Administration of Blood Products Packed Red Cells Administration of Blood Products Dena Evans, MPH, BSN, CNE Assistant Professor Department of Nursing The University of North Carolina at Pembroke Slide 001

ABO Typing ABO Blood Type Antigen A Antigen B Antibody anti-A   Antigen A Antigen B   Antibody anti-A   Antibody Anti-B A yes no B O AB Slide 002

Components

What can be transfused? Whole blood Plasma Albumin Thrombocytes Packed Red Cells

Comparisons Different components Different colors Different administration procedures

Why transfuse? Restore blood volume after hemorrhage Maintain hemoglobin levels in severe anemia Replace specific blood component.

Nursing Assessment You have just admitted a client from the ER. He has D5W at 50mL/hr infusing through a 20G in his (L) AC. He is pale, dyspneic, confused and complains of weakness. Upon reviewing his new labs you find his hemoglobin is 7g/dL and hematocrit is 34%. What is your next action?

If we think ABCs….. Administer O2 Call MD who says “Type, cross and infuse 1U PRBCs over 2 hours, continue O2 @ 2L via NC, pre-medicate with 650 mg of Tylenol and 50mg of Benadryl 30 minutes before administration .” Be aware that there is a difference between the order to “Type and Cross” and the order to “Type, Cross and Infuse.”

What will you need? Informed consent You cannot administer blood products without first getting written informed consent from the patient. Consent can be given for the entire hospital stay or over a specified period of time (outpatient).

Next Take a set of vital signs—Why? A temperature 100° or higher should be reported to the MD even if it is pre-existing If a transfusion reaction occurs—this will be important for careful assessment of the situation

The right IV The size of the IV catheter is important. Too small = hemolysis = wasted infusion Need at least a 20G but preferably an 18G.

Tubing and Fluid Y-tubing A bag of NS (no other fluid—must be isotonic) 500 mL will suffice No other fluids or medications can be mixed in this Y tubing Prime Y tubing with the NS

Next Go to the blood bank and get the blood Special procedures MUST be followed The Type and Cross paperwork (generated when you sent the T/C order to the lab) must be taken with you to pick up the unit of blood The paperwork has information which will be matched up with the unit of blood in the blood bank

Next Once in the blood bank, you tell the blood bank employee that you are there for Mr. “X” blood. Following a particular order, the two of you will verbally check her paperwork against your paperwork against the data on the unit of blood. You will then be asked to sign a log book indicating which unit you picked up.

Once on the Floor You MUST go through the same procedure with another licensed nurse, one must be an RN. This is documented on paperwork you brought with the unit of blood and that you will return with the empty bag once the infusion is complete.

At the patient’s bedside The 5-Rights still apply here One difference—The addition of a bracelet from the lab that was applied when they came to do the type and cross. The verification includes patient name, hospital number, transfusion number, ABO group and Rh type, donor number, expiration date, and volume of blood. The information on the blood tag is compared with that on the blood bag itself, and the patient name on the blood tag is compared to that of the name band and blood bank identification band.

Timing You only have 4-hours to get the PRBCs infused. Any blood not infused in 4-hours could become contaminated. For this same reason, you must hang it within 30 minutes of your arrival to the floor.

Complications Volume overload Transfusion reactions Iron overload Infections

Types of Transfusion Reactions Acute hemolytic reactions (ABO incompatibility) Febrile reactions (leukocyte incompatability) Allergic reactions (reaction to plasma proteins—IgM,IgA,IgD,IgG, IgE) Circulatory overload: Cardiac or renal insufficiency. Need fluid balance assessment Sepsis: Improper handling/contamination

Most Common-ABO incompatibility Mislabeling and administering to wrong person Antibodies react to antigens Agglutination of cells occurs Blocks capillaries and therefore bloodflow Hemolysis of RBCs = free hemoglobin This hemoglobin is filtered by kidneys = hemoglobinuria Obstructs renal tubules = renal failure (flank pain)

Nursing Assessment During Transfusion Observing for signs of transfusion reaction Fever, chills, elevation in temperature, nausea, itching, flank pain Will usually occur within the first 15 minutes of the infusion Note that this is when we conduct strict assessment (VS) of the patient. Stay with the patient. Infuse slowly 2mL/min. Elderly/cardiac—breath sounds. Lasix. Vitals signs per policy after first 15 but usually q15-30

What if the patient has a reaction? What are your interventions? FIRST—Stop the transfusion Keep the line open with the 0.9% NS Call the MD and the blood bank Stay with the client. Monitor VS q 5minutes Prepare to administer emergency meds Collect urine specimen Return blood, bag, tubing, labels, transfusion record to the blood bank

No reaction? Great Most patients who are not at risk of fluid overload 1 U over 2hours 1 U PRBCs = 250-350 mL How many mL/hour for a 250mL bag?

When you are done? Reasses the client– this includes vital signs and ordering another H&H Complete paperwork (transfusion record) Vital signs Pre-medication Tolerance Time started/completed Transfusion reaction “yes” “No” This goes into the side of the blood bag and back to the lab. Additional paperwork for nursing unit.

For your information There has been debate regarding the use of infusion pumps for blood administration. Studies show (Houck & Whiteford, 2007; Burch, 1991) that there is no clinically significant difference in blood products administered via pump. Additionally, each unit of PRBCs should raise the hemoglobin at least 1 gram (Simmons, 2003). Change usually seen 4-6 hours after transfusion

Questions

1 A client receiving PRBCs begins to vomit. The nurse takes the client’s blood pressure and it is 90/50 from a baseline of 125/78 mm/Hg. The client’s temperature is 100.8° F orally from a baseline of 99.2°F orally. The nurse determines that the client may be experiencing which complication of blood transfusions? Septicemia Hyperkalemia Circulatory overload Delayed transfusion reaction

2 The nurse enters a client’s room to assess the client who began receiving a blood transfusion 45 minutes earlier. She notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication? Bacteremia Hypovolemia Fluid overload Transfusion reaction

3 The nurse determines that the client is having a transfusion reaction. After the nurse stops the transfusion, which action should be immediately taken next? Remove the IV line Run normal saline to keep the vein open Run a solution of 5% dextrose Obtain a culture of the tip of the catheter device removed from the client

4 PRBCs have been ordered for a client with a low hemoglobin and hematocrit. The nurse takes that clients temperature before hanging the blood transfusion and records 100.6°F orally. Which of the following is the appropriate nursing action? Begin the transfusion as prescribed Delay hanging the blood and notify the MD Administer an antihistamine and begin the transfusion Administer two tablets of Tylenol and begin the transfusion

5 The nurse is picking up a unit of PRBCs at the hospital blood bank. After putting the pen down, the nurse glances at the clock which reads 1:00. The nurse calculates that the infusion must be started by: 1:30 2:00 2:30 3:00

6 The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as ordered. Before preparing the transfusion, the nurse next looks for which of the following members of the health care team to assist in checking the unit of blood? Phlebotomist Medical student Registered nurse Blood bank technician

7 The nurse has obtained a unit of PRBCs from the blood bank and has checked the bag properly with another nurse. Before beginning the transfusion the nurse should first: Assess vital signs Assess skin color Assess urine output Get the latest hematocrit level

8 The nurse has just received an order to transfuse a unit of PRBCs for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? 5 minutes 15 minutes 30 minutes 45 minutes

9 A unit of PRBCs has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order and a blood specimen is drawn from the client for typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. Number the actions in order of priority that the nurse should take to administer the blood: Hang the bag of blood Obtain the unit of blood from the blood bank Ensure that an informed consent has been signed Verify the physician’s order for the blood transfusion Insert an 18-19 gauge IV catheter into the client Ask a licensed nurse to assist in confirming blood compatibility and verifying client ID

References Houck, D. & Whiteford, J. (2007). Improving patient outcomes: Transfusion with infusion pump for peripherally inserted central catheters and other vascular access devices. Journal of Infusion Nursing, 30(6), 341-344. Lewis, S.M., Heitkemper, M.M., & Dirsken, S.R. (2004). Medical surgical nursing: Assessment and management of clinical problems. St. Louis: Mosby. Simmons, P. (2003). A primer for nurses who administer blood products. Medical surgical nursing, June 2003.