Blood Administration

1. Blood Administration

2. Blood Administration • Clinical 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?

3. Blood Administration • Right If you said: • Check for T&C • Ensure IV access. • What gauge and why? • Verify informed consent • Gather equipment

4. 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

5. Blood Administration Objectives • Discuss: • Common blood products • Steps in blood administration • Complications of blood administration • **Always consult specific hospital policy**

6. Blood Components

7. Blood Components

8. Blood Components

9. 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

10. ABO compatibility chart • Who is universal donor? • Who is universal recipient? • What do the - & + mean?

11. Population percentages How common is each blood type?

12. Donor eligibility requirements 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

13. 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 administration Step 1: preparation

14. Blood administration Step 2: 2 rn check 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

15. Blood administration Step 3: administration • 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

16. Blood administration Step 2: 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

20. 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 administration Step 4: post administration

21. Blood administration Critical points • 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)

22. How would you manage this? • 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)?

23. Blood transfusion reaction: adverse reaction to blood therapy: range from mild symptoms to life threatening; can be acute or delayed! Transfusion Reactions • What vital signs might you see? Vital signs taken prior to start of infusion are critical • 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!

24. Acute Transfusion reactions • 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

25. 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

26. 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 /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 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

27. Acute transfusion reactions: hemolytic 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

28. Acute transfusion reactions: hemolytic If hemolytic reaction occurs: Stop transfusion, keepIV 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!

29. transfusion reactions: hemolytic ABO incompatibility causes RBC’s to clump, block capillaries, decreasing blood flow to organs and resulting in organ damage.

30. Acute transfusion reactions: hemolytic Hgb is released blocking renal tubules-- Can cause renal failure.

31. Acute Transfusion reactions • 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

32. Delayed 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)

33. Autologous transfusion / autotransfusion 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.

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