Bedside Labs: Blood Transfusions What, When, and How?

Nursing Role in Transfusion Virtually all blood products at Parkview Health facilities are transfused by nurses. More than 15,000 units are transfused per year system-wide!

Nursing Role in Transfusion Patient, sample, & blood product identification process failures are responsible for the majority of mistransfusion events. Our processes must ensure the correct patient, the correct sample, & correct blood product, every time! Clearly nurses play a huge role in transfusion safety!

Nursing Role in Transfusion As a patient advocate in transfusion, consider the following questions to maximize effectiveness & safety of transfusions: Why is the blood or component being given? What is in the product? How is it handled and stored? Is it ABO- and Rh- compatible? How should it be administered? What adverse reactions may develop? Have physician’s orders been issued? Has patient consent been obtained?

Types of Blood Products Red Blood Cells (RBCs) Used to restore oxygen-carrying capacity Crossmatch is required for routine transfusion One unit should raise the hemoglobin level 1 to 1.5 g/dL Must be stored in a monitored refrigerator. Indicated for symptomatic anemia due to chronic or acute blood loss

Types of Blood Products Fresh Frozen Plasma (FFP) Indicated to replace clotting factors lost due to severe bleeding or disease, reverse effects of warfarin & bring aPTT /PT within hemostatic range ABO/Rh is required (or a previous blood type on file), but a crossmatch is NOT required Expires 5 days after thawing & must be stored refrigerated Cannot be refrozen

Types of Blood Products Platelets (apheresis platelets, single donor platelets, platelet pool or random platelets) Indicated for treatment of bleeding due to critically decreased circulating platelet counts or functionally abnormal platelets Platelets are necessary to form blood clots to stop bleeding ABO/Rh is required (or a previous blood type on file), but a crossmatch is NOT required One unit should raise the platelet count 30,000 to 50,000 Must be stored at room temperature, 20-24 ˚C. Because apheresis platelets are obtained from a single donor (reducing the number of donors that the patient is exposed to) they are the most commonly used platelet product

Types of Blood Products Cryoprecipitate (CRYO) Used to replace clotting factors for which there is no specific factor concentrate, and fibrinogen ABO/Rh is required (or a previous type on file), but a crossmatch is NOT required Expires 4 hours after thawing and must be stored at ROOM TEMPERATURE Cannot be refrozen Indicated for severe bleeding or immediately prior to an invasive procedure in patients with significantly low fibrinogen

Transfusion Safety Infectious Diseases Blood transfusion is a “living tissue transplant” Even though all donors are tested for infectious diseases, no blood product can be guaranteed to be disease-free Transfusion-transmitted diseases include: HIV Hepatitis B and Hepatitis C Other viruses, bacteria, and parasites

Transfusion Safety Bacterial Contamination: Can cause serious or fatal septic reactions Platelets are more likely to cause septic transfusion reactions Bacterial growth is accelerated in products stored at room temperature Sources most often are donor skin or blood Less likely sources are disposables or environmental Remember, blood products are collected aseptically but are not necessarily sterile!

Transfusion Safety Mistransfusions Administration of incorrect or incompatible blood component Currently, most significant risk associated with blood transfusion Can be fatal The most common cause is error during bedside clerical check Much greater rate of fatalities than that of infectious disease transmission Occurs in approximately 1 in 16,000 transfusions

Transfusion Safety Mistransfusions - Examples Transfusing ABO-incompatible RBCs Transfusing to an unintended recipient Transfusing the wrong type of product, for example, FFP instead of platelets

Transfusion Safety Other Noninfectious complications of transfusion: Immune responses TRALI, febrile non-hemolytic reactions Formation of antibodies to donor red cells Iron overload with chronic transfusion Circulatory overload Allergic reactions

Agencies that Regulate Blood Product Administration FDA - Food & Drug Administration CAP - College of American Pathologists AABB - American Association of Blood Banks TJC – The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations)

Regulatory Oversight We are governed by many regulatory agencies These agencies work together to maintain the safety of blood supply Hospitals are REQUIRED to monitor blood transfusion practices & adverse outcomes Our Transfusion Medicine Committee develops evidence-based transfusion practice guidelines to promote efficient use of blood supply

Orders/Ordering Required elements of a transfusion order: Physician order, written on chart Blood product to be transfused Number of products to be transfused Ideally should include administration rate (or use standard infusion rate) For example: “transfuse 2 units of packed red blood cells over 2 ½ hours each” Not valid orders: “Give 2 units now” or “Give FFP”

Orders/Ordering: Important Points Correct patient! Correct product type & quantity Packed cells may be added on to a current type & screen Specify “to give” or “to hold” when entering order Surgery may call orders to Blood Bank. The order requires patient name, MRN, physician name, caller name, blood product, & number of units

Orders/Ordering: Important Points Are there any special instructions? Irradiated - prevention of Graft vs. Host complications in immunocompromised patient. CMV negative - prevention of CMV transmission to immunocompromised patient. Autologous - ordered ONLY when the patient has donated blood for themselves (AUTO=self)

Orders/Ordering: Important Points Special instructions (continued) Directed - patient has had specific donor donate for him Split unit - usually ordered when a unit is to be given slowly (>4 hours from time issued to end of transfusion) Leukoreduced - this instruction does not need to be added to any order because our blood supplier universally leukoreduces our blood products by filtration

What is a CMV negative and irradiated blood product? CMV negative refers to the donor testing and means the donor does not possess antibodies to Cytomegalovirus, which generally means that they have not had this virus and cannot transmit it to the transfusion recipient. Irradiated means that the donor unit has received a specific “dose” of radiation that will disrupt the WBCs present in the donor unit, but does not damage platelets or red blood cells.

CMV negative and irradiated packed cell units CMV negative and irradiated packed cell units. Look for the green “ANTI-CMV NEGATIVE” sticker, and the white RAD-SURE sticker indicating that the unit has been irradiated. The RAD-SURE sticker may be anywhere on the donor unit face.

CMV negative and irradiated platelet unit.

Why would my patient require CMV negative products? Cytomegalovirus is transmitted by transfused WBCs in the donor blood, and in an immunocompromised patient may lead to a severe infection with multiple organ involvement. Immunocompromised patients include newborns, patients with stem cell or bone marrow transplants, and patients with leukemia or lymphoma. Specifying CMV negative products for these patients decreases the risk of transfusion associated virus transmission.

Why would my patient require irradiated blood products? Immunocompromised patients are also at higher risk for transfusion-associated graft-versus-host disease or TA-GVHD. TA-GVHD occurs when WBCs from the donor unit migrate to the patient’s bone marrow, engraft there and begin producing antibodies that recognize the “host” (recipient) as foreign. Symptoms include macropapular rash, erythroderma, vomiting, profuse diarrhea, pancytopenia and liver dysfunction. Death is usually due to infection and hemorrhage and the mortality rate is >90%. The disease is virtually untreatable. The effect of irradiation on a blood product is to neutralize the donor WBCs present, thereby avoiding TA-GVHD.

Specimen Collection Specimen requirements: 2 full tubes: one pink top and one red top (NO SERUM SEPARATOR TUBES) Pink top tube may be used for automated testing in Blood Bank A lavender tube may be substituted for the pink tube Type & screen specimens expire on third day after collection at 23:59

Specimen Collection Labeling requirements: Full name of patient Medical record number Date & time of collection Employee ID number (initials are NOT acceptable for nurse collected samples & will be refused)

Specimen Collection A specimen will be rejected if: ANY required labeling is missing Specimen is grossly hemolyzed IV contamination is suspected Volume is insufficient Testing reveals an ABO discrepancy HEMOLYSIS

Preparing for Transfusion Educate the patient and/or family about reason for transfusion, including the risks & benefits of procedure Ensure consent is signed before initiation of transfusion Review history of transfusions including: Previous transfusion reactions Any problems reported by the patient Notify lab if any problems to previous transfusions

Preparing for Transfusion Pretransfusion medications, if any - administer per prescribing physician’s order Obtain pretransfusion vital signs within 30 minutes of the beginning of transfusion

Assess patency and size of IV line – Needle Size A large-gauge needle is preferred. Adults: 18- to 20-gauge needles are recommended for a good rate of flow, without undue discomfort for the patient. Chronically transfused or pediatric patients: When adequate venous access is difficult to maintain, the largest possible needle should be used. Red Blood Cells (RBCs) can be safely administered through 23- to 25-gauge needles; however, the flow rate will be slower. Non-Red-Cell-Containing Blood Components Examples: Platelets, Fresh Frozen Plasma (FFP), and Cryoprecipitated AHF. Can be rapidly administered through small-gauge needles.

Blood Administration Set and Filters All blood components should be infused through administration sets designed specifically for this use. The set usually contains a 170-micron filter designed to trap fibrin clots and other debris that accumulate during blood storage. Most standard filters have a four-unit maximum capacity. (Check the manufacturer’s instructions.) If the first unit requires ≥4 hours for infusion, the filter should not be reused. Blood collected in surgery by cell saver process, and wound drainage collections, should be infused with a 40-micron filter.

Blood Administration Set and Filters Tubing is available in two basic configurations: Straight: Usually has a medication injection site a few inches from the hub. If an adverse reaction develops, a “keep-vein-open” saline drip initiated at this site will maintain IV patency but avoid exposure to the 30 to 50 mL of blood remaining in the tubing and filter. Y-type: Simplifies the process of adding normal saline to red cells (if necessary). Provides ready access to a saline flush if the blood component remaining in the tubing at the end of the transfusion.

Preparing for Transfusion Blood Dispensing Form-Send completed blood dispensing form to the lab only after all pre-transfusion preparations are completed Essentially a list of indications for transfusion at Parkview Health as established by our Transfusion and Medical Executive Committees Used to determine if transfusion is appropriate It is important to complete it correctly, including: Name & medical record number of patient Name & signature of the nurse requesting blood product

Preparing for Transfusion Blood Dispensing Form (continued) Must indicate reason for transfusion If nurse cannot determine from patient assessment or from physician’s notes, call for clarification “Per doctor’s order” or “low hemoglobin” are NOT acceptable indications

Transfusing A bedside clerical check must be performed by one RN & one licensed professional/paramedic Full name & MRN on patient armband MUST match name & MRN on compatibility label of blood product AND transfusion administration record Unit number & ABO/Rh on blood product face label must match unit number ABO/Rh on compatibility label AND transfusion administration record

Transfusing Bedside Clerical Check (continued) Unit ABO/Rh must be compatible with patient ABO/Rh Reverse side of transfusion administration record includes a compatibility chart for red cell & non-red cell products Unit must not be expired Expiration date (and time, if applicable) is located on unit face label & compatibility label Take the chart or a copy of the order to the bedside to be sure that special instructions, such as irradiation, have been met.

Special Instructions or Attributes Check the patient’s written order to be sure that any special attributes, such as CMV negative and irradiation, have been met.

Transfusing Face label Back of unit Unit number Expiration date Product type Unit ABO and Rh Compatibility label

Transfusing Compatibility Label PATIENT INFORMATION DONOR INFORMATION

Transfusing Visual inspection of unit For non-red cell products: check for clots or leaking For packed cells: check for clots, leaking, purple red cell mass, or murky, purple, brown or bright red plasma above cell mass If any of above are found upon inspection, call blood bank immediately. Do not hang the unit!

Transfusing Return unit to the blood bank if unable to transfuse product for any reason A unit which is not spiked may be returned to the blood bank up to 30 minutes after time of issue If unit has been spiked or was issued >30 minutes ago, it is still acceptable to transfuse as long as transfusion is complete within 4 hours of original issue time Notify blood bank that a unit is being returned & reason for returning it

Transfusing Initiation of transfusion Except for normal saline, no medications or solutions should be added or transfused concurrently with blood products All blood products must be transfused using tubing specific for blood product administration that includes a filter to remove clots & aggregates. An RN must remain at the beside with patient for first 15 minutes of transfusion. Before leaving the patient unattended, instruct him or her to report anything “unusual” immediately. For non-emergent transfusions infusion should start slowly during first 15 minutes, at approximately 2 ml per minute

Suggested adult infusion rate Transfusing If there is no sign of a reaction after first 15 minutes, flow can be increased to rate prescribed by physician or according to chart below: Component Suggested adult infusion rate Red Blood Cells 150-300 mL/hour FFP 200-300 mL/hour or gravity flow Platelets Cryoprecipitate As rapidly as tolerated Flow rate should be adjusted according to the volume that patient’s circulatory system can tolerate

Transfusing Nurse to check vital signs & assess patient 15 minutes after initiation of transfusion A licensed professional/paramedic must then perform assessment of patient every 30 minutes until completion of transfusion Vital signs must be checked at completion of transfusion & an assessment performed one hour post-transfusion Outpatients may choose to leave prior to one hour assessment Provide post-transfusion instructions to the patient and/or family

After Transfusion Signatures of professionals identifying blood Transfusion Administration Record should thoroughly document transfusion, including: Signatures of professionals identifying blood Starting transfusionist Ending transfusionist Professionals performing vital signs/assessments Date/ time transfusion started & completed All product inspections, pre-transfusion preparations, bedside clerical checks, vital signs, & assessments Any patient care notes, e.g., “patient experiencing chills”, “increased blood pressure - patient was ambulatory”, or “patient had headache prior to transfusion”

After Transfusion Return yellow copy of completed transfusion administration record to blood bank within 24 hours. White copy must be placed in chart

Congratulations. You have Completed the Course.  Back Congratulations. You have Completed the Course. We hope this Computer Based Learning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented. Go to the Net Learning Tutorial entitled Bedside Labs: Transfusion Reaction to complete the written test and receive credit on your educational transcript. This education is required yearly for all coworkers who perform blood transfusions.