Blood Administration

1. Blood Administration Lisa Randall, RN, MSN, ACNS-BC RNSG 2432

2. CURRENTLY USED • Packed RBC’s • Frozen RBC’s • Platelets • Fresh Frozen Plasma • Albumin • Cryoprecipitates & commercial concentrates • NO LONGER USED • Whole blood except • Exchange transfusions • Massive blood loss Types of Blood Components

3. Leukocyte reduction prior to storage • More effective than previous washing process • Packed RBC’s are removed from plasma • Removal of most WBC’s and Plasma reduces the risk of reactions/infection • Drawback – bacterial growth if contaminated during collection/processing Current Blood Preparation

4. Used to treat anemia and replace blood volume (Additional NS used for volume) • Usually ordered when Hgb 9 and Hct 27 • For asymptomatic elderly <7g/dl • Epoetin alfa (Procrit & Epogen) - increase hemoglobin levels & reduce the need for blood transfusion • **1 unit of PRBC’s will increase the Hgb by 1 and the Hct by 3 • Usually contains 250 ml. • Usually not use a leukocyte filter Packed Red Cells (PRBC’s)

5. Platelets • To control or prevent bleeding in platelet deficiencies -thrombocytopenia • To treat platelet dysfunction • Given when <20,000 • Risks • Not a substitute for plasma or clotting factors • May form antibodies • Hypersensitivity reaction Blood components cont.

6. 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 Platelets

7. Albumin • To expand blood volume or replace protein • Used to treat shock from trauma, infection and in surgery • Risks • Vascular overload • Hypersensitivity reaction Blood components cont.

8. 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 Albumin

9. 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

10. One unit = 200-250 mls • Outcomes: improved coagulation, PT,INR, and aPTT Fresh Frozen Plasma (FFP)

11. 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 Willebrand’s factor, & fibrinogen from plasma • Used to treat clients with specific clotting factor deficiencies • May cause ABO incompatibilities Blood components –cont.

12. RBC’s - Type and cross match with potential donor blood to check minor antigens on cells Usually 2 orders: Type Administer RBC & Plasma Transfusions

14. Check MD’s order & Obtain permit • ID patient, draw blood for T+C in red top tube, place blood band and label tube. • Start 18-20 gauge IV. Initiation of Transfusion

15. 2 people check unit of blood or component with laboratory slip, patient’s chart & hospital forms should include: • Patient’s name, Medical Record #, blood band number, Unit # • Blood component, Group & Rh factor, donor number • Expiration date Initiation Cont.

18. 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

20. Use appropriate filters • For intraoperatively salvaged washed blood. • Reduces leukocytes • Decreases fat globules • Reduces microaggregates

21. 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

22. 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 Important Points

23. 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!! Important Points

24. 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!! Important Points

25. Transfusion Reactions • Anaphylactic • Allergic or Hypersensitivity • Hemolytic • Febrile

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

27. 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? Transfusion Reactions

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

29. 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

30. 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 Anaphylactic Reactions

31. ABO incompatibility RBC’s clump & block capillaries decreasing blood flow to organs. Hgb released, blocks renal tubules – can cause renal failure. Potassium released. Hemolytic Reactions - 0.004% or 1:25,000

32. 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 Hemolytic Reactions

33. Pyrogenic: (non-hemolytic) Febrile or Bacterial Occurs within first 15 minutes • Sensations of Cold • Fever • Chills • Hypotension • Shock Reaction to donors WBC’s, plasma proteins, or contamination

34. Reaction between recipient’s 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 Transfusion-Related Acute Lung Injury

35. 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 Massive Blood Transfusion Reaction

36. 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 Graft vs. Host

37. 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 andurine specimen for free hemoglobin test Nursing actions if reaction occurs

38. 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 patient’s response to treatment. •         If required by your facility policy, complete the transfusion reaction form and any quality variance forms. Charting

39. Ablative procedures: • Amputations • Colostomy • Reconstructive: • Total joint replacement • Heart bypass surgery • Palliative • Colostomy for CA • C-sections Major/Urgent Surgeries Performed in the Inpatient Setting

40. Emergency Surgery • Transplants • Ruptured aneurysm • Life-threatening trauma Major Surgeries Performed in the Inpatient Setting

41. 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? Critical Thinking Exercise

42. The pt.’s Type & Crossmatch report indicates that he is Type A-. The unit of PRBC’s that the bank has provided is labeled as Type O+. Can this patient safely receive this blood? Why or Why not? Critical Thinking Exercise #2

43. 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? Critical Thinking Exercise #2

44. Rh – mother with Rh + baby What med is used?

45. Drug used: RHo (D) Immune Globulin (RhoGAM)

46. The patient is a Jehovah’s 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? Critical Thinking Exercise #3

47. 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? Critical Thinking Exercise #4

48. 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. Autologous transfusion

49. 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 Autologous transfusion

50. 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 continuousloop.