Blood Administration

1. Blood Administration

2. Blood Administration Your patient’s Hgb & HCT is 6.2 & 18.4; the doctors orders 3 units of packed RBC’s! What actions do you take first?

3. Blood Administration • Right If you said: • Check for T& C • Verify informed consent • Insure IV access; need large bore catheter (18-20 gauge); smaller cause destruction of RBC’s • Gather equipment: • Y-tubing blood administration set with filter • NS solution and pump • Prime tubing with saline.

4. Blood Administration • Learn: • Common blood products • Steps in blood administration • Complications of blood administration • *Transfusion reactions • Circulatory overload • Septicemia • Iron overload • Disease transmission

5. Blood Products*Know products and how to safely administer!

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8. “Cell-saver" technology collects blood lost during surgery, cleanses it, and places it back in the patient's body, all in a continuousloop.

9. Preparation for Blood Administration Physicians order Obtain IV access; large bore catheter (18-20 gauge); 2 lines if possible T&C done? Blood on hold? * Get client ready for transfusion prior to getting blood from the lab * Staff signs and obtains blood (only one client a time!) Verify informed consent 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? *Universal RBC donor is O negative; universal recipient is AB positive Blood must be completed within 3-4 hours after receipt from blood bank!

10. Compatibility Chart Recipient Donor A B AB O A X X B X X AB X O X X X X O- universal donor, AB+ universal recipient

11. Initiation of Transfusion • Verify informed consent for blood • Check physician’s orders • ID patient, draw blood for T&C in red top tube; start 18-20 gauge IV (if not already done), place blood band and label tube. Blood tubing & 0.9NS IV fluid ready! • T&C to lab!

12. Cont*** • Obtain blood from blood bank (2 persons verify) • Blood to unit for administration: 2 RN’s check unit of blood with lab slip, patient’s chart; forms to include patient’s name, hospital #, and bloodtype • Expiration date of unit of blood • Pt’s ID #, blood band (Fenward) and state name • Blood band #- blood armband, issue transfusion card • Blood component, donor #, expiration date, gp and Rh factor • If blood not to be given, must be returned to blood bank within 20 minutes; CANNOT be kept in unit refrigerator (requires special refrigeration)!

16. Verify identification!

17. Compare all labels second time • Check vital signs and record • IV 18-20 gauge adult, 23-child • 0.9% Sodium Chloride(NS) only!!! • Invert unit to mix cells • Prime Y-type blood tubing with NS • Spike blood bag, clamp off NS • Cover blood filter with blood

18. Use appropriate filters • Use blood administration set no more than 4 hours – infusion must be complete in 4 hours • Check facility policy re: # units per administration set • May give blood on a pump- use pump tubing Blood to cover filter

19. Example of filters For intraoperatively salvaged washed blood. Reduces leukocytes Decreases fat globules Reduces microaggregates • Use appropriate filters Platelet filter: Patient protection against leukocyte-related transfusion complications Primes directly with platelets quickly and conveniently High platelet recovery achieved without saline flush

20. Critical Points • Client identification and blood compatibility! • Drip rate no higher than 2 cc per minute X 15 minutes (25-50 cc) • Remain with pt for first 15 minutes • *Vital signs prior to administration, in 15 minutes, then q 30 minutes, until transfusion complete--then X 2 • No meds or fluid other than NS to be given in line with blood (Saline ONLY)!!! • CHECK POLICY AND PROCEDURE

21. *Monitor for signs of transfusion reaction • Infuse over period specified (2-4 hours) • Blood cannot be out of blood bank refrigerator more than 30 minutes prior to administration-PLAN ahead! • *Do not allow blood to hang no longer than 4 hours (longer time, greater chance of bacterial contamination/septicemia) • If multiple units being given for rapid blood loss; may have to give under pressure and warm blood prior to administration (only agency approved warming devices)

22. How would you manage this? 1. Client to receive a unit of packed red blood cells….unable to initiate an IV access. What actions should you take? Return to blood bank within 20 minutes if left out longer run risk of bacterial growth and sepsis; get help with starting IV (should have started IV before requesting…plan ahead) blood) Ask An Expert Double Click

23. How would you manage this? 2. In addition to transfusion reaction; what is a major risk related to administration of whole blood? Circulatory overload due to volume; whole blood is typically 500cc and would cause fluid overload, especially in at risk client. Ask An Expert Double Click

24. How would you manage this? 3. Your client receives a unit of RBC’s…what response to this unit of blood is anticipated? Recall that 1 unit of PRBC’s increases the Hgb by 1g/dl and Hct by 2-3%-result > Hgb 9 & Hct 24 Ask An Expert Double Click

25. Transfusion Reactions/Complications • Febrile (most common) • Sensitization to donor WBC, platelets, plasma proteins • Bacterial (pyrogenic or sepsis) (not in text) • Transfusion of bacterially infected components • Allergic (hypersensitivity to donor plasma proteins) • Mild allergic to severe • Hemolytic (life-threatening!) • Acute hemolytic: ABO incompatible; red cell destruction • *Circulatory overload • Fluid given too fast & too much • Iron overload-delayed reaction • Hypocalcemia- citrate in blood binds with calcium & is excreted

26. 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 would you expect to see? Ask An Expert Vital signs taken prior to start of infusion critical; may actually give blood even if patient has slight temp elevation; must inform MD and Tylenol might be administered! • Consider a temperature increase of 2 degrees significant Ask An Expert • Action taken will be determined by type of reaction; careful assessment, monitoring of patient!

27. Febrile Caused by leukocyte incompatibility; sudden onset: usually within first 15 minutes of transfusion! • Fever/chills (^1 degree) • Sensations of Cold • Hypotension/Shock • Flushed skin, abdominal pain, vomiting and diarrhea • Prevent by use of leukocyte poor blood! • Stop infusion/antipyretics **Bacterial (pyrogenic): similar to febrile; due to bacterial contamination of blood: see S & S above

28. Allergic Reactions (Hypersensitivity reactions) • Mild (initially) • *Urticaria • Pruritis • Itching • Severe (text does not include this description) • Wheezing • Dyspnea • Bronchospasm • Swelling of tongue, face • Shock, pulmonary edema Antibodies in patient’s blood react against proteins, such as immunoglobulin A in donor blood May occur during or after the transfusion Mild and transient: stop infusion, possibly restart, give antihistamine prophylactically, use washed RBCs Severe: stop infusion, keep line open with new saline tubing; CPR & epinephrine (if indicated)

29. 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; delayed at 2-14 days Occurs after 100-200 ml blood infused! 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) • Fever/chills • SOB/dyspnea/wheezing • Apprehension • Headache/low back pain • Chest pain/chest tightness • Urticaria/tachycardia • *Hematuria

30. Hemolytic/Transfusion Reaction! If hemolytic reaction occurs: Stop transfusion, keep IV line open with new tubing, saline, 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 testing 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!

31. Reactions/complications • *Circulatory overload • Fluid given too fast & too much • Note cough, dyspnea, HTN, etc • Slow infusion, elevate HOB, treat overload, phlebotomy • Iron overload- • delayed reaction • Vomiting diarrhea, hypotension, altered hematological values • Administer deferoxamine (Desferal) Iv to remove accumulated iron via the kidneys (urine red) • Hypocalcemia- • citrate in blood binds with calcium & is excreted • Check lab values • Also hyperkalemia: stored blood liberates potassium through hemolysis (older blood greater risk for hemolysis)

32. Review Good job What is the purpose of administering blood and blood components? treat hypervolemia. A. NO…Blood and its components increase intravascular volume, not decrease. In fact, a potential complication with the administration of blood when given too rapidly is hypervolemia. alleviate sodium retention. B. NO…Alleviate sodium retention: an answer for consideration; however, it is not the reason that blood is given; indirectly sodium retention might be decreased by effect on restoration of intravascular volume and normal hemodynamics (renin-angiotensin-aldosterone) increase the level of electrolytes. C. NO…Increase level of electrolytes…perhaps indirectly as normal hemodynamics are restored, but not primary reason for giving blood and blood products. promote tissue oxygenation. D. (RBC’s carry oxygen! Blood and it components also provide clotting factors and maintain intravascular volume.)

33. PRBC’s are utilized to treat impaired clotting such as in liver dysfunction. True or False ? False! If you said false you were right on! PRBC’s are used to correct anemia and blood loss, not given for clotting factors, need fresh frozen plasma or cryoprecipitates True. If you said true, you were not correct. PRBC’s are used to correct anemia and blood loss.

34. Platelets are used to treat? Hemophilia A. hemophilia No Platelets do not contain the specific clotting factors needed by a client with hemophilia; platelet levels are typically normal B. Thrombocytopenia thrombocytopenia RIGHT Platelets (if normal) release thromboxane to cause vessel; spasm when there is damage to a vessel activates the clotting pathway to convert fibrinogen to fibrin Polycythemia C. polycythemia No Polycythemia is the presence of excess RBC’s; administration of platelets would not decrease the abnormal amount of RBCs in fact would cause increased problems…increased viscosity and more likely to form clots. Good job D. Low white cell count low white cell count N WBCs are leukocytes and originate from hemopoietic stem cells in the bone marrow; must use hematopoietic growth factors to stimulate granulocyte maturation and differentiation

35. Congratulations on Your Successful Completion!