2. Blood Administration

3. 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?

4. 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.

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

6. Blood Products *Know products and how to safely administer! Packed RBC’s From whole blood; 2/3 of plasma removed); *most commonly used! Inc. O2 carrying capacity Treat anemia; replace blood volume Use leukocyte poor red cells or leukocyte filter if history of febrile reaction Vol. 250-300 cc Only RBCs used (remaining platelets, albumin, plasma used for other purposes) Less chance for fluid overload! *Ordered when HGB 8-9 and HCT 24-27; each unit inc. HGB by 1g/dl & HCT by 3 takes 4-6 hrs for lab values to chg. No viable platelets or granulocytes Whole blood: Replace blood volume Inc. O2 carrying capacity in hypovolemic shock Contains RBC’s, plasma proteins, clotting factors and plasma Few platelets or granulocytes Vol. 500 cc Danger of fluid overload and incompatibility Deficient in some clotting factors Rarely used! Platelets: To control, prevent bleeding in platelet dysfunction, thrombocytopenia From whole fresh blood From multiple donors Vol. 30-60 cc of platelets in 1 unit Expected inc-10,000 per/unit-each unit Measure at 1 hr & 18-24 hr post admin. Usually given if platelet count less than 10-20,000 danger of bleeding!

7. Frozen RBC’s (from RBC’s) can be frozen stored for 3 years Infrequently used Use within 24 hours of thawing successive washing with saline solution removes majority of WBC/’s and plasma proteins Fresh Frozen Plasma (FFP) Contains clotting factors Used for DIC, liver failure patients Improves coagulation, PT and PTT Vol. 200-300cc = 1 unit Rich in clotting factors NO platelets Good for volume expansion to restore clotting factors in hypovolemic shock Albumin-Plasma derivative Prepared from plasma Volume expander Use for clients who are 3 rd spacing and hypovolemic (hyperosmolar solution moves water from extravascular space to intravascular space) Outcome: adequate BP and volume Available in 5% or 25% solution Albumin 25g/100ml = to 500 ml of plasma Can be stored for 5 years

8. ! Cryprecipitates- C lotting factors VIII, Xiii< von Willebrand’s factor & fibrinogen from plasma and commercial concentrates Prepared from fresh frozen plasma Store for 1 year, once thawed, must be used. Prothrombin complex-Prothrombin, factors Vii, IX, X and part of Xi Used to specific clotting factor deficiencies May cause ABO incompatibilities Used to specific clotting factor deficiencies WBC’s or Granulocytes Improvement of infection Rarely used except for cancer patients, chemotherapy patients AutotransfusionAutotransfusion; Surgery and in emergency setting Autologous blood-collection of own blood prior to scheduled surgery or in emergency situation ( blood salvage; cell saver) Requires special equipment; filters, patients own blood is returned No T&C needed if pre-donation, begin collection within 5 weeks of transfusion date and end at least 3 days prior to transfusion need.

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

10. Preparation for Blood AdministrationBlood 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!

11. Compatibility Chart Recipient Donor ABAB O AXX BXX ABX O XXX X O- universal donor, AB+ universal recipient

12. 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!

13. 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 blood type 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)!

17. Verify identification!

18. 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

19. 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

20. Example of filters Use appropriate filters For intraoperatively salvaged washed blood.For intraoperatively salvaged washed blood. Significantly reduces leukocytes in salvaged blood Substantially decreases fat globules in salvaged blood Reduces microaggregates present in salvaged blood For intraoperatively salvaged washed blood. Reduces leukocytes Decreases fat globules Reduces microaggregates

21. 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

22. *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)

23. How would you manage this? 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) 1. Client to receive a unit of packed red blood cells….unable to initiate an IV access. What actions should you take? Ask An Expert Double Click

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

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

26. 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

27. Transfusion Reactions 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! 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 2 degrees significant Action taken will be determined by type of reaction; careful assessment, monitoring of patient! Ask An Expert

28. 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

29. 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)

30. Hemolytic/Transfusion Reaction ! 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

31. 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!

32. *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) Reactions/complications

33. What is the purpose of administering blood and blood components? Review A. B. C. D. treat hypervolemia. alleviate sodium retention. increase the level of electrolytes. promote tissue oxygenation. (RBC’s carry oxygen! Blood and it components also provide clotting factors and maintain intravascular volume.) 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. 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) NO…Increase level of electrolytes…perhaps indirectly as normal hemodynamics are restored, but not primary reason for giving blood and blood products. Good job

34. 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. True. If you said true, you were not correct. PRBC’s are used to correct anemia and blood loss.

35. Platelets are used to treat? Hemophilia A. B. C. D. Good job hemophilia No Platelets do not contain the specific clotting factors needed by a client with hemophilia; platelet levels are typically normal 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 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. 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 Low white cell count Polycythemia Thrombocytopenia

36. Congratulations on Your Successful Completion!