blood administration

BLOOD ADMINISTRATION

BLOOD ADMINISTRATIONClinical Decision Making Case:

•You’re caring for a 35 year old male admitted to the ER for severe bruising.

•Labs show:

• Hgb: 6.9

• Hct 20%

•Doctor’s Orders:

• Transfuse 2 units of PRBC’s!

•What actions do you take?


Right If you said:

1. Check for T&C

2. Ensure IV access.

• What gauge and why?

3. Verify informed consent

4. Gather equipment

TYPE/CROSS VS. TYPE/SCREEN

Type & Cross (T&C)

•Patient will need blood

•Blood bank performs all necessary testing AND cross-matches the number of units requested.

•This ties up inventor, as blood is set aside for that particular patient for 3 days

Type&Screen (T&S)

•There is a chance blood will be needed.

•The blood bank staff performs all necessary testing on the patient’s sample.

•Blood will not be cross-matched and set aside until a request for blood is received. However, the existence of a screen allows this to take place quickly.

•Allows blood bank to be flexible with blood


Objectives

•Discuss:

• Common blood products

• Steps in blood administration

• Complications of blood administration

• **Always consult specific hospital policy**

Description Indications for Use

Special Considerations

Application

Whole Blood:•Contains RBCs, plasma proteins, clotting factors and plasma

(few platelets & granulocytes)

•Volume: 500mL

• To replace blood volume and O2 carrying capacity.

• To treat hemorrhage and shock.

• Possible incompatibility issues

• Circulatory overload• Use Lasix to

prevent overload• Deficient in some

clotting factors

Rarely used

Packed RBCs:•Prepared from whole blood by centrifuge.•Most commonly used blood component•Volume: 250-350 mL

• To increase O2 carrying capacity

• To treat anemia, acute blood loss

Advantages:•Allows other components (ie platelets, etc) to be used for other purposes. •Smaller chance of fluid overload

•Leukocyte depletion can be used to reduce febrile reactions.

- Ordered when hgb 8-9- 1 unit PRBC will result in hgb inc of 1g/dL or Hct inc of 3%- Takes 4-6h to see Hgb change-Infuse over 2-4 hrs

BLOOD COMPONENTS



Application

Platelets•Platelets are colorless cell fragments whose main function is to interact with clotting proteins to stop or prevent bleeding.•Volume: 30-60mL

• To control or prevent bleeding in platelet deficiencies (thrombocytopenia)

Risk:•May form antibodies•Hypersensitivity reaction

•Consider leuko reduced, HLA or type specific to prevent alloimmunization

-Ordered when platelet 10-20,000-Expect plt inc of 10,000/unit-Measure at 1h and 18-24h post admin-Infused over 15-30 minutes

Fresh Frozen Plasma•Plasma is a fluid, composed primarily of water that is also rich in clotting factors. •Does not contain platelets•Volume:200-250mL

• Bleeding caused by deficiency of clotting factors

• Ex: DIC, hemorrhage, liver disease, vitamin K deficiency, excess warfarin

• Increases PT/INR

Advantages:•Good for volume expansion•Restoring clotting factorsRisks:•Vascular overload•Hypersensitivity reaction•Hemolytic reactions

-May be infused over 15-30 minutes

BLOOD COMPONENTS



Application

Albumin:•Protein prepared from plasma. •Hyperosmolar soln that acts by moving H2O from extravascular to intravascular space•Vol: 25g/100mL=500mL plasma

• Used to expand blood volume or replace protein

• Hypovolemic shock, hypoalbuminemia

Risks:•Hypersensitivity reaction

Frozen RBCs, Cryoprecipitates, Prothrombin complex:

See table 31-32 on page 706 of your text.




BLOOD COMPONENTS

• Leukocyte reduction prior to storage– Removal of most WBC’s and Plasma reduces the risk of

reactions• Irradiated

– Red cells that have been irradiated to prevent graft-versus-host disease leak more potassium than non-irradiated products.

– As a result, their shelf life is reduced to 28 days

BLOOD PREPARATION OPTIONS

1. Who is universal donor?2. Who is universal recipient? 3. What do the - & + mean?

ABO COMPATIBILITY CHART

POPULATION PERCENTAGES

A+ 34.3% A- 5.7%

B+ 8.6% B- 1.7%

AB+ 4.3% AB- 0.7%

O+ 38.5% O- 6.5%

How common is each blood type?

For good reason, eligibility requirements for giving blood are

stringent. For a full listing of requirements, please refer to the American Red Cross website and browse requirements by topic:

http://www.redcrossblood.org/donating-blood/eligibility-

requirements/eligibility-criteria-topic

DONOR ELIGIBILITY REQUIREMENTS

• Review order• Look at labs • Verify/sign consent*• Obtain IV access, large bore catheter (18-20 gauge), 2 lines if

possible– *Get client ready for transfusion prior to getting blood from the lab

• T&C done – 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 to most people? • *Universal RBC donor is O negative

• Gather supplies • *Staff signs for and obtains blood (only one client & 1 unit a time!)• 2 RN check at the bedside with patient chart (see next slide for 2 RN check)

• Blood admin must be completed within 3-4 hours after receipt from blood bank!

BLOOD ADMINISTRATIONSTEP 1: PREPARATION

What do you check for?

•Entire process requires 2 RNs for independent double check at bedside•Verify informed consent•Check physician’s orders•Match this information to the information on label on blood, lab sheet, patient blood band, and the chart:

– Name, DOB, MR#, Blood Band #, unit expiration date, unit number, blood type (group and Rh)

90% of all reactions occur because of mistakes in labeling and verification

BLOOD ADMINISTRATIONSTEP 2: 2 RN CHECK

• IV 18-20 gauge adult, 23-child • 0.9% Sodium Chloride (NS) only• Prime Y-type blood tubing with NS, before admin/picking up

blood.• Clamp off NS• Pick blood up from blood bank/invert unit to mix cells (do not

shake it) • Compare all labels second time• Be prepared – once you begin, don’t leave the room• Spike blood bag• Squeeze tubing to cover blood filter with blood• Set pump – start slow• Check vital signs and record – educate pt on what to look for

– Initial vitals before admin (RR, Temp, HR, BP)– Vitals 15 minutes after admin. (stay with pt 1st 15mins)– Vitals q30min after that until transfusion complete– Vitals post admin. and then in 1hr

• If unable to give blood – must be returned within 15-30 minutes of removing from lab – DO NOT STORE IN UNIT REFRIGERATOR

BLOOD ADMINISTRATIONSTEP 3: ADMINISTRATION

• Use appropriate filters• Use blood

administration set no more than 4 hours – infusion must be complete in 4 hours

• New unit, use new set• Always follow hospital

specific blood administration policy

BLOOD ADMINISTRATIONSTEP 2: ADMINISTRATION

• Flush IV site with NS• Post administration vitals• Dispose of tubing and blood bag in biohazard bag

• If a 2nd unit is ordered: –Prime new tubing with new NS bag–Retrieve 2nd unit–Repeat RN checks

• Document:–When started & ended–Volume infused–Premeds given–How the pt tolerated procedure–Protocols followed

BLOOD ADMINISTRATIONSTEP 4: POST ADMINISTRATION

• Monitor for signs of transfusion reaction• Infuse over ordered period• 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)

BLOOD ADMINISTRATIONCRITICAL POINTS

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?

2. Your client is to receive a unit of RBC’s for a Hgb/HCT of 8/22…

How will the order be written?

What response to this unit of blood is anticipated (related to the Hgb/HCT)?

TRANSFUSION REACTIONS

Vital signs taken prior to start of infusion are critical

Blood transfusion reaction: adverse reaction to blood therapy: range from mild symptoms to life threatening; can be acute or delayed!

•What vital signs might you see?

•Consider a temperature increase of 1 degree significant

Action taken will be determined by the type of reaction; careful assessment & monitoring of the patient is a must!

• 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– Too much fluid given too quickly

• TRALI– Transfusion reaction acute lung injury– Non cardiogenic pulmonary edema

• Sepsis– Caused by transfusion of bacterially infected components

ACUTE TRANSFUSION REACTIONS

FEBRILEPYROGENIC /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)

Signs/Symptoms:• Fever/chills (^1 degree)• Sensation of cold• Flushed skin, abdominal pain,

vomiting and diarrhea• Hypotension/Shock

• Prevent by use of leukocyte poor blood!

• Stop infusion• Give antipyretics• Call MD

ALLERGIC REACTIONS (HYPERSENSITIVITY REACTIONS)

Signs and Symptoms:Mild (initially) (1% of pts.)

– Urticaria– Pruritis

Severe (Anaphylactic)– Anxiety– Wheezing & Chest tightness– Dyspnea– Bronchospasm– Hypotension– Tachycardia– Swelling of tongue, face– Loss of consciousness– Shock, pulmonary edema

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 /transient: stop infusion, alert MD, keep line open with new saline & tubing, give antihistamine prophylactically, use washed RBCs

Severe: stop infusion, keep line open with new saline & tubing; CPR & epinephrine (if indicated)

DO NOT RESTART TRANSFUSION

Most dangerous!

Develops within first 15 minutes of transfusion: free hemoglobin in blood and urine specimens provide evidence of acute hemolytic reaction

Occurs in 1:25,000

Usually occurs after 50-100 ml blood infused! (Lewis cites as little as 10mL)

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

•Signs/Symptoms:•Fever/chills•SOB/dyspnea/wheezing•Apprehension•Headache/low back pain•Chest pain/tightness•Urticaria•Tachycardia•N&V•Hypotension•Hematuria •Burning at IV site

ACUTE TRANSFUSION REACTIONS:HEMOLYTIC

If hemolytic reaction occurs:

Stop transfusion, keep IV line open with new tubing, saline, possible 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 & crossmatch verification

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 AND RESULTING IN ORGAN DAMAGE.

TRANSFUSION REACTIONS:HEMOLYTIC

HGB IS RELEASED BLOCKING RENAL TUBULES-- CAN CAUSE RENAL FAILURE.


• Circulatory overload– Who’s at risk?– Too much fluid given too quickly– Signs/Symptoms: Note cough, dyspnea, lung sounds, HTN

etc– Interventions: Slow infusion, elevate HOB, treat overload (ie

diuretics)

• Transfusion Related Lung Injury (TRALI)– Antibody mediated reaction that results in noncardiogenic

pulmonary edema– Usually occurs 2-6 hrs after transfusion– Signs/Symptoms: Note fever, dyspnea, tachycardia,

hypotension, decreased O2 saturation, frothy sputum– Interventions: Stop infusion, elevate HOB, provide O2,

administer corticosteroids, initiate CPR if needed.

• Massive Blood Transfusion Reaction– Complication that occurs when replacement of blood

exceeds total blood volume within 24 hours.– See pg. 709 of text

ACUTE TRANSFUSION REACTIONS

• Infections– Hep B and C, HIV, HSV-6, EBV, HTLV-1, CMV,

malaria • Iron overload

– Excess iron deposited in heart, liver, pancreas, joints resulting in organ damage and/or dysfunction

– Treat with chelating agents• Delayed hemolytic

– Results from destruction of RBCs by alloantibodies not detected during crossmatch

– Usually occurs 5-10d post transfusion, but may occur anywhere between 3d and several months.

– Signs/Symptoms: Fever, mild jaundice, decreased Hgb

– No acute treatment required (usually)

DELAYED TRANSFUSION REACTIONS

Definition• Consists of removing whole blood

from a person and transfusing that blood back into the same person.

Indications• Used in surgery & emergency

settings• Autologous blood-collection of

own blood prior to scheduled surgery

Risks and Benefits• Eliminates problems of

incompatibility, allergic reactions and transmission of disease.

• Requires special equipment

“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 / AUTOTRANSFUSION

CONGRATULATIONS ON YOUR SUCCESSFUL

COMPLETION!

blood administration

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