ADULT & PEDIATRIC TRANSFUSION THERAPY 2010 Annual Review for Registered Nurses & other Transfusionists

Purpose This learning activity will update and reaffirm essential safe practices related to transfusion therapy at Kaleida Health*. This learning activity will update and reaffirm essential safe practices related to transfusion therapy at Kaleida Health*. * Refer to Policy CL.53 Adult & Pediatric Transfusion Therapy 2

Objectives Upon completion of this activity, the RN and other Transfusionists will be able to: Discuss the process for obtaining an ordered blood product. Discuss the process for obtaining an ordered blood product. Recite the steps involved in checking and administering blood products. Recite the steps involved in checking and administering blood products. Describe the signs, symptoms and nursing interventions for common transfusion reactions, according to KH policy. Describe the signs, symptoms and nursing interventions for common transfusion reactions, according to KH policy. 3

To ALL transfusionists: In this program, the terms ‘Transfusion Record’ and ‘bag tag’ are used interchangeably. To the Transfusionists in the Operating Rooms: (i.e. Anesthesia, Perfusionists) there are 2 new protocols available for your review in Policy CL.53: o Normovolemic Hemodilution Protocol for o Transfusion of Autologous Blood o Platelet Rich Plasma 4

Process Once there is an order to transfuse a patient with a blood product, the transfusion process begins…in a nutshell, you must: 1. Check the MD order for transfusion 2. Assess the patient 3. Obtain informed transfusion consent 4. Draw blood sample for Blood Bank testing 5. Obtain the blood product 6. Check the blood product 7. Administer the blood product 8. Document patient assessment at assigned intervals 5

More about each step in the transfusion process STEPS 1 & 2. Check the MD order for transfusion and assess the patient: Review the MD order in the chart Review the MD order in the chart Assess the patient for: Assess the patient for: ~History of previous transfusion reaction ~Pre-transfusion symptoms that could be confused with a transfusion reaction (e.g. fever, chills) ~Any objections to transfusion therapy 6

More about each step in the transfusion process STEP 3. Obtain informed transfusion consent.  If there is no consent for a transfusion, be sure to obtain it prior to the issuance of the blood product from the Blood Bank. 7

More about each step in the transfusion process STEP 4. Draw blood sample for Blood Bank testing.  Blood is needed for a type and cross match.  Obtain the blood sample from the patient.  Note: To prevent a transfusion error-a label MUST be affixed to the tube of blood BEFORE leaving the patient’s BEDSIDE with:  Initials - of the person who drew the sample  Date - sample drawn  Time - sample drawn 8

Mis-labeled pre-transfusion samples Did you know that in one study, 59% of transfusion errors occurred with Did you know that in one study, 59% of transfusion errors occurred with mis-labeled pre-transfusion samples! On follow-up, 16% showed a different blood group with repeated testing. On follow-up, 16% showed a different blood group with repeated testing. 9

More about each step in the transfusion process STEP 5. Obtain the blood product: Remember at Kaleida Health, the RN, GN, or UAP (PCA) are the only authorized hospital employees to pick up blood products from the Blood Bank. Volunteers, Student Nurses and LPNs may NOT go to the Blood Bank to pick up blood. 10

More about each step in the transfusion process STEP 6. Checking the blood product at the bedside of the patient: This means, once the blood is available on the nursing unit, the transfusionist…. CHECKS: Physician order Consent Blood Product with attached Transfusion Record (bag tag) Patient and ID band Vital Signs –TPR & BP (take immediately before the start of the transfusion)…document VS on bag tag. 11

Checking the blood product Next, two authorized healthcare professionals must check the following on the blood product’s attached transfusion record (bag tag) at the bedside: –Patient name –Patient identification number/MR number –Patient date of birth –Patient blood type –Donor blood type, unit expiration date, unit number 12

Checking the blood product* *This checking process is done for: whole blood packed red blood cells plasmaplatelets white blood cells cryoprecipitate 13

KEYPOINT Keep the Transfusion Record (bag tag) attached to the blood product at all times until an uneventful transfusion is completed. This piece of paper links the patient to the specific unit of blood. 14

Checking the blood product The two authorized healthcare professionals must compare the information on the blood product (Transfusion Record also known as the bag tag) against the information on the patient ID band— AT THE BEDSIDE All information MUST match! –Patient name –Patient identification number/MR number –Patient date of birth 15

Checking the blood product One more thing to check….. ABO and Rh group of the donor MUST match or be compatible with the patient’s information. ABO and Rh group of the donor MUST match or be compatible with the patient’s information. If the ABO & Rh of the donor does not match the patient’s ABO and Rh, check Blood Compatibility Table on the back of the Transfusion Record. If the ABO & Rh of the donor does not match the patient’s ABO and Rh, check Blood Compatibility Table on the back of the Transfusion Record. Questions? Call the Blood Bank…. before transfusing. 16

Checking the blood product If all information matches, both healthcare professionals (authorized to transfuse) place their signatures and date on the bag tag at the commencement of the transfusion. If all information matches, both healthcare professionals (authorized to transfuse) place their signatures and date on the bag tag at the commencement of the transfusion. 17

Signatures of 2 transfusionists on the Transfusion Record verifies that--- “We verify that prior to starting this transfusion we have: 1.Confirmed that this blood product was ordered for transfusion to this patient. 2.Reviewed the patient transfusion consent form. 3.Confirmed that the unit has not expired. 4.Confirmed the identity of the patient and the unit information and that there are no discrepancies between this unit, the tag attached to this unit and the patient identification.” 18

More about each step in the transfusion process STEP 7. Administering the blood product This is one of those steps that should be initiated before sending someone to pick up the blood product from the Bank.  IV access- be sure patient has patent IV access that will be dedicated for the transfusion-(Adult patient:18-20 gauge, Pediatric patient: gauge) for good blood flow)  Set up tubing for blood administration.  Use of a IV pump is highly recommended.*  Change blood tubing after each unit unless consecutive blood products are ordered. See policy CL.53 for specifics on this point. * You can safely transfuse adult patients PRBC, WB and FFP (plasma) using safety software/drug library on Hospira IV pump. In the neonatal setting, use of a pump is expected practice. In the pediatric setting, use of a pump is also highly recommended. In emergencies (urgent need, high desired flow rate), use of a pump may be optional. 19

More about each step in the transfusion process STEP 7. (continued) Administering the blood product Keypoints:  Only normal saline (0.9% sodium chloride) may be infused in the same IV line with most blood products; otherwise you may risk hemolysis.  No medications may be administered through the same line as the blood.  Hang time: once a unit of blood is dispensed from the blood bank, you have only 4 hours to administer it…otherwise the risk of bacterial growth is too great to use it safely. 20

Administering the blood product—New for 2010 NEW for infusion rates for blood products have changed: For NON-EMERGENT transfusions in ADULTS, infuse blood SLOWLY during the initial phase of transfusion=  Transfuse 2 mL/min for the first 15 minutes while you are observing the patient for any adverse reactions. Once you are sure the patient can tolerate the transfusion---  REASSESS patient and document this set of vital signs on the bag tag.  Then adjust the flow rate as in the table on slide

New for 2010—Rates for Peds NEW for infusion rates for blood products have changed For NON-EMERGENT transfusions in NEONATES/ PEDIATRICS, infuse blood SLOWLY during the initial phase of transfusion=  The order to transfuse from the physician must include a rate of transfusion.  Observe the patient carefully for adverse reactions during first 15 minutes. Once you are sure the patient can tolerate the transfusion---  REASSESS patient and document this set of vital signs on the bag tag.  Then continue transfusion at the flow rate specified in the physician order (see the following table for guidelines). 22

New suggested* transfusion rates after first 15 minutes: ComponentAdultPediatric Red Blood Cells mL/hr 2-5 mL/kg/hr Fresh Frozen Plasma mL/hr mL/hr Platelets mL/hr mL/hr Cryoprecipitated AHF As rapidly as tolerated As rapidly as tolerated Granulocytes (WBC) mL/hr mL/hr (* Suggested rates for blood components in non-emergency settings AABB 2008) 23

Administering the blood product Also NEW for 2010……. The transfusionist should remain near the patient during the first 15 minutes of the transfusion. The transfusionist should remain near the patient during the first 15 minutes of the transfusion. Rationale—to closely monitor the patient for a transfusion reaction, so prompt interventions can be initiated if necessary. 24

Administering blood products Vital Signs Intrauterine transfusions are not exempt from vital sign monitoring. Maternal VS should be recorded at the same intervals as all other transfusions. Intrauterine transfusions are not exempt from vital sign monitoring. Maternal VS should be recorded at the same intervals as all other transfusions. On completion of all uneventful (reaction-free) transfusions, the patient must be REASSESSED, and vital signs documented one last time. On completion of all uneventful (reaction-free) transfusions, the patient must be REASSESSED, and vital signs documented one last time. If the blood product was infused rapidly (within 15 minutes) take and document vital signs twice (immediately before and 15 minutes later). If the blood product was infused rapidly (within 15 minutes) take and document vital signs twice (immediately before and 15 minutes later). Then, cross off the last time frame on the Transfusion Record, so it is clear that the blood was given rapidly, for an emergent reason. Then, cross off the last time frame on the Transfusion Record, so it is clear that the blood was given rapidly, for an emergent reason. 25

Transfusion Process-uneventful At the end of a transfusion, make one final check: Are all vital signs written in the appropriate spaces on bag tag? Are all vital signs written in the appropriate spaces on bag tag? Are there 2 signatures in the verification area on the bag tag? Are there 2 signatures in the verification area on the bag tag? Is there a date and time indicated for start and end of the transfusion? Is there a date and time indicated for start and end of the transfusion? If you answered YES to all of the above, detach the bag tag from the blood product and place it in the medical record. 26

Keeping Vigilant It is important that the nurse remain vigilant and observes for the development of any adverse reactions both during and after the completion of a blood transfusion. It is important that the nurse remain vigilant and observes for the development of any adverse reactions both during and after the completion of a blood transfusion. Reactions can be potentially life threatening and most commonly occur within minutes of initiating a transfusion. Reactions can be potentially life threatening and most commonly occur within minutes of initiating a transfusion. If you suspect a patient is having a reaction, refer to the Transfusion Record (bag tag) for signs, symptoms and interventions or refer to the policy CL.53 Appendices C & D. If you suspect a patient is having a reaction, refer to the Transfusion Record (bag tag) for signs, symptoms and interventions or refer to the policy CL.53 Appendices C & D. 27

Common Transfusion Reactions Allergic (mild) Allergic (mild) Allergic (moderate to severe) Allergic (moderate to severe) Febrile (mild to moderate) Febrile (mild to moderate) Acute Hemolytic Acute Hemolytic Fluid Overload Fluid Overload –(fluid overload is more often encountered in neonatal, pediatrics and geriatrics) For a complete list of possible signs and symptoms of a reaction see CL.53 appendix C. 28

Transfusion Reaction Scenario 1 While assessing your patient during a transfusion, you discover that he has hives on his chest. Referring to the back of the Transfusion Record or the policy, you find the ‘Clinical Action’ to take to intervene You confirm that he is having what is considered an mild allergic reaction with signs and symptoms of hives and/or pruritis. What are your interventions? 29

Transfusion Reaction Scenario 1 continued According to policy (and the Transfusion Record) the interventions you should take for a mild allergic reaction are: 1. Turn off the blood product. (temporarily interrupt the transfusion) Keep IV line open with NS 2. Recheck patient, blood product information and the attached bag tag for clerical discrepancies. 3. Assess VS 4. Call Physician (using SBAR), ask for an order for antihistamine. 5. Restart transfusion if symptoms resolve, with MD order. 6. Monitor for subsequent reactions. If there is no improvement in 30 minutes treat as a moderate to severe reaction. 30

Transfusion Reaction Scenario 1 continued Your patient with the hives (mild allergic reaction) received an ordered antihistamine, but 30 minutes later, the hives have spread from his chest to his neck, face and back. His blood pressure has dropped from 138/84 to 100/68. According to the policy (and the bag tag) your patient’s reaction has progressed from mild to the moderate to severe level. What is your next intervention? 31

Transfusion Reaction Scenario 1 continued You should: 1. Discontinue the blood transfusion. Keep IV line open with 0.9% sodium chloride. 1. Discontinue the blood transfusion. Keep IV line open with 0.9% sodium chloride. Note the volume of unit infused on bag tag, also for I&O 2. Call physician* for further orders …. e.g. antihistamines, epinephrine, vasopressors may be ordered as needed to treat symptoms. 2. Call physician* for further orders …. e.g. antihistamines, epinephrine, vasopressors may be ordered as needed to treat symptoms. 3.Continue to closely monitor the patient. 3.Continue to closely monitor the patient. 4. Complete Adverse Reaction Section on front of bag tag 4. Complete Adverse Reaction Section on front of bag tag 5. Document change in patient condition in progress notes! 5. Document change in patient condition in progress notes! 6. Call Transfusion Services/Blood Bank to report reaction. 6. Call Transfusion Services/Blood Bank to report reaction. * Note in some cases, it may be necessary to call the Rapid Response Team 32

For All Other Transfusion Reactions (other than Hives) You should: Stop the transfusion, Keep IV open with 0.9% sodium chloride Stop the transfusion, Keep IV open with 0.9% sodium chloride 1. Recheck patient, blood product information and the attached bag tag for clerical discrepancies. Call MD for further direction Call MD for further direction Treat symptoms as ordered by MD Treat symptoms as ordered by MD Document symptoms on bag tag Document symptoms on bag tag Call Transfusion Service/Blood Bank to report reaction Call Transfusion Service/Blood Bank to report reaction ASAP Draw and send a fully labeled EDTA lavender or pink tube of blood to Transfusion Service/Blood Bank ASAP Draw and send a fully labeled EDTA lavender or pink tube of blood to Transfusion Service/Blood Bank Hand deliver* unit with remaining product and administration set to Blood Bank (remove all needles, cap tubing with a port protector) Hand deliver* unit with remaining product and administration set to Blood Bank (remove all needles, cap tubing with a port protector) *Do not send through the mail or pneumatic tube. 33

Transfusion Reaction Scenario 2 It is 2000, while making hourly rounds, a PCA discovers that a patient (who is receiving a unit of PRBCs) has chills and is complaining of itching. She reports this to you. When assessing the patient, you look at the vital signs (on bag tag) that had been taken at the start of the transfusion and 15 minutes later: 1800-T=99.6, P= 84, R=20, B/P=107/ T=99.1, P=72, R=18, B/P=104/68 34

Transfusion Reaction Scenario 2 You immediately recheck his vital signs: T=101.3, P=132, R=16, B/P 175/95. In summary, he is febrile, hypertensive, has a rapid pulse, has generalized itching and states that he feels ‘funny’. His wife is concerned, says he has received blood before, but never looked like this. Only ½ of the unit has been transfused. What are your interventions? 35

Transfusion Reaction Scenario 2 You will: Stop the transfusion, Keep IV open with 0.9% sodium chloride Stop the transfusion, Keep IV open with 0.9% sodium chloride 1. Recheck patient, blood product information and the attached bag tag for clerical discrepancies. Call MD for further direction Call MD for further direction Treat symptoms as ordered by MD Treat symptoms as ordered by MD Document symptoms on bag tag Document symptoms on bag tag Call Transfusion Service/Blood Bank to report reaction Call Transfusion Service/Blood Bank to report reaction ASAP Draw and send a fully labeled EDTA lavender or pink tube of blood to Transfusion Service/Blood Bank ASAP Draw and send a fully labeled EDTA lavender or pink tube of blood to Transfusion Service/Blood Bank Hand deliver* unit with remaining product and administration set to Blood Bank (remove all needles, cap tubing with a port protector) Hand deliver* unit with remaining product and administration set to Blood Bank (remove all needles, cap tubing with a port protector) *Do not send through the mail or pneumatic tube. 36

Blood has been called “a gift of life”. For patients with critical medical and surgical conditions, a blood transfusion can literally mean the difference between life and death. Let’s make sure we administer this gift safely… Sure…. there is a lot of checking and rechecking with a transfusion---but it is worth it! Do the right thing! 37