1. Lisa Randall, RN, MSN, ACNS-BC RNSG 2432
Blood Administration
Lisa Randall, RN, MSN, ACNS-BC
RNSG 2432

2. Types of Blood Components
CURRENTLY USED
Packed RBC’s
Frozen RBC’s
Platelets
Fresh Frozen Plasma
Albumin
Cryoprecipitates & commercial concentrates
NO LONGER USED
Whole blood except
Exchange transfusions
Massive blood loss

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

4. Packed Red Cells (PRBC’s)
Used to treat anemia and replace blood volume (Additional NS used for volume)
Usually ordered when Hgb 9 and Hct 27
For asymptomatic elderly <7g/dl
Epoetin alfa (Procrit & Epogen) - increase hemoglobin levels & reduce the need for blood transfusion
**1 unit of PRBC’s will increase the Hgb by 1 and the Hct by 3
Usually contains 250 ml.
Usually not use a leukocyte filter

5. Blood components cont. Platelets Risks
Not a substitute for plasma or clotting factors
May form antibodies
Hypersensitivity reaction
Platelets
To control or prevent bleeding in platelet deficiencies -thrombocytopenia
To treat platelet dysfunction
Given when <20,000

6. Platelets One unit contains 30-60 ml platelet concentration
Expected increase is 10,000 per unit
Outcome: measured by platelet counts at 1 hour and hours post transfusion

7. Blood components cont. Albumin Risks
To expand blood volume or replace protein
Used to treat shock from trauma, infection and in surgery
Blood components cont.
Risks
Vascular overload
Hypersensitivity reaction

8. Albumin As a volume expander…
Used for patients 3rd spacing and are hypovolemic, liver patients
Hyperosmolar solution acts by moving water from extravascular to intravascular space
Outcome: adequate blood pressure and volume

9. Fresh Frozen Plasma (FFP)
Risks
Vascular overload
Hypersensitivity reaction
Hemolytic reactions contains antibodies
Plasma
Contains clotting factors & protein
No platelets
Used for clotting problems as:
DIC
Liver patients
Urgent warfarin reversal

10. Fresh Frozen Plasma (FFP)
One unit = mls
Outcomes: improved coagulation, PT,INR, and aPTT
Fresh Frozen Plasma (FFP)

11. Blood components –cont.
Prothrombin Complex – Prothrombin, Factors VII, IX, X, and part of XI
Used to treat clients with specific clotting factor deficiencies
Cryoprecipitate – Clotting Factors VIII, XIII, von Willebrand’s factor, & fibrinogen from plasma
May cause ABO incompatibilities

12. RBC & Plasma Transfusions
RBC’s - Type and cross match with potential donor blood to check minor antigens on cells
Usually 2 orders:
Type
Administer

13. % of General Population
Blood Type (ABO & Rh)
% of General Population
O, +
35%
O, -   *
7 %
A, +
A, -
B, + 8%
B, -
2 %
AB, +   ~ 4%
AB, - 2%

14. Initiation of Transfusion
Check MD’s order & Obtain permit
ID patient, draw blood for T+C in red top tube, place blood band and label tube.
Start gauge IV.

15. Initiation Cont.
2 people check unit of blood or component with laboratory slip, patient’s chart & hospital forms should include:
Patient’s name, Medical Record #, blood band number, Unit #
Blood component, Group & Rh factor, donor number
Expiration date

18. Compare all labels & forms of ID second time
Check vital signs and record
0.9% Sodium Chloride (NS) only!!!
Prime Y-type blood tubing with NS
Invert unit to mix cells
Spike blood bag, clamp off NS
Cover blood filter with blood

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

21. Check facility policy re: # units per administration set
Use blood administration set no more than 4 hours – each infusion must be completed in 4 hours
Check facility policy re: # units per administration set
No more than 1 or 2 units per tubing
Use IV pump

22. Important Points
Drip rate no higher than 2 ml per minute X 15 minutes (30 ml per 15 minutes or 120 ml/hr.)
Seton etc. set pump at 75 to 80 ml/hr. for 15 min.
Remain with pt for first 15 minutes or first 50 ml

23. Important Points Vital signs prior to administration & in 15 min. X 4,
then q 30 minutes, until transfusion complete--then X 2
No meds or fluid other than NS to be given in line with blood!!!
CHECK POLICY AND PROCEDURE of facility!!

24. Important Points 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!!

25. Transfusion Reactions
Anaphylactic
Allergic or Hypersensitivity
Hemolytic
Febrile

26. Transfusion Reactions
Transfusion-Related Acute Lung Injury
Massive Blood Transfusion Reaction
Sepsis
Circulatory Overload

27. Transfusion Reactions
Incompatibility between donor and recipient's blood
What changes in vital signs would you expect to see?
Consider a temperature increase of 2 degrees significant
What drugs are commonly given prior to transfusion?
Transfusion Reactions

28. Prophylaxis/preadministration
History of an allergic reaction to a previous blood transfusion:
acetaminophen (Tylenol)
diphenhydramine (Benadryl)
High risk of fluid overload:
furosemide (Lasix) or another diuretic

29. Allergic Reactions - 1% can occur during or after transfusion
Mild
Urticaria
Itching
Flushing
Severe
Wheezing
Dyspnea
Bronchospasm
Obtain order for antihistamine and antipyretic if pt. has temp elevation
If pt. responds to these, may have order to resume transfusion

30. Anaphylactic Reactions
Can occur very quickly, with only a small amount of transfusion – usually within 50 mls
Hypotension, SOB, Tachycardia, Shock
Loss of consciousness
Facial or laryngeal edema
Dizziness, Chest tightness, abdominal cramping
Get order for epinephrine & corticosteroids

31. Hemolytic Reactions - 0.004% or 1:25,000
ABO incompatibility
RBC’s clump &
block capillaries decreasing blood flow to organs.
Hgb released, blocks renal tubules – can cause renal failure.
Potassium released.

32. 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
Lemone – after 100 to 200 ml infused
3 or 5-10 days up to several months later

33. Pyrogenic: (non-hemolytic) Febrile or Bacterial
Occurs within first 15 minutes
Sensations of Cold
Fever
Chills
Hypotension
Shock
Reaction to donors WBC’s, plasma proteins, or contamination

34. Transfusion-Related Acute Lung Injury
Reaction between recipient’s leukocytes & donors antileukocyte antibodies due to sensitization by pregnancy or previous transfusions
Pulmonary capillaries inflamed
Fluid in alveoli
Respiratory distress
Risk greatly reduced with leukocyte removal and washed packed cells

35. Massive Blood Transfusion Reaction
Replacement exceeds usual blood volume
Drop in clotting factors, albumin, & platelets
Hypothermia
Citrate toxicity & hypocalcemia – Pedi pt.
10 ml 10% calcium gluconate / liter of blood
Hyperkalemia
Massive Blood Transfusion Reaction

36. Stem cells in blood products invade marrow of immunodeficient pt
Stem cells in blood products invade marrow of immunodeficient pt.and grow as a foreign tissue which is rejected
Lymphocytes in blood products attack immunodeficient pt.
7 to 30 days after transfusion
Skin, GI tract, & liver damage
Graft vs. Host

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

38. Charting Document the following: • Time of the transfusion reaction
•         Type and amount of infused blood or blood product
•         Clinical signs of the transfusion reaction in order of occurrence
•         Vital signs
•         Specimens sent to the lab
•         Treatments given and patient’s response to treatment.
•         If required by your facility policy, complete the transfusion reaction form and any quality variance forms.
Charting

39. Major/Urgent Surgeries Performed in the Inpatient Setting
Ablative procedures:
Amputations
Colostomy
Reconstructive:
Total joint replacement
Heart bypass surgery
Palliative
Colostomy for CA
C-sections 8

40. Major Surgeries Performed in the Inpatient Setting
Emergency Surgery
Transplants
Ruptured aneurysm
Life-threatening trauma 8

41. Critical Thinking Exercise
The pt.’s blood type report indicates that he is Type A+. The unit of PRBC's that the bank has provided is labeled as Type O negative. Can this patient safely receive this blood? Why or Why not?

42. Critical Thinking Exercise #2
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+.
Can this patient safely receive this blood?
Why or Why not?

43. Critical Thinking Exercise #2
The pt. is Type A-. The unit of whole blood is labeled as Type O+.
Can this patient safely receive this blood?
Universal donor in emergency
Type O has A & B antibodies but no A or B antigens
Rh+ D antigen to a Rh- patient
male vs. female?
Age of female?
Level of emergency situation?

44. Rh – mother
with
Rh + baby
What med is used?

45. Drug used:
RHo (D) Immune Globulin (RhoGAM)

46. Critical Thinking Exercise #3
The patient is a Jehovah’s Witness. What factors impact care for bleeding in an emergency situation? Compare this situation to the patient who is concerned about the safety of blood component transfusions?

47. Critical Thinking Exercise #4
The patient is scheduled for an elective procedure such as a total knee replacement. What measures can be taken to decrease the risk of transfusion reaction? What type of reaction might still be possible?

48. 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. Safe and well-tested procedure.

49. 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

50. Autologous transfusion
A "cell-saver" technology collects blood as it is lost during surgery, cleanses it, and places it back in the patient's body, all in a continuous loop.

51. Directed donation of blood
Sticker "Directed Donation" affixed directly on the unit.
Note: Directed donations units may also be collected by facilities other than yours.
A complete check of the unit identification compared to the patient identification is performed on each unit to ensure unit is given to the correct patient.

52. Every unit of blood is tested for
HIV-1 and HIV-2 (AIDS)
HBV
HBsAg
HCV
HTLV-I/II Human T-Lymphotropic Virus (HTLV-I and HTLV-II)
ABO and Rh factor & cross match if RBC’s
syphilis
elevated ALT

53. The presence of unexpected antibodies that may cause reactions after the transfusion
CMV, a test for the cytomegalovirus (performed on physician request) * OK if WBC’s filtered out
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 in USA are filtered to remove leukocytes that can harbor viruses and infections.

54. THE END!