Transcript Blood Administration

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 first?
Blood Administration
Right If you said:
•Check for T&C
•Verify informed consent
•Insure IV access; need large bore
catheter (18-20 gauge); smaller bore
causes destruction of RBC’s
• Gather equipment:
• Y-tubing blood administration set
with filter
•NS solution
•IV pump
•Prime tubing with Normal Saline.
Blood Administration
Objectives
Discuss:
•Common blood products
•Steps in blood administration
•Complications of blood
administration
•*Transfusion reactions
•Circulatory overload
•Septicemia
•Iron overload
•Disease transmission
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
 O2 carrying capacity in slow
bleeding, anemia, leukemia, surgery
Volume = 250-300ml/unit
Risks & Benefits
 Possible incompatibility issues
 Circulatory overload
 Deficient in some clotting
factors
 Rarely used
 Use Lasix to prevent overload
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Risks & Benefits
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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
Takes 4-6 hours for Hgb & HCT
to change
Most commonly used!!
Current Blood Preparation
Leukocyte reduction prior to storage
 More effective than previous washing
process
 Packed RBC’s are removed from plasma
 Removal of most WBC’s and Plasma
reduces the risk of reactions
 Drawback – bacterial growth if
contaminated during collection/processing
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Types of Blood Components
Con’t
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Platelets
To control or prevent bleeding in
platelet deficiencies, i.e.
thrombocytopenia
(ordered when platelets count <1020,000)
 From whole fresh blood
 Expected platelet 10,000/unit
 Measure at 1hr & 18-24 hr post
admin
Volume = 30-60ml/unit
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Albumin (plasma derivative)
To expand blood volume or replace
protein
 Used to treat shock from trauma,
infection, 3rd spacing, hypovolemia,
and in surgery
 Available in 5% -25% solution
Volume 25g/100ml = 500ml of plasma
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Risks & Benefits
Not a substitute for whole
blood
 May form antibodies
 Hypersensitivity reaction
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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
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Types of Blood Components cont’d
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Frozen RBCs
 Rarely used
 Successive washing with
saline solution removes
majority of WBCs and
plasma proteins
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Fresh Frozen Plasma (FFP)
 To treat DIC, reverse effects
of Coumadin, treat liver
failure pts
 Contains clotting factors
 Improves coagulation, PT &
PTT
Volume = 200-250ml/unit
Risks and Benefits
- Can be stored for 3 years
- Use within 24hrs of
thawing
- No WBC’s
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Risks & Benefits
 Rich in clotting factors
 No platelets
 Good for volume expansion
to restore clotting factors in
hypovolemic shock
 Risk for vascular overload
 Hypersensitivity reaction
 Hemolytic reactions
Types of Blood Components
Cont’d
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Prothrombin Complex – Prothrombin,
Factors VII, IX, X, and part of XI
Used to treat clients with specific clotting factor
deficiencies
 Prepared from FFP
 Store for 1 year, once thawed, must be used
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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
WBC’s or Granulocytes
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Outcomes & Uses
 Improvement
of infection is measure of
treatment effectiveness
 Used in cancer & chemotherapy patients
 Hazards - febrile reaction & new infections
carried in WBC’s
Preparation
for
Blood Administration
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Physicians order
Verify signed consent
Obtain IV acess, 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 for and obtains blood (only one client & 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
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
Donor
A
B
AB
O
Recipient
A
B
AB
X
X
X
X
X
X
X
X
O
X
O- universal donor, AB+ universal recipient
RBC & Plasma Transfusions
Initiation of Transfusion
Verify informed consent
 Check physician’s orders
 ID patient, draw blood for T+C in red top tube and start
18-20 gauge IV, place blood band and label tube.
 Blood tubing & 0.9NS IV solution ready
 T&C to lab
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Initiation of Transfusion
Con’t
Obtain blood from blood bank
 2 RNs check unit of blood with laboratory slip,
patient’s chart, forms should include patient’s
name, unit #, and blood type, etc.
 Check expiration date
 Patient’s ID#, blood band #, & state name
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(@ St. David’s – blood band number on blood band)
(@ Seton - transfusion card)
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Blood component, donor #, expiration date,
Group & 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
Blood Product Administration
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Compare all labels second time
Check vital signs and record
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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 1hr
IV 18-20 gauge adult, 23-child
 0.9% Sodium Chloride (NS) only!!!
 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
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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 on a pumpuse pump tubing
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Blood to cover filter
Use appropriate filters
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Product Features:
Patient protection against leukocyte-related
transfusion complications
 Primes directly with red cells quickly and
conveniently
 Patented filtration media and minimal hold-up
volume provides minimal loss of red cells
 No saline prime or flush required
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 For
intraoperatively
salvaged washed
blood
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Reduces leukocytes
Decreases fat globules
Reduces microaggregates
 Use
appropriate filters
for Platelets
Product Features:
 Patient protection against leukocyte-related transfusion
complications
 Primes directly with platelets quickly and conveniently
 High platelet recovery achieved without saline flush
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Critical Points
Client indentification & blood compatability
 Drip rate no higher than 2 cc 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 2hr
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No meds or fluid other than NS to be given in line
with blood!!!
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CHECK POLICY AND PROCEDURE of facility!!
Critical Points
Monitor for signs of transfusion reaction
Infuse over period specified (2-4 hours)
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)
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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?
How would you manage this?
2. In addition to transfusion reaction;
what is a major risk related to
administration of whole blood?
How would you manage this?
3. Your client receives a unit of
RBC’s…what response to this unit of
blood is anticipated?
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 2 degrees
significant
Action taken will be determined by type of reaction;
careful assessment, monitoring of patient!
What drugs are commonly given prior to transfusion?
Transfusion Reactions/Complications
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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)
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*Circulatory overload
Fluid given too fast & too much
Iron overload- delayed reaction
Hypocalcemia- citrate in blood binds with calcium
& is excreted
Bacterial (pyrogenic or sepsis) (not in text)
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Transfusion of bacterially infected components
Febrile
pyrogenic /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)
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Fever/chills (^1 degree)
Sensations of Cold
Flushed skin, abdominal pain,
vomiting and diarrhea
Hypotension/Shock
Prevent by use of leukocyte
poor blood!
Stop infusion/antipyretics
**Bacterial (pyrogenic): similar
to febrile; due to bacterial
contamination of blood:
see S & S above
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 (initially) (1% of pts.)
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Severe (Anaphylactic)
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Mild and transient: stop infusion,
possibly restart, give antihistamine
prophylactically, use washed RBCs
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Severe: stop infusion, keep line open
with new saline tubing; CPR &
epinephrine (if indicated)
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DO NOT RESTART TRANSFUSION
*Urticaria
Pruritis
Itching
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Anxiety
Wheezing & Chest tightness
Dyspnea
Bronchospasm
Hypotension
Tachycardia
Swelling of tongue, face
Loss of consciousness
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 in 1:25,000
Usually occurs after 50-100 ml blood
infused! (possibly 200mls)
ABO/Blood incompatibility
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*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
•Fever/chills
•SOB/dyspnea/wheezing
•Apprehension
•Headache/low back pain
•Chest pain/chest
tightness
•Urticaria
•Tachycardia
•N&V
•*Hematuria
•Burning at IV site
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 free Hgb 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!
ABO incompatibility causes RBC’s to
clump, block capillaries, decreasing
blood flow to organs.
Hemolytic Reactions
Hgb is released
blocking renal
tubules
Can cause
renal failure.
Impact of K+ ?
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
Reactions/Complications
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*Circulatory overload
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Iron overload
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Fluid given too fast & too much
Note cough, dyspnea, lung sounds, HTN etc
Slow infusion, elevate HOB, treat overload,
phlebotomy
Delayed reaction
Vomiting diarrhea, hypotension, altered
hematological values
Administer deferoxamine (Desferal) Iv to remove
accumulated iron via the kidneys (urine red)
Hypocalcemia
Citrate in blood binds with calcium & is excreted
 Check lab values
Also hyperkalemia: stored blood liberates potassium
through hemolysis (older blood greater risk for
hemolysis)
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Nursing actions if reaction
occurs
Stop transfusion immediately
 Continue N/S IV with new tubing
 Provide appropriate care for client
 Notify physician of clients signs and
symptoms
 Follow facility policy and procedure
 Obtain urine specimen for free
hemoglobin test
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Autologous transfusion
 What
are the benefits of Autologous transfusion?
Blood you receive should definitely match yours.
Risk of getting any allergic reaction will be very
low.
Blood will be available if you have a rare blood
type.
No infectious diseases - hepatitis, syphilis, AIDS,
etc.
Safe and well-tested procedure.
Autotransfusion
Indications
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Used in surgery & emergency
settings
Autologous blood-collection of
own blood prior to scheduled
surgery or in emergency
situation (blood salvage; cell
saver)
Risks and Benefits
Requires special
equipment
 No T&C needed
 If pre-donation, begin
collection within 5
weeks of transfusion
date end at least 3
days prior to
transfusion need
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“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
Who can have Autologous transfusion?
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Patients less than 65 years old.
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Patients without serious medical conditions like
serious heart and lung diseases.
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Patient’s with hemoglobin level of at least 11g / dl
before each donation
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, the agent that causes syphilis
ALT, an elevated ALT may indicate liver inflammation,
which may be caused by a hepatitis virus
 Cont.
The 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) - a new technology
that can detect the genetic material of Hepatitis C
and HIV to identify these viruses faster and more
accurately
100% of the blood products are filtered to remove
leukocytes that can harbor viruses and infections.
Congratulations on Your Successful
Completion!