1. Blood Administration

2. 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?

3. 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.

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

5. 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 = ml/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

6. 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.

7. Types of Blood Components Con’t
Risks & Benefits
Not a substitute for whole blood
May form antibodies
Hypersensitivity reaction
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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 & 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

8. Types of Blood Components cont’d
Frozen RBCs
Rarely used
Successive washing with saline solution removes majority of WBCs and plasma proteins
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Fresh Frozen Plasma (FFP)
To treat DIC, reverse effects of Coumadin, treat liver failure pts
Contains clotting factors
Improves coagulation, PT & PTT
Volume = ml/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

9. 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

10. 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

11. 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!

12. 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

13. RBC & Plasma Transfusions

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

15. 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)!)

20. Verify Identification

21. 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 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

23. 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

24. 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

25. 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

26. 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

27. 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)

28. 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?

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

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

31. 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?

32. 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

33. 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

34. 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

35. 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 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

36. 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!

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

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

39. 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

40. 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)

41. 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

42. 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.

43. 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.

44. 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

45. 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

46. 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.

47. Congratulations on Your Successful Completion!