Transcript Blood AdministrationPPT

Blood Administration
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 ?
Blood Administration
Right If you said:
•Check for T& C (What is T &C vs T &S?)
• T& C blood available for patient for 3 days
•Verify informed consent
•Insure IV access; need large bore
catheter (18-23 gauge); smaller bore
causes destruction of RBC’s and slow
blood administration.
• Gather equipment:
• Y-tubing blood administration set
with filter
•NS solution
•IV pump
•Prime tubing with 0.9NS
Objectives
•Identify common blood products
•List steps in blood administration
•Identify complications of blood administration
•Acute Transfusion Reactions
•*Transfusion reactions
•Circulatory overload
•Septicemia
•Other
•Iron overload
•TRALI & Massive Transfusion reaction*
•Delayed Transfusion Reactions
•Describe autotransfusion/cell savers
•Apply concepts
Blood Components
• CURRENTLY USED
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Packed RBC’s
Frozen RBC’s
Platelets
Fresh Frozen Plasma
Albumin
Cryoprecipitates &
commercial
concentrates
• Rarely USED
– Whole blood
Current Blood Preparation
• Leukocyte reduction prior to storage
• More effective than previous washing
process
• Packed RBC’s removed from plasma
• Removal of most WBC’s and Plasma
reduces risk of reactions
• Drawback – bacterial growth if
contaminated during collection/processing
Types of Blood Components
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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
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– **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
– Purpose: O2 carrying capacity in
patients with slow bleeding,
anemia, leukemia, surgery
Volume = 300-350ml/unit
Risks & Benefits
– Possible incompatibility issues
– Circulatory overload
– **Deficient in some clotting factors
– Rarely used
– Use Lasix to prevent overload
________________
Risks & Benefits
– 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 than
whole blood
– Takes 4-6 hours for Hgb & HCT to
change
– Shelf life: 42 days
(takes 1 day to process)
– Most commonly used!!
Types of Blood Components con’t
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Platelets
Risks & Benefits
– Control or prevent bleeding in
platelet deficiencies, i.e.
thrombocytopenia-(ordered when
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platelets count <10-20,000 - unless?
– From whole fresh blood(plateletpharesis)
– Expected platelet 10,000uL/U
– Measure at 1hr & 18-24 hr post
admin
Platelet donations
Volume = 30-60ml/unit
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Risks & Benefits
– Vascular overload
– Hyperosmolar solution moves
water from extravascular space
to intravascular space
– Outcome: adequate BP &
volume
– Hypersensitivity reaction
– Can be stored for 5 years
Albumin (plasma derivative)
– Expand blood volume or replace
protein
– Treat shock from trauma, infection,
3rd spacing, hypovolemia,
*hypoalbuminemia burns and in
surgery,
– Available in 5% -25% solution
– Paid donation
Volume 25g/100ml = 500ml of
plasma
Not a substitute for whole blood
May form antibodies
Hypersensitivity reaction
Use within 5 days of donation
Can keep at room temp
depending upon
storage/collection
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Albumin therapy
Types of Blood Components cont
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Risks and Benefits
- Store for 10 years/use within 24 hr
Frozen RBCs
thawing
– Rarely used *
- Use within 24hrs of thawing
– Successive washing with saline
- *Atotransfusion; stockpiling or
removes most WBCs & plasma
rare donors for patients with
proteins
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alloantibodies
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Fresh Frozen Plasma (FFP)
Risks & Benefits
– Treat DIC, reverse effects of
– No platelets
Coumadin, treat liver failure pts
– Use for volume expansion to
– From liquid portion whole blood,
restore clotting factors in
separated from cells > frozen
hypovolemic shock- being
– *Rich in clotting factors
replaced by albumin plasma
– Volume = 200-250ml/unit
expanders. (from text)
– Outcome- Improved coagulation, PT
– Can store for 1 yr; *use within 2
& PTT
hrs post thawing
– Risk for vascular overload
/hypersensitivity reaction/
Hemolytic reactions
Types of Blood Components cont
• Prothrombin Complex – Prothrombin, Factors VII, IX, X,
and part of XI
– Used to treat clients with specific clotting factor
deficiencies
• Cryoprecipitate – Clotting Factors VIII, XIII, von
Willebrand’s factor, & fibrinogen from plasma
– Used to treat clients with specific clotting factor
deficiencies
– May cause ABO incompatibilities
– Prepared from FFP
– Store for 1 year, once thawed > use
Also
WBC’s or Granulocytes
• Uses
– Improvement of infection- measure of
treatment effectiveness
– Used in cancer & chemotherapy patients
– Hazards - febrile reaction & new infections
carried in WBC’s
Autotransfusion or Autologous Transfusion
Autotransfusion (autologous
transfusion)
Indications
Risks & Benefit
– Used in surgery & emergency – Special equipment
required
settings
– Autologous –collection of own – No T & C required
blood scheduled surgery or in – Minimal risk of allergic
emergency situation (blood
reaction; *monitor
salvage; cell saver)
coagulation
– Blood available if rare
blood type
– *No infections diseasehepatitis, syphillis, HIV,
etc
– Safe, well tested
– *Drainage after 1st 24
hrs not used; may
contain pathogens
“Cell-saver“ collects blood lost during
surgery, cleanses it, returns to patient's
body, all in a continuous loop.
For intraoperatively
salvaged washed
blood- filters•Reduces leukocytes
•Dec fat globules
Reduces
microaggregates
Autologous Donation/Elective Phlebotomy
Who can make Autologous donation? (predeposit transfusion)
 Less
than 65 years old (usually).
 Without serious medical conditions like serious heart
and lung diseases.
 Start before planned surgery- (about 5 weeks); have
hemoglobin level of at least 11g / dl before each
donation
 *Store up to 10 years, if frozen, given within a few
weeks of donation
Blood
Transfusions
RBC & Plasma
Transfusions-Compatibility
O- universal donor, AB+ universal recipient
ABO Compatibility Chart
• Who is universal donor & recipient?
• What do the - & + mean?
Population Percentages- FYI
A+ 34.3%
B+ 8.6%
AB+ 4.3%
O+ 38.5%
A- 5.7%
B- 1.7%
AB- 0.7%
O- 6.5%
Who Can Donate Blood
Paid vs Volunteer – what is the difference?
What percentage of population can donate?
How many do?
Who cannot donate?
In Europe in the 80’s & 90’s – indefinitely
Previous history of malaria – years
Incarceration for 72 hours – 1 yr
Hepatitis after age 11 –
indefinitely
HCT < 38% until resolved
Homosexual Male after 1977 – indefinitely
Needle stick –
1 yr
Medical history of vascular disease, bleeding or cancer - until resolved
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Preparation for Blood Administration*
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Physicians order
Look at labs
Verify/sign consent*
Obtain IV access, large bore catheter (18-20 gauge), 2 lines if possible
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*Get patient ready for transfusion prior to getting blood from the lab
T&C done
Gather supplies
*Staff signs for and obtains blood (only one patient & 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
without serologic testing.
• Why can O-neg blood be safely given to most people?
– *Universal RBC donor is O negative; universal recipient is AB positive
• 2 RN check at bedside with patient chart (see next slide for 2 RN check)
• Blood admin must complete within 3-4 hours after receipt from blood bank!
2 RN check
What do you check for?
• Verify informed consent
• Check physician’s orders
• Match this information to the information on lab slip and
the chart:
– Name, DOB, MR#, Blood Band #, unit expiration date, unit
number, blood type (group and Rh)
*Remember know agency policy for blood administration
90% of all reactions occur because of mistakes in labeling and verification
Initiation of Transfusion *at bedside
• 2 RNs (or licensed staff according to state NPA and agency
policy) check unit of blood with laboratory slip,
patient’s chart, forms 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/follow policy)
• Blood component, donor #, expiration date,
Group & Rh factor
(If blood not to be given, must be returned to blood bank within 30 minutes;
CANNOT be kept in unit refrigerator (requires special refrigeration)!)
Verify Identification
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 per pump sing
blood pump tubing
Saddleback NursingBlood Transfusions
Blood Product Administration * at bedside
• 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 1hrd
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0.9% Sodium Chloride (NS) only!!!*remember
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
Post 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
• Can you use the same NS bag?
– Retrieve 2nd unit
– Repeat RN checks
• Document:
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When started & ended
Volume infused
Premeds given
How the pt tolerated procedure
Protocols followed
Critical Points- Test Self!
List at least 4 critical safety measures in administering blood
products
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Correct MD order/permit; patient identification & blood
compatibility
Correct blood tubing, blood set-up, saline only (No other
solutions/medications/products with blood-other than saline)
Follow procedure for measurement vital signs, starting infusion
etc.
Drip rate no higher than 2 ml 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 2
• *Rapid blood replacement-use blood warmer
• “Other blood components FFP and platelets, can infuse over 1530 min. (text p. 706-707)
More Critical Points
• Monitor for signs of transfusion reaction
• Infuse over period specified (2-4 hours) and rememberblood cannot be out of refrigerator (blood bank) more than
30 minutes prior to administration –PLAN AHEAD!!
• BE READY TO START BEFORE GETTING BLOOD!!
• If multiple units required as in cases of rapid blood lossmay be given under pressure and warmed prior to
administration (only agency approved warming device)
Thermacor blood warmer/rapid infusor
How would you manage this?
1. A patient is to receive a unit of packed red
blood cells. The blood has been obtained from
the blood bank and brought to the unit. The
nurse flushes the patient’s IV prior to hanging
the blood and finds that the IV has infiltrated.
What action(s) should the nurse take?
Answer
Return the blood to the blood bank within 30
minutes of picking it up. If left out longer >
risk of bacterial growth and sepsis; get
help with starting IV.
(Nurse should have checked that the IV
was patent before requesting the blood…
plan ahead)
How would you manage this?
2. In addition to transfusion reaction; what is
a major risk related to administration of
whole blood? *Rarely used today!
Answer
Circulatory overload due to volume (500ml >
fluid overload, especially in at risk client
• Was used most often for volume and RBC’s
• Contained RBC’s, plasma proteins, some clotting factors, few
platelets, & granulocytes
• Significant Dangers / Problems:
– Incompatibility reactions
– Circulatory overload
– Febrile reactions
– Infection transmission
– And potential-increased hospital stay, increased cost of care
Another question?
3. A client receives a unit of PRBC’s-what response
to this unit of blood is anticipated?
Recall that 1 unit of PRBC’s increases the Hgb by 1g/dl and Hct by 2-3%result > Hgb 9 & Hct 24
*Remember, change in lab values is not immediate, must consider if
patient is also receiving fluid volume replacement (is RBC mass
concentrated, diluted, is blood volume loss sudden or chronic
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 1 degrees
significant
Action taken will be determined by type of reaction;
careful assessment, monitoring of patient!
Transfusion Reactions/Complications
• Acute Transfusion Reactions
– Acute hemolytic
– Febrile-non hemolytic
– Allergic –mild
– Allergic-Anaphylactic/severe
– Septic
– Circulatory overload
– Transfusion-related lung injury (TRALI)
– Massive Blood Transfusion Reactions
• Delayed Transfusion Reactions
– Delayed hemolytic
– Infections
– Iron overload
– Other
Transfusion Reactions/Complications
• Hemolytic (life-threatening!)
– Acute hemolytic: ABO incompatible; red cell
destruction (wrong blood type given to pt)
• Febrile (most common)
– Sensitization to donor WBC, platelets, plasma
proteins
• Allergic (hypersensitivity to donor plasma proteins)
– Mild allergic to severe -Anaphylactic)
• Septic: transfusion bacterially contaminated blood
• *Circulatory overload
– Fluid given too fast & too much
• *TRALI: sudden onset-non-cardiogenic pulmonary
edema (transfusion related acute lung injury)
• Massive Blood Transfusion Reaction:
– Clotting issues, citrate toxicity, hypocalcemia
Hemolytic/Transfusion Reaction!
Most dangerous!
Develops within first 15 minutes of
transfusion: free hemoglobin in blood and
urine specimens > acute hemolytic reaction;
delayed at 2-14 days
Occurs in 1:25,000
Occurs after approx 50 ml blood infused!
Blood incompatibility (ABO 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)
•Fever/chills
•SOB/dyspnea/wheezing
•Apprehension
•Headache/low back pain
•Chest pain/chest
tightness
•Urticaria/tachycardia
•*Hematuria
Hemolytic Reactions
*Hgb is released
blocking renal
tubules-can cause
renal failure.
Hemolytic Reactions
Key Indicators:
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Apprehension
Headache
Chest pain
Tachycardia
Urticaria
N/V
Fever/chills
Burning at IV site
Low back pain
Hypotension
• Acute-usually occurs after
50 ml. infused
Lewis – can occur within infusion of as little as 10mls
Febrile
Caused by leukocyte
incompatibility; sudden
onset: usually within first 15
minutes of transfusion!
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Fever/chills (^1 degree)
Sensations of Cold
Hypotension/Shock
Flushed skin, abdominal pain,
vomiting and diarrhea
**Bacterial (pyrogenic):
• Prevent by use of leukocyte
poor blood!
• Stop infusion/antipyretics
similar to febrile; due to
bacterial contamination of
blood:
see S & S above
Allergic Reactions
(Hypersensitivity reactions)
Antibodies in patient’s blood react
Severe (Anaphylactic)
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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 (initially) (1% of pts.)
*Urticaria
Pruritis
Itching
Mild and transient: stop infusion,
possibly restart, give antihistamine
prophylactically, use washed RBCs
Anxiety
Wheezing
Dyspnea
Bronchospasm
Hypotension
Swelling of tongue, face
Loss of consciousness
Shock, pulmonary edema
• Stop infusion, keep line open
with new saline tubing; CPR &
epinephrine (if indicated)
•
DO NOT RESTART TRANSFUSION
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)
– Delayed reaction
– Vomiting diarrhea, hypotension, altered hematological
values
– Administer deferoxamine (Desferal) Iv to remove
accumulated iron via the kidneys (urine red)
• Hypocalcemia (massive blood transfusions)
– Citrate in blood binds with calcium & is excreted
– Check lab values
• Hyperkalemia: stored blood liberates potassium through
hemolysis (“older” blood greater risk for hemolysis)*
significance of elevated potassium?
Hemolytic Transfusion Reaction!
If hemolytic reaction occurs:
• Stop transfusion
•, Keep IV line open/new tubing saline
solution, maintain BP; monitor
•Notify HCP and blood bank immediatelysigns/symptoms; recheck identifying tags/
numbers
•Monitor VS, urine output
•Treat symptoms- shock (anaphylactic) if
present (epinephrine, oxygen,
antihistamines, vasopressors, fluids,
corticosteroids)
•Save blood bag, tubing, send to blood
bank for exam
•Complete transfusion reaction reports
•Collect required blood, urine samples as
per policy to ck for hemolysis
•Document on transfusion reaction form
and patient chart
• Prevent acute renal failure-diuretic, fluids
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!
Review
What is a primary purpose of administering
blood and blood components?
(click on right answer)
A.
treat hypervolemia.
NO…Blood and its components inc intravascular volume, not dec.
Potential complication with administration of blood esp when given too
rapidly > hypervolemia.
B.
C.
D.
alleviate sodium retention.
NO…Alleviate sodium retention: an answer for consideration;
indirectly sodium retention might dec by effect on restoration of
intravascular volume and normal hemodynamics (renin-angiotensinaldosterone)
inc the level of electrolytes.
NO…Inc level of electrolytes…perhaps indirectly as normal
hemodynamics restored, not primary reason for giving blood
and blood products.
promote tissue oxygenation.
YES…RBC’s carry oxygen! Blood and components also
provide clotting factors and maintain intravascular volume.)
PRBC’s are utilized to treat impaired
clotting such as in liver dysfunction.
Click on True/False for answers
True or False
True. If you said true,
you were not correct.
PRBC’s are used to
correct anemia and
blood loss.
?
False! If you said false you
were right on! PRBC’s are
used to correct anemia and
blood loss, not given for
clotting factors, need fresh
frozen plasma or
cryoprecipitates
Review
A nurse is to hanging a 250 ml. unit of Packed RBC’s to
prepare a patient for urgent surgery. *next slide
Describe how to set the infusion pump.
1. Total time recommended for
transfusion of 1 unit of PRBC?
Variables as age/condition?
2. First 15 min. of infusion (80 – 120 ml/hr.)
3. Rate after first 15 minutes?
Pump Settings
• 2 ml X 15 min. =
30ml
• 30 ml = X ml
15 min. 60 min.
Run pump at 120 for
first 15 min.
 What
• 250 ml – 30 ml = 220ml
• 2 hr (120 min-15 min.) =
remaining run time of
105 minutes
220 ml = X ml = 125.7ml/hr.
105 min. 60 min.
Run pump at 126 for rest of
transfusion
is the rate if you started at 80ml/15 min.?
Review
cont
The pt.’s Type & Crossmatch report
indicates that he is Type A+. The unit of
PRBC's that the bank has provided is
labeled as Type O negative.
Can patient safely receive this blood?
Why or Why not?
Yes-O-neg universal donor!
Platelets are used to treat?
click on letter for answers
A.
Hemophilia
No Platelets do not contain the specific clotting factors
needed by a client with hemophilia; platelet levels are
typically normal
B.
Thrombocytopenia
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 fibrin
C.
Polycythemia
No Polycythemia is the presence of excess RBC’s;
administration of platelets would not decrease the abnormal
amount of RBCs in fact would cause increased
problems…increased viscosity and more likely to form clots.
Good job
D.
Low white cell count
No WBCs are leukocytes and originate from
hemopoietic stem cells in the bone marrow; must
use hematopoietic growth factors to stimulate
granulocyte maturation and differentiation
Consider ethical dilemma (from text)
• An elderly woman with dementia, transferred from a nursing home
due to GI bleeding. Some of her family members tell the nurse that
she is a Jehovah’s Witness and must not receive blood products.
The surgeon indicates that if she does not have exploratory surgery
and receive blood products, she will die.
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What actions will you as her nurse take?
What resources do you have available to consult?
How can you determine if the family is acting is the patient’s best interest?
What non-blood alternatives are available for Jevohah’s Witnesses or others who
do not wish to receive blood products?
FYI-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- agent that causes syphilis
*ALT,-elevated ALT may indicate liver inflammation, which may be caused by a
hepatitis virus
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) - new technology that can detect genetic material of
Hepatitis C and HIV to identify these viruses faster and more accurately
All blood products filtered to remove leukocytes that can harbor viruses and
infections
Congratulations on Successful Completion!