Blood Administration

Blood AdministrationNurminie H. Ladja, BSN, RN

Blood Administration

Your patients Hgb & HCT is 6.2 & 18.4; the doctors orders 3 units of packed RBCs!

What actions do you take first?Blood AdministrationRight If you said:

Check for T&C Verify informed consentInsure IV access; need large bore catheter (18-20 gauge); smaller cause destruction of RBCs Gather equipment: Y-tubing blood administration set with filter NS solution and pumpPrime tubing with saline.

Blood AdministrationLearn:Common blood productsSteps in blood administrationComplications of blood administration*Transfusion reactionsCirculatory overloadSepticemiaIron overloadDisease transmission

Blood Products *Know products and how to safely administer!Packed RBCsFrom whole blood; 2/3 of plasma removed); *most commonly used!Inc. O2 carrying capacityTreat anemia; replace blood volumeUse leukocyte poor red cells or leukocyte filter if history of febrile reactionVol. 250-300 ccOnly RBCs used (remaining platelets, albumin, plasma used for other purposes)Less chance for fluid overload!*Ordered when HGB 8-9 and HCT 24-27; each unit inc. HGB by 1g/dl & HCT by 3 takes 4-6 hrs for lab values to chg.No viable platelets or granulocytesWhole blood:Replace blood volumeInc. O2 carrying capacity in hypovolemic shock Contains RBCs, plasma proteins, clotting factors and plasmaFew platelets or granulocytesVol. 500 ccDanger of fluid overload and incompatibilityDeficient in some clotting factorsRarely used!Platelets:To control, prevent bleeding in platelet dysfunction, thrombocytopeniaFrom whole fresh bloodFrom multiple donors

Vol. 30-60 cc of platelets in 1 unitExpected inc-10,000 per/unit-each unit Measure at 1 hr & 18-24 hr post admin.Usually given if platelet count less than 10-20,000 danger of bleeding!Frozen RBCs (from RBCs)can be frozen stored for 3 yearsInfrequently used

Use within 24 hours of thawingsuccessive washing with saline solution removes majority of WBC/s and plasma proteinsFresh Frozen Plasma (FFP)Contains clotting factorsUsed for DIC, liver failure patientsImproves coagulation, PT and PTTVol. 200-300cc = 1 unitRich in clotting factors NO plateletsGood for volume expansion to restore clotting factors in hypovolemic shockAlbumin-Plasma derivativePrepared from plasmaVolume expanderUse for clients who are 3rd spacing and hypovolemic (hyperosmolar solution moves water from extravascular space to intravascular space)Outcome: adequate BP and volume

Available in 5% or 25% solutionAlbumin 25g/100ml = to 500 ml of plasmaCan be stored for 5 years

!Cryprecipitates- Clotting factors VIII, Xiii< von Willebrands factor & fibrinogen from plasma and commercial concentratesPrepared from fresh frozen plasma Store for 1 year, once thawed, must be used.

Prothrombin complex-Prothrombin, factors Vii, IX, X and part of XiUsed to specific clotting factor deficienciesMay cause ABO incompatibilities

Used to specific clotting factor deficienciesWBCs or GranulocytesImprovement of infectionRarely used except for cancer patients, chemotherapy patientsAutotransfusion;Surgery and in emergency settingAutologous blood-collection of own blood prior to scheduled surgery or in emergency situation ( blood salvage; cell saver)Requires special equipment; filters, patients own blood is returnedNo T&C neededif pre-donation, begin collection within 5 weeks of transfusion date and 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.

Preparation for Blood AdministrationPhysicians order

Obtain IV access; 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 and obtains blood (only one client a time!)

Verify informed consent

Routine compatibility testing takes about 1 hour to identify recipient ABO and Rh type; in emergency O-negative RBCs 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

RecipientDonor ABAB O AXX BXX ABX O XXX XO- universal donor, AB+ universal recipient Initiation of TransfusionVerify informed consent for bloodCheck physicians ordersID patient, draw blood for T&C in red top tube; start 18-20 gauge IV (if not already done), place blood band and label tube. Blood tubing & 0.9NS IV fluid ready!T&C to lab!

Cont***Obtain blood from blood bank (2 persons verify)

Blood to unit for administration: 2 RNs check unit of blood with lab slip, patients chart; forms to include patients name, hospital #, and blood type

Expiration date of unit of blood

Pts ID #, blood band (Fenward) and state name

Blood band #- blood armband, issue transfusion card

Blood component, donor #, expiration date, gp and 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! Compare all labels second timeCheck vital signs and recordIV 18-20 gauge adult, 23-child0.9% Sodium Chloride(NS) only!!!Invert unit to mix cellsPrime Y-type blood tubing with NSSpike blood bag, clamp off NSCover blood filter with bloodUse appropriate filtersUse blood administration set no more than 4 hours infusion must be complete in 4 hours Check facility policy re: # units per administration setMay give blood on a pump- use pump tubing

Blood to cover filterExample of filtersUse appropriate filters

For intraoperatively salvaged washed blood. Significantly reduces leukocytes in salvaged blood Substantially decreases fat globules in salvaged blood Reduces microaggregates present in salvaged blood

Platelet filter:Patient protection against leukocyte-related transfusion complications Primes directly with platelets quickly and conveniently High platelet recovery achieved without saline flush For intraoperatively salvaged washed blood. Reduces leukocytes Decreases fat globules Reduces microaggregatesCritical PointsClient identification and blood compatibility!

Drip rate no higher than 2 cc per minute X 15 minutes (25-50 cc)

Remain with pt for first 15 minutes

*Vital signs prior to administration, in 15 minutes, then q 30 minutes, until transfusion complete--then X 2

No meds or fluid other than NS to be given in line with blood (Saline ONLY)!!!

CHECK POLICY AND PROCEDURE*Monitor for signs of transfusion reaction

Infuse over period specified (2-4 hours)

Blood cannot be out of blood bank refrigerator more than 30 minutes prior to administration-PLAN ahead!

*Do not allow blood to hang no longer than 4 hours (longer time, greater chance of bacterial contamination/septicemia)

If multiple units being given for rapid blood loss; may have to give under pressure and warm blood prior to administration (only agency approved warming devices)

How would you manage this? Return to blood bank within 20 minutes if left out longer run risk of bacterial growth and sepsis; get help with starting IV (should have started IV before requestingplan ahead) blood)

1. Client to receive a unit of packed red blood cells.unable to initiate an IV access. What actions should you take?Ask An ExpertDouble ClickHow would you manage this? Circulatory overload due to volume; whole blood is typically 500cc and would cause fluid overload, especially in at risk client.

2. In addition to transfusion reaction; what is a major risk related to administration of whole blood?Ask An ExpertDouble ClickHow would you manage this? Recall that 1 unit of PRBCs increases the Hgb by 1g/dl and Hct by 2-3%-result > Hgb 9 & Hct 24

3. Your client receives a unit of RBCswhat response to this unit of blood is anticipated?Ask An ExpertDouble ClickTransfusion Reactions/ComplicationsFebrile (most common)Sensitization to donor WBC, platelets, plasma proteinsBacterial (pyrogenic or sepsis) (not in text) Transfusion of bacterially infected componentsAllergic (hypersensitivity to donor plasma proteins)Mild allergic to severeHemolytic (life-threatening!)Acute hemolytic: ABO incompatible; red cell destruction*Circulatory overloadFluid given too fast & too muchIron overload- delayed reactionHypocalcemia- citrate in blood binds with calcium & is excreted

Transfusion Reactions

Ask An ExpertVital 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!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?

Consider a temperature increase of 2 degrees significantAction taken will be determined by type of reaction; careful assessment, monitoring of patient!

Ask An ExpertFebrile Caused by leukocyte incompatibility; sudden onset: usually within first 15 minutes of transfusion!

Fever/chills (^1 degree)Sensations of ColdHypotension/ShockFlushed skin, abdominal pain, vomiting and diarrhea

Prevent by use of leukocyte poor blood!Stop infusion/antipyretics

**Bacterial (pyrogenic): similar to febrile; due to bacterial contamination of blood: see S & S aboveAllergic Reactions (Hypersensitivity reactions)Mild (initially)*UrticariaPruritisItching

Severe (text does not include this description)WheezingDyspneaBronchospasmSwelling of tongue, faceShock, pulmonary edemaAntibodies in patients blood react against proteins, such as immunoglobulin A in donor bloodMay occur during or after the transfusion

Mild and transient: stop infusion, possibly restart, give antihistamine prophylactically, use washed RBCsSevere: stop infusion, keep line open with new saline tubing; CPR & epinephrine (if indicated) 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 after 100-200 ml blood infused!

Blood incompatibility*RBCs clump (lysis of RBCc), block capillaries, decrease blood flow to organs.Hgb released (myogloburia), blocks renal tubules > acute renal failure=ATN (acute tubular necrosis)

Fever/chillsSOB/dyspnea/wheezingApprehensionHeadache/low back painChest pain/chest tightnessUrticaria/tachycardia*Hematuria

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 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!

*Circulatory overloadFluid given too fast & too muchNote cough, dyspnea, HTN, etcSlow infusion, elevate HOB, treat overload, phlebotomyIron overload- delayed reactionVomiting diarrhea, hypotension, altered hematological valuesAdminister deferoxamine (Desferal) Iv to remove accumulated iron via the kidneys (urine red)Hypocalcemia- citrate in blood binds with calcium & is excretedCheck lab valuesAlso hyperkalemia: stored blood liberates potassium through hemolysis (older blood greater risk for hemolysis)

Reactions/complicationsWhat is the purpose of administering blood and blood components?

Review

A.B.C.D.treat hypervolemia.alleviate sodium retention.increase the level of electrolytes.promote tissue oxygenation.(RBCs carry oxygen! Blood and it components also provide clotting factors and maintain intravascular volume.)

NOBlood and its components increase intravascular volume, not decrease. In fact, a potential complication with the administration of blood when given too rapidly is hypervolemia.NOAlleviate sodium retention: an answer for consideration; however, it is not the reason that blood is given; indirectly sodium retention might be decreased by effect on restoration of intravascular volume and normal hemodynamics (renin-angiotensin-aldosterone)NOIncrease level of electrolytesperhaps indirectly as normal hemodynamics are restored, but not primary reason for giving blood and blood products. Good jobTrueFalseor?False! If you said false you were right on! PRBCs are used to correct anemia and blood loss, not given for clotting factors, need fresh frozen plasma or cryoprecipitatesPRBCs are utilized to treat impaired clotting such as in liver dysfunction.True. If you said true, you were not correct. PRBCs are used to correct anemia and blood loss.Platelets are used to treat?

Hemophilia

A.B.C.D.Good jobhemophilia No Platelets do not contain the specific clotting factors needed by a client with hemophilia; platelet levels are typically normalthrombocytopenia RIGHT Platelets (if normal) release thromboxane to cause vessel; spasm when there is damage to a vessel activates the clotting pathway to convert fibrinogen to fibrinpolycythemia No Polycythemia is the presence of excess RBCs; administration of platelets would not decrease the abnormal amount of RBCs in fact would cause increased problemsincreased viscosity and more likely to form clots.low white cell count N WBCs are leukocytes and originate from hemopoietic stem cells in the bone marrow; must use hematopoietic growth factors to stimulate granulocyte maturation and differentiationLow white cell countPolycythemiaThrombocytopenia

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