Blood Administration

1. Blood Administration

2. Blood Administration Your patient’s Hgb & HCT is 6.2 & 18.4; the doctor orders 2 units of packed RBC’s! What actions do you take?

3. Blood Administration • Right If you said: • Check for T&C • Verify informed consent • Insure IV access: prefer large bore catheter (18-20 gauge); smaller bore could cause destruction of RBCs • Gather equipment

4. What is T&C vs T&S • What does TYPE mean? • What does crossmatch mean? • T&S • *chance blood will be needed • *allows blood bank to be flexible with • blood • T&C • *pt will need blood • *ties up inventory, blood is set aside for • that particular patient for 3 days

5. Blood Administration • Objectives • Discuss: • Common blood products • Steps in blood administration • Complications of blood administration • Always consult specific hospital policy

6. Types of Blood Components Whole Blood To replace blood volume and O2 carrying capacity in Treat hemorrhage and shock Contains PRB’C, plasma proteins, clotting factors and plasma (few platelets & granulocytes) Volume = 500ml/unit __________________ Packed Red cells (PRBCs) Treat anemia, replace blood volume (ordered when Hgb 8-9 & HCT 24-27) 1 unit PRBC = Hgb by 1/HCT by 3 From whole blood (2/3 of plasma removed) Only RBCs used Purpose: O2 carrying capacity in patients with slow bleeding, anemia, leukemia, surgery Volume = 300-350ml/unit Risks & Benefits Possible incompatibility issues Circulatory overload **Deficient in some clotting factors Rarely used Use Lasix to prevent overload ________________ Risks & Benefits Use leukocyte poor red cells or leukocyte filter if history of febrile reaction No viable platelets or granulocytes Incompatibility may cause hemolytic reaction Less chance of fluid overload than whole blood Takes 4-6 hours for Hgb & HCT to change Shelf life: 42 days (takes 1 day to process) Most commonly used!!

7. Current Blood Preparation Leukocyte reduction prior to storage Removal of most WBC’s and Plasma reduces the risk of reactions Irradiated for those with CA or risk for GVHD good for 28 days Drawback bacterial growth if contaminated during collection/processing

8. Types of Blood Components Con’t Platelets To control or prevent bleeding in platelet deficiencies, i.e. thrombocytopenia (often ordered when platelets count <10-20,000) From whole fresh blood Expected platelet 10,000/unit Measure at 1hr & 18-24 hr post admin Volume = 30-60ml/unit ________________________ Albumin (plasma derivative) To expand blood volume or replace protein Used to treat shock from trauma, infection, 3rd spacing, hypovolemia, burns and in surgery Available in 5% -25% solution Paid donation Volume 25g/100ml = 500ml of plasma Risks & Benefits Not a substitute for whole blood May form antibodies Hypersensitivity reaction Must be used within 5 days of donation _______________ Risks & Benefits Vascular overload Hyperosmolar solution moves water from extravascular space to intravascular space Outcome: adequate BP & volume Hypersensitivity reaction Can be stored for 5 years

9. Types of Blood Components cont’d • Frozen RBCs • Rarely used • Successive washing with saline solution removes majority of WBCs and plasma proteins ________________________ • Fresh Frozen Plasma (FFP) • To treat DIC, reverse effects of Coumadin, treat liver failure pts • Contains clotting factors • Improves coagulation, PT & PTT Volume = 200-250ml/unit Risks and Benefits - Can be stored for 3 years - Use within 24hrs of thawing - No WBC’s ___________________ Risks & Benefits • Rich in clotting factors • No platelets • Good for volume expansion to restore clotting factors in hypovolemic shock • Risk for vascular overload • Hypersensitivity reaction • Hemolytic reactions

10. Types of Blood Components Cont’d • Prothrombin Complex – Prothrombin, Factors VII, IX, X, and part of XI • Used to treat clients with specific clotting factor deficiencies • Prepared from FFP • Store for 1 year, once thawed, must be used • Cryoprecipitate – Clotting Factors VIII, XIII, von Willebrand’s factor, & fibrinogen from plasma • Used to treat clients with specific clotting factor deficiencies • May cause ABO incompatibilities

11. ABO Compatibility Chart Who is universal donor & recipient? What do the - & + mean?

12. Population Percentages

13. Donor Eligibility • Donor Eligibility Resource

14. *Preparation for Blood Administration* Physicians order Look at labs Verify/sign consent* Obtain IV access, large bore catheter (18-20 gauge), 2 lines if possible *Get client ready for transfusion prior to getting blood from the lab T&C done Gather supplies *Staff signs for and obtains blood (only one client & 1 unit a time!) Routine compatibility testing takes about 1 hour to identify recipient ABO and Rh type; in emergency O-negative RBC’s can be safely given to most clients without serologic testing. Why can O-neg blood be safely given to most people? *Universal RBC donor is O negative 2 RN check at the bedside with patient chart (see next slide for 2 RN check) Blood admin must be completed within 3-4 hours after receipt from blood bank!

15. 2 RN checkWhat do you check for? • Entire process needs 2 RN independent double check at bedside • Verify informed consent • Check physician’s orders • Match this information to the information on label on blood, lab sheet, patient blood band, and the chart: • Name, DOB, MR#, Blood Band #, unit expiration date, unit number, blood type (group and Rh) 90% of all reactions occur because of mistakes in labeling and verification

16. Blood Product Administration • IV 18-20 gauge adult, 23-child • 0.9% Sodium Chloride (NS) only • Prime Y-type blood tubing with NS, before admin/picking up blood. • Clamp off NS • Pick blood up from blood bank/invert unit to mix cells (do not shake it) • Compare all labels second time • Be prepared – once you begin, don’t leave the room • Spike blood bag • Squeeze tubing to cover blood filter with blood • Set pump – start slow • Check vital signs and record – educate pt on what to look for • Initial vitals before admin (RR, Temp, HR, BP) • Vitals 15 minutes after admin. (stay with pt 1st 15mins) • Vitals q30min after that until transfusion complete • Vitals post admin. and then in 1hr • If unable to give blood – must be returned within 15-30 minutes of removing from lab – DO NOT STORE IN UNIT REFRIGERATOR

17. Blood Product Administration • Use appropriate filters • Use blood administration set no more than 4 hours – infusion must be complete in 4 hours • New unit, use new set • Always follow hospital specific blood administration policy Blood to cover filter

21. Flush IV site with NS Post administration vitals Dispose of tubing and blood bag in biohazard bag If a 2nd unit is ordered: Prime new tubing with new NS bag Retrieve 2nd unit Repeat RN checks Document: When started & ended Volume infused Premeds given How the pt tolerated procedure Protocols followed Post Administration

22. Critical Points • Monitor for signs of transfusion reaction • Infuse over ordered period • Blood cannot be out of refrigerator more than 30 minutes prior to administration –PLAN AHEAD!! • BE READY TO START BEFORE GETTING BLOOD!! • Allow blood to hang no longer than 4 hours • If multiple units to be given for replacement of rapid blood loss, may be given under pressure and warmed prior to administration (only agency approved warming device)

23. How would you manage this? • Your client is to receive a unit of packed red blood cells. You have picked the blood up from the blood bank and brought it to the unit. You flush the patient’s IV before hanging the blood and find that it has infiltrated. You are unable to initiate IV access. What actions should you take? • 2. Your client is to receive a unit of RBC’s for a Hgb/HCT of 8/22… • How will the order be written? • What response to this unit of blood is anticipated (related to the Hgb/HCT)?

24. Transfusion Reactions Blood transfusion reaction: adverse reaction to blood therapy: range from mild symptoms to life threatening; can be acute or delayed! • What vital signs might you see? Vital signs taken prior to start of infusion are critical • Consider a temperature increase of 1 degree significant • Action taken will be determined by the type of reaction; careful assessment & monitoring of the patient is a must!

25. Transfusion Reactions/Complications • Febrile (most common) • Sensitization to donor WBC, platelets, plasma proteins • Allergic (hypersensitivity to donor plasma proteins) • Mild allergic to severe (anaphylactic) • Hemolytic (life-threatening!) • Acute hemolytic: ABO incompatible; red cell destruction (wrong blood type given to pt) • Circulatory overload • Fluid given too fast & too much • TRALI • Transfusion reaction acute lung injury • Non cardiogenic pulmonary edema • Bacterial (pyrogenic or sepsis) • Transfusion of bacterially infected components

26. Febrilepyrogenic /non-hemolytic Caused by leukocyte incompatibility; sudden onset: usually within first 15 minutes of transfusion! (usually a reaction to donor WBC’s or plasma proteins) • Fever/chills (^1 degree) • Sensations of cold • Flushed skin, abdominal pain, vomiting and diarrhea • Hypotension/Shock • Prevent by use of leukocyte poor blood! • Stop infusion/antipyretics • Call MD **Bacterial (pyrogenic): similar to febrile; due to bacterial contamination of blood: see S & S above

27. Allergic Reactions (hypersensitivity reactions) Antibodies in patient’s blood react against proteins, such as immunoglobulin A in donor blood May occur during or after the transfusion Can occur quickly, within 50mls of blood administered Mild and transient: stop infusion, alert MD, give antihistamine prophylactically, use washed RBCs Severe: stop infusion, keep line open with new saline & tubing; CPR & epinephrine (if indicated) DO NOT RESTART TRANSFUSION Mild (initially) (1% of pts.) • Urticaria • Pruritis Severe (Anaphylactic) • Anxiety • Wheezing & Chest tightness • Dyspnea • Bronchospasm • Hypotension • Tachycardia • Swelling of tongue, face • Loss of consciousness • Shock, pulmonary edema

28. Hemolytic Transfusion Reaction! Most dangerous! Develops within first 15 minutes of transfusion: free hemoglobin in blood and urine specimens provide evidence of acute hemolytic reaction Occurs in 1:25,000 Usually occurs after 50-100 ml blood infused! (possibly 200mls) ABO/Blood incompatibility • *RBC’s clump (lysis of RBC’c), block capillaries, decrease blood flow to organs • Hgb released (myogloburia), blocks renal tubules > acute renal failure=ATN (acute tubular necrosis) • Potassium released • Fever/chills • SOB/dyspnea/wheezing • Apprehension • Headache/low back pain • Chest pain/chest • tightness • Urticaria • Tachycardia • N&V • Hematuria • Burning at IV site

29. Hemolytic Transfusion Reaction! If hemolytic reaction occurs: Stop transfusion, keep IV line open with new tubing, saline, possible colloid solution to maintain BP; monitor Notify MD of patient signs and symptoms Treat shock (anaphylactic) if present (epinephrine, oxygen, antihistamines, vasopressors, fluids, corticosteroids) Draw blood samples for serologic testing; send urine to lab and return blood & tubing to blood bank for free Hgb testing & crossmatch verification Prevent acute renal failure:give diuretic, fluid challenge Stop the blood, send tubing and remaining blood to lab; urine to lab! Follow facility policy and procedure for administering blood, blood products and transfusion reaction!

30. ABO incompatibility causes RBC’s to clump, block capillaries, decreasing blood flow to organs.

31. Hemolytic Reactions Hgb is released blocking renal tubules Can cause renal failure.

32. 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 Lewis – can occur within infusion of as little as 10mls

33. Reactions/Complications • Circulatory overload • Fluid given too fast & too much • Note cough, dyspnea, lung sounds, HTN etc • Slow infusion, elevate HOB, treat overload • Iron overload • Delayed reaction • Vomiting diarrhea, hypotension, altered hematological values

34. Nursing actions if reaction occurs • Stop transfusion immediately • Continue Normal Saline IV with new tubing • Provide appropriate care for client • Notify physician of client signs and symptoms • Follow facility policy and procedure • Obtain urine & blood specimen for free hemoglobin test

35. Autotransfusion (autologous transfusion) Indications • Used in surgery & emergency settings • Autologous blood-collection of own blood prior to scheduled surgery Risks and Benefits • Requires special equipment • If pre-donation, begin collection within 5 weeks of transfusion date end at least 3 days prior to transfusion need “Cell-saver" technology collects blood lost during surgery, cleanses it, and places it back in the patient's body, all in a continuous loop.

36. Autotransfusion • 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. • What are the issues related to Autologous transfusion? • Usually the pateint is already medically not well • 2/3 of donations do not get used • Many end up in the hospital post procedure

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

38. Every unit of blood is tested for • Antibodies to HIV-1 and HIV-2 (AIDS). • Antibodies to HBV produced during and after infection with Hepatitis B Virus • Antibodies to HCV produced after infection with the Hepatitis C virus • Antibodies to HTLV-I/II produced after infection with Human T-Lymphotropic Virus (HTLV-I and HTLV-II) • Antibodies to HBsAg produced after infection with Hepatitis B • For blood type (ABO) and Rh factor • Tp, the agent that causes syphilis • ALT, an elevated ALT may indicate liver inflammation, which may be caused by a hepatitis virus

39. Cont. • The presence of unexpected antibodies that may cause reactions after the transfusion • CMV, a test for the cytomegalovirus (performed on physician request) • 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 are filtered to remove leukocytes that can harbor viruses and infections.

40. Congratulations on Your Successful Completion!