Chp 14: Administration of Blood Products

Hypocalcemia

1. Citrate in transfused blood binds with calcium and is excreted. 2. Assess serum calcium level before and after the transfusion. 3. Monitor for signs of hypocalcemia (hyperactive reflexes, paresthesias, tetany, muscle cramps, positive Trousseau's sign, positive Chvostek's sign). 4. Slow the transfusion and notify the HCP if signs of hypocalcemia occur.

Citrate toxicity

1. Citrate, the anticoagulant used in blood products, is metabolized by the liver. 2. Rapid administration of multiple units of stored blood may cause hypocalcemia and hypomagnesemia when citrate binds calcium and magnesium; this results in citrate toxicity, causing myocardial depression and coagulopathy. 3. Those most at risk include individuals with liver dysfunction or neonates with immature liver function. 4. Treatment includes slowing or stopping the transfusion to allow the citrate to be metabolized; hypocalcemia and hypomagnesemia are also treated with replacement therapy.

Iron overload

1. Description: A delayed transfusion complication that occurs in clients who receive multiple blood transfusions, such as clients with anemia or thrombocytopenia Assessment a. Vomiting b. Diarrhea c. Hypotension d. Altered hematological values Interventions a. Deferoxamine, administered intravenously or subcutaneously, removes accumulated iron via the kidneys. b. Urine turns red as iron is excreted after the administration of deferoxamine; treatment is discontinued when serum iron levels return to normal.

Circulatory overload

1. Description: Caused by the infusion of blood at a rate too rapid for the client to tolerate Assessment a. Cough, dyspnea, chest pain, and wheezing on auscultation of the lungs b. Headache c. Hypertension d. Tachycardia and a bounding pulse e. Distended neck veins Interventions a. Slow the rate of infusion. b. Place the client in an upright position, with the feet in a dependent position. c. Notify the HCP. d. Administer oxygen, diuretics, and morphine sulfate, as prescribed. e. Monitor for dysrhythmias. f. Phlebotomy also may be a method of prescribed treatment in a severe case. If circulatory overload is suspected, immediately slow the rate of infusion and place the client in an upright position, with the feet in a dependent position.

Septicemia

1. Description: Occurs with the transfusion of blood that is contaminated with microorganisms Assessment a. Rapid onset of chills and a high fever b. Vomiting c. Diarrhea d. Hypotension e. Shock Interventions a. Notify the HCP. b. Obtain blood cultures and cultures of the blood bag. c. Administer oxygen, IV fluids, antibiotics, vasopressors, and corticosteroids as prescribed.

Transfusion Reaction: Nursing Interventions

1. Stop the transfusion. 2. Change the intravenous (IV) tubing down to the IV site and keep the IV line open with normal saline. 3. Notify the health care provider (HCP) and blood bank. 4. Stay with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. 5. Prepare to administer emergency medications as prescribed (antihistamines, vasopressors, fluids, corticosteroids) 6. Obtain a urine specimen for laboratory studies (perform any other laboratory studies as prescribed). 7. Return blood bag, tubing, attached labels, and transfusion record to the blood bank. 8. Document the occurrence, actions taken, and the client's response.

Hyperkalemia

1. Stored blood liberates potassium through hemolysis. 2. The older the blood, the greater the risk of hyperkalemia; therefore, clients at risk for hyperkalemia, such as those with renal insufficiency or renal failure, should receive fresh blood. 3. Assess the date on the blood and the serum potassium level before and after the transfusion. 4. Monitor the potassium level and for signs and symptoms of hyperkalemia (paresthesias, weakness, abdominal cramps, diarrhea, and dysrhythmias). 5. Slow the transfusion and notify the HCP if signs of hyperkalemia occur.

Disease transmission

1. The disease most commonly transmitted is hepatitis C, which is manifested by anorexia, nausea, vomiting, dark urine, and jaundice; the symptoms usually occur within 4 to 6 weeks after the transfusion. 2. Other infectious agents and diseases transmitted by blood transfusion include hepatitis B virus, human immunodeficiency virus (HIV), human herpes virus type 6, Epstein-Barr virus, human T-cell leukemia, cytomegalovirus, and malaria. 3. Donor screening has greatly reduced the risk of transmission of infectious agents; in addition, antibody testing of donors for HIV has greatly reduced the risk of transmission.

Types of Blood Donations

A. Autologous 1. A donation of the client's own blood before a scheduled procedure is an autologous donation; it reduces the risk of disease transmission and potential transfusion complications. 2. Autologous donation is not an option for a client with leukemia or bacteremia. 3. A donation can be made every 3 days as long as the hemoglobin remains within a safe range. 4. Donations should begin within 5 weeks of the transfusion date and end at least 3 days before the date of transfusion. B. Blood salvage 1. Blood salvage is an autologous donation that involves suctioning blood from body cavities, joint spaces, or other closed body sites. 2. Blood may need to be "washed," a special process that removes tissue debris before reinfusion. C. Designated donor 1. Designated donation occurs when recipients select their own compatible donors. 2. Donation does not reduce the risk of contracting infections transmitted by the blood; however, recipients feel more comfortable identifying their donors.

Types of Blood Components

A. Packed red blood cells (PRBCs) 1. PBRCs are a blood product used to replace erythrocytes (RBCs); infusion time for 1 unit is usually between 2 and 4 hours. 2. Each unit increases the hemoglobin level by 1 g/dL (10 mmol/L) and hematocrit by 3% (0.03); the change in laboratory values takes 4 to 6 hours after completion of the blood transfusion. 3. Evaluation of an effective response is based on the resolution of the symptoms of anemia and an increase in the erythrocyte, hemoglobin, and hematocrit count. 4. Leukocyte-poor or leukocyte-depleted units are units in which leukocytes, proteins, and plasma have been reduced. They are used to restore oxygen-carrying capacity of blood and intravascular volume. B. Platelet transfusion 1. Platelets are used to treat thrombocytopenia and platelet dysfunctions. a. Clients receiving multiple units of platelets can become "alloimmunized" to different platelet antigens. These clients may benefit from receiving only platelets that match their specific human leukocyte antigen (HLA). 2. Crossmatching is not required but usually is done (platelet concentrates contain few red blood cells [RBCs]). 3. The volume in a unit of platelets may vary; always check the bag for the volume of the blood component (in milliliters). 4. Platelets are administered immediately upon receipt from the blood bank and are given rapidly, usually over 15 to 30 minutes. 5. Evaluation of an effective response is based on improvement in the platelet count, and platelet counts normally are evaluated 1 hour and 18 to 24 hours after the transfusion; for each unit of platelets administered, an increase of 5000 to 10,000 mm3 (5 to 10 × 109/L) is expected. C. Fresh-frozen plasma 1. Fresh-frozen plasma may be used to provide clotting factors or volume expansion; it contains no platelets. 2. Fresh-frozen plasma is infused within 2 hours of thawing, while clotting factors are still viable, and is infused over a period of 15 to 30 minutes. 3. Rh compatibility and ABO compatibility are required for the transfusion of plasma products. 4. Evaluation of an effective response is assessed by monitoring coagulation studies, particularly the prothrombin time and the partial thromboplastin time, and resolution of hypovolemia. D. Cryoprecipitates 1. Prepared from fresh-frozen plasma, cryoprecipitates can be stored for 1 year. Once thawed, the product must be used; 1 unit is administered over 15 to 30 minutes. 2. Used to replace clotting factors, especially factor VIII and fibrinogen 3. Evaluation of an effective response is assessed by monitoring coagulation studies and fibrinogen levels. E. Granulocytes 1. May be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics 2. Evaluation of an effective response is assessed by monitoring the WBC and differential counts.

Blood Transfusion Reactions

A. Transfusion reactions 1. Description a. A transfusion reaction is an adverse reaction that happens as a result of receiving a blood transfusion. b. Types of transfusion reactions include hemolytic, allergic, febrile or bacterial reactions (septicemia), or transfusion-associated graft-versus-host disease (GVHD). 2. Signs of an immediate transfusion reaction a. Chills and diaphoresis b. Muscle aches, back pain, or chest pain c. Rashes, hives, itching, and swelling d. Rapid, thready pulse e. Dyspnea, cough, or wheezing f. Pallor and cyanosis g. Apprehension h. Tingling and numbness i. Headache j. Nausea, vomiting, abdominal cramping, and diarrhea 3. Signs of a transfusion reaction in an unconscious client a. Weak pulse b. Fever c. Tachycardia or bradycardia d. Hypotension e. Visible hemoglobinuria f. Oliguria or anuria 4. Delayed transfusion reactions a. Reactions can occur days to years after a transfusion. b. Signs include fever, mild jaundice, and a decreased hematocrit level.

Precautions and Nursing Responsibilities

General Precautions A large volume of refrigerated blood infused rapidly through a central venous catheter into the ventricle of the heart can cause cardiac dysrhythmias. No solution other than normal saline should be added to blood components. Medications are never added to blood components or piggybacked into a blood transfusion. To avoid the risk of septicemia, infusions (1 unit) should not exceed the prescribed time for administration (2 to 4 hours for packed red blood cells); follow evidence-based practice guidelines and agency procedure. The blood administration set should be changed with each unit of blood, or according to agency policy, to reduce the risk of septicemia. Check the blood bag for the date of expiration; components expire at midnight on the day marked on the bag unless otherwise specified. Inspect the blood bag for leaks, abnormal color, clots, and bubbles. Blood must be administered as soon as possible (within 20 to 30 minutes) after being received from the blood bank, because this is the maximal allowable time out of monitored storage. Never refrigerate blood in refrigerators other than those used in blood banks; if the blood is not administered within 20 to 30 minutes, return it to the blood bank. The recommended rate of infusion varies with the blood component being transfused and depends on the client's condition; generally blood is infused as quickly as the client's condition allows. Components containing few red blood cells (RBCs) and platelets may be infused rapidly, but caution should be taken to avoid circulatory overload. The nurse should measure vital signs and assess lung sounds before the transfusion and again after the first 15 minutes and every 30 minutes to 1 hour (per agency policy) until 1 hour after the transfusion is completed. Client Assessment Assess for any cultural or religious beliefs regarding blood transfusions. A Jehovah's Witness cannot receive blood or blood products; this group believes that receiving a blood transfusion has eternal consequences. Ensure that an informed consent has been obtained. Explain the procedure to the client and determine whether the client has ever received a blood transfusion or experienced any previous reactions to blood transfusions. Check the client's vital signs; assess renal, circulatory, and respiratory status and the client's ability to tolerate intravenously administered fluids. If the client's temperature is elevated, notify the health care provider (HCP) before beginning the transfusion; a fever may be a cause for delaying the transfusion in addition to masking a possible symptom of an acute transfusion reaction. Blood Bank Precautions Blood will be released from the blood bank only to personnel specified by agency policy. The name and identification number of the intended recipient must be provided to the blood bank, and a documented permanent record of this information must be maintained. Blood should be transported from the blood bank to only 1 client at a time to prevent blood delivery to the wrong client. Only 1 unit of blood should be transported at a time, even if the client is prescribed to have more than 1 unit transfused. Client Identity and Compatibility Check the HCP's prescription for the administration of the blood product. The most critical phase of the transfusion is confirming product compatibility and verifying client identity. Universal barcode systems for blood transfusions should be used to confirm product compatibility, client identity, and expiration. Two licensed nurses (follow agency policy) need to check the HCP's prescription, the client's identity, and the client's identification band or bracelet and number, verifying that the name and number are identical to those on the blood component tag. At the bedside, the nurse asks the client to state his or her name, and the nurse compares the name with the name on the identification band or bracelet. The nurse checks the blood bag tag, label, and blood requisition form to ensure that ABO and Rh types are compatible. The nurse uses the barcode scanning system per agency policy. If the nurse notes any inconsistencies when verifying client identity and compatibility, the nurse notifies the blood bank immediately. Administration of the Transfusion Maintain standard and transmission-based precautions and surgical asepsis as necessary. Insert an intravenous (IV) line and infuse normal saline; maintain the infusion at a keep-vein-open rate. An 18- or 19-gauge IV needle will be needed to achieve a maximum flow rate of blood products and to prevent damage to RBCs; if a smaller gauge needle must be used, RBCs may be diluted with normal saline (check agency procedure). A central venous catheter is an acceptable venous access option for blood transfusions; for a multilumen catheter, use the largest catheter port available or check the port size to ensure that it is adequate for blood administration. Always check the bag for the volume of the blood component. Blood products should be infused through administration sets designed specifically for blood; use a Y-tubing or straight tubing blood administration set that contains a filter designed to trap fibrin clots and other debris that accumulate during blood storage Premedicate the client with acetaminophen or diphenhydramine, as prescribed, if the client has a history of adverse reactions; if prescribed, oral medications should be administered 30 minutes before the transfusion is started, and intravenously administered medications may be given immediately before the transfusion is started. Instruct the client to report anything unusual immediately. Determine the rate of infusion by the HCP's prescription or, if not specified, by agency policy. Begin the transfusion slowly under close supervision; if no reaction is noted within the first 15 minutes, the flow can be increased to the prescribed rate. During the transfusion, monitor the client for signs and symptoms of a transfusion reaction; the first 15 minutes of the transfusion are the most critical, and the nurse must stay with the client. If an ABO incompatibility exists or a severe allergic reaction occurs, the reaction is usually evident within the first 50 mL of the transfusion. Document the client's tolerance to the administration of the blood product. Monitor appropriate laboratory values and document effectiveness of treatment related to the specific type of blood product. Reactions to the Transfusion If a transfusion reaction occurs, stop the transfusion, change the IV tubing down to the IV site, keep the IV line open with normal saline, notify the HCP and blood bank, and return the blood bag and tubing to the blood bank. Do not leave the client alone, and monitor the client's vital signs and monitor for any life-threatening signs or symptoms. Obtain appropriate laboratory samples, such as blood and urine samples (free hemoglobin indicates that RBCs were hemolyzed), according to agency policies. Check the client's identity before administering a blood product. Be sure to check the health care provider's (HCP's) prescription, that the client has an appropriate venous access site, that crossmatching procedures have been completed, that an informed consent has been obtained, and that the correct client is receiving the correct type of blood. Use barcode scanning systems per agency policy to ensure client safety.

Compatibility Chart for Red Blood Cell Transfusions

The ABO type of the donor should be compatible with the recipient's. Type A can receive from type A or O; type B from type B or O; type AB can receive from type A, B, AB, or O; type O only from type O.

crossmatching

method of matching a donor's blood to the recipient by mixing a sample in a test tube to determine compatibility To determine compatibility, crossmatching is done, in which donor red blood cells are combined with the recipient's serum and Coombs' serum; the crossmatch is compatible if no RBC agglutination occurs.

what are priority concepts when administering blood products?

perfusion & safety

Complications of a Blood Transfusion

▪ Transfusion reactions ▪ Circulatory overload ▪ Septicemia ▪ Iron overload ▪ Disease transmission ▪ Hypocalcemia ▪ Hyperkalemia ▪ Citrate toxicity