BLOOD TRANSFUSION Mary Vanderhoef MSN, ARNP Revised by Octavia Mercado, BSN, RN, CCRN SEPT 2015

Blood Transfusion Blood transfusion is the process of transferring blood or blood-based products from one person to another Can be life saving as in massive blood loss due to trauma Treatment for severe anemia Thrombocytopenia

History First fully documented human blood transfusion by Dr. Jean-Baptiste Denis, physician to King Louis XIV of France in 1667. Transfusion of blood from a sheep into a 15 year old boy that survived

History Dr. James Blundell, British Obstetrician, performed the first successful blood transfusion of human blood in 1818 for treatment of post partum hemorrhage. Used the blood of the patient’s husband and directly infused into the patient.

History In the 1910’s it was discovered that by adding anticoagualnt and refrigerating the blood, it was possible to store the blood for several days.. First non-direct transfusion was performed in 1914 Dr. Luis Agote (2nd from right) overseeing one of the first safe and effective blood transfusions in 1914

History In the 1930’s and 1940’s Dr Charles Drew’s research led to discovery that blood could be separated into plasma and red blood cells.

Indications Indications for blood transfusion ANEMIA: A decrease in red blood cells (rbc’s) secondary to blood loss or deficient production

Blood Transfusion Normal Hgb Levels Males: 14-18 g/dl Females 12-16 g /dl Hematocrit is the proportion of rbc’s in total volume of blood Males: 40-54% Females 38-48%

Blood Transfusions are generally ordered when Hgb 8 g/dl or less OR If patient is symptomatic

S&S Effects of Anemia and decreased O2 delivery: Tachycardia, dyspnea, palpitations, fatigue, weakness, light headedness If severe, anemia could lead to: CVA, or MI secondary to decreased perfusion to heart and brain

Causes of Anemia Causes of Anemia Sudden blood loss Chronic bleeding Phlebotomy in critically ill patients (increases with blood draws 3 x greater in ICU patients)

BLOOD PRODUCTS Whole Blood Packed Red Blood Cells (prbc’s) Platelets Fresh Frozen Plasma (FFP) Cryoprecipitate

Whole Blood Rarely used in the US Restores fluid volume and circulation Contains rbc’s, wbc’s plasma and platelets

Packed Red Blood Cells Most common transfusion Restores blood’s ability to carry O2 Contains few platelets and wbc’s Generally 250- 350 mls per unit Transfuse over 2-4 hours: based on pts need to receive blood and pts other issues Shorter transfusion time: symptomatic Longer transfusion time: CHF, ESRD Increases the Hgb 1 g/Hct 3-4 % Shelf life 42 days

Platelets Platelets are thrombocytes Restores clotting ability Usual dose is 5-10 units OK for rapid transfusion (1 unit over 10 min) Increases platelet count by 5000 per one unit 4-5 day shelf life

Fresh Frozen Plasma (FFP) Unconcentrated source of all clotting factors and proteins from a single unit of blood (contains albumin, fibrinogen, and antibodies) Treats bleeding caused by factor deficiencies and for Liver failure, DIC, and reversal of coumadin/warfarin therapy Is frozen and can be stored for up to 1 year Notify blood bank 30 minutes prior to when needed in order for them to thaw the FFP After thawing by blood blank must infuse within 6 hours Generally 250-300 ml per unit ordered OK for rapid transfusion (1 unit over 10 min)

CRYOPRECIPITATE Concentrate of 4 clotting factors from FFP. Usually used for patients with specific bleeding disorders sucha as hemophilia, von Willibrands disease. Storage and usage same as for FFP

BLOOD TYPES A+ B+ AB+ O+ A- B- AB- 0-

Blood Types Universal Donor O- (only 6.6% of the population) Universal Recipient AB+ Most prevalent blood type O+ (37% of the population)

Giving and Receiving http://www.thebloodcenter.org/donor/BloodFacts.aspx

Rh Factor Rh typing Looks at 8 different genes Rh present (positive) Rh absent (negative) Typing is done to prevent complications from giving incompatible blood

Transfusion Reactions

What to do in Case of Reaction If transfusion reaction suspected STOP the transfusion Notify Physician Give supportive treatment (per orders/protocol): Normal saline fluids Antipyretics antihistamines

Blood Screening Viral is the most common transfusion-transmitted infection Hepatitis B Hepatitis C HIV (most feared) Long period for seroconversion (25-45 days) CMV which belongs to the herpes group (transmitted by whole blood and rbc’s) Can cause immunosuppression leading to risk of pneumonia, gastroenteritis, and hepatitis particularly in the critically ill

Bacterial Contamination Stored units can become contaminated with bacteria and cause infection to recipient Mortaility rate from bacteremia = 50% Causes: Inadequate skin prep at phlebotomy site, small leaks in blood containers, contaminated containers, asymptomatic bacteremia at time of donation

Shelf Life of Blood/Components Whole Blood ~ 35 days PRBC’s ~ 42 days (after this there is a decline in the quality with an increase in inflammatory mediator release) Can be frozen up to 10 years WBC’s ~ <42 days (after this wbc’s begin to die and release toxic cell enzymes) Platelets 5 days

Blood Donation Types Autologous Allogenic/Homologous Cell Saver

Autologous Safest Giving pt their own blood Can donate 72 hours before the scheduled surgery Limiting factors: Hgb < 12.5 g/dl Age < 17 Weight < 110 lbs (50kg) No chronic health problems Tatoos/body piercing < 1 year

Allogenic/Homologous All other donated blood, other than the patients own blood.

Cell Saver Collects, Washes and spins blood that has been suctioned from patient during surgery Debris and hemolytic by products removed Reinfused into patient

Contraindications to Autologous and Cell Saver Transfusions Malignancy Sepsis Enteric contamination Coagulopathy Pulmonary infection Impaired renal function Excessive hemolysis

Incidence of Infection from Transfusions HIV – 1: 2 million Hepatitis B - 1: 200,000 Hepatitis C – 1: 1-2 million Creuzfeldt-Jacob disease – very rare