Blood Administration

Blood Administration Your patient’s Hgb & HCT is 6.2 & 18.4; the doctor orders 3 units of packed RBC’s! What actions do you take first?

Blood Administration Right If you said: Check for T&C Verify informed consent Insure IV access; need large bore catheter (18-20 gauge); smaller bore causes destruction of RBC’s Gather equipment: Y-tubing blood administration set with filter NS solution IV pump Prime tubing with Normal Saline.

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

Types of Blood Components Whole Blood To replace blood volume and O2 carrying capacity in Treat hemorrhage and shock Contains PRB’C, plasma proteins, clotting factors and plasma (few platelets & granulocytes) Volume = 500ml/unit __________________ Packed Red cells (PRBCs) Treat anemia, replace blood volume (ordered when Hgb 8-9 & HCT 24-27) 1 unit PRBC = Hgb by 1/HCT by 3 From whole blood (2/3 of plasma removed) Only RBCs used O2 carrying capacity in slow bleeding, anemia, leukemia, surgery Volume = 250-300ml/unit Risks & Benefits Possible incompatibility issues Circulatory overload Deficient in some clotting factors Rarely used Use Lasix to prevent overload ________________ Use leukocyte poor red cells or leukocyte filter if history of febrile reaction No viable platelets or granulocytes Incompatibility may cause hemolytic reaction Less chance of fluid overload Takes 4-6 hours for Hgb & HCT to change Most commonly used!! FRESH WHOLE BLOOD ------ Must be irradiated blood , use leukocyte filter

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 Drawback – bacterial growth if contaminated during collection/processing WASHING: A method of cleaning red blood cells which have been separated from undesirable components of blood in a centrifugal separating chamber includes the steps of pulsating a washing solution through the red blood cells in an alternating high flow rate/low flow rate sequence so as to alternately agitate the red cells for optimal cleaning and stabilize the red cells to prevent a flushing of the cells from the separation chamber.

Types of Blood Components Con’t Risks & Benefits Not a substitute for whole blood May form antibodies Hypersensitivity reaction ____________ Vascular overload Hyperosmolar solution moves water from extravascular space to intravascular space Outcome: adequate BP & volume Can be stored for 5 years Platelets To control or prevent bleeding in platelet deficiencies, i.e. thrombocytopenia (ordered when platelets count <10-20,000) From whole fresh blood Expected platelet 10,000/unit Measure at 1hr & 18-24 hr post admin Volume = 30-60ml/unit ________________________ Albumin (plasma derivative) To expand blood volume or replace protein Used to treat shock from trauma, infection, 3rd spacing, hypovolemia, and in surgery Available in 5% -25% solution Volume 25g/100ml = 500ml of plasma

Types of Blood Components cont’d Frozen RBCs Rarely used Successive washing with saline solution removes majority of WBCs and plasma proteins ________________________ Fresh Frozen Plasma (FFP) To treat DIC, reverse effects of Coumadin, treat liver failure pts Contains clotting factors Improves coagulation, PT & PTT Volume = 200-250ml/unit Risks and Benefits - Can be stored for 3 years - Use within 24hrs of thawing - No WBC’s ___________________ Risks & Benefits Rich in clotting factors No platelets Good for volume expansion to restore clotting factors in hypovolemic shock Risk for vascular overload Hypersensitivity reaction Hemolytic reactions

Types of Blood Components Cont’d Prothrombin Complex – Prothrombin, Factors VII, IX, X, and part of XI Used to treat clients with specific clotting factor deficiencies Prepared from FFP Store for 1 year, once thawed, must be used Cryoprecipitate – Clotting Factors VIII, XIII, von Willebrand’s factor, & fibrinogen from plasma May cause ABO incompatibilities

WBC’s or Granulocytes Outcomes & Uses Improvement of infection is measure of treatment effectiveness Used in cancer & chemotherapy patients Hazards - febrile reaction & new infections carried in WBC’s

Preparation for Blood Administration Physicians order Verify signed consent Obtain IV acess, 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 for and obtains blood (only one client & 1 unit a time!) 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!

Compatibility Chart Recipient Donor A B AB O A X X B X X AB X O X X X X Many pregnant women carry a fetus with a different blood type from their own, and the mother can form antibodies against fetal RBCs. Sometimes these maternal antibodies are IgG, a small immunoglobulin, which can cross the placenta and cause hemolysis of fetal RBCs, which in turn can lead to hemolytic disease of the newborn, an illness of low fetal blood counts which ranges from mild to severe.[3] The RhD antigen is also important in determining a person's blood type. The terms "positive" or "negative" refer to either the presence or absence of the RhD antigen irrespective of the presence or absence of the other antigens of the Rhesus system. Anti-RhD is not usually a naturally occurring antibody as the Anti-A and Anti-B antibodies are. Cross-matching for the RhD antigen is extremely important, because the RhD antigen is immunogenic, meaning that a person who is RhD negative is very likely to make Anti-RhD when exposed to the RhD antigen (perhaps through either transfusion or pregnancy). Once an individual is sensitised to RhD antigens their blood will contain RhD IgG antibodies which can bind to RhD positive RBCs and may cross the placenta. O- universal donor, AB+ universal recipient

RBC & Plasma Transfusions

Initiation of Transfusion Verify informed consent Check physician’s orders ID patient, draw blood for T+C in red top tube and start 18-20 gauge IV, place blood band and label tube. Blood tubing & 0.9NS IV solution ready T&C to lab

Initiation of Transfusion Con’t Obtain blood from blood bank 2 RNs check unit of blood with laboratory slip, patient’s chart, forms should include patient’s name, unit #, and blood type, etc. Check expiration date Patient’s ID#, blood band #, & state name (@ St. David’s – blood band number on blood band) (@ Seton - transfusion card) Blood component, donor #, expiration date, Group & 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)!)

Verify Identification

Blood Product Administration Compare all labels second time Check vital signs and record Initial vitals before admin. Vitals 15 minutes after admin. (stay with pt 1st 15mins) Vitals q30min after that until transfusion complete Vitals post admin. and then in 1hr 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, before admin. Spike blood bag, clamp off NS Squeeze tubing to cover blood filter with blood

Blood Product Administration 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 Blood to cover filter

Use appropriate filters Product Features: Patient protection against leukocyte-related transfusion complications Primes directly with red cells quickly and conveniently Patented filtration media and minimal hold-up volume provides minimal loss of red cells No saline prime or flush required For intraoperatively salvaged washed blood Reduces leukocytes Decreases fat globules Reduces microaggregates

Use appropriate filters for Platelets Product Features: Patient protection against leukocyte-related transfusion complications Primes directly with platelets quickly and conveniently High platelet recovery achieved without saline flush

Critical Points Client indentification & blood compatability Drip rate no higher than 2 cc per minute X 15 minutes (30 cc per 15 minutes or 120 cc/hr.) Seton etc. set pump at 75 to 80 cc/hr. for 15 min. Remain with pt for first 15 minutes Vital signs prior to administration, in 15 minutes, then q 30 minutes, until transfusion complete--then X 2hr No meds or fluid other than NS to be given in line with blood!!! CHECK POLICY AND PROCEDURE of facility!! Set pump for 75-80cc/hr during first 15min

Critical Points Monitor for signs of transfusion reaction 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!! Allow blood to hang no longer than 4 hours If multiple units to be given for replacement of rapid blood loss, may be given under pressure and warmed prior to administration (only agency approved warming device)

How would you manage this? 1. Your client is to receive a unit of packed red blood cells. You have picked the blood up from the blood bank and brought it to the unit. You flush the patient’s IV before hanging the blood and find that it has infiltrated. You are unable to initiate IV access. What actions should you take?

How would you manage this? 2. In addition to transfusion reaction; what is a major risk related to administration of whole blood?

How would you manage this? 3. Your client receives a unit of RBC’s…what response to this unit of blood is anticipated?

Transfusion Reactions 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? 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! Consider a temperature increase of 2 degrees significant Action taken will be determined by type of reaction; careful assessment, monitoring of patient! What drugs are commonly given prior to transfusion?

Transfusion Reactions/Complications Febrile (most common) Sensitization to donor WBC, platelets, plasma proteins Allergic (hypersensitivity to donor plasma proteins) Mild allergic to severe (anaphylactic) Hemolytic (life-threatening!) Acute hemolytic: ABO incompatible; red cell destruction (wrong blood type given to pt) *Circulatory overload Fluid given too fast & too much Iron overload- delayed reaction Hypocalcemia- citrate in blood binds with calcium & is excreted Bacterial (pyrogenic or sepsis) (not in text) Transfusion of bacterially infected components

Febrile pyrogenic /non-hemolytic Caused by leukocyte incompatibility; sudden onset: usually within first 15 minutes of transfusion! (usually a reaction to donor WBC’s or plasma proteins) Fever/chills (^1 degree) Sensations of Cold Flushed skin, abdominal pain, vomiting and diarrhea Hypotension/Shock Prevent by use of leukocyte poor blood! Stop infusion/antipyretics NON-Hemolytic **Bacterial (pyrogenic): similar to febrile; due to bacterial contamination of blood: see S & S above

Allergic Reactions (Hypersensitivity reactions) Antibodies in patient’s blood react against proteins, such as immunoglobulin A in donor blood May occur during or after the transfusion Can occur quickly, within 50mls of blood administered 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) DO NOT RESTART TRANSFUSION Mild (initially) (1% of pts.) *Urticaria Pruritis Itching Severe (Anaphylactic) Anxiety Wheezing & Chest tightness Dyspnea Bronchospasm Hypotension Tachycardia Swelling of tongue, face Loss of consciousness Shock, pulmonary edema

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 in 1:25,000 Usually occurs after 50-100 ml blood infused! (possibly 200mls) ABO/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) Potassium released Fever/chills SOB/dyspnea/wheezing Apprehension Headache/low back pain Chest pain/chest tightness Urticaria Tachycardia N&V *Hematuria Burning at IV site

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 free Hgb 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!

ABO incompatibility causes RBC’s to clump, block capillaries, decreasing blood flow to organs.

Hemolytic Reactions Hgb is released blocking renal tubules Can cause renal failure. Impact of K+ ?

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 Lewis – can occur within infusion of as little as 10mls

Reactions/Complications *Circulatory overload Fluid given too fast & too much Note cough, dyspnea, lung sounds, 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)

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 procedure Obtain urine specimen for free hemoglobin test

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.

Autotransfusion Indications Used in surgery & emergency settings Autologous blood-collection of own blood prior to scheduled surgery or in emergency situation (blood salvage; cell saver) Risks and Benefits Requires special equipment No T&C needed If pre-donation, begin collection within 5 weeks of transfusion date end at least 3 days prior to transfusion need “Cell-saver" technology collects blood lost during surgery, cleanses it, and places it back in the patient's body, all in a continuous loop.

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

Every unit of blood is tested for Antibodies to HIV-1 and HIV-2 (AIDS). Antibodies to HBV produced during and after infection with Hepatitis B Virus Antibodies to HCV produced after infection with the Hepatitis C virus Antibodies to HTLV-I/II produced after infection with Human T-Lymphotropic Virus (HTLV-I and HTLV-II) Antibodies to HBsAg produced after infection with Hepatitis B For blood type (ABO) and Rh factor Tp, the agent that causes syphilis ALT, an elevated ALT may indicate liver inflammation, which may be caused by a hepatitis virus

Cont. The presence of unexpected antibodies that may cause reactions after the transfusion CMV, a test for the cytomegalovirus (performed on physician request) 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 are filtered to remove leukocytes that can harbor viruses and infections.

Congratulations on Your Successful Completion!