2011

Objectives Identify various blood products available for transfusion Identify possible blood transfusion side effects Identify the various blood product forms 2

Blood Components 3

ABO Blood Group System There are four major blood groups determined by the presence or absence of two antigens – A and B – on the surface of red blood cells: Group A – has only the A antigen on red cells (and B antibody in the plasma) Group B – has only the B antigen on red cells (and A antibody in the plasma) Group AB – has both A and B antigens on red cells (but neither A nor B antibody in the plasma); Universal recipient Group O – has neither A nor B antigens on red cells (but both A and B antibody are in the plasma); Universal donor American Red Cross Blood Types. 4

Blood Compatibility 5

Did You Know? Every two seconds someone in the U.S. needs blood. American Red Cross Blood Facts and Statistics. 6

Types of Blood Products Packed Red Blood Cells (PRBCs) Leukocyte-poor RBCs Platelets Fresh Frozen Plasma (FFP) Albumin Factor VIII Concentrate (antihemophilic factor) Cryoprecipitate 7

Packed Red Blood Cells (PRBCs) Indications: To restore or maintain oxygen-carrying capacity To correct anemia and surgical blood loss To increase RBC mass Red cell exchange Lippincott Williams & Wilkins Blood and blood product transfusion. 8

Packed RBCs Nursing Considerations: Use blood administration tubing to infuse within 4 hours. Use only with normal saline (0.9% NaCl) solution. Avoid administering packed RBCs for anemic conditions correctable by nutritional or drug therapy. Lippincott Williams & Wilkins Blood and blood product transfusion. 9

Leukocyte-Poor RBCs (Same as packed RBCs with about 70% of the leukocytes removed) Indications: Same indications as packed RBCs To prevent febrile reactions from leukocyte antibodies To treat immunocompromised patients To restore RBCs to patients who have had two or more non-hemolytic febrile reactions Lippincott Williams & Wilkins Blood and blood product transfusion. 10

Leukocyte-Poor RBCs Nursing Considerations : Use blood administration tubing May require a 40-micron filter suitable for hard-spun, leukocyte-poor RBCs. Use only with normal saline solution (0.9% NaCl). Cells expire 24 hours after washing. Rh type must match. Lippincott Williams & Wilkins Blood and blood product transfusion. 11

Platelets (Platelet sediment from RBCs or plasma products) Indications: To treat bleeding caused by decreased circulating platelets or functionally abnormal platelets To improve platelet count preoperatively in a patient whose count is 50,000/ μ l or less. Lippincott Williams & Wilkins Blood and blood product transfusion. 12

Platelets Nursing Considerations: Use a blood filter or leukocyte-reduction filter. As prescribed, premedicate with antipyretics and antihistamines if patient’s history includes a platelet transfusion reaction or to reduce chills, fever, and allergic reactions. Complete transfusion within 20 minutes or at the fastest rate the patient can tolerate. Use single donor platelets if patient has a need for repeated transfusions. Platelets are not used to treat autoimmune thrombocytopenia or thrombycytopenic purpura unless the patient has a life-threatening hemorrhage. ABO compatibility identical; Rh-negative recipients should receive Rh-negative platelets. Lippincott Williams & Wilkins Blood and blood product transfusion. 13

Fresh Frozen Plasma (FFP) Indications: To correct a coagulation factor deficiency To replace a specific factor when that factor is not available Warfarin (Coumadin) reversal To treat thrombotic thrombocytopenic purpura Lippincott Williams & Wilkins Blood and blood product transfusion. 14

Fresh Frozen Plasma (FFP) Nursing Considerations: Use a blood administration set Complete transfusion within 20 minutes or at the fastest rate the patient can tolerate Keep in mind that large-volume transfusions of FFP may require correction for hypocalcemia because citric acid in FFP binds calcium. Must be infused within 6 hours of being thawed. ABO compatibility required; Rh match not required Only blood product that is not received from Blood Bank – it is issued by Pharmacy – and no consent is required. Lippincott Williams & Wilkins Blood and blood product transfusion. 15

Albumin (a small plasma protein prepared by fractionating pooled plasma) Indications: To replace volume lost because of shock from burns, trauma, surgery, or infections To treat hypoproteinemia (with or without edema) Nursing Considerations: Use administration set supplied by manufacturer and set rate based on patient’s condition and response. Keep in mind that albumin is contraindicated in severe anemia Administer cautiously in cardiac and pulmonary disease because heart failure may result from circulatory overload. Lippincott Williams & Wilkins Blood and blood product transfusion. 16

Blood Transfusion A blood transfusion is a safe, common procedure in which blood is given to someone through an intravenous (IV) line. It is done to replace blood lost from surgery, injury, or illness. Each year, nearly 5 million Americans require a blood transfusion. National Heart Lung and Blood Institute Blood Transfusion. 17

History of Blood Transfusions 1628 ………….William Harvey discovers the circulation of blood; first known attempt of blood transfusion soon afterwards First successful transfusion occurred in England using dogs 1818 ………..James Blundell performs the first successful transfusion of human blood to a patient for treatment of postpartum hemorrhage ………..Karl Landsteiner discovers the first three human blood groups …………First blood typing and cross-matching 1914 ………..Anticoagulants developed for blood preservation 1939 ………..Rh system developed 1940 ………..Albumin, gamma globulin and fibrinogen used clinically 1947 …………ABO blood-typing and syphilis testing is performed on each unit of blood 1971 …………Hepatitis B surface antigen testing of blood began 1985 …………HIV testing on all donated blood began American Red Cross History of Blood Transfusion. 18

Did You Know? A total of 30 million blood components are transfused each year in the U.S. American Red Cross Blood Facts and Statistics. 19

Blood Pick-Up Only Registered Nurses, Licensed Practical Nurses, Nursing Assistants, Physicians and Physician’s Assistants are authorized to transport blood components from the Blood Bank to the patient care unit. No one will be issued blood for more than one patient. When picking up blood products from the Blood Bank, a copy of the physician order is required. 20

Administration Time The time that blood is removed from the refrigerator in the Blood Bank to the time that the transfusion is started should not exceed 30 minutes. The transfusion must be completed within four hours If a specimen is in the Blood Bank from a previous draw, less than 72 hours old, match the patient with the doctor order and the patient’s arm band to request for additional crossmatch. 21

Final Identification Verification Prior to initiating the transfusion, two (2) qualified persons will identify: Patient states name and SSN Name and SSN match armband, Blood Transfusion Record Form, and the blood unit label ABO Group, Rh type, crossmatch result, unit identification number, expiration date on unit label match the Blood Transfusion Record Form The two persons must sign the Blood Transfusion Record Form in indicated areas and place a check to ensure that there is a signed consent on the patient’s record. SEE NEXT SLIDE. Qualified persons include physicians, physician assistants, and nurses (nurse practitioners, registered nurse, licensed practical nurses or nurse anesthesiologists). One must be a registered nurse. 22

Administration of Blood Obtain vital signs prior to, at 15 minutes, mid-point, and immediately post-transfusion at a minimum and document on Blood Transfusion Record Form. Additional vitals may be obtained and can be documented in patient’s chart. Start and titrate the rate as tolerated based on component being transfused Severe reactions can occur with as little as 10 ml transfused; therefore, the registered nurse must remain with the patient during first 15 minutes to monitor for reaction. 23

Administration of Blood Once the transfusion is completed, the nurse must complete the remaining (post-transfusion) areas, indicating the total volume infused, if the transfusion was completed/interrupted, and if there was any reaction. The nurse should then sign the form to verify the information provided is correct. 24

Transfusion Reaction If you suspect an adverse reaction Stop the transfusion Notify the doctor and blood bank immediately Take a post-transfusion blood sample (pink top tube) from the arm opposite the infusion Return the blood sample along with the Blood Transfusion Record Form, the remainder of the unit of blood, and the blood administration tubing to the lab. Send a post-reaction urine specimen to the lab 25

Did You Know? Your risk of getting HIV from a blood transfusion is lower than your risk of getting killed by lightning (about 1 in 2 million donations). The risk of having a donation that carries hepatitis B is about 1 in 205,000. The risk for hepatitis C is 1 in 2 million. National Heart Lung and and Blood Institute. What are the Risks of a Blood Transfusion? 26

Immediate Transfusion Reactions Hemolytic Transfusion Reaction Febrile Transfusion Reaction Allergic Reaction Transfusion Related Acute Lung Injury (TRALI) 27

Hemolytic Transfusion Reaction Caused by administration of incompatible blood Signs and Symptoms include: Chest Pain Dyspnea Facial Flushing Fever Chills Hypotension Flank Pain Nausea Tachycardia Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 28

Hemolytic Transfusion Reaction Ways to Prevent Compare patient ID bracelet against blood product Monitor patient closely at start of infusion Label all blood samples and request forms correctly Nursing Actions Monitor patient closely Administer I.V. fluids, oxygen, epinephrine, and a vasopressor as ordered Observe patient for signs of coagulopathy Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 29

Bacterial Contamination Caused by a contamination of blood product Signs and Symptoms Chills Fever Vomiting Abdominal Cramping Diarrhea Shock Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 30

Bacterial Contamination Ways to Prevent Use careful technique when collecting or administering blood Change blood tubing and filter at least every four (4) hours Transfuse blood or blood product within 30 minutes of receiving Complete transfusion of blood within four (4) hours Nursing Actions Monitor patient for fever for several hours after completion of transfusion Obtain blood cultures from site other than I.V. infusion site Keep all blood bags and tubing and send to the blood bank Provide broad-spectrum antibiotics, as prescribed Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 31

Febrile Nonhemolytic Caused by bacterial lipopolysaccharides or antileukocyte recipient antibodies directed against donor white blood cells Signs and Symptoms: Fever within two (2) hours of transfusion Chills Rigors Headache Palpitation Cough Tachycardia Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 32

Febrile Nonhemolytic Ways to Prevent Premedicate the patient with antipyretics Limit the number of transfusions the patient receives, if possible Nursing Actions Relieve the symptoms with an antipyretic If the patient requires further transfusions, consider using a leukocyte removal filter Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 33

Transfusion-related Acute Lung Injury (TRALI) Caused by granulocyte antibodies in the donor or recipient cause complement and histamine release Leading cause of transfusion related mortality Signs and Symptoms Severe respiratory distress within six (6) hours of transfusion Fever Chills Cyanosis Hypotension Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 34

Transfusion-related Acute Lung Injury (TRALI) Ways to Prevent No prevention known Nursing Actions Provide oxygen as needed Monitor pulse oximetry Prepare for intubation and ventilatory support and hemodynamic monitoring Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 35

Allergic Reaction Caused by an allergen in the donor blood Signs and Symptoms Urticaria (Hives/Rash) Fever Nausea Vomiting Anaphylaxis (Facial Swelling, Laryngeal edema, Respiratory Distress) Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 36

Allergic Reaction Ways to Prevent Administer antihistamines if patient has a history of allergic reaction Nursing Actions Administer antihistamine, corticosteroid, or epinephrine as ordered Prepare for intubation and respiratory support if patient develops anaphylaxis Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 37

Transfusion-Associated Circulatory Overload (TACO) Caused by rapid infusion of blood or excessive volume of transfusion Signs and Symptoms Usually occur 2-6 hours post-transfusion Chest tightness Chills Dyspnea Tachypnea Hypoxemia Hypertension Jugular Vein Distention Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 38

Transfusion-Associated Circulatory Overload (TACO) Ways to Prevent Infuse at lowest rate needed while keeping total transfusion time in mind Ask Blood Bank to divide unit Nursing Actions Monitor intake and output, breath sounds, and blood pressure Administer diuretics as needed Elderly patients and those with history of cardiac disease at higher risk Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 39

Hypocalcemia Caused by rapid infusion of citrate-treated blood (citrate binds to calcium) Signs and Symptoms Arrhythmias Hypotension Muscle Cramps Nausea/Vomiting Seizures Prolonged Q-T interval Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 40

Hypocalcemia Ways to Prevent Monitor ionized calcium levels in patients receiving large amounts of transfused blood Nursing Actions Administer calcium gluconate I.V., as ordered Monitor ECG for arrhythmias or prolonged Q-T interval Monitor patients with an elevated potassium level closely; they are more at risk for hypocalcemia Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 41

Delayed Reactions Delayed Hemolytic Infection Transmission Post-Transfusion Post-Transfusion Purpura Graft-Versus-Host Disease Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 42

Delayed Hemolytic Caused by production of antibodies by red cells to antigens on transfused red cells Signs and Symptoms Occurs 5 to 10 days after transfusion Fever Anemia Jaundice Ways to Prevent No known prevention Nursing Actions Recheck the patient's blood group Administer antipyretics for fever Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 43

Infection Transmission Caused by transmission of infectious agent in the blood Signs and symptoms depend on infection transmitted Ways to Prevent: Careful screening of blood Nursing Actions: Treatment based on individual infection transmitted Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 44

Post-Transfusion Purpura Caused by destruction of autologous and allogenic platelets Signs and symptoms occur 7 to 10 days post-transfusion Thrombocytopenia Bleeding Ways to Prevent Limit transfusion in patients with history of sensitization through pregnancy or previous transfusion Nursing Actions Administer high doses of immune globulin intravenous, as ordered Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 45

Graft-Versus-Host Disease Caused by T-lymphocytes in blood or blood product react against patient’s tissue antigens Signs and Symptoms Occurs 10 to 12 days after transfusion Fever Skin Rash and Desquamation Diarrhea Pancytopenia Ways to Prevent Transfuse irradiated blood components to immunocompromised patients Nursing Actions Provide supportive care to patient and family Lippincott Williams & Wilkins Blood and blood product transfusion reaction management. 46

In Summary There are various blood products available for transfusion There are many types of immediate and delayed reactions In the case of a suspected reaction, there are specific steps that are to be taken 47