Red Blood Cell Administration

Facilitator: Barbara Bischoff

Policy

• Physicians: Administer and discontinue blood products by order

• RN’s and LPN’s: Administer and discontinue blood products by physician’s order• LPN’s:

Second witness must be an RN or physician

Purpose

• RBCs contain hemoglobin• RBCs serve as primary agent for oxygen transport to cells• RBC components increase :

Mass of circulating red cellsOxygen carrying capacity

ContraindicationsRBC containing components should not be used: Solely for volume expansion To increase oncotic pressure of circulating blood To treat anemias treatable with hematinic medications such as:

IronVitamin B12Folic acid Erythropoietin

Ordering•Written consent must be obtained prior to ordering• Nurses use order entry for request• Complete:

Consent for Infusion of Blood, Blood Product(s), Derivatives and/or Tissue

• Computer downtime use:Instructions for Completing Blood/Blood Product Orders

Transfusion Checklist

Consent Form

Equipment

• Unit Issue and Transfusion Record form• IV Tray (#18 Cathlon preferred)• Blood Secondary set with 170 micron filter• IV Pole• Infusion Pump

• Extension Set• Vital Sign Machine• Normal Saline• Transfusion Checklist• Unit of packed cells

Requisition for Pick Up

• LPN or RN may pick up blood from Blood Bank• Blood Product Pickup slip:

Contains patient informationIndicates red blood cells are ready

Issuing of Red Blood Cell Product

• “Issue Unit” in Meditech• Generates Transfusion Record form• Preprinted:• Issue time• Date•Messenger’s initials• Blood Bank technologist’s initials

Signatures

Signature

Fill out completely

Lab Check• Completed by both Blood Bank technologist and LPN/RN.• Preprinted:

Issue time Date Messenger’s initials Technologist's initials

• Both persons sign on the appropriate signature line• Secure form to unit bag• Place both in a sealed biohazard Zip-lock bag for transport

Lab Check (Cont)• Check:

Patient’s ID numberRed blood cell unit ID numberABO compatibility

• Documents to be checked:Written request for pick-upUnit Issue and Transfusion Record FormLabel on packed red blood cell bag

Warning

• All comparisons must match exactly

• Do not initiate transfusions with discrepancy

• Contact Blood Band immediately

Packed Red Blood Cell Unit Verification

• At bedside:• Compare patient armband • Form attached to unit of cells.

• Verify: • Patient: Name, ID number, Blood type • Donor Unit: Number, Blood Type, Expiration Date

• Patient must state their name• Both identifiers sign the Unit Issue and Transfusion Record Form•Most transfusion reactions result from identification error.

Precautions

• Verify with the attending physician: • Interruption of existing IV solution • Starting a new line • Consider total fluid volume

• Never add medication to unit of blood • Use new Blood Secondary Set with every unit • Patient must always receive ABO compatible blood.

Storage and Handling

•Maximum room temperature time prior to infusing:• 30 minutes

• Blood Bank will dispose as Regulated Medical Waste•May be returned to Blood Bank Refrigerator for:• Delay before use• Temporary discontinue

• Never place in Nursing Unit refrigerator• Not adequate for safe storage

Procedure• Prior to obtaining blood product• Administer pre-medications • Check order verification• Obtain baseline vital signs:• Temperature• Pulse• Respirations• Blood Pressure

• Chart vital signs

Procedure (Cont)• Set up blood secondary set following instructions• Don gloves and personal protective equipment.• Connect blood Secondary set with a 170 micron filter to red

blood cell blood unit • Rotate pack gently to mix cells and small amount of plasma.• Close clamp and suspend red blood cell unit from IV pole.

Procedure (Cont)

• Compress plastic chamber filling filter and drip chambers

•Make sure filter is submerged with blood

• Blood dripping on filter can damage RBC’s

• Open clamp to expel all air from tubing

Transfusion Time

• Recommendation: < 2 hours• Never > 4 hours• Delay of completion increases:• Deterioration of labile components• Possibility of inadvertent bacterial contamination

• Transfusion time dependent on size of IV cathlon• Infusion time increased with smaller cathlon

Flow Rate• Adjust flow to 20-30 drops per minute for first 10-15 minutes• If no immediate adverse symptoms occur:• Flow rate may be adjusted to 40-45 drops per minute

• Closely follow transfusion to verify the desired rate continues• Adjust as necessary

Gravity Pump

4 hours =20 drops/min =90 ml/hr

3 hours =40 drops/min =120 ml/hr

2 hours =60 drops/min =175 ml/hr

35 minutes =200 drops/min =700 ml/hr

Management of Flow• Causes of slow flow:• Obstruction of the filter or needle• Excessive viscosity of the component

• Steps to investigate and correct the problem include:• Elevating the blood container to increase hydrostatic

pressure.• Checking the patency of the needle.• Examining the filter for excessive debris.• Consult with an attending physician

Observation

• Observe patient closely during the transfusion: • Continuously for the first 15 minutes• Recheck after second 15 minutes• Continue to assess patient every half hour

•Monitor and document vital signs. • Observe for signs and symptoms of a transfusion reaction.

Monitor

•Monitor the patient for signs of possible transfusion reaction:• Flushing of face• Tachypnea•Wheezing• Tachycardia• Sudden chills and fever• Distended neck veins• Oppressive feeling in chest• Sharp pain in lumbar area• Decrease in blood pressure

Flushing• Flush only with Normal Saline• Dextrose and calcium ions (L R) can hemolyze, clot• Do not interrupt Blood Transfusion for any medication

Action for Reaction

• If any signs of reaction occurStop the Transfusion

• Add 50 ml normal saline piggyback to keep vein open• Notify: • Attending physician• Nursing supervisor• Blood Bank.

• Follow instructions: “Suspected Transfusion Reaction Form”

Suspected Transfusion Reaction

Documentation

• Record: • Date and start time • Vital signs throughout transfusion• Date and time discontinued• Amount given and any reaction• Signature

• Use Unit Issue and Transfusion Record form • Second nurse verifies no omissions on the form

Completion• Place white copy of Unit Issue and Transfusion Record on the

patient’s chart • Return to the Lab: • Yellow copy • Empty blood container• Tubing in a clear plastic biohazard bag.

• Never place sharps in bag.• Separate yellow copy from empty unit using the outside pocket.

Delayed Reactions

• Ambulatory Care Patients• Discharged patient’s who received blood/blood products• Notify doctor of:• Rash• Fever• Chills• Difficulty Breathing• Leg or Chest pain

Thank you for your attention !

Any questions or comments?

References

• Swartz, C.F. (2012). Red blood cell administration. Amsterdam, NY. St Mary’s Hospital.