Blood Administration

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Blood Administration

• Lisa Randall, RN, MSN, ACNS-BC
• RNSG 2432

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Types of Blood Components

• CURRENTLY USED
• Packed RBCs
• Frozen RBCs
• Platelets
• Fresh Frozen Plasma
• Albumin
• Cryoprecipitates commercial concentrates

• NO LONGER USED
• Whole blood except
• Exchange transfusions
• Massive blood loss

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Current Blood Preparation

• Leukocyte reduction prior to storage
• More effective than previous washing process
• Packed RBCs are removed from plasma
• Removal of most WBCs and Plasma reduces the risk
  of reactions/infection
• Drawback bacterial growth if contaminated
  during collection/processing

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Packed Red Cells (PRBCs)

• Used to treat anemia and replace blood volume
  (Additional NS used for volume)
• Usually ordered when Hgb 9 and Hct 27
• For asymptomatic elderly lt7g/dl
• Epoetin alfa (Procrit Epogen) - increase
  hemoglobin levels reduce the need for blood
  transfusion
• 1 unit of PRBCs will increase the Hgb by 1 and
  the Hct by 3
• Usually contains 250 ml.
• Usually not use a leukocyte filter

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Blood components cont.

• Risks
• Not a substitute for plasma or clotting factors
• May form antibodies
• Hypersensitivity reaction

• Platelets
• To control or prevent bleeding in platelet
  deficiencies -thrombocytopenia
• To treat platelet dysfunction
• Given when lt20,000

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Platelets

• One unit contains 30-60 ml platelet concentration
• Expected increase is 10,000 per unit
• Outcome measured by platelet counts at 1 hour
  and 18-24 hours post transfusion

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Blood components cont.

• Albumin
• To expand blood volume or replace protein
• Used to treat shock from trauma, infection and in
  surgery

• Risks
• Vascular overload
• Hypersensitivity reaction

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Albumin

• As a volume expander
• Used for patients 3rd spacing and are
  hypovolemic, liver patients
• Hyperosmolar solution acts by moving water from
  extravascular to intravascular space
• Outcome adequate blood pressure and volume

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Fresh Frozen Plasma (FFP)

• Risks
• Vascular overload
• Hypersensitivity reaction
• Hemolytic reactions contains antibodies

• Plasma
• Contains clotting factors protein
• No platelets
• Used for clotting problems as
• DIC
• Liver patients
• Urgent warfarin reversal

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Fresh Frozen Plasma (FFP)

• One unit 200-250 mls
• Outcomes improved coagulation, PT,INR, and aPTT

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Blood components cont.

• Prothrombin Complex Prothrombin, Factors VII,
  IX, X, and part of XI
• Used to treat clients with specific clotting
  factor deficiencies
• Cryoprecipitate Clotting Factors VIII, XIII,
  von Willebrands factor, fibrinogen from plasma
• Used to treat clients with specific clotting
  factor deficiencies
• May cause ABO incompatibilities

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RBC Plasma Transfusions
RBCs - Type and cross match with potential donor
blood to check minor antigens on cells Usually 2
orders Type Administer
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Blood Type (ABO Rh) of General Population
O, 35
O, -   7
A, 35
A, - 7
B, 8
B, - 2
AB,   4
AB, - 2
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Initiation of Transfusion

• Check MDs order Obtain permit
• ID patient, draw blood for TC in red top tube,
  place blood band and label tube.
• Start 18-20 gauge IV.

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Initiation Cont.

• 2 people check unit of blood or component with
  laboratory slip, patients chart hospital forms
  should include
• Patients name, Medical Record , blood band
  number, Unit
• Blood component, Group Rh factor, donor number
• Expiration date

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• Compare all labels forms of ID second time
• Check vital signs and record
• 0.9 Sodium Chloride (NS) only!!!
• Prime Y-type blood tubing with NS
• Invert unit to mix cells
• Spike blood bag, clamp off NS
• Cover blood filter with blood

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For intraoperatively salvaged washed blood.

• Use appropriate filters

• For intraoperatively salvaged washed blood.
• Reduces leukocytes
• Decreases fat globules
• Reduces microaggregates

                                                                             
Significantly reduces leukocytes in salvaged blood   Substantially decreases fat globules in salvaged blood
                                  
Reduces microaggregates present in salvaged blood
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• Use blood administration set no more than 4 hours
  each infusion must be completed in 4 hours
• Check facility policy re units per
  administration set
• No more than 1 or 2 units per tubing
• Use IV pump

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Important Points

• Drip rate no higher than 2 ml per minute X 15
  minutes (30 ml per 15 minutes or 120 ml/hr.)
• Seton etc. set pump at 75 to 80 ml/hr. for 15
  min.
• Remain with pt for first 15 minutes or first 50 ml

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Important Points

• Vital signs prior to administration in 15 min.
  X 4,
• then q 30 minutes, until transfusion
  complete--then X 2
• No meds or fluid other than NS to be given in
  line with blood!!!
• CHECK POLICY AND PROCEDURE of facility!!

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Important Points

• Infuse over period specified (2-4 hours)
• Blood cannot be out of refrigerator more than 30
  minutes prior to administration PLAN AHEAD!!
• BE READY TO START BEFORE GETTING BLOOD!!

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Transfusion Reactions

• Anaphylactic
• Allergic or Hypersensitivity
• Hemolytic
• Febrile

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Transfusion Reactions

• Transfusion-Related Acute Lung Injury
• Massive Blood Transfusion Reaction
• Sepsis
• Circulatory Overload

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Transfusion Reactions

• Incompatibility between donor and recipient's
  blood
• What changes in vital signs would you expect to
  see?
• Consider a temperature increase of 2 degrees
  significant
• What drugs are commonly given prior to
  transfusion?

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Prophylaxis/preadministration

• History of an allergic reaction to a previous
  blood transfusion
• acetaminophen (Tylenol)
• diphenhydramine (Benadryl)
• High risk of fluid overload
• furosemide (Lasix) or another diuretic

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Allergic Reactions - 1 can occur during
or after transfusion

• Mild
• Urticaria
• Itching
• Flushing

• Severe
• Wheezing
• Dyspnea
• Bronchospasm

• Obtain order for antihistamine and antipyretic if
  pt. has temp elevation
• If pt. responds to these, may have order to
  resume transfusion

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Anaphylactic Reactions

• Can occur very quickly, with only a small amount
  of transfusion usually within 50 mls
• Hypotension, SOB, Tachycardia, Shock
• Loss of consciousness
• Facial or laryngeal edema
• Dizziness, Chest tightness, abdominal cramping
• Get order for epinephrine corticosteroids

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Hemolytic Reactions - 0.004 or
125,000

• ABO incompatibility
• RBCs clump
• block capillaries decreasing blood flow to
  organs.
• Hgb released, blocks renal tubules can cause
  renal failure.
• Potassium released.

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Hemolytic Reactions

• Key Indicators
• Apprehension Fever/chills
• Headache Burning at IV site
• Chest pain Low back pain
• Tachycardia Hypotension
• Urticaria
• N/V
• Acute-usually occurs after
• 50 ml. infused
• Lemone after 100 to 200 ml infused
• 3 or 5-10 days up to several months later

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Pyrogenic (non-hemolytic)
Febrile
or Bacterial

• Occurs within first 15 minutes
• Sensations of Cold
• Fever
• Chills
• Hypotension
• Shock
• Reaction to donors WBCs, plasma proteins, or
  contamination

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Transfusion-Related Acute Lung Injury

• Reaction between recipients leukocytes donors
  antileukocyte antibodies due to sensitization by
  pregnancy or previous transfusions
• Pulmonary capillaries inflamed
• Fluid in alveoli
• Respiratory distress
• Risk greatly reduced with leukocyte removal and
  washed packed cells

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Massive Blood Transfusion Reaction

• Replacement exceeds usual blood volume
• Drop in clotting factors, albumin, platelets
• Hypothermia
• Citrate toxicity hypocalcemia Pedi pt.
• 10 ml 10 calcium gluconate / liter of blood
• Hyperkalemia

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Graft vs. Host

• Stem cells in blood products invade marrow of
  immunodeficient pt.and grow as a foreign tissue
  which is rejected
• Lymphocytes in blood products attack
  immunodeficient pt.
• 7 to 30 days after transfusion
• Skin, GI tract, liver damage

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Nursing actions if reaction occurs

• Stop transfusion immediately
• Continue N/S IV with new tubing
• Provide appropriate care for client
• Notify physician of clients signs and symptoms
• Follow facility policy and send bag and tubing to
  lab
• Obtain blood and urine specimen for free
  hemoglobin test

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Charting

• Document the following
•          Time of the transfusion reaction
•          Type and amount of infused blood or
  blood product
•          Clinical signs of the transfusion
  reaction in order of occurrence
•          Vital signs
•          Specimens sent to the lab
•          Treatments given and patients
  response to treatment.
•          If required by your facility policy,
  complete the transfusion
  reaction form and any quality variance
  forms.

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Major/Urgent Surgeries Performed in the Inpatient
Setting

• Ablative procedures
• Amputations
• Colostomy
• Reconstructive
• Total joint replacement
• Heart bypass surgery
• Palliative
• Colostomy for CA
• C-sections

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Major Surgeries Performed in the Inpatient
Setting

• Emergency Surgery
• Transplants
• Ruptured aneurysm
• Life-threatening trauma

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Critical Thinking Exercise

• The pt.s blood type report indicates that he is
  Type A. The unit of PRBC's that the bank has
  provided is labeled as Type O negative.
• Can this patient safely receive this blood?
• Why or Why not?

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Critical Thinking Exercise 2

• The pt.s Type Crossmatch report indicates that
  he is Type A-. The unit of PRBCs that the bank
  has provided is labeled as Type O.
• Can this patient safely receive this blood?
• Why or Why not?

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Critical Thinking Exercise 2

• The pt. is Type A-. The unit of whole blood is
  labeled as Type O.
• Can this patient safely receive this blood?
• Universal donor in emergency
• Type O has A B antibodies but no A or B
  antigens
• Rh D antigen to a Rh- patient
• male vs. female?
• Age of female?
• Level of emergency situation?

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Rh mother with Rh baby What med is used?
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Drug used RHo (D) Immune Globulin (RhoGAM)
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Critical Thinking Exercise 3

• The patient is a Jehovahs Witness. What factors
  impact care for bleeding in an emergency
  situation?
• Compare this situation to the patient who is
  concerned about the safety of blood component
  transfusions?

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Critical Thinking Exercise 4

• The patient is scheduled for an elective
  procedure such as a total knee replacement.
• What measures can be taken to decrease the risk
  of transfusion reaction?
• What type of reaction might still be possible?

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Autologous transfusion

• What are the benefits of Autologous transfusion?
• Blood you receive should definitely match
  yours. Risk of getting any allergic reaction
  will be very low. Blood will be available if you
  have a rare blood type. No infectious diseases -
  hepatitis, syphilis, AIDS, etc. Safe and
  well-tested procedure.

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Autologous transfusion

• Who can have Autologous transfusion?
• Patients less than 65 years old.
• Patients without serious medical conditions like
  serious heart and lung diseases.
• Patients with hemoglobin level of at least 11g /
  dl before each donation

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• Autologous transfusion

A "cell-saver" technology collects blood as it is
lost during surgery, cleanses it, and places it
back in the patient's body, all in a continuous
loop.
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Directed donation of blood

• Sticker "Directed Donation" affixed directly on
  the unit.
• Note Directed donations units may also be
  collected by facilities other than yours.
• A complete check of the unit identification
  compared to the patient identification is
  performed on each unit to ensure unit is given to
  the correct patient.

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Every unit of blood is tested for HIV-1 and
HIV-2 (AIDS) HBV HBsAg HCV HTLV-I/II Human
T-Lymphotropic Virus (HTLV-I and HTLV-II) ABO
and Rh factor cross match if RBCs syphilis
elevated ALT
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The presence of unexpected antibodies that may
cause reactions after the transfusion CMV, a
test for the cytomegalovirus (performed on
physician request) OK if WBCs filtered
out NAT (Nucleic Acid Testing) - a new
technology that can detect the genetic material
of Hepatitis C and HIV to identify these viruses
faster and more accurately 100 of the blood
products in USA are filtered to remove leukocytes
that can harbor viruses and infections.
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THE END!