358: Blood Transfusion
approximate values for blood components
-55% plasma -45% formed elements a. RBCs, WBCs, and platelets
plasma
-7% proteins a. Albumins 57% b. Globulins 38% c. Fibrinogen 4% d. Prothrombin 1% -91% water -2% other solutes a. Ions, Nutrients, Waster Products, Gases, and Regulatory Substances
total body weight
-8% blood -92% other fluids and tissues
blood tubing
-Blood is administered using special Y-Tubing that has an in-line filter. -0.9% Normal Saline (No other fluids) are administered with blood. Fluids like dextrose can cause clumping of the blood cells. The normal saline is used to prime the IV line and flush it afterwards. -Blood bag and tubing NEVER goes in the regular trash but in the red biohazard bag. -Follow hospital protocol for how often to change the y-tubing.
verification process:
-Verify order -Patient's ID and Blood Bank info -Patients blood type and donor's type and RH Factor -Check expiration Date -EVERYTHING must MATCH -Baseline VS
blood therapy reactions - hemolytic reaction
-Wrong blood-ABO incompatible -Antibodies in recipient attach to donor antigens and cause RBC destruction -Occur 1st 15 min -S/S: •Chills, fever, low back pain, flushing, tachy, dyspnea, tachypnea, hypotension, acute jaundice, dark urine, bleeding, kidney, injury, shock, cardiac arrest, death •Prevention-identify patient
platelets
140,000-340,00
must start blood within
30 minutes of receiving from blood bank. Blood products are housed with special refrigeration (not the refrigerator on the floor) -RN must remain with pt for 1st 15 minutes after transfusion as this is when most reactions occur -VS, assessment, and observation cannot be delegated to an unlicensed individual
transfusion of blood components that are contaminated with
bacteria, especially gram-negative bacteria, can cause sepsis.
blood transfusion or blood component therapy is:
•the IV administration of whole blood or a blood component such as packed red blood cells (RBCs), platelets, or plasma.
blood therapy - cyroprecipitate
-Made from FFP -10-20 ml -Used for hemophilias •Factor VIII-hemophilia A •Factor IX-hemophilia B -Whole Blood •Used for massive loss
blood therapy - albumin
-Made from plasma -5% or 25% concentrations -Hypovolemia, hypovolemic shock, hypoalbuminemia
blood therapy - Platelets
-Made from whole blood -Pooled from several donors or one donor by plasmapheresis -Used for bleeding caused by thrombocytopenia
Leukocytes
-Neutrophils: 60-70% -Lymphocytes: 20-25% -Monocytes: 3-8% -Eosinophils 2-4% -Basophils 0.5-1%
blood adminsitration
-Packed red blood cells -250-300 mL -One unit = 1 gm Hgb increase -One unit = 3% hct increase -One unit = replace 500 ml blood loss •requires a specific procedure for correctly identifying patient and blood products and responding quickly to transfusion reactions.
blood therapy - fresh frozen plasma (FFP)
-Pooled from several donors -200-250 ml -Contains clotting factors but no platelets -Use for bleeding from deficient clotting factors •Excess Coumadin, Vit. K deficiency, hemorrhage, liver disease
plasma is composed primarily of:
-water, but it also contains proteins, electrolytes, gases, nutrients, and waste -serum refers to plasma without its clotting factors -most plasma proteins are produced by the liver except for antibodies (immunoglobulins) which are produced by plasma cells
blood is administered with
0.9% Normal Saline - no other fluid. May have to change out IV solution if an IV solution other than than 0.9% Normal Saline is infusing.
erythrocytes
4.2-6.2 million
leukocytes
5,000-9,000
blood therapy reactions - febrile reaction
90% of blood reactions -Usually occurs after multiply transfusions •Cancer patients •Kidney failure -Immune response to donor cells -S/S-sudden chills, fever, headache, flushing, anxiety, vomiting, muscle pain -Treatment: •Blood products filtered for leukocytes •Tylenol or Benedryl before transfusion
blood products have citrate
as a preservative which binds with calcium so no lactated ringers
there are many nursing responsibilities related to blood product administration
Prior to administration, the patient will need to be typed and crossmatched There will be an order to administer blood.....the order will be something broad like "Transfuse patient with 2 units of PRBC's. It won't tell you the type of tubing to use, what solution to infuse the blood with, etc.
watch for:
REACTION •Rash (hives) •Elevated temp •Aching (back, chest or head) •Chills •Tachycardia •Increased RR •Oliguric (low urine output, purplish urine) •Nausea
circulatory overload is a risk when:
a patient receives massive whole blood or packed RBC transfusions for massive hemorrhagic shock, or when a patient with normal blood volume receives blood.
quarts of blood in average adult who weighs between 150-180 pounds
about 5-6 quarts (4.7-5.5L) of blood
jaundice can occur as the result of
hemolysis -Start the transfusion SLOWLY on an infusion pump and stay with the patient for the first 15 minutes. -If patient tolerates the transfusion for 15 minutes, rate can be increased.
when transfusion reaction occurs:
maintain or restore the pt's physiological stability. when you suspect acute intravascular hemolysis, do the following: •Stop the transfusion immediately. •Keep the IV line open by replacing the IV tubing down to the catheter hub with new tubing and running 0.9% sodium chloride (normal saline). •Do not turn off the blood and simply turn on the 0.9% sodium chloride (normal saline) that is connected to the Y-tubing infusion set. This would cause blood remaining in the IV tubing to infuse into the patient. Even a small amount of mismatched blood can cause a major reaction. •Immediately notify the health care provider or emergency response team. •Remain with the patient, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. •Prepare to administer emergency drugs such as antihistamines, vasopressors, fluids, and corticosteroids per health care provider order or protocol. •Prepare to perform cardiopulmonary resuscitation. •Save the blood container, tubing, attached labels, and transfusion record for return to the blood bank. •Obtain blood and urine specimens per health care provider order or protocol.
blood transfusion must be:
matched to each patient to avoid incompatibility. •If incompatible blood is transfused (i.e., a patient's RBC antigens differ from those transfused), the patient's antibodies trigger RBC destruction in a potentially dangerous transfusion reaction (i.e., an immune response to the transfused blood components).
objectives for administering blood transfusion include:
•(1) increasing circulating blood volume after surgery, trauma, or hemorrhage •(2) increasing the number of RBCs and maintaining hemoglobin levels in patients with severe anemia; and •(3) providing selected cellular components as replacement therapy (e.g., clotting factors, platelets, albumin).
administration
•18-20 gauge IV or larger a. to prevent damage to transfusing RBCs. b. RBC lysis can occur if the cannula is too small •0.9% Normal Saline •No medications in blood tubing unless flushed well a. best practice recommends no other medication or fluids during administration
packed red blood cells
•ABO blood types -Presence or absence of A or B antigens -Type AB universal recipient (can receive any type antigens) -Type O universal donor (no antigens present) -Reaction if given wrong antigen as patient's response is to make antibodies against it •Rh factor -Rh negative can only receive Rh negative blood
the most important grouping for transfusion purposes is the:
•ABO system, which identifies A, B, O, and AB blood types. Determination of blood type is based on the presence or absence of A and B red blood cell (RBC) antigens. People with type O blood are considered universal blood donors because they can donate packed RBCs and platelets to people with any ABO blood type. People with type AB blood are called universal blood recipients because they can receive packed RBCs and platelets of any ABO type.
blood therapy
•Blood cells make up 45% of blood -Erythrocytes (RBCs) •Oxygen transportation -Leukocytes (WBCs) •Protection from infection -Thrombocytes (platelets) •Promote coagulation -Blood components are separated or fractionated
Transfusion
•Normal Hgb: -Male: 14-18 g/dL -Female: 12-16 g/dL •Normal Hct: -Male: 38 -48% -Female: 35-44% •Old criterion for transfusing - •New - no specific criterion -Depends on situation, diagnosis, age, medical condition
blood therapy - nursing care
•PRBC's - 50-75 cc/hr for 1st 15 min - -Increase if no complications •1 unit over 2 hours •Don't use after 4 hours •FFP or platelets infused over 15-30 minutes -either the nurse will get the blood from the blood bank/lab or it will be sent to the unit. -be sure to have checked VS, patent IV, etc prior to having blood on unit - A blood warmer can be used when giving large amounts of blood quickly and for patients who have a hypothermic response.
prep work!
•Patient will have been typed and crossmatched •Check order •IV access •Special Y-tubing with in-line filter •Patient consent •Verification process •Verified by 2 licensed individuals •VS -Notify provider if abnormal •Special refrigeration for blood products •Remain with patient -1st 15 minutes of infusion -Vital Signs again after 1st 15 minutes, may do VS every 30 minutes -VS after transfusion complete -See facility policy •Full unit over 2 hours •Don't use after 4 hours •Stop transfusion if there is a reaction
another consideration when matching blood components for transfusions is the
•Rh factor, which refers to another antigen in RBC membranes. Most people have this antigen and are Rh positive; a person without it is Rh negative. People who are Rh negative receive only Rh-negative blood components.
blood therapy reactions - other
•Sepsis •Circulatory overload -s/s-cough, dyspnea, crackles to lungs, HTN, tachy. •Allergic Reaction -Mild to severe -s/s-mild-flushing, itching, hives -s/s-severe-anxiety dyspnea, wheezing, bronchospasm, hypotension, shock, death
when are pts usually transfused?
•There used to be guidelines such as when a patient's Hgb dropped below a certain level, they would receive a transfusion -The new guidelines are that there are really "no criteria' any longer. •So, basically each clinical situation is looked at and depends on the clinical situation, patient's diagnosis, age, condition, etc.
Blood tranfusion
•Transfusion of new red blood cells via venous access •Reasons: -Anemia -Renal failure a. CKD (erythropoietin) -Cancer -Liver failure -Blood loss from •Surgery/trauma
a transfusion reaction is an:
•an immune system reaction to the transfusion that ranges from a mild response to severe anaphylactic shock or acute intravascular hemolysis, both of which are life threatening.
transfusion of blood or blood components is a nursing procedure that requires:
•an order from a health care provider. A blood transfusion reaction is one of the National Quality Forum's patient safety measures that should be included in a health care institution's public reporting of safety events. Patient safety is a nursing priority, and patient assessment, verification of health care provider's order, and verification of correct blood products for the correct patient are imperative.
autologous transfusion (autotransfusion)
•is the collection and reinfusion of a patient's own blood. Blood for an autologous transfusion most commonly is obtained by preoperative donation up to 6 weeks before a scheduled surgery. Autologous transfusions are safer for patients because they decrease the risk of mismatched blood and exposure to bloodborne infectious agents.
for pt safety, always verify three things:
•that blood components delivered are the ones that were ordered; that blood delivered to the patient is compatible with the blood type listed in the medical record; and that the right patient receives the blood. •Together, two RNs or one RN and an LPN (check agency policy and procedures) must check the label on the blood product against the medical record and against the patient's identification number, blood group, and complete name. If even a minor discrepancy exists, do not give the blood; notify the blood bank immediately to prevent infusion errors.