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 ?

Blood Administration Right If you said: Check for T& C (What is T &C vs T &S?)(What is T &C vs T &S?) T& C blood available for patient for 3 days Verify informed consent Insure IV access; need large bore catheter (18-23 gauge); smaller bore causes destruction of RBC’s and slow blood administration. Gather equipment: Y-tubing blood administration set with filter NS solution IV pump Prime tubing with 0.9NS

Objectives Identify common blood products List steps in blood administration Identify complications of blood administration Acute Transfusion Reactions *Transfusion reactions Circulatory overload Septicemia Other Iron overload TRALI & Massive Transfusion reaction* Delayed Transfusion Reactions Describe autotransfusion/cell savers Apply concepts

Blood Components CURRENTLY USED –Packed RBC’s –Frozen RBC’s –Platelets –Fresh Frozen Plasma –Albumin –Cryoprecipitates & commercial concentrates Rarely USED –Whole blood

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

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)Packed Red cells (PRBCs –Treat anemia, replace blood volume ( ordered when Hgb 8-9 & HCT ) –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 ________________ 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!!

Types of Blood Components con’t Platelets –Control or prevent bleeding in platelet deficiencies, i.e. thrombocytopenia- (ordered when platelets count <10-20,000 - unless? –From whole fresh blood- (plateletpharesis) (plateletpharesis –Expected platelet 10,000uL/U –Measure at 1hr & hr post admin Volume = 30-60ml/unit ________________________ Albumin (plasma derivative) –Expand blood volume or replace protein –Treat shock from trauma, infection, 3 rd spacing, hypovolemia, *hypoalbuminemia 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 –Use within 5 days of donation –Can keep at room temp depending upon storage/collection 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 Albumin therapy Platelet donations

Types of Blood Components cont Frozen RBCs –Rarely used * –Successive washing with saline removes most WBCs & plasma proteins ________________________ Fresh Frozen Plasma (FFP)Fresh Frozen Plasma (FFP –Treat DIC, reverse effects of Coumadin, treat liver failure pts –From liquid portion whole blood, separated from cells > frozen –*Rich in clotting factors –Volume = ml/unit –Outcome- Improved coagulation, PT & PTT Risks and Benefits - Store for 10 years/use within 24 hr thawing - Use within 24hrs of thawing - *Atotransfusion; stockpiling or rare donors for patients with alloantibodies ___________________ Risks & Benefits –No platelets –Use for volume expansion to restore clotting factors in hypovolemic shock- being replaced by albumin plasma expanders. (from text) –Can store for 1 yr; *use within 2 hrs post thawing –Risk for vascular overload /hypersensitivity reaction/ Hemolytic reactions

Types of Blood Components cont Prothrombin Complex – Prothrombin, Factors VII, IX, X, and part of XIProthrombin Complex –Used to treat clients with specific clotting factor deficiencies Cryoprecipitate – Clotting Factors VIII, XIII, von Willebrand’s factor, & fibrinogen from plasmaCryoprecipitate –Used to treat clients with specific clotting factor deficiencies –May cause ABO incompatibilities –Prepared from FFP –Store for 1 year, once thawed > use

WBC’s or Granulocytes Uses –Improvement of infection- measure of treatment effectiveness –Used in cancer & chemotherapy patients –Hazards - febrile reaction & new infections carried in WBC’s Also

AutotransfusionAutotransfusion (autologous transfusion) Indications –Used in surgery & emergency settings –Autologous –collection of own blood scheduled surgery or in emergency situation (blood salvage; cell saver) Risks & Benefit –Special equipment required –No T & C required –Minimal risk of allergic reaction; *monitor coagulation –Blood available if rare blood type –*No infections disease- hepatitis, syphillis, HIV, etc –Safe, well tested –*Drainage after 1 st 24 hrs not used; may contain pathogens “Cell-saver“ “Cell-saver“ collects blood lost during surgery, cleanses it, returns to patient's body, all in a continuous loop. Autotransfusion or Autologous Transfusion For intraoperatively salvaged washed blood- filters-intraoperatively salvaged washed blood- filters- Reduces leukocytes Dec fat globules Reduces microaggregates

Autologous Donation/Elective Phlebotomy Who can make Autologous donation? (pre- deposit transfusion) u Less than 65 years old (usually). u Without serious medical conditions like serious heart and lung diseases. u Start before planned surgery- (about 5 weeks); have hemoglobin level of at least 11g / dl before each donation u *Store up to 10 years, if frozen, given within a few weeks of donation

RBC & Plasma Transfusions-Compatibility O- universal donor, AB+ universal recipient Blood Transfusions

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

Population Percentages- FYI A+ 34.3%A- 5.7% B+ 8.6%B- 1.7% AB+ 4.3%AB- 0.7% O+ 38.5%O- 6.5% Paid vs Volunteer – what is the difference? What percentage of population can donate? How many do? Who cannot donate? In Europe in the 80’s & 90’s – indefinitely Previous history of malaria – years Incarceration for 72 hours – 1 yr Hepatitis after age 11 – indefinitely HCT < 38% - until resolved Homosexual Male after 1977 – indefinitely Needle stick – 1 yr Medical history of vascular disease, bleeding or cancer - until resolved Who Can Donate Blood

* Preparation for Blood Administration * Blood Administration Physicians order Look at labs Verify/sign consent* Obtain IV access, large bore catheter (18-20 gauge), 2 lines if possible – *Get patient ready for transfusion prior to getting blood from the lab T&C done Gather supplies *Staff signs for and obtains blood (only one patient & 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 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 bedside with patient chart (see next slide for 2 RN check) Blood admin must complete within 3-4 hours after receipt from blood bank!

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) *Remember know agency policy for blood administration 90% of all reactions occur because of mistakes in labeling and verification

Initiation of Transfusion * at bedside 2 RNs ( or licensed staff according to state NPA and agency policy ) check unit of blood with laboratory slip, patient’s chart, forms include patient’s name, unit #, and blood type, etc. Check expiration date Patient’s ID#, blood band #, & state name St. David’s – blood band number on blood band) Seton - transfusion card/follow policy) Blood component, donor #, expiration date, Group & Rh factor (If blood not to be given, must be returned to blood bank within 30 minutes; CANNOT be kept in unit refrigerator (requires special refrigeration)!)

Verify Identification

Saddleback Nursing- Blood TransfusionsNursing- Blood Transfusions 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 per pump sing blood pump tubing Blood Product Administration

Compare all labels second time Check vital signs and record –Initial vitals before admin. –Vitals 15 minutes after admin. (stay with pt 1 st 15mins) –Vitals q30min after that until transfusion complete –Vitals post admin. and then in 1hr d 0.9% Sodium Chloride (NS) only!!!*remember Invert unit to mix cells Prime Y-type blood tubing with NS, before admin. Spike blood bag, clamp off NS Squeeze tubing to cover blood filter with blood Blood Product Administration * at bedside

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

Critical Points- Test Self! Correct MD order/permit; patient identification & blood compatibility Correct blood tubing, blood set-up, saline only (No other solutions/medications/products with blood-other than saline) Follow procedure for measurement vital signs, starting infusion etc. Drip rate no higher than 2 ml per minute X 15 minutes (30 cc per 15 minutes or 120 cc/hr.) –Seton etc. set pump at 75 to 80 cc/hr. for 15 min. –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 *Rapid blood replacement-use blood warmer “Other blood components FFP and platelets, can infuse over min. (text p ) List at least 4 critical safety measures in administering blood products

Monitor for signs of transfusion reaction 30 minutesInfuse over period specified (2-4 hours) and remember- blood cannot be out of refrigerator (blood bank) more than 30 minutes prior to administration –PLAN AHEAD!! BE READY TO START BEFORE GETTING BLOOD!! If multiple units required as in cases of rapid blood loss- may be given under pressure and warmed prior to administration (only agency approved warming device) More Critical Points Thermacor blood warmer/rapid infusor

How would you manage this? 1. A patient is to receive a unit of packed red blood cells. The blood has been obtained from the blood bank and brought to the unit. The nurse flushes the patient’s IV prior to hanging the blood and finds that the IV has infiltrated. What action(s) should the nurse take?

Answer Return the blood to the blood bank within 30 minutes of picking it up. If left out longer > risk of bacterial growth and sepsis; get help with starting IV. (Nurse should have checked that the IV was patent before requesting the blood… plan ahead)

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

Answer Circulatory overload due to volume (500ml > fluid overload, especially in at risk client Was used most often for volume and RBC’s Contained RBC’s, plasma proteins, some clotting factors, few platelets, & granulocytes Significant Dangers / Problems: –Incompatibility reactions –Circulatory overload –Febrile reactions –Infection transmission –And potential-increased hospital stay, increased cost of care

Another question? 3. A client receives a unit of PRBC’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 *Remember, change in lab values is not immediate, must consider if patient is also receiving fluid volume replacement (is RBC mass concentrated, diluted, is blood volume loss sudden or chronic

Transfusion Reactions 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! 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? Consider a temperature increase of 1 degrees significant Action taken will be determined by type of reaction; careful assessment, monitoring of patient!

Transfusion Reactions/Complications Acute Transfusion Reactions –Acute hemolytic –Febrile-non hemolytic –Allergic –mild –Allergic-Anaphylactic/severe –Septic –Circulatory overload –Transfusion-related lung injury (TRALI) –Massive Blood Transfusion Reactions Delayed Transfusion Reactions –Delayed hemolytic –Infections –Iron overload –Other

Transfusion Reactions/Complications Hemolytic (life-threatening!) –Acute hemolytic: ABO incompatible; red cell destruction (wrong blood type given to pt) Febrile (most common) –Sensitization to donor WBC, platelets, plasma proteins Allergic (hypersensitivity to donor plasma proteins) –Mild allergic to severe -Anaphylactic) Septic: transfusion bacterially contaminated blood *Circulatory overload –Fluid given too fast & too much * TRALI: sudden onset-non-cardiogenic pulmonary edema (transfusion related acute lung injury) TRALI: Massive Blood Transfusion Reaction: –Clotting issues, citrate toxicity, hypocalcemia

Hemolytic/Transfusion Reaction ! Most dangerous! Develops within first 15 minutes of transfusion: free hemoglobin in blood and urine specimens > acute hemolytic reaction; delayed at 2-14 days Occurs in 1:25,000 Occurs after approx 50 ml blood infused! Blood incompatibility (ABO 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

*Hgb is released blocking renal tubules-can cause renal failure. 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

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

Allergic Reactions Allergic Reactions (Hypersensitivity reactions) Severe (Anaphylactic) –Anxiety –Wheezing –Dyspnea –Bronchospasm –Hypotension –Swelling of tongue, face –Loss of consciousness –Shock, pulmonary edema Stop infusion, keep line open with new saline tubing; CPR & epinephrine (if indicated) DO NOT RESTART TRANSFUSION 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 (initially) (1% of pts.) *Urticaria Pruritis Itching Mild and transient: stop infusion, possibly restart, give antihistamine prophylactically, use washed RBCs

*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) –Delayed reaction –Vomiting diarrhea, hypotension, altered hematological values –Administer deferoxamine (Desferal) Iv to remove accumulated iron via the kidneys (urine red) Hypocalcemia (massive blood transfusions) –Citrate in blood binds with calcium & is excreted –Check lab values Hyperkalemia: stored blood liberates potassium through hemolysis (“older” blood greater risk for hemolysis)* significance of elevated potassium? Reactions/Complications

Hemolytic Transfusion Reaction ! ! If hemolytic reaction occurs: Stop transfusion, Keep IV line open/new tubing saline solution, maintain BP; monitor Notify HCP and blood bank immediately- signs/symptoms; recheck identifying tags/ numbers Monitor VS, urine output Treat symptoms- shock (anaphylactic) if present (epinephrine, oxygen, antihistamines, vasopressors, fluids, corticosteroids) Save blood bag, tubing, send to blood bank for exam Complete transfusion reaction reports Collect required blood, urine samples as per policy to ck for hemolysis Document on transfusion reaction form and patient chart Prevent acute renal failure-diuretic, fluids 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!

What is a primary purpose of administering blood and blood components? (click on right answer) Review A. B. C. D. treat hypervolemia. alleviate sodium retention. inc the level of electrolytes. promote tissue oxygenation. YES…RBC’s carry oxygen! Blood and components also provide clotting factors and maintain intravascular volume.) NO…Blood and its components inc intravascular volume, not dec. Potential complication with administration of blood esp when given too rapidly > hypervolemia. NO…Alleviate sodium retention: an answer for consideration; indirectly sodium retention might dec by effect on restoration of intravascular volume and normal hemodynamics (renin-angiotensin- aldosterone) NO…Inc level of electrolytes…perhaps indirectly as normal hemodynamics restored, not primary reason for giving blood and blood products.

TrueFalseor ? 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 PRBC’s are utilized to treat impaired clotting such as in liver dysfunction. Click on True/False for answers True. If you said true, you were not correct. PRBC’s are used to correct anemia and blood loss.

Review A nurse is to hanging a 250 ml. unit of Packed RBC’s to prepare a patient for urgent surgery. *next slide Describe how to set the infusion pump. 1. Total time recommended for transfusion of 1 unit of PRBC? Variables as age/condition? 2. First 15 min. of infusion (80 – 120 ml/hr.) 3. Rate after first 15 minutes?

Pump Settings 2 ml X 15 min. = 30ml 30 ml = X ml 15 min. 60 min. Run pump at 120 for first 15 min. 250 ml – 30 ml = 220ml 2 hr (120 min-15 min.) = remaining run time of 105 minutes 220 ml = X ml = 125.7ml/hr. 105 min. 60 min. Run pump at 126 for rest of transfusion u What is the rate if you started at 80ml/15 min.?

Review cont 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 negative. Can patient safely receive this blood? Why or Why not? Yes-O-neg universal donor!

Platelets are used to treat? click on letter for answers Hemophilia A. B. C. D. Good job No Platelets do not contain the specific clotting factors needed by a client with hemophilia; platelet levels are typically normal 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 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. No WBCs are leukocytes and originate from hemopoietic stem cells in the bone marrow; must use hematopoietic growth factors to stimulate granulocyte maturation and differentiation Low white cell count Polycythemia Thrombocytopenia

Consider ethical dilemma (from text) An elderly woman with dementia, transferred from a nursing home due to GI bleeding. Some of her family members tell the nurse that she is a Jehovah’s Witness and must not receive blood products. The surgeon indicates that if she does not have exploratory surgery and receive blood products, she will die. –What actions will you as her nurse take? –What resources do you have available to consult? –How can you determine if the family is acting is the patient’s best interest? –What non-blood alternatives are available for Jevohah’s Witnesses or others who do not wish to receive blood products?

Every unit of blood is tested for FYI-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- agent that causes syphilis *ALT,-elevated ALT may indicate liver inflammation, which may be caused by a hepatitis virus 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) - new technology that can detect genetic material of Hepatitis C and HIV to identify these viruses faster and more accurately All blood products filtered to remove leukocytes that can harbor viruses and infections

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