1. Blood Administration

2. Blood Administration
Your patient’s Hgb & HCT is 6.2 & 18.4; the doctor orders
3 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; need large bore catheter (18-20 gauge); smaller bore can cause destruction of RBC’s
Gather equipment:
Y-tubing blood administration set with filter
NS solution
IV pump
Prime tubing with Normal Saline.

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
How long are they good for? Why?

5. Blood Administration Objectives Discuss: Common blood products
Steps in blood administration
Complications of blood administration

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 = ml/unit
Risks & Benefits
Possible incompatibility issues
Circulatory overload
**Deficient in some clotting factors
Rarely used
Use Lasix to prevent overload
________________
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!! 6

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
Leukocyte reduction: prevents non-hemolytic febrile reaction from donor cytokines
CMV attaches to DNA
Alloimmunization – body reactions to leukocytes --- creates antibodies – cannot benefit from procedure.

8. Types of Blood Components Con’t
Risks & Benefits
Not a substitute for whole blood
May form antibodies
Hypersensitivity reaction
Must be used within 5 days of donation
____________
Vascular overload
Hyperosmolar solution moves water from extravascular space to intravascular space
Outcome: adequate BP & volume
Can be stored for 5 years
Platelets
To control or prevent bleeding in platelet deficiencies, i.e. thrombocytopenia
(ordered when platelets count <10-20,000
unless what?)
From whole fresh blood
Expected platelet 10,000/unit
Measure at 1hr & 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 8

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 = ml/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. Questions How much blood in human body?
Do platelets have clotting factors?
Do you understand the process of making a clot?

11. 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
May cause ABO incompatibilities

12. WBC’s or Granulocytes Outcomes & Uses
Improvement of infection is measure of treatment effectiveness
Used in cancer & chemotherapy patients
Hazards
febrile reaction & new infections carried in WBC’s

13. ABO Compatibility Chart
Who is universal donor & recipient?
What do the - & + mean? 13

14. Compatibility Chart Recipient Donor A B AB O A X X B X X AB X
O X X X X
Many pregnant women carry a fetus with a different blood type from their own, and the mother can form antibodies against fetal RBCs. Sometimes these maternal antibodies are IgG, a small immunoglobulin, which can cross the placenta and cause hemolysis of fetal RBCs, which in turn can lead to hemolytic disease of the newborn, an illness of low fetal blood counts which ranges from mild to severe.[3]
The RhD antigen is also important in determining a person's blood type. The terms "positive" or "negative" refer to either the presence or absence of the RhD antigen irrespective of the presence or absence of the other antigens of the Rhesus system. Anti-RhD is not usually a naturally occurring antibody as the Anti-A and Anti-B antibodies are. Cross-matching for the RhD antigen is extremely important, because the RhD antigen is immunogenic, meaning that a person who is RhD negative is very likely to make Anti-RhD when exposed to the RhD antigen (perhaps through either transfusion or pregnancy). Once an individual is sensitised to RhD antigens their blood will contain RhD IgG antibodies which can bind to RhD positive RBCs and may cross the placenta.
O- universal donor, AB+ universal recipient

15. Population Percentages
B+ 8.6%
B- 1.7%
AB+ 4.3%
AB- 0.7%
O+ 38.5%
O- 6.5%

16. RBC & Plasma Transfusions
Blood Type
RBC
Plasma O
O, A, B, AB A AO
A, AB B BO
B, AB AB
AB, A, B, O
AB*

17. Donations Paid vs Volunteer – what is the difference?
What percentage of population can donate?
How many do?
Who cannot donate?

18. Ineligible Donors In Europe in the 80’s & 90’s – indefinitely
Previous history of maleria – years
Incarceration for 72 hours – 1 yr
Hep C after age 11 – indefinitley
HCT < 38% until resolved
Homosexual Male after 1977 – indefinitely
Needle stick – yr
Medical history of vascular disease, bleeding or cancer until resolved

19. *Preparation for Blood Administration*
Physicians order
Look at labs
Verify/sign consent*
Obtain IV acess, 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; universal recipient is AB positive
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! 19

20. 2 RN check What do you check for?
Verify informed consent
Check physician’s orders
Match this information to the information on lab slip 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

21. Blood Product Administration
Compare all labels second time
Be prepared – once you begin, don’t leave the room
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
IV gauge adult, 23-child
0.9% Sodium Chloride (NS) only!!!
Invert unit to mix cells (do not shake it)
Prime Y-type blood tubing with NS, before admin.
Clamp off NS , Spike blood bag
Squeeze tubing to cover blood filter with blood
Set pump – start slow
If unable to give blood – must be returned within 30 minutes of removing from lab – DO NOT STORE IN UNIT REFRIGERATOR

22. Blood Product Administration
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
Blood to cover filter
Emergency

27. Critical Points Monitor for signs of transfusion reaction
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!!
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)

28. How would you manage this?
1. 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?

29. How would you manage this?
2. In addition to transfusion reaction; what is a major risk related to administration of whole blood?

30. How would you manage this?
3. Your client receives a unit of RBC’s…what response to this unit of blood is anticipated?

31. 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?
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 1 degree significant
Action taken will be determined by type of reaction; careful assessment, monitoring of patient!
What drugs are commonly given prior to transfusion?

32. 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
Iron overload- delayed reaction
Hypocalcemia- citrate in blood binds with calcium & is excreted
Bacterial (pyrogenic or sepsis)
Transfusion of bacterially infected components

33. Febrile pyrogenic /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
**Bacterial (pyrogenic): similar to febrile; due to bacterial contamination of blood:
see S & S above
NON-Hemolytic

34. 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, possibly restart, 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

35. 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 in 1:25,000
Usually occurs after 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

36. 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 free Hgb 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!

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

38. Hemolytic Reactions
Hgb is released blocking renal tubules Can cause renal failure. Impact of K+ ?

39. Hemolytic Reactions Key Indicators: Acute-usually occurs after
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

40. Reactions/Complications
Circulatory overload
Fluid given too fast & too much
Note cough, dyspnea, lung sounds, 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)

41. Nursing actions if reaction occurs
Stop transfusion immediately
Continue N/S IV with new tubing
Provide appropriate care for client
Notify physician of client signs and symptoms
Follow facility policy and procedure
Obtain urine specimen for free hemoglobin test

42. Autotransfusion
Indications
Used in surgery & emergency settings
Autologous blood-collection of own blood prior to scheduled surgery
Risks and Benefits
Requires special equipment
No T&C needed
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.

43. 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.
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

44. Autologous transfusion
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

45. 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

46. 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.

47. Congratulations on Your Successful Completion!