1. BLOOD AND BLOOD PRODUCT TRANSFUSION SONGOMA J. MPANGALALA RN, BSc N MNH- EMERGENCY DEPARTMENT

2. DEFINITION  BLOOD TRANSFUSION it is the procedure in which a patient receive a blood product through intravenous line  It is a the introduction of blood or blood components into venous circulation  Process of transferring blood –based product from one person into the circulatory system of another.  Infusion of blood products for the purpose of restoring circulating volume.

3. PURPOSE OF BLOOD TRANSFUSION  Restore blood lost during surgery or serious injury  Replace clotting factors  Improve oxygen carrying capacity  Restore blood elements that are depleted  Prevent complications

4. Indication for need of a blood transfusion  Major injuries after accident or disaster  Surgery on an organ such as the liver and the heart  Severe anemia  Serious infection  Disturbances of blood coagulation

5. The Contraindications of Blood Transfusion  Acute pulmonary edema  Congestive heart failure  Pulmonary embolism  Malignant hypertension  Serious allergy to blood transfusion

6. Donation Guidelines  donor must:  Be healthy  Be at least 17 years  Weigh at least 50kg  Not have donated blood in the last 8 weeks

7. Donation Guidelines  Individuals with the following are not permitted to donate blood:  Fever  High blood pressure  Very high or very low pulse rate (with the exception of highly conditioned athletes)  Irregular heartbeat

8. Donation Procedures  Donation procedures use standard precautions for both donor and phlebotomist  Donor is asked to remain in a recumbent position until s/he feels ready to sit up. Blood banks typically offer donors both food and fluids

9. Donation Procedures  Donors are asked to:  Leave the dressing in place  Avoid heavy lifting for several hours  Increase fluid intake for 2 days  Avoid alcoholic beverages for 3 hours  Avoid smoking for 1 hour  Eat healthy meals for 2 weeks

10. Complications of Donating  Excessive bleed at donor site  Anginal chest pain  Can occur with those with CAD  Seizure  (rare but can occur with those with epilepsy)  Fainting : most common  Hypotension  Syncope

11. Blood Supply Safety  Once blood has been received from the donor it is immediately tested for blood type and infectious diseases -Hepatitis -Syphilis -Malaria - Human immunodeficiency virus

12. Whole blood Platelets rich plasma 1 st centrifugation Platelets concentrate Whole blood Whole blood 2 nd centrifugation Fresh plasma FFP for clinical use FFP for fractionation Optimal additive solution Red cells in OAS Cryoprecipitate Red Cell concentrate

13. Whole Blood  Composition: - Red Blood Cells - White Blood Cells - Plasma - Platelets - Hematocrit - Clotting Factors  Purpose: - Volume replacement - Increase oxygen-carrying capacity - be preserved in 4 ℃ within 1 week for fresh blood or be preserved in 4 ℃ for 2 to 3 weeks for stored blood  Indications: - Significant blood loss (>25% blood lost, i.e. hemorrhage) - Newborn babies with hemolytic disease

14. Packed Red Blood Cells (RBCs)  Administer no exceed four hours.  Composition: - RBCs with little plasma (hematocrit about 75%) - Some platelets and WBCs remain  Purpose: - Increase RBC mass and oxygen-carrying capacity -Raises Hgb 1 g/dL and Hct 3% per one unit - Assists the body to rid carbon dioxide and other waste products  Indications: - Symptomatic and chronic anemia - Blood loss due to injury or surgery  Max hang time per unit: 4 hours from refrigerator removal. Can split into smaller bags.

15. Platelets  Composition: - Platelets,Plasma, RBCs, WBCs  Storage be preserved in 22 ℃ and is valid for 24 hours  Purpose: - Helps to stop bleeding (restore clotting ability) - Essential for coagulation of blood  Indications: - Decreased platelet count - Hemophilia - Thrombocytopenia - Platelet dysfunction (End stage renal disease, DIC)  Max hang time per unit: 4 hours or by expiration time marked on the unit label

16. White Blood Cells (WBCs)  be preserved in 4 ℃ and are valid for 48 hour  Composition: - WBCs or leukocytes suspended in 20% of the plasma  Purpose: - Increase number of WBC’s - Replaces WBC’s that are functioning abnormally  Indications: - Sepsis (not responsive to antibiotics) - Persistent fever - Granulocytopenia  Administration: -1 unit (30 – 50 mL) over 5 – 10 min. -ABO compatibility not required but preferred. -1 unit raises platelet count 5 – 10,000 -Administer 6-8 units/time

17. Fresh Frozen Plasma  Composition: - Plasma - All coagulation factors  be preserved in -30 ℃ and is valid for 1 year; thaw in 37 ℃ ; be transfused within 6 hours. Dry frozen plasma: validity is 5 years ; be dissolved in normal saline before transfusion  Purpose: - Increase blood plasma - Replenish clotting factors  Indications: - Bleeding in patients with coagulation factor deficiencies; plasmapheresis - Burn - Liver Failure - Severe Infection  Maximum hang time for one unit; 6 hours.

18. Albumin  Composition: - Albumin  Purpose: - Volume expansion leading to increased blood volume  Indications: - Hypoproteinemia - Burns - Shock - Trauma - Surgery - Infections

19. Blood Groups and Types  Blood groups are named by types of the proteins as antigens on the surface of an individual’s red blood cells.  ABO Blood Groups System  Rhesus ( Rh ) Blood Group System

20. Giving and Receiving Blood Group Antigens on cell Antibodies in serum Can give blood to: Can Receive blood from: ABA & B None ABAB, A B, 0 AA Anti-B A & ABA & O BB Anti-A B & ABB & O ONone anti-A & anti-B AB, A B,0 O 20

21. Rh Blood Group  Blood that contains the D antigen is known as Rh-positive.  If Rh-positive blood is transfused into an Rh-negative person, the recipient will form antibodies to the Rh factor and a second exposure to Rh-positive blood will result in red blood cells destruction (hemolysis) in the recipient.  The Rh factor is of special importance during pregnancy.

22. Rh Blood Group  An Rh positive person may receive either – or + blood  An Rh negative person must receive only Rh– blood  If an Rh– person receives Rh+ blood, antibodies will form  If another transfusion of Rh+ blood is given, the antibodies will agglutinate with the Rh antigens of the blood being transfused

23. Blood compatibilities

24. Blood Typing and Cross-matching Test  Direct Cross-matching Test Red blood cells from the donor blood are mixed with serum from the recipient to examine whether the antibodies to the donated red blood cells are present in the recipient’s serum.  Indirect Cross-matching Test Red blood cells from the recipient blood are mixed with serum from the donor to examine whether the antibodies to the recipient’s red blood cells are present in the donated serum.

25. Blood typing for transfusion  Universal donor= O-  Does not contain A, B, or Rh antigens  Universal recipients= AB+  Blood contains A, B, and RH antigens  Usually blood banks exactly match the pt blood

26. ADMINISTRATION PROCESS  ASSESS Transfusion history  Previous transfusions, allergies and reactions  Type of transfusion reaction, manifestations, and treatment  GET SET OF BASELINE VITALS

27. Interventions  Once the blood has been taken from the blood bank, it must be administered within 30 minutes  The nurse must ensure:  Three checks include: The expiry date of the blood is not beyond. The pack is intact and without any leaking. The quality of the blood.  Eight rights include: the patient’s name, the bed number, inpatient number, the number of the blood bag label, the ABO groups and Rh type on the blood bag label, the result of cross-matching, the category and the amount of the blood*

28. adminstration on blood  Pt needs 18 or 20 gauge IV needle so cells are not lysed (destroyed)  Prior to administration, blood needs to be checked by 2 licensed nurses. Check the expiration date, name, medical record number, type of blood, blood band id, pt birthday  Check vitals prior to administration  **blood must be initiated with in 30 minutes of arrival from lab to floor  Use blood tubing for administration  Monitor for blood reactions  Monitor vitals continuously during administration

29. NOTE  Red blood cells and plasma exposed to temperatures over 40°C may cause severe transfusion reactions.  Blood components must NOT be warmed by improvisations such as putting the pack into hot water, in a microwave, or on a radiator, as uncontrolled heating can damage the contents of the pack

30. TRANSFUSION REACTIONS AND NURSING INTERVENTIONS  Fever Reaction Fever Reaction  Anaphylactic Transfusion Reactions Anaphylactic Transfusion Reactions  Hemolytic Reaction Hemolytic Reaction  The reaction Related to Large Volume of Blood Transfusion The reaction Related to Large Volume of Blood Transfusion  Other Reactions Other Reactions

31. 1.Fever Reaction  Causes  The blood, blood bag or blood administration set is contaminated by bacteria.  The principles of surgical asepsis are violated during blood transfusion.  Antibodies in recipient’s blood react to antigens on donor’s white blood cells, platelets, or plasma proteins, especially with multiple transfusions.

32. Fever Reaction  Clinical Manifestations  After first 30 minutes to 6 hours after the transfusion, the patient may have chills and fever suddenly ( the temperature can range from 38 ℃ to 40 ℃ ), flushing, headache, anxiety, nausea, vomiting, muscle pain.  The mild reaction may be relieved within 1 to 2 hours, and the temperature drops to the normal level gradually.

33. Fever Reaction  Preventing Intervention  remove the factors causing fever  follow the principles of surgical asepsis during blood transfusion  choose disposable blood administration set

34. Fever Reaction  Nursing Intervention  Transfusion should be administered slowly if mild reaction occurs.  Stop transfusion immediately and send the blood bag and blood administration set to the laboratory if severe reaction occurs.  Monitor the vital signs.  Provide cold therapy if the patient has hyperthermia.  Administer antipyretics as ordered.

35. 2.Anaphylactic Transfusion Reactions  Causes  The patient has anaphylactic predisposition.  There are substances causing anaphylaxis in donor’s blood.  After the patient received several blood transfusion, the allergic antibody is produced in patient’s plasma. When blood transfusion is performed again, the antibody-antigen reaction cause anaphylaxis.  The allergic antibodies in donor’s blood is infused into the patient. The anaphylaxis may occur if the antibody reacts to corresponding antigen.

36. Anaphylactic Transfusion Reactions  Clinical Manifestations  In mild anaphylaxis After blood transfusion, the patient may feel skin itching, and covered with urticaria.  In middle anaphylaxis The patient may have vascular and neuropathic edema, normally appear in face. The patient may have eyelid, or lip edema. The laryngeal edema also may occur. The patient may have dyspnea, bronchial spasm, or chest pain. The wheezing sounds are found when lungs auscultated.  In serious anaphylaxis The patient may suffer from anaphylaxis shock.

37. Anaphylactic Transfusion Reactions  Preventing Intervention  Administer blood or blood products correctly.  Choose blood donor without allergy history.  Blood donor should be fasting for 4 hours before blood donation.  The patient having history of allergy should be given antihistamines as ordered before transfusion.

38. Anaphylactic Transfusion Reactions  Nursing Interventions  In mild anaphylaxis Slow down the transfusion. Administer antihistamines as ordered. Monitor vital signs.  In middle or serious anaphylaxis 1.Stop transfusion immediately. Notify physician and blood bank.

39. 2. Administer 0.5 to 1ml of 0.1% adrenaline by hypodermic injection as ordered. The antihistamines should be given as ordered. 3. Maintain intravenous access with normal saline. 4. Give oxygen therapy to patient with dyspnea. Give tracheotomy for patient with severe laryngeal edema. 5. Manage shock. Initiate cardiopulmonary resuscitation if necessary. 6. Monitor the patient’s vital signs.

40. 3.Haemolytic Reaction  Intravascular Haemolytic reaction  Extravascular Haemolytic Reaction

41. Intravascular Haemolytic reaction  Causes  Incompatibility blood infusion: 10ml or more of ABO incompatible whole blood or red blood cells are infused.  Degenerated blood transfusion: The red blood cells are destructive and haemolytic in infused blood.  Hyperosmolar, hypoosmolar solution or medicines that influence the blood pH may have been added into the infused blood, then resulting in damage of red blood cells.

42. Intravascular Haemolytic reaction  Clinical Manifestations (3 stages)  In the first stage: headache, nausea, vomiting, chest pain, limbs numbness, and increased pain in kidney region  In the second stage: hemoglobinuria, jaundice （, chills, fever, dyspnea, cyanosis, and hypotension  In the third stage: oliguria, anuria, even acute renal failure or death

43. Intravascular Haemolytic reaction  Preventing Intervention  The nurse should meticulously verify and document patient identification from sample collection to component infusion to prevent the haemolytic reaction, and make sure the compatibility of blood typing and cross-matching.

44. Intravascular Haemolytic reaction  Nursing Interventions 1. Stop transfusion immediately, remove blood and any blood- filled tubing, and replace with saline bag and new tubing to keep line open, notify the physician and blood bank immediately. 2. Provide oxygen therapy, maintain intavenous access, administer medications as ordered.

45. Intravascular Haemolytic reaction  Nursing Interventions 3. Return blood bag and tubing to blood bank. Obtain blood and urine samples of the patient and send to the laboratory. 4. Local blocking in both renal regions; heat therapy on the back should be provided to reduce the spasm of renal blood vessels.

46. Intravascular Haemolytic reaction  Nursing Interventions 5. Infuse sodium bicarbonate by intravenous injection to make urine alkaline to promote hemoglobin dissolved to reduce the obstruction of renal tubule. 6. Monitor vital signs every 15 minutes; monitor and record urine output hourly by inserting indwelling catheter. Peritoneal dialysis or haemodialysis may be required if renal failure occurs. 7. Treating shock as prescribed, if present. 8. Give mental support.

47. Extravascular Haemolytic Reaction  caused by D, C, and E antibodies in Rh system.  is present after one week or more of blood transfusion.  the signs of reaction are mild: mild fever, anemia, feel tired. The bilirubin in blood is increasing.  These kinds of patients should avoid transfusion again as far as possible.

48. The reaction Related to Large Volume of Blood Transfusion  Circulatory Overload  Hemorrhage  Sodium Citrate Poisoning Reaction

49. 4.Circulatory Overload  Causes: pulmonary edema  Clinical Manifestations: occur at anytime during or immediately after completion of the transfusion; chest pressed ， shortness of breath ， dyspnea, cough, frothy or pinkish sputum ， facial paleness ， diaphoresis ， anxiety, headache, tachycardia, tachypnea, orthopnea, increased venous pressure, neck veins tension, rales in lungs

50. Circulatory Overload  Nursing Interventions  slow or stop the transfusion immediately ， notify the physician  assume a Folower ’ s position with the feet dangling at the bedside if the patient ’ s condition is allowed  apply oxygen inhale with higher flow rate, put 20 ％ to 30 ％ ethanol solution into humidifying bottle  administer the sedative ， vasodilators ， antiasthma ， digitalis ， and diuretics to the patient according to the physician ’ s order  apply tourniquet to limbs of the patient in alternation in order to reduce the venous return if necessary

51. 5.Hemorrhage  Causes  Platelets and thrombogen are damaged in stored blood.  Too much sodium citrate is infused, and may cause the disturbances of blood coagulation.  Clinical Manifestations wound bleeding, skin bleeding, gingival bleeding, bleeding in venipuncture site, or hematuria

52. Hemorrhage  Nursing Interventions  Monitor the symptoms and signs of hemorrhage.  One unit of fresh blood is infused after 3 units of stored blood.  The patient should be provided the blood components according to the lack of clotting factors.

53. 6.Sodium Citrate Poisoning Reaction  Causes sodium citrate and serum calcium are combined -- hypocalcemia  Clinical Manifestations tetany, hypotension, Q—T interval is prolonged in EKG, cardiac arrest may occur if the condition is serious  Nursing Intervention 1000ml of blood--10ml of 10% calcium gluconate IV

54. Other Reactions  air embolism  Sepsis （  hypothermia  blood transmitted disease (hepatitis, malaria, AIDS )  hyperkalemia (stored blood )  Acidosis (stored blood )

55. References Perry, A.G., & Potter, P. A. (2006). Clinical nursing skills & techniques (6th Ed.). St. Louis, MI: Mosby, Inc. Watson, D., & Hearnshaw, K. (2010). Understanding blood groups and transfusion in nursing practice. Nursing Standard, 24 (30), 41-48. Bare, B., Smeltzer, S. C., Williams, B., Paul, P., & Day, R. A. (2004). Medical-surgical nursing (10th Ed.). Philadelphia, PA: Lippincott Williams & Wilkins Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Brunner and Suddarth’s textbook of medical-surgical nursing (1st Canadian Ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Malarkey, L., & McMorrow, M. (2005). Nursing guide to laboratory and diagnostic tests. St. Louis, MI: Elsevier Saunders.