Transcript Blood Administration

Blood Administration
by: Kelle Howard, RN, MSN
revised fall 2012
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
•Verify informed consent
•Insure IV access: need large bore
catheter (18-20 gauge); why?
• Gather equipment
What is T&C vs T&S
•What does TYPE mean?
•What does crossmatch mean?
•How long are they good for?
•Why?
Blood Administration
Objectives
Discuss:
•Common blood products
•Steps in blood administration
•Complications of blood
administration
Types of Blood Components
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Whole Blood
– To replace blood volume and O2 carrying
capacity
– Treat hemorrhage and shock
– Contains PRB’C, plasma proteins, clotting
factors and plasma
(few platelets & granulocytes)
Volume = 500ml/unit
•
__________________
Packed Red cells (PRBCs)
– Treat anemia, replace blood volume
(usually 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!!
Current Blood Preparation
• Leukocyte reduction prior to storage
– Removal of most WBC’s and Plasma reduces the
risk of reactions
• Irradiated
– for those with CA or risk for GVHD
– good for 28 days
• Drawback
– bacterial growth if contaminated during
collection/processing
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 <10-20,000
unless what?)
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–
Volume = 30-60ml/unit
________________________
____________
– To expand blood volume or replace
protein
– Used to treat
shock from trauma,
infection, 3rd spacing, hypovolemia, burns
and in surgery
– Available in 5% -25% solution
– Paid donation
– Vascular overload
– Hyperosmolar solution moves
water from extravascular space to
intravascular space
– Outcome: adequate BP & volume
– Hypersensitivity reaction
– Can be stored for 5 years
– From whole fresh blood
– Expected platelet 10,000/unit
– Measure at 1hr & 18-24 hr post admin
•
Risks & Benefits
Albumin (plasma derivative)
Volume 25g/100ml = 500ml of plasma
Not a substitute for whole blood
May form antibodies
Hypersensitivity reaction
Must be used within 5 days of
donation
Risks & Benefits
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
________________________
•
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
___________________
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
Questions
• How much blood in
human body?
• Do platelets have
clotting factors?
• Do you understand the
process of making a
clot?
Types of Blood Components
Cont’d
• 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
• 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
• Outcomes & Uses
– Improvement of infection is measure of treatment
effectiveness
– Used in cancer & chemotherapy patients
– Hazards
• __________________ & ___________________
ABO Compatibility Chart
• Who is universal donor & recipient?
• What do the - & + mean?
Compatibility Chart
Recipient
Donor
A
B
AB
O
A
X
B
X
X
X
AB
X
X
X
X
O
X
O- universal donor, AB+ universal recipient
Population Percentages
A+ 34.3%
A- 5.7%
B+ 8.6%
B- 1.7%
AB+ 4.3%
AB- 0.7%
O+ 38.5%
O- 6.5%
RBC & Plasma Transfusions
Blood Type
RBC
Plasma
O
O
O, A, B, AB
A
AO
A, AB
B
BO
B, AB
AB
AB, A, B, O
AB*
Donations
• Paid vs Volunteer
• What percentage of population can donate?
• How many do?
• Who cannot donate?
Ineligible Donors
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In Europe in the 80’s & 90’s – indefinitely
Previous history of maleria – years
Incarceration for 72 hours – 1 yr
Hepatitis after age 11 –
indefinitley
HCT < 38% until resolved
Homosexual Male after 1977 – indefinitely
Needle stick –
1 yr
Medical history of vascular disease, bleeding or
cancer until resolved
*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
–
*Get client ready for transfusion prior to getting blood from the lab
T&C done
Gather supplies
*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 _________________ can be safely given to most clients
without serologic testing.
– Why ?
• *Universal RBC donor is ___________; universal recipient is ____________
• 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!
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)
90% of all reactions occur because of mistakes in labeling and verification
Blood Product Administration
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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 30 minutes of removing
from lab – DO NOT STORE IN UNIT REFRIGERATOR
Blood Product
Administration
• Use appropriate filters
• Use blood administration set no
more than 4 hours
• Check facility policy re: # units
per administration set
Post Administration
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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
– 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
• Monitor
– signs of transfusion reaction
• Infuse over period specified
– _______ hours
• Blood cannot be out of refrigerator more
than____ minutes prior to administration
– PLAN AHEAD!!
• BE READY TO START BEFORE GETTING BLOOD!!
• Allow blood to hang no longer than ____ 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)
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 the administration of
whole blood?
How would you manage this?
3. 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)?
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 are 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 degree
significant
Action taken will be determined by the type of
reaction; careful assessment & monitoring of the
patient is a must!
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)
Circulatory overload
– Fluid given too fast & too much
TRALI
– Transfusion reaction acute lung injury
– Non cardiogenic pulmonary edema
Iron overload– delayed reaction
Hypocalcemia– citrate in blood binds with calcium & is excreted
Bacterial (pyrogenic or sepsis)
– 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)
**Bacterial (pyrogenic): similar
to febrile; due to bacterial
• Fever/chills (^1 degree)
contamination of blood:
• Sensations of cold
see S & S to left
• Flushed skin, abdominal pain, vomiting
and diarrhea
• Hypotension/Shock
• Prevent by use of leukocyte poor blood!
• Stop infusion/antipyretics
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 and transient: stop infusion,
possibly restart, give antihistamine
prophylactically, use washed RBCs
Severe: stop infusion, keep line open
with new saline & tubing; CPR &
epinephrine (if indicated)
DO NOT RESTART TRANSFUSION
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
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
Occurs in 1:25,000
Usually occurs after 50-100 ml blood infused!
(possibly 200mls)
ABO/Blood incompatibility
• *RBC’s clump (lysis of RBC’c), block capillaries,
decrease blood flow to organs
• Hgb released (myogloburia), blocks renal
tubules > acute kidney injury=
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, 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 kidney injury: 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!
Hemolytic Reactions
Hgb is released
blocking renal
tubules
Can cause
acute kidney injury.
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
Usually occurs after 50 ml. infused
Lewis – can occur within infusion of as little as 10mls
Reactions/Complications
• Circulatory overload
– Fluid given too fast & too much
– Note cough, dyspnea, lung sounds, HTN etc
– Slow infusion, elevate HOB, treat overload
• Iron overload
– Delayed reaction
– Vomiting diarrhea, hypotension, altered hematological
values
– Administer deferoxamine (Desferal) IV to remove
accumulated iron via the kidneys (urine red)
Nursing actions if reaction occurs
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Stop transfusion immediately
Continue NS IV with new tubing
Provide appropriate care for client
Notify physician of client signs and
symptoms
• Follow facility policy and procedure
• Obtain urine & blood specimen for free
hemoglobin test
Autotransfusion
(autologous transfusion)
Indications
– Used in surgery & emergency
settings
– Autologous blood-collection of
own blood prior to scheduled
surgery
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
“Cell-saver" technology collects blood
lost during surgery, cleanses it, and
places it back in the patient's body, all in
a continuous loop.
Autotransfusion
What are the benefits of Autologous transfusion?
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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.
What are the issues related to Autologous transfusion?
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Usually the pateint is already medically not well
2/3 of donations do not get used
Many end up in the hospital post procedure
Autotransfusion
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.
ALT, an elevated ALT may indicate liver inflammation, which may be caused by a
hepatitis virus
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)
For blood type (ABO) and Rh factor
Tp, the agent that causes syphilis
Every unit of blood is tested for
The presence of unexpected antibodies that may cause
reactions after the transfusion
CMV: cytomegalovirus
(performed on physician request)
NAT (Nucleic Acid Testing)
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!