BLOOD TRANSFUSIONS

1. BLOOD TRANSFUSIONS

2. BLOOD TRANSFUSION PERMIT • Signed blood transfusion permit on chart • Acute patients must get a permit for each admission • LTC residents-permits must be within the last 30 days

3. Verify Physician’s order in HMS. If there is no order, one must be obtained and entered into HMS before proceeding. • Verify Hemoglobin and Hematocrit level (If there is no Hgb/Hct, or the level is not from a hospital laboratory, or is older than 72 hours; put an order in HMS for an Hgb/Hct to be drawn. This order can be classified as written (There is a protocol under blood administration in the policy and procedure manual) • Obtain baseline assessment and vital signs

4. IV Site • Prior to obtaining the blood from the blood bank, verify the IV site and patency. • An 18 gauge IV catheter is preferred. Anything less than a 20 gauge physician’s order must be obtained to administer the Packed Red Blood Cells via a catheter this small. (Reason: PRBC are fragile and they could lyse when flowing thru a catheter lumen that small.) • Establish your blood tubing and prime with 250 cc bag of Normal Saline

5. Blood Bank • Only an RN can get blood from the blood bank (Lab) • Take the blood slip brought to the unit by lab that verifies that the blood has been typed and crossmatched. • Verify with the lab staff that the unit of blood is the unit matching the blood slip • Sign out the blood in the blood bank log

6. Blood Bank • The unit of blood has to be administered within 4 hours of leaving the blood bank • The time that was placed in the blood bank log is when the clock started for the administration of the blood. • The blood can not be out of the blood bank refrigeration longer than 4 hours for risk of contamination. REGARDLESS OF HOW MUCH BLOOD IS LEFT, YOU MUST STOP THE TRANSFUSION AFTER 4 HOURS HAS ELAPSED.

7. PACKED RED BLOOD CELLS • Check the expiration date on your PRBC • The closer the date of expiration, the more fragile the RBCs. • Handle the RBCs with care to prevent cell lysis. • Start the blood transfusion within 30 minutes of leaving the blood bank

8. Verify at the patients bedside with another nurse the following information: Numbers on blood bag matches # on lab request and the patient’s unique blood bank ID band. • This must be done at the bedside with 2 licensed nurses to prevent the administration of a blood product to the wrong patient. • The administration of a blood product to a patient that the blood was not intended for could result in a hemolytic transfusion reaction and possible death.

9. The transfusion start time is the time that the first RBC enters the patient’s body. • The RN must remain with the patient for the first 15 minutes of the transfusion start time. Monitor the patient for signs and symptoms of a possible transfusion reaction • Patient assessment and vital signs are to be done within the first 15 minutes of starting the transfusion (i.e. transfusion start time =1300, 1st set of vital signs must occur between 1301-1315)

10. 2nd patient assessment • The second patient assessment must occur within 30 minutes after the START of the transfusion (i.e. transfusion start time = 1300, second set of vitals must occur between 1316-1330) • The rest of the patient assessments are then every hour until the transfusion is complete, unless the patient’s condition warrants further. • The NSG Blood Transfusion Assessment Detail must be completed and include the names (signatures) of the two nurses that completed the blood verification.

11. Transfusion Reactions Types of Reactions • Acute Hemolytic • Febrile Non-hemolytic Transfusion Reactions • Transfusion- related acute lung injury

12. Acute Hemolytic Transfusion Reaction • Donor and patient blood type does not match which causes them to break open (hemolyze) and release harmful substance into the blood stream. • Blood must be STOPPED immediately and normal saline should be started!

13. Hemolytic Symptoms • Symptoms include: • Back pain • Bloody urine • Chills • Fainting • Dizziness • Fever • Flank pain • Flushing of skin Symptoms usually appear during or right after transfusion.

14. Delayed Hemolytic Reaction • Delayed reaction – the antigens on the transfused blood cells are attacked causing them to break down. This may occur days or weeks after the transfusion. • There may be no symptoms but RBCs that are transfused are destroyed and RBC count drops. • Special blood testing to identify the antigen the body is attacking must be completed before more blood can be transfused. This is to ensure blood without the antigen the body is attacking is not present in the blood being transfused.

15. Febrile Non-Hemolytic Transfusion Reactions • Due to accumulation of cytokines during storage or recipient antibodies reacting with white cell antigens. • Typically defined as a 1ºC or 2ºF increase in temperature during transfusion or up to six hours after. Symptoms • Fever • Chills • Dyspnea

16. Transfusion-related acute lung injury (TRALI) • An inflammatory immune response that occurs within the pulmonary system due to the WBC antibodies from the donor blood reacting to the antigens on the WBC of the receipt.

17. TRALI • Classic TRALI occurs 1-2 hours of starting transfusion or may be delayed for up to 6 hours after • Delayed TRALI may occur 72 hours after • Delayed TRALI poses the highest risk of death

18. Characteristics of “classic” and “delayed” TRALI syndromes

19. TRALI Symptoms Typical • Sudden shortness of breath (respiratory distress) Other • Fever • Tachycardia • Tachypnea • Hypotension

20. TRALI Treatment • Blood must be STOPPED immediately and normal saline should be started! • Notify MD • Supportive Care • diuretics • supplemental oxygen • intubation

21. Blood Transfusion Reaction What else do you need to do? • Notify lab of a possible transfusion reaction. • Lab staff will bring the blood transfusion reaction form, complete the Nursing section • Notify MD of possible blood transfusion reaction. • Lab staff will check the patient’s blood to determine if the reaction is hemolytic. This usually will only take 30 minutes or less.

22. Obtain vital signs. Complete a physical examination, auscultation of lungs and heart; inspect for hives, bleeding and collect urine. • RN will resume the blood transfusion if the blood bank reports that review is negative for transfusion reaction. • Report physician result of blood back review and follow physician orders. • REMEMBER, you have 4 hours from the time you signed the blood out of the blood bank to get the blood infused.

23. Blood Transfusion Complete • Note on the transfusion record, the time that all of the blood (including the blood in the tubing) was completed • Note vital signs 1 hour post transfusion

24. Reaction Key Points To provide fast and efficient care to patients monitor for the following signs and symptoms: • Fever (1 degree Celsius or 2 degrees Fahrenheit with or without chills • Shaking chills (rigors), with or without fever • Pain, at infusion site, or in chest, abdomen or flanks • Respiratory distress, including flushing, urticaria, localized or generalized edema • Skin changes, including flushing fever, severe chills, hypotension, high-output cardiac failure • Nausea, with or without vomiting. • Acute onset of sepsis, including fever, severe chills, hypotension, high-output cardiac failure • Anaphylaxis If reaction is suspected STOP the transfusion immediately.

25. Note • Please refer to the nursing policy and procedure manual for more information and review.