA must receive Type A blood, a BA must receive Type B blood. An ABA, as they're so rare, they should receive AB type blood, but they could potentially receive Aty blood as well.

And there is also another known blood type which is called the Mic antigen, but that's not something that we commonly test for in our kind of blood typing tests that we do in-house. So what we commonly test for is A, B, or AB. And as I said, they really cats really do need to be grouped, so they do, we do need to know their blood type before we go ahead with any transfusion.

And potentially even to know that, to be able to cross match as well before their first transfusion. So that really depends on kind of which literature your clinician, your vet is going by, as to whether they choose to crossmatch for the first transfusion or, you know, kind of after the first kind of 3 to 5 days after the first transfusion. As there's a couple of studies out there.

Both relatively recently saying two different things. So that'll be really dependent on your, on your vet, and what they choose to do. And also, of course, depending on the time that you have, if it's an emergency, you may not have time to do a cross match before the first transfusion, and kind of cost restraints and things like that as well.

So just a little recap for our blood types, we have our cat blood types and we have type A, type B, and type AB. And as you see on these diagrams, if you've got a bit more of a visual mind like I do, you can see that the A-type cats have these A antigens on the surface of their, of their red blood cell. And, B type cats have these B antigens on the surface of the cell, and AB type cats have A and B antigens on the surface of their cell.

And these will have antibodies against B, the B type cats will have antibodies already against type A. Andy A B cats don't actually have naturally occurring antibodies against type A or B. And then we have our dog blood type, and as I say, I've just put here the DEA 1.1, as that's the one we generally test for in-house.

And they'll be even negative or positive, and what this means is either they will have it, they will have it, sorry, or and be positive or they won't, and they'll be negative. That's all that means. And they have no naturally occurring antibodies against these antigens for DA 1.1 at least.

So a little bit about cross matching. So cross matching, as I've written here, determines compatibility between the patients and the donor's blood. And this is to be performed when the recipient has received a previous transfusion, so at least over 4 days ago.

And so that, again, depends on your practise protocol. And that where I work in the hospital that I work in, we actually do it, 72 hours post transfusions. So kind of anywhere between 3 to 5 days is quite normal.

And also you need to be doing it before any transfusion, if, if there's an unknown transfusion history. So if it's a rescue dog, for example, and we know that they've had a previous owner. Potentially they have had some medical issues in the past.

Then it may be worth doing a cross match before, we're given the first transfusion. And I've put here plus minus the first transfusion in cats. Again, as I say, I think that's really dependent on what your case and what your clinician chooses to do and which literature they're gonna, they're going by.

It may also depend on which country you're in, as the studies were from the US and from the UK. So maybe they'll have kind of, an affinity to either of those. So, again, I've just put here plus minus before, the first transfusion in cats.

And it's really important to know that reactions are still possible. So even if a, crossmatch kind of detects a match, we need to make sure that we're monitoring those patients just as we would do for, any other transfusion. And if we do do a cross match and that patient, you know, has a match, they'll receive a transfusion and then 4 days later they need another transfusion, then those patients will actually need to have another cross match.

So that's just, I thought interesting to note. And the last bit about cross-matching, I think, we have two different types of cross matches. So we have the major or the minor.

And so the major, that detects the incompatibility between the dogs, sorry, the donor red blood cell and the patient's serum or plasma. And that's really important when we're giving red blood cells, so packed red blood cells, to the recipient. And the minor crossmatch, that's important when we're given large amounts of plasma because that detects the incompatibility between the donor serum and plasma and the patient's red blood cells.

So just if you hear, I don't think that's something you kind of, you need to know off the top of your head, but you may have heard, oh, they are, you know, crossmatched major, positive or minor, that's all that that means. So list the current blood products available. I think I may have missed a slide, but sorry if I have.

So, blood components, what we have available. So we have our fresh whole blood, and you may see that shortened down to FWB our packed red blood cells, so PRBCs, and our fresh frozen plasmas is our FFP. So fresh whole blood.

So this really needs to be used within 8 hours of collection. And the reason we need to use that within 8 hours of collection is to make sure that the, especially the platelets, so the red blood cells, the platelets, and all the coagulation factors are. Present and functional.

And as I said, like, that's something that, that, for sure, the platelets will really start to break down, soon after collection. So, we can get that blood into them as soon as possible, especially if it's a thrombocytopenic or a thrombocytopathic pathic patient. And that's really, really important that we get that blood into them as soon as possible and kind of as late as 8 hours after collection.

And indications for giving fresh whole blood. And this will be our anaemic patients, with concurrent coagulopathies. This may also be given in patients who are kind of just, so to say, anaemic.

And, that might have been something that's done more in common, you know, commonly in private practise. I'm not sure. I definitely remember back, way back when, when I was working in, in kind of a smaller private practise, taking a sort of practise dog or a nurse's, or a vet's dog and use.

Using them as a donor and giving that kind of fresh whole blood very, quickly, not storing it to a patient who needed it was, was quite a thing. Where I am now, we have component therapy, so we have our pack red blood cells. We have our fresh frozen plasma.

So, unless we need to give a fresh whole blood for reasons such as a thrombocytopenic patient, we would generally kind of do our component therapy. It's just actually more convenient for us. And then we have our packed red blood cells.

So, this is just, fresh whole blood that has been separated into plasma and red blood cells. And yeah, this is just separated by a kind of a, a huge centrifuge, and then they kind of separate that out nice and cleanly, very aseptically. And the storage for these products, it's really important that they're stored upright, and that's to preserve the red blood cells.

And they really should be stored, in a specialised fridge between 1 to 6 °C. So that's just kind of a normal temperature for a fridge. But the reason I say a specialised fridge, if at all possible, and if you're not so lucky to have a specialised fridge, it just in one that's really low traffic, so not kind of your vaccine.

The fridge that your vet is in and out of every kind of other consultation, because we don't want to have fluctuations in the temperature of the fridge. And there's actually been deaths that could be attributed to reactions due to lies to packed red blood cells as a result of temperature fluctuations. And so there's a study in 2011 that showed that, so that's why I say that and kind of really make a point of making sure that we're keeping these products in a in ideally a specialised fridge, and if you can't have that, then just one that's really low traffic.

And these can actually be kept for between 35 to 42 days, and that depends on the additive that was used at collection. But I do say that a bit of trepidation because we're finding with more and more literature these days, from human and now coming in the veterinary fields as well, that the longer it's stored for, the more likely it is to have some storage lesions, which, really can have an, an. Impact, like, so an increased risk of transfusion reaction, the longer we, we store these, these, these blood products for.

So, ideally, we want to use these blood products kind of as soon as 14 days after the collection. But at the moment, the expiry dates will still show between 35 days to 42 days. But as I say, if we can use them, you know, kind of more quickly than that, then that would be ideal.

And the indications for packed red blood cells, so forgiving these would be anaemia. So that could be due to kind of an array of different reasons. So we could have some active haemorrhage, we could have hemolysis, ineffective erythroparesis, so kind of ineffective making of these red blood cells.

But what's really important to note with this as well is that, and again, and also with the fresh whole blood, when we're giving these products, it's not just because they've got a PCV of, you know, 20 or even 15, for example. They may be really stable with those PCVs. If it's a really chronic blood loss, then we could have patients come in.

And be absolutely fine with a PCVO 15. So it doesn't mean that they need to be transfused straight away. Perhaps they need to start on other medication that will help them produce their own, blood cells quickly enough, and they can stay stable stable with that.

So, what I think is just important to, to talk about is just looking at the patient and as always, you know, really looking at the whole picture. And that's nothing new here. But, you know, especially with, with giving these products because these are a scarce resource, they're not just a drug that you, you get out of the cupboard and, and they can cause adverse side effects as well to our patients.

So we need to make sure that these patients are also, you know, not only anaemic but also clinical for that anaemia. I hope that makes sense. And then last product that we're gonna talk about at least tonight is the fresh frozen plasma.

So this can be shortened down to this FFP and this contains all hemostatic proteins, so that contains all of our coagulation factors basically. And it has a 12, it has a shelf life of 12 months, as long as it's kept at -18 °C. So in a freezer.

And also, as I say, said before, in a minimal traffic freezer or one that's specifically used for fresh frozen plasma. And even better than that, ideally would be to have a temperature kind of alarm as well on that freezer. Just if there's a malfunction, you know, in the middle of the night or whatnot, and there's someone on call, perhaps in the practise, and, you know, if, if that freezer has an alarm that it's going below us, or above a certain temperature, then they, that could potentially be fixed as and, as and when, you know, rather than it all, defrosting and then kind of losing a lot of that fresh frozen plasma, which would be a real shame, of course.

But I, what I will say on that note is that, the, if it is stored over 12 months, then it, it isn't, it's no longer fresh frozen plasma, but it would still be able to be kept for up to 5 years, and it would just be known as frozen plasma at that point. And that just will have variable amounts of certain coagulation factors, but it will still have good amounts of vitamin K dependent factors, so this could still be useful for our rodenticide, poisoning, you know, patients. And another tip on fresh frozen plasma, so if you are collecting it and storing it in-house, what you can do when when on collection is actually pop like an elastic band around the middle of it before you freeze it for the first time.

And then once it's frozen, take that elastic band away. And what that would do is it will cause, it will make a, a waste, in the product. And Then you can keep that in your freezer.

And, and then you'll know if there's been any malfunction in the freezer, because you won't have that waste anymore. So if it's thawed and then refrozen, then you won't have that waste anymore. So you'll know that that is no longer fresh frozen plasma, that it's only frozen plasma.

And the indications for use of fresh frozen plasma is generally coagulopathies, and these can be inherited or acquired, or it may even be used prophylactically in surgery patients with known coagulopathies. So a little summary here, what to use when. So fresh whole blood, this is gonna be used for our anaemic patients, so generally acute blood loss, so with concurrent coagulopathy, so we're losing our we we're losing our red blood cells, we're also losing just a lot of volume, so we're losing potentially our coagulation factors as well.

And it also could be useful for our thrombocytopenic or thrombocytopathic patients, so where the platelets aren't functioning properly is what that means. And then we have our packed red blood cells. So this is useful in our anaemic patients, and this could be acute or chronic, blood loss, but important to say for both of these products is to make sure that those patients are clinical for, for those that anaemia before we're just kind of giving these products willy-nilly.

And then fresh frozen plasma, and this would be useful for our coelopathies, as we've spoken about. And then we have also a couple of other products, which I just thought I'd mention here very briefly, but we won't really have time to go into tonight, but there are a couple of other products that are available. They are actually available on Pet Blood Bank as well.

And this is platelet rich plasma, so those would be, that would be useful for our thrombocytopathic or penic patients. And there's also something called cryoprecipitate, so cryoppe. And this is useful for active bleeding or prophylactic treatment, for patients with haemophilia A or Ron Willebrand disease like deficiency patients before surgical procedures.

So we get onto our common coagulation disturbances. And this really could be a talk within itself, but unfortunately I don't have so much time to talk to you about this. I've had to take quite a lot of slides out.

Which is a real shame because I just, I find it a really interesting topic, but as I was going through, there's just so much to cover in this topic, but I just thought I would go through a little bit about common coagulation coagulopathies, but kind of a little caveat there that it's not, it's only one slide, so, potentially something that we can go into in the future as a whole talk. But some common coagulopathies that I see in practise, are immune mediated thrombocytopenia, and this anticoagulant rodenticy toxicity and disseminated intravascular coagulation. Or coagulopathy, sorry, and, that can be shortened down to DIC.

You may have seen that, written somewhere, people were talking about that. And with all of these kind of problems, they aren't gonna be solved just by giving one of our products, so fresh frozen plasma or, you know, whole blood or whatnot. They need to be treated with other, you know, kind of medication as well as potentially having some support from our products.

And so immune media thrombocytopenia. And now that would be a product, that would be a a problem, a disease process where if they've got really low thrombocytes, then actually we'd need to give them this that you know, fresh whole blood really ideally. But I've also had a patient before that was, you know, actually pretty stable, but we had him in the ICU because he had pretty much zero thrombocytes.

And then of course in the middle of the night he proceeded to bleed into his GI tract. And get really clinical. His PCV dropped very quickly, very acutely, and we needed to treat this patient.

And so we were able actually to support the patient overnight. We've just given him that oxygen carrying capacity with some packed red blood cells because we had no fresh blood available. And, and that kind of did the trick and bridging over the gap until the the medication that he was on, he could then start to produce or throw out some, some thrombocytes.

And again with the anticoagulant rodenticcy toxicity. Now, these are patients that unfortunately, if they, if they've ingested this and they haven't come in straight away, the owner hasn't noticed that and they come in, you know, a few days later, up to a week later, with some bleeding, they may already be bleeding in cavity, so intrathorax or intraabdominally. And depending on how clinical they are and what their PCV is, is saying, we may need to give those patients as well some help with some packed red blood cells, you know, all freshhold blood, but packed red blood cells to get that oxygen carrying capacity up again, to get that PCV up again and even also some, fresh frozen plasma as well.

. For those patients just to give them a kick, give them some coagulation factors, whilst their body is, you know, kicking into overdrive, once we've started them on vitamin K therapy. And the same goes for the DIC, now these patients. Also may need support with, with kind of different types of products, so we may need to be given these patients also some fresh frozen plasma.

And if they've already gone into the hypocoagulation phase and actually started bleeding as well. Those patients may also need some, blood, you know, kind of some packed red blood cells as well, just to kind of get them through, just in the meantime, whilst we're trying to battle the primary disease process that's going on, that's causing, the DIC in the first place. So it's just a little bit about the coagulopathies and as I say, this is really something that we could go delve you know, a lot more into but unfortunately we don't have the the time tonight at least.

So we'll get into this understanding the process of administering blood products, and I think this is really where we as nurses come into our own, and it's really important that we are aware of, of, of kind of how to repair the, the blood product, you know, at least before giving it. Now, I personally, I'm not. Involved in the collection process, but I'm heavily involved in the kind of preparation of the blood product before we give it to the patient, administering it and monitoring them.

So that's what I think I would, you know, kind of talk to you guys about this evening and probably the part that you'd be most involved with as well. And so, a little bit kind of, you know, information that might be new to you. So blood products don't actually need to be warmed before administration, but of course, fresh frozen plasma should be thawed gently in warm water.

And I would also put that fresh frozen plasma in a Ziploc bag before you pop it in that kind of warm water bath as well. And just to make sure it's staying as clean as possible. And the, like, generally blood products don't not needing to be warm before administration.

Now, if you're giving really large volumes and very quickly, then you may consider, warming it just slightly, but you need to be very, very careful that you're not going over 37 °C and potentially causing kind of actually more, more harm than good. Or the neonates, you may wanna warm that product gently and, what I've seen kind of, in practise and and written is, is, potentially actually just warming the line just before it gets to the patient's cage, so maybe just popping that in a water bath. And making sure, obviously, there's no way that water can kind of get near the patient.

And then you're just, and it's not hot water, it's just warm water that you're running the blood through before it gets to the patient because in any case, if you warm up the blood, by the time it's trickled through and gone down. To the patient. And once we've actually started that that blood really, really slowly, it may not have made a difference in any case.

By that point, it's probably got up to room temperature. And if you'd warmed it before, it may have then dropped down to room temperature in any case. And kind of a .

A simple note, but just something that you should make sure that your vets are doing before you get cracking on the transfusion is that making sure that they figured out the dosage. So the dosage should be calculated and the minimum volume and administers we've spoken before about blood, it's really a limited resource, and I think on ethical grounds, we need to make sure that we are just using what we need from these patients to, you know, from these donors to make sure that there's enough to go around. So before we, you know, go any further, we want to inspect the bag.

So we want to make sure that there aren't any, you know, discolorings, are there any clots, and this could be due to poor storage. You know, or you know, problems on collection. There could be storage homolysis as well, or bacterial contamination.

So making sure that it's, the blood is looking kind of, you know, the colour it should be, having no clots. We also want to check the date and making sure that the blood type is correct. So we're giving the right blood type to the, to that, you know, that patient what they need.

And I always get someone to check this for me, so, this sort of 4 eye principle, especially with the date and the blood type. I don't think it takes very long just to get someone to go, OK, this patient is negative, I'm giving negative blood. Yes, negative, you're giving negative blood.

Great. And that the expiry date that it's within the expiry date. I personally like to get this ready, so I connect the blood giving set using gloves, so whenever I'm working with these blood products, I'm always using gloves, always staying as aseptic as possible.

And I like to get it all prepared on sort of a clean, like lower traffic surface area. So what I mean by that is I'm not gonna get it ready on the, like meds in the middle, sorry, I'm speaking in German, and the meds tables, so where we prepare the medication in the ICU I'm gonna take it out to our lab area which is right next door, and I can still keep an eye on the patients where it's just a little bit less traffic, less people coming and going. And I can kind of prepare the blood there.

And as I said, you just wanna keep as aseptic as possible and to make sure that you're not introducing bacteria yourself. And we always need to use a philtre, when we are getting these blood products prepared and ready for administration. So with the large bags, then we have the, you know, the blood giving sets and the philtres already attached and already in that.

And with smaller amounts, so potentially with cats, there are these small square philtres, and they're called humanmanate philtres. So, just important that we're always using a philtre for those patients. And then administration, so this, the products that we have, they can be administered IVs intravenously or intraosseous.

So intraosseous, that could be useful for your knee innate patients where you can't get an IV into them. Personally, in kind of the seven years of in the ECC that I've been in, I've, we've always given it IV. We've always managed to get an IV in even the kind of neonates.

And we wanna flush the patient's catheter with saline before connecting. And actually this kind of belongs to the preparation side of things, but actually flushing the patient's catheter now, personally, I like to unpack the whole catheter. Make sure that the catheter is patent, looking good, that it's not kind of looking a little bit, you know, not very nice.

It's over 3 days older it's like coming up to 3 days old, not so happy with it. All of those things, you can't see that when it's got a bandage over the top of it. So if the patient is cooperative, then I like to take off all of the bandage, make sure I'm really happy with the catheter, and then flush it with saline before connecting.

So it's, I say so long, it's really important. You've probably heard this before, but it's important that we don't flush it with something like ringers, for example, as that contains calcium. And it's thought that the calcium and the citrate, can cause a reaction, and, and can conform clots.

So if they're on ringers, which I guess a lot of our patients are, then the, catheter really needs to be flushed with saline before connecting that blood. And now I think is really the time as well, or probably actually, to be honest with you, beforehand, before we've got that blood out of the fridge, is the time to be thinking about does this patient need to have a second IV in. So if they are a patient who are on CRIs or receiving medications, IV, you know, every 2 hours, or even more frequently.

Then it might be a good idea for you to suggest placing a new IV in that patient that you can give that blood through. Just so you're not, excuse me, constantly disturbing that blood transfusion by disconnecting, flushing, giving medication, flushing, reconnecting. Every time we do that, we can introduce bacteria and that's clearly no good for our patient.

So that's something also to think about and that will really depend on the patient and how critical they are as to what medication they're on. And no food or medication during the transfusion, so whilst we're administering. And that is because if we have a reaction to our food or our medications, so the patient vomits off the food or has kind of a full blown, anaphylactic reaction.

Then we have no idea if that was from the food or medication or from the blood. And we'll have to stop that blood transfusion. We'll have to figure out what's going on and then potentially give other drugs just in case, and then restart the transfusion, hopefully.

So I just, I mean, that's something that's really important that you're not kind of giving food or medication during the transfusion. And it's something to consider as I think a nursing consideration, if you're looking at your patient's charts. And seeing, oh, they do a a tube feed in half an hour and speak to a vet and say, look, is that OK?

I'm just gonna bring this tube feed forward. And it's especially important with your critical patients with, you know, low albumin, for example, that we need to be getting this nutrition into them and then not skipping a feed. That we potentially give that feed a little bit early before we've started the blood transfusion, and these are all things to really consider before we've even got that blood out of the fridge, to be honest with you.

And starting slow, so we really need to give this transfusion slowly, to start with for sure. So the first kind of half an hour, 20 minutes, half an hour, at our practise we actually give it at 0.25 millilitres per kilo per hour, so super slow.

And, the place I was at before we started at 1 millilitre per kilo per hour. What I've seen in, in kind of the books and literature is starting between 0.25 and 0.5 millilitres per kilo per hour.

So, yeah, just super slow basically. So we're kind of seeing if we're having a reaction and we can and we can react to that very quickly. And also just a note, sorry, on administration, now whether you're using syringe drivers or infusion pumps or not.

Now what's just really important is that, is that you, you're making sure that that in infusion pump or syringe driver is actually compatible with given blood products and also that your vet is happy, especially if you've got kind of a new vet who you're not used to working with and you've got different protocols, perhaps at the hospital. That your vet is happy with you using a syringe driver or an infusion pump. Is there different evidence, that really not consistent to say whether we should use or or not to use these pumps or drivers and whether they could cause some damage themselves, potentially some homolysis themselves during the process of giving it.

And then one last thing I haven't written on the slide, I'm afraid, but I've got it as my notes. Just a little extra nursing tip, walkouts. So I get a lot of students asking me whether we can, you know, take the patient out or, or actually more likely I see that .

The patient is really needing a wee and the student who, you know, is kind of doing some of the monitoring for me it doesn't think to, to let them out because they're not allowed to break that circuit, you know, we're not allowed to disconnect the blood once it's on, you know, the catheter ideally. But what you can do is, is wait just that kind of at least the first half an hour and so we can see that we hopefully haven't got any acute reactions going on. And and then just go out with that patient.

So do a walkout, but just keep it all connected, so just keep the line all connected to keep it on the catheter and maybe see if you can get someone to a student or a hospital assistant or another nurse to help you out and taking all that stuff outside of you. So, you know, the dog doesn't pull you anywhere. But that, that could be possible still.

So monitoring, I'm gonna try starting whizzing through because I'm just looking at the time, we've got a little bit more to get through. So we wanna make sure that we're monitoring all of the vital parameters. And making sure that you're checking the baseline just before starting that transfusion.

So what I mean by that is if the patients come in an hour ago, and we've done this baseline, you know, kind of checked over, they may have been hypothermic as they came in, just slightly, you know, kind of 37 degrees. And then they've, you know, been reperfused. They've had, some fluid, for example.

They've, they, their temperatures come up a bit. They're now normalised 37.7, and we haven't rechecked it in the meantime.

And then the first temperature check that we do, you know, after starting our transfusion, they're already at 38 or, you know, a little bit higher, even 38.2. We don't know if they are having a reaction already because their their temperature has increased for us to, you know, a degree or or more.

But actually if we did just checked their parameters just previous to them having the transfusion, to starting the transfusion, then we would have known, oh actually their their temperature was normalised. It was now 30 7.7, and we don't need to worry about it being 38.

Right now at least. So that's just really important that I, I thought I would just note that. monitoring the vital parameters, so we wanted to be checking their temperature, their rest rate, their rest effort, heart rate, mucous membranes, capillary full time, non-invasive blood pressure if possible, so kind of all the whole shebang, basically, and checking that every 15 to 30 minutes at, at least.

So where I work, this is actually a transfusion protocol monitoring protocol, but unfortunately it's in, in German, but I think you can kind of make out what it says. But what I did notice, while I was online on Pet Blood Bank UK and they have a transfusion record there as well, which you can download for use, so that's really handy. But we actually monitor them 5 minutes after starting, then 5 minutes after that, and then 10 minutes after that.

So in the 1st 20 minutes they get a lot of checks and then thereafter it's every half an hour and then it goes up to an hour on the, on the last hour. So we need to be giving these products over 4 hours, and that is 4 hours from it leaving the fridge. So try to be as prepared as possible before you're getting that product even out of the fridge, to, you know, minimise the risk of you having to give that product quickly to a patient who can't handle that product quickly and then potentially having some, problems with, you know, circulation overload.

That's really something we don't want. And just also a little note that we could deliver this in portions if necessary. So if you have the correct equipment, so ideally like a spike with a philtre, then you could potentially draw up a certain amount of blood, give that over a few hours.

And then keep the rest in the fridge and then draw up the rest and then give that over a few hours. Of course, making sure that your vet is is happy with this process, but that's something that I've definitely done with cats that are at risk for a circulation overload. And then with our monitoring, so, I've definitely had patients that are super aggressive and I could not get near them to do all of this monitoring all of those vital parameters every 5 minutes or even every hour.

And what I did is I got that patient out with another nurse who's really experienced. We checked the cath to make sure that that was all running smoothly because what the last thing I want is for the blood to go paravenously. And then placed an ECG.

Luckily enough, we, we have the multi-parameter devices, so we can use those for, for these sorts of patients, and then popped her back in the kennel. And I actually wasn't able to get near that cat for the rest of her transfusion. Her catheter was really precarious, and we were really concerned about losing that catheter and not being able to get near her again.

She was super anaemic, She had lots of other injuries, and I just wanted her to get that blood so that she would be feeling a little bit better, after we got that into her. I checked with my clinician, the case fair that they were happy with what I was doing, and I basically had to monitor that patient from outside the kennel. Now, I did that as, as well as I possibly could do, really keeping an eye on her rest rate and her rest effort as well.

And the ECG when it was working, so that we had something. I also put a, a, a blood pressure cuff on her, but that kind of, flew off on the first time that she, went crazy in her, in her kennel bouncing all around. So, basically, kind of, with the monitoring, you know, also do what you can.

So it's ideal, we're gonna have. All of these vital parameters. But if you have a patient who's like, super nervous, who's bitey, who's aggressive, or, you know, they're acting in an aggressive way, at least, because they're so painful or nervous or whatnot, speak to your vet and talk about what is, you know, feasible, what is physically feasible for you as a nurse and also for the patient.

And use the devices that you have. So if you have these multi-parameter devices, you know, and you have a really busy either ICU or, you know, you're on a night shift and you have to monitor an anaesthetic in a really critical patient, plus you've got this other guy over here that's receiving a blood transfusion. Then use your multiparameter devices if you have them.

So you've got everything on one screen. And that does not, substitute for you going over to that patient and you're checking them and really, you know, seeing what's going on with them, checking their mucous membranes and whatnot. But at least it gives you all that information on the screen at a glance.

So that's something that I definitely have used, when I'm on my own on a night shift and it's crazy busy. I'm super grateful for those devices. And one, or a couple of last tips on this subject of monitoring.

So firstly, try and get the same person, so that's a nurse, to monitor that patient throughout the whole transfusion protocol. So throughout the whole transfusion, those 4 hours. And that, it just means that you will pick up on more of the subtle changes.

And if you can't do that, then try and get the same person to check them, monitor that patient at least for the first half an hour, . And then the other tip is that making sure that you have a good visibility. So using a kennel, so a patient, putting them in that kennel that has got good visibility.

So if you have them kind of stuck away in a corner, then you're not gonna be seeing if they're having, you know, that they've just kind of keeled over and having some sort of horrible reaction to the blood. So trying to pop them in a place where you can, you can see them really well. And then we'll get onto our last bit, which is recognising different types of reactions and also when to report them to a vet.

So this is my dog doing her best impression of having a a horrible reaction on the couch, of course. So we have different types of reactions. We have our immunological, which could be acute or delayed, and we have our non-immunological as well.

And so here's a nice long list of all the different types of transfusion reactions that we could have. But firstly, the question is, when should we report this to a vet? Now that's basically whenever we're concerned about anything going on with our patient that's receiving a transfusion.

And if you are suspecting that there's a reaction going on on in on our transfusion protocol, we actually have, if there's a change by 20% or the temperature goes up by 1 degrees, make sure that you're calling the vet straight away and stopping the transfusion. But, on that note, so always let your vet know whatever's going on, if there's any changes. But just important for you, I think, as a nurse, just to kind of think about it a bit more logically as well.

So if we have an increase or decrease in temperatures, of the patient, this could be due to us giving that blood that's, that's a bit cold or potentially they're better, they're better perfused now, so their temperature's actually gone up a little bit. So they were hypothermic before and now they're Better perfuse so they're, they're kind of nothermic. Again, you still need to let your vet know.

You still need to always have that open channel of communication with them. But just kind of, potentially to stop you from panicking, was the reason why I say that. And, and also, the same goes for the decrease in heart rate.

So as we have a more oxygen carrying capacity from giving these, you know, blood cells, the heart rate, hopefully, will go down if they were clinical and they were really, tachycardic. So that potentially is not a reaction, so that's just kind of something to, to think about. And as I say, we have all of these different reactions, but we have not enough time to talk through them all, cos again I think that would be a a talk probably within itself.

But the main kind of important transfusion reactions I think are the febrile nonhemolytic reactions, so this top one here. And this is characterised by a, increase of temperature by one degree or, or more, and that generally happens quite quickly, you know, kind of during the transfusion, or it could be just afterwards as well. And also that is not attributable to another disease process going on, so it's only attributable to the actual transfusion.

And this is the most common type of reaction that we, we see with our patients receiving blood transfusions. So the treatment for this would be in severe cases. The transfusion would need to be stopped and antipyretics need to be given, but in milder cases, the transfusion rate can just be slowed down or stopped and then restarted once temperature has come down a little bit.

And then we also have other ones that we're really concerned about, so we have our acute hypersensitivity, so that's our anaphylaxis, or we have our intravascular or extravascular hemolysis, or again, we said that a bit differently in German. And, and that can be acute or delayed. Now, I've definitely seen delayed ones of those patients, but luckily I haven't seen an acute intravascular or extravascular hemolysis as those patients are very, very poorly.

They get kind of all sorts of symptoms, so fever, weakness, tachycardia, dyspnea, and they Have this really sort of port wine, urine or this really dark brown urine as well. And with those patients, the transfusion, as, as with any of these reactions actually, it needs to, you know, kind of be stopped. But with those patients, they have to have some shock therapy, you know, it could be fluid and different types of medication.

To get them back on track, before even thinking about restarting any type of transfusion. So that's kind of like the worst, one of the, well I would say probably the worst case scenario. But luckily, not so common, less common.

And then there's also the delayed hemolytic, which I'd say is probably a bit more common, and those patients are the patients where the PCV isn't rising to, as much as we would want it to, it's risen and then it's dropped again, so they've, you know, got some, hemolysis of the blood that we've given them. And, as I said again, we have the anaphylaxis as well. So those patients will have this kind of outbreak of high utticaria and puritis, potentially some edoema as well.

And again, the treatment is to stop it, stop the transfusion and give them some medication. So give them some antihistamines or some cortical steroids or both. And also with those patients, it's important that you're checking for any, You know, hemolytic signs.

So if they're having those issues, you know, an extreme anaphylactic reaction and, and then you notice that they're having some kind of really dark coloured urine, for example, then it could actually be an intravascular or extravascular acute hemolysis. So yeah, just something important to, to note. And another one that you may also see in in practise is this taco, and that is a transfusion associated circulation overload, so that is especially important in our patients that are, you know, kind of our cardiac patients or our kidney patients that are more likely to, to get, you know, more sensitive to circulation overload.

And that's not an immunological reaction, that's just a reaction from receiving. For them, too many, too much fluids too quickly at least. And as I say, there's a bunch of other reactions that we could have, but not enough time to talk about it.

And then I will just whiz through this last slide, which I think would potentially, as we've only got 10 minutes for questions, so I won't talk about this a lot, but I did have a slide here about xenotranfusions. And so that might be if you've ever heard or you've seen or you've given an intraspecies transfusion. So a dog, dog blood being given to a cat.

And there was a nice interesting study just recently. I think it was 2019. And I really, encourage you to give that a read.

I thought it was really interesting, what they found, and kind of the main thing they found was the kind of absence of severe adverse effects. So, in a last resort scenario, this may be something that, that could be, administered, if there's no feline blood available, no matching feline blood available. Yeah, and so just to finish off on some practical nursing tips.

So store your blood upright, so store your pattern of blood cells upright to preserve the cells. Store in a separate fridge or freezer, wherever possible, or a low traffic unit. Not all anaemic patients may need a blood transfusion.

You need to make sure that they are also clinical for those signs for that, for that kind of PCV level. Food and medication that could be given before commencing the transfusion where possible, so that's something you need to discuss with the vet before you do that, but that's something I think is important as a nurse that we're thinking about for our patients. Blood products don't particularly need to be warmed before administration and use your multi-parameter devices to help you.

And the last 0.4 eyes are better than 2, so making sure that your kind of your colleagues are looking and checking your expiry dates, looking and checking that your blood groups are correct before you're administering those products. And there we are.

Hopefully we've had time, we've gone through all of our learning outcomes for today's lecture. I won't go through all of those again with you. And we will go through to any questions if you have any.

And if we don't get time to go through them all tonight, then please, I'll leave this slide up and you can take down my email address here and you can write to me. I'll be very happy to reply. And that's me done.

Thank you. Thank you, Natasha, that was splendid, really enjoyed that. What I love to see also is we've got a really mixed audience, names that I recognise, vets and nurses.

And I think it's great because obviously we've got vets on nursing webinars and nurses on vet webinars, which we do on on the Thursday, because of course it's a great way of learning to understand each each other's jobs more and. You know, I've learned a lot today and I'm sure it reciprocates when the nurses go on some of the veterinary webinars as well. So thank you so much for that.

Do come up with some questions. I'm sure there is there are a few of you on there that could give us your thoughts on maybe how many transfusions are you doing on a monthly basis or on an annual, let's say on an annual basis, how often are you? Doing this as a as a procedure in your veterinary practise, while you're having a think to ask some good questions to Natasha, just wanted to.

Remind you all that we've got the Vet Trust awards on Thursday, 7:30. We're in the middle of lockdown, obviously, Natasha, I know you were in Switzerland, you are also cordially invited. It'll be 8:38 with you, but 7:37, we, we did a, survey in the summer and we asked people, you know, what companies do they most like and trust.

So there's various awards going out and I think the idea was. We're in lockdown, we can't go out to the pub, so we're gonna get dressed up. And usually this event would take place at the London Vet Show, which, as you know, didn't happen.

So when we're at the London Vet Show, we do pizza and prosecco with the awards. People come early evening, we do the awards, and then people can go off to their their dinners. This year, of course we we can't do that, so.

We're suggesting to people to get dressed up and cook your own pizza and open a bottle of of something nice to enjoy. Prosecco possibly, but we're we're not too bothered if you want to drink something else that you will enjoy. And Dawn very kindly has just put up the page there.

So if you want to register for that and have a bit of fun on Thursday night and. Perhaps we all need a bit of a cheer up in these tough days. I've just come out two weeks of isolation after my wife went down with coronavirus, thankfully is improving.

So, if that is of use, if you think you'll enjoy that, please do come on to the Vet Trust Awards. Want to very quickly mention that obviously as one of our nurse members, I think pretty much everybody here will be one of our webinar members. You will hear it first.

We've got the virtual congress 2021, which will be something like on 98 or 9. So we started virtual congressing when when nobody else did, when it wasn't really that interesting for people to do. We'd love to see you on it.

We, we do give a free ticket to every member to come to the conference, and I think, Natasha, you were, you were so interesting today and kept on saying, I'd love to spend a bit more time talking about the the various conditions and also towards the end there. So maybe we can twist your arm to to come on the virtual Congress 2021. Starting on the 22nd of February and we're gonna do it all week with recorded webinars, live webinars, and a big .

A big day on the Saturday when we'll be running several streams and going on, midnight to midnight so that we pick up people listening in from all over the world. So I, I don't, I'm putting you on the, on the spot there, Natasha. Yeah, maybe you can twist my arm.

That sounds like quite a proposition. That's really exciting and it was exciting of doing it kind of 12 to 12 and getting all those people from, from different places as well. That's a really nice idea.

Yeah. It's always been an interesting day in our early days I did try and do the whole 24 hours myself, with, with Dawn, but now that we've got a slightly bigger team, we, we can, chill out a bit more. Yeah, sounds, sounds like a better idea.

No, Dawn will definitely follow you up on that, Natasha. We've got a couple of, comments and questions, but do keep them, do keep them coming. Another Natasha said they're very interesting, thank you.

Not something we see enough of in first opinion. It was interesting, you know, when I had my own practise, it was probably. You know, 1 or 2 a year, but it was possibly because it seemed a bit difficult and awkward that.

You didn't rush to do it, whereas I think as I've understood it more, and obviously I haven't had my own practise since 2011. There are a lot of cases that you could do it with if you really understand all the indications, isn't there? Yeah, for sure.

And I think, you know, companies like Pet Blood Bank in the UK making this much more accessible. And as, as far as I'm aware, there's also these kind of tox boxes in the different vets now, right? And I think they also potentially store some, some products.

So you've got those, those products near you, but you don't need to keep them, you know, you don't need to have that specialised fridge or freezer, which makes it just so much more accessible. And to kind of everyone in, in all the smaller practises as well, and I think that's really great. There's also another, blood, kind of, what they call, they have a I don't think they have a colony.

I think they, they have donors coming in as well in in Portugal, which, is quite interesting, and that's where we, we get some of our products from. We have an in-house system, but we actually need so much that, we don't have enough donors for all of the blood that we give. And, we have started getting some blood from them and them as well, which just makes it so much more accessible, especially with cats having stored product.

It's really, really great. It's a real lifesaver, actually. I mean, literally, sorry, excuse the pun.

Yeah, in, in every sense of the word, yeah, yeah. We, we have done some webinars everyone for the pet blood bank as well. It's a fantastic charity and we, we've done several webinars for them.

So do sort of go onto the site as well if you do want to learn more about this, but now if, if I was gonna say to you, you know, you're obviously doing a lot of blood transfusions at Zurich. What are you sort of maybe 5 top indications where you would go on ahead and do a blood transfusion? So I mean, these, the, especially we give packed red blood cells, so we're talking about that then you need to be looking of course at the PCV so seeing what the hematocrit is doing and you know that.

That's kind of under 10, then those patients, you know, it's generally indicated to, to give that. But it needs to be clinical as well. So you wanna be looking at their, vital parameters.

So it's, you know, res respiration rate and their heart rate, especially. And also kind of taking into consideration, those patients have just come in and they're really stressed, or they're in pain. So they're, you know, you're a road traffic accident patient.

And they've come in, they're in pain. The PCV is, you know, is dropping, but, you know, it's not too low right now. Well, actually, you need to address something else first.

You need to address perhaps their fluid status or their, you know, their pain status before you can really get a reasonable, you know, heart rate on those patients that you can, that you. Can rely on. That being said, if they have, you know, concurrent bleeding and, you know, a low PCB already, then those patients are, are gonna be patients that you, you're gonna need to, to give those products to.

We also see a lot of the immune-mediated hemolytic anaemia patients, so that would be due to so many different causes, so primary or secondary. And we also have quite a lot of these, . I guess what you would call them in the UK is like exotic, you know, diseases.

So we have more free movement in Switzerland. So we have kind of animals coming in from, you know, southern Italy and other places in Europe. So we do get these Babeia cases and whatnot as well.

So we get all sorts, all sorts of patients needing blood transfusions, really. The ones I saw a lot of, and now I'm in the ER, but you know, before that I was in the ICU. And we kind of set them quite separate, and I would see a lot of road traffic accidents that actually, when they first came in, they were quite stable.

But once they'd been in for a while and they continued to potentially have some internal bleeding, and then go for surgery. So like a, you know, a hip. Surgery cap, and they would bleed, you know, during surgery or just after, and they would need some extra support as well, you know, during surgery or just after, or before, if their PCB was already a bit low and they were a bit, you know, compensated.

Or decompensated. So I saw the most, for sure, see the most. Yeah.

He's got a question. He said, would you recommend giving blood at lower than Blood the body temperature without warming the blood. Why do you particularly say don't warm the blood?

So it's not that I say don't like don't do it, but I just saw it it was in the literature and what I, what I was always taught from private practise or from kind of starting days was pop it under your arm and kind of warm it up to body temperature before you, you give that blood. Well, I think the literature behind it, to be honest with you, I didn't read through the whole, study, and please forgive me. But, it didn't show any, adverse effects of giving that blood to them, even though it was a bit cooler.

Obviously we get a Of hypothermia, potentially, but, apart from that, and when we take that blood out of the fridge, we have 4 hours to give that blood. Now, we spend half an hour warming that blood underneath, you know, nice and slowly underneath our wherever, then that's time that we haven't given that to our patient, and then we need to speed up the transfusion, potentially, so that we get that in within 4 hours. And that's Like, obviously, you know, clearly not ideal.

Now, the, what I did see was that if you are giving it to a neonate. Or you're giving it, you know, very quickly and you're giving large volumes, that could be an indication to warm that up to body temperature. And again, you, you need to be really careful when you are warming that, that you're not warming it to above 37 degrees, cause then we could have, you know, bacterial growth and contamination in the back as well, which is, something that, that we really, really need to be cautious of.

If you've enjoyed the talk, as I say, you want to know more, we have got those Pet Blood Bank webinars which Dawn, Dawn is just amazing. She kind of just gets things done, gets it on the page that do click on that link and you can have a look at those other ones as well. Natasha, the problem with do webinars, as I'm sure you're aware, is you don't get the tumultuous applause from the audience, but, Sarah says fantastic, thank you so much.

And I think we also Did say before right Natasha saying very interesting as well. So thank you so much for that. That's been really, really interesting.

If anybody has got a a question that they are dying to ask, then, then do come up with it now and I, I will ask it to Natasha. But otherwise, please do try and come to the Vet Trust awards. I think it'll be a really nice evening.

We're looking forward to it. I'm gonna get dressed up in my blood rags. Please feel free to do the same as well, or if you don't want to, just come along and enjoy the fun.

Hopefully we'll, we'll have a really good evening. Natasha, I, we will definitely get in contact with you. I think there's definitely another webinar in there somewhere and maybe, the, the virtual congress would be really nice as well.

Minka's saying excellent presentation, come to California. So she's obviously keen to get some help over there. I think we'd all volunteer for that particular.

Yeah exactly. Get some sunshine. That sounds nice.

But no, thank you so much for having me. I've really enjoyed it, and, I really appreciate all of you guys for coming along and spending some of your evening with me. And I, I just, I hope it was, usable for you, and wherever you're working, if that's kind of first opinion all the way through to referral, I hope you've been able to pick up.

At least, you know, a couple of tips, on this talk. I always think that whenever I go to a talk, you know, that even if I've just picked up one new thing, then it was, you know, worth doing, and I've, I've taken something away from it. So that's, that's how I like to look at things.

Maybe I'm a bit of an optome. Well, I think exactly the same, because if I take one thing from this lecture, obviously I'm not in clinical practise now, but I can add that into my clinical practise and that makes My clinical practise better then that's a very well spent hour, isn't it? Yeah, for sure, for sure.

Natasha, Vien Dank and Guttenach. OK, thanks everyone, and see you soon. Take care, bye bye.