IV therapy & Blood Transfusion

3 Common Complications Resulting from Long-Term Packed Red Blood Cell Transfusion Therapy

- Infection -Iron overload -Transfusion reaction

Thrombopoietin (TPO)

- stimulates platelet formation

Most institutions limit transfusions to just ___________ units per filter and limit the duration of tubing use to ________, whichever comes first.

-2 (or as much as 4) -4 hours

Ideally, a unit of whole blood or packed RBCs is transfused in ___hours. This time can be lengthened to ___ hours if the patient is at risk for ECV excess.

-2 hours -4 hours Beyond 4 hours, risk for bacterial contamination of the blood is present.

Blood is usually transfused at a rate no faster than _____________ for the first 15 minutes, in order to assess for adverse reactions.

-25 to 50 units per hour

Blood transfusion should begin within __________ of blood pickup from the lab and be completed within _________ of removal from a controlled temperature storage environment in order to minimize blood degradation and microbial contamination.

-30 minutes -4 hours

Diseases Potentially Transmitted by Blood Transfusion: (5)

-Hepatitis (Viral Hepatitis B, C) -AIDS (HIV) -Cytomegalovirus (CMV) -Graft-Versus-Host Disease (GVHD) -Creutzfeldt-Jakob Disease (CJD)

If a hemolytic transfusion reaction or bacterial infection is suspected, the nurse does the following:

-Obtains appropriate blood specimens from the patient -Collects a urine sample as soon as possible to detect hemoglobin in the urine -Documents the reaction according to the institution's policy

Pre-transfusion verification with 2nd nurse: (6)

-PHCP order, -Consent signed, -Right client, -Right blood product and blood group, -expiration date, -Check all info against client ID band and medical record (usually the client will have a separate ID band from the Blood Bank with their number on it to check also.)

Vital signs, which should include respiratory rate, are measured _____, _____, and _____ .

-before the infusion, -and again every 15 minutes for the first 30 minutes, -then hourly until completion of the transfusion.

Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF) (sargramostim [Leukine])

-causes a rapid increase in Neutrophils (wbc's) -GM-CSF is not as specific to neutrophils as is G-CSF; thus, an increase in erythroid (red blood cell) and megakaryocytic (platelet) production may also be seen. -it may have a greater effect on macrophage function and therefore may be more useful against fungal infections

Pre-transfusion client assessment: (4)

-does pt know the reason for the transfusion? -have they ever had a transfusion before, if so have they ever had a transfusion reaction? -(vitals)temperature, pulse, respiration, blood pressure -fluid volume status (e.g., auscultate lungs, assess for jugular venous distention) (to serve as a baseline for comparison during transfusion.)

Erythropoietin (EPO)

-stimulates erythropoiesis (RBC production)

Transfusion of Packed Red Blood Cells: Preprocedure (8)

1. Confirm that the transfusion has been prescribed. 2. Check that patient's blood has been typed and cross-matched. 3. Verify that patient has signed a written consent form per institution or agency policy and agrees to procedure. 4. Explain procedure to patient. Instruct patient in signs and symptoms of transfusion reaction (itching, hives, swelling, shortness of breath, fever, chills). 5. Take patient's temperature, pulse, respiration, blood pressure and assess fluid volume status (e.g., auscultate lungs, assess for jugular venous distention) to serve as a baseline for comparison during transfusion. 6. Note if signs of increased fluid overload present (e.g., heart failure, see Chapter 29), contact primary provider to discuss potential need for a prescription for diuretic, as warranted. 7. Use hand hygiene and wear gloves in accordance with standard precautions. 8. Use appropriately sized needle for insertion in a peripheral vein. Use special tubing that contains a blood filter to screen out fibrin clots and other particulate matter. Do not vent blood container.

Transfusion of Packed Red Blood Cells: Procedure: (9)

1. Obtain packed red blood cells (PRBCs) from the blood bank after the IV line is started. (Institution policy may limit release to only 1 unit at a time.) 2. Double-check labels with another nurse or physician to ensure that the ABO group and Rh type agree with the compatibility record. Check to see that number and type on donor blood label and on patient's medical record are correct. Confirm patient's identification by asking the patient's name and checking the identification wristband. 3. Check blood for gas bubbles and any unusual color or cloudiness. (Gas bubbles may indicate bacterial growth. Abnormal color or cloudiness may be a sign of hemolysis.) 4. Make sure that PRBC transfusion is initiated within 30 minutes after removal of PRBCs from blood bank refrigerator. 5. For the first 15 minutes, run the transfusion slowly—no faster than 5 mL/min. Observe patient carefully for adverse effects. If no adverse effects occur during the first 15 minutes, increase the flow rate unless patient is at high risk for circulatory overload. 6. Monitor closely for 15-30 minutes to detect signs of reaction. Monitor vital signs at regular intervals per institution or agency policy; compare results with baseline measurements. Increase frequency of measurements based on patient's condition. Observe patient frequently throughout the transfusion for any signs of adverse reaction, including restlessness, hives, nausea, vomiting, torso or back pain, shortness of breath, flushing, hematuria, fever, or chills. Should any adverse reaction occur, stop infusion immediately, notify primary provider, and follow the agency's transfusion reaction standard. 7. Note that administration time does not exceed 4 hours because of increased risk of bacterial proliferation. 8. Be alert for signs of adverse reactions: circulatory overload, sepsis, febrile reaction, allergic reaction, and acute hemolytic reaction. 9. Change blood tubing after every 2 units transfused to decrease chance of bacterial contamination.

Transfusion of Packed Red Blood Cells: Post-Procedure:(4)

1. Obtain vital signs and breath sounds; compare with baseline measurements. If signs of increased fluid overload present (e.g., heart failure, see Chapter 29), consider obtaining prescription for diuretic as warranted. 2. Dispose of used materials properly. 3. Document procedure in patient's medical record, including patient assessment findings and tolerance to procedure. 4. Monitor patient for response to and effectiveness of procedure. If patient is at risk, monitor for at least 6 hours for signs of transfusion-associated circulatory overload (TACO); also monitor for signs of delayed hemolytic reaction.

Blood for an autologous transfusion most commonly is obtained by preoperative donation up to ____ weeks before a scheduled surgery.

6 weeks

Delayed hemolytic transfusion reaction

A much milder version of acute hemolytic transfusion reaction that occurs between 24 hours and 28 days after a transfusion. Symptoms are usually milder than in acute hemolytic transfusion reactions and may even be absent. Signs and symptoms of a delayed hemolytic reaction are fever, anemia, increased bilirubin level, decreased or absent haptoglobin, and possibly jaundice. Rarely, there is hemoglobinuria.

Posttransfusion purpura

A rare but potentially fatal condition that may occur when a transfusion recipient develops antibodies against donor platelets, resulting in destruction of both transfused platelets and the patient's own platelets. Can cause a severe decline in the platelet count; usually occurs 5-12 days after a transfusion. Women are more affected than men.

Transfusion-related acute lung injury (TRALI)

A rare but serious reaction that occurs when fluid builds up in the lung within 6 hours of transfusion, but is not related to the volume of blood or blood products infused. Symptoms include inexplicable, profound acute respiratory distress. Signs and symptoms include acute shortness of breath, hypoxia (arterial oxygen saturation [SaO2] less than 90%; partial pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FIO2] ratio of less than 300), hypotension, fever, and eventual pulmonary edema. Cause is not well understood, but reaction is thought to be associated with antibodies in donor blood. TRALI is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury occurring within 6 hours after the blood transfusion. All blood components have been implicated in TRALI, including IVIG, cryoprecipitate, and stem cells. TRALI is the most common cause of transfusion-related death

Transfusion-associated graft vs host disease (TA-GvHD)

A rare, inflammatory response to transfusion that occurs when donor ("graft") T lymphocytes introduced via the transfused blood rapidly increase in number in the recipient (the "host") and then attack the recipient's own cells. Symptoms occur between 2 days and 6 weeks after the transfusion and include fever, a characteristic rash, enlargement of the liver, and diarrhea. A very difficult complication to treat; may result in death.

Hypotensive transfusion reaction

A sudden decrease in systolic blood pressure may occur soon after a transfusion begins and is quickly resolved by stopping the transfusion and delivery of fluid volume.

A patient with a recent diagnosis of ITP (Immune thrombocytopenia) has asked the nurse why the care team has not chosen to administer platelets, stating, I have low platelets, so why not give me a transfusion of exactly what I'm missing? How should the nurse best respond? A) Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body. B) A platelet transfusion often blunts your body's own production of platelets even further. C) Finding a matching donor for a platelet transfusion is exceedingly difficult. D) A very small percentage of the platelets in a transfusion are actually functional.

Ans: A Feedback: Despite extremely low platelet counts, platelet transfusions are usually avoided. Transfusions tend to be ineffective not because the platelets are nonfunctional, but because the patient's antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed.

Deferoxamine (Desferal) & Deferasirox (Exjade)

Deferoxamine (Desferal). Deferoxamine is usually administered by subcutaneous (under the skin) infusion using a small portable pump about the size of a CD player. Patients using the pump are instructed how to sterilize the skin, insert the needle, and operate the pump. The pump is worn for 8-12 hours a day, usually at night while sleeping. Patients who are severely iron overloaded may need a continuous infusion through a central venous catheter. Deferoxamine works by binding with the excess iron so that it can be excreted. Many patients find it hard to tolerate deferoxamine because of the discomfort and inconvenience of using the pump. However, many studies have demonstrated that deferoxamine is very effective at reducing iron overload. Deferasirox (Exjade). Deferasirox is a newer iron chelating medication that comes in a tablet form. It is dissolved in juice or water and taken (by mouth) once a day. Most patients tolerate it very well, but side effects can include: nausea, diarrhea, rash, and more serious effects such as kidney or liver injury. Once the body gets used to the drug, side effects usually go away. Your doctor should monitor your liver and kidneys for potentially serious side effects while you are taking deferasirox. When taking either deferoxamine or deferasirox, you should: Have your vision and hearing tested prior to starting therapy, with re-testing every 6-12 months. Both deferoxamine and deferasirox can cause damage to the eyes and ears.

Long-term transfusion therapy complication and treatment:

Iron overload is a complication unique to people who have had long-term PRBC transfusions. Over time, the excess iron deposits in body tissues can cause organ damage, particularly in the liver, heart, testes, and pancreas. Iron Chelation: Iron chelation is a drug therapy for iron overload. This therapy uses drugs called iron chelators to remove extra iron from your body. There are two iron chelators that are approved by the U.S. Food and Drug Administration (FDA) for use in the United States. Avoid taking Vitamin C unless it is prescribed by your doctor. Under your doctor's specific orders, Vitamin C can be added at a later time to iron chelation therapy and may improve results for some patients. Vitamin C should only be taken in a moderate dose, such as 100 mg daily.

Acute hemolytic transfusion reaction:

Occurs when a patient is given an incompatible blood type and occurs during, immediately after, or within 24 hours of a transfusion. The recipient's body immediately begins to destroy the donated red blood cells, resulting in fever, pain, and sometimes kidney failure. The most rapid hemolysis occurs in ABO incompatibility. Rh incompatibility often causes a less severe reaction. Symptoms consist of · Chills, fever, low back pain, nausea, tachycardia, tachypnea (respiratory distress), blood in urine, pain at the IV site, or anything "unusual." As the erythrocytes are destroyed, the hemoglobin is released from the cells and excreted by the kidneys; therefore, hemoglobin appears in the urine (hemoglobinuria). Hypotension, bronchospasm, and vascular collapse may result. Diminished renal perfusion results in acute kidney injury, and disseminated intravascular coagulation may also occur.

Transfusion-transmitted infection (bacterial contamination)

Occurs when bacteria, parasites, viruses, or other potential pathogens are transmitted in donated blood. Contamination can occur at any point during procurement or processing but often results from organisms on the donor's skin. Preventive measures include meticulous care in the procurement and processing of blood components. When PRBCs or whole blood is transfused, it should be given within a 4-hour period, because warm room temperatures promote bacterial growth. A contaminated unit of blood product may appear normal, or it may have an abnormal color. The signs of bacterial contamination are fever, chills, and hypotension. These manifestations may not occur until the transfusion is complete, occasionally not until several hours after the transfusion. As soon as the reaction is recognized, any remaining transfusion is discontinued. If the condition is not treated immediately with fluids and broad-spectrum antibiotics, sepsis can occur. Sepsis is treated with IV fluids and antibiotics; corticosteroids and vasopressors are often also necessary

Transfusion-associated circulatory overload (TACO)

Occurs when the volume of blood or blood components are transfused and cannot be effectively processed by the recipient. -Can be due to an excessively high infusion rate and/or volume. -Patients with heart or kidney disorders are at greatest risk. PRBCs are safer to use than whole blood. If the administration rate is sufficiently slow, circulatory overload may be prevented. For patients who are at risk for, or already in, circulatory overload, diuretics are given prior to the transfusion or between units of PRBCs. Patients receiving fresh-frozen plasma or even platelets may also develop circulatory overload. The infusion rate of these blood components must also be titrated to the patient's tolerance. Rates of transfusion may need to decrease to less than 100 to 120 mL/hr. Signs of circulatory overload include dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety. Jugular vein distention, crackles at the base of the lungs, and hypoxemia will also develop. Pulmonary edema can quickly develop, as manifested by severe dyspnea and coughing of pink, frothy sputum. Oxygen and morphine may be needed to treat severe dyspnea (see Chapter 29). TACO can develop as late as 6 hours after transfusion. Therefore, patients need close monitoring after the transfusion is completed, particularly those who are at higher risk for developing this complication (e.g., older adults, those with a positive fluid balance prior to transfusion, patients with renal dysfunction, patients with left ventricular dysfunction). Monitoring vital signs, auscultating breath sounds, and assessing for jugular venous distention should be included in patient monitoring.

Allergic reaction

Results from an interaction of an allergen in the transfused blood with antibodies in the blood recipient. Occasionally, infusion of antibodies from the donor may be involved. Reactions can range from skin irritation to more serious symptoms such as difficulty breathing. Symptoms of an allergic reaction are urticaria, itching, and flushing. The reactions are usually mild and respond to antihistamines. If the symptoms resolve after administration of an antihistamine (e.g., diphenhydramine [Benadryl]), the transfusion may be resumed. Rarely, the allergic reaction is severe, with bronchospasm, laryngeal edema, and shock. These reactions are managed with epinephrine, corticosteroids, and vasopressor support, if necessary. Giving the patient antihistamines or corticosteroids before the transfusion may prevent future reactions. For severe reactions, future blood components are washed to remove any remaining plasma proteins.

Adverse reactions associated with blood transfusions

See following cards:

Febrile nonhemolytic transfusion reaction

The most common transfusion reaction, characterized by fever and/or chills in the absence of hemolysis. May occur during or up to 4 hours after a transfusion. These reactions are generally mild and respond quickly to treatment, but fever indicates a more severe reaction with more serious causes. It occurs more frequently in patients who have had previous transfusions (exposure to multiple antigens from previous blood products) and in Rh-negative women who have borne Rh-positive children (exposure to an Rh-positive fetus raises antibody levels in the untreated mother). The diagnosis of a febrile nonhemolytic reaction is made by excluding other potential causes, such as a hemolytic reaction or bacterial contamination of the blood product. The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion has begun. Although the reaction is not life-threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the patient. This reaction can be diminished, even prevented, by further depleting the blood component of donor leukocytes; this is accomplished by a leukocyte reduction filter. Antipyretic agents can be given to prevent fever; however, routine premedication is not advised because it can mask the beginning of a more serious transfusion reaction.

Granulocyte Colony-Stimulating Factor (G-CSF) (filgrastim [Neupogen, Zarxio, Granix])

causes a rapid increase in Neutrophils (wbc's)

When patients have severe blood loss, as with hemorrhage, they often receive rapid transfusions through a _____________________

central venous catheter. A blood-warming device often is necessary because the tip of the central venous catheter lies in the superior vena cava, above the right atrium. Rapid administration of cold blood can cause cardiac dysrhythmias.

Patients who receive large-volume transfusion of citrated blood are at high risk for:

hyperkalemia, hypocalcemia, hypomagnesemia, and metabolic alkalosis.

Researchers in a variety of recent, controlled studies have reported a direct relationship between the liberal use of blood products in a patient and the resulting increase in serious complications, such as: (5)

increased: -nosocomial infection rates, -ventilator times, -ICU and hospital lengths of stay, -autoimmune diseases, -and cancer recurrence rates.

When implementing a blood transfusion, the nurse's primary focus should be on patient safety and the 3 "rights":

right blood component, right patient, and right time.

Transfusion Reaction: Intervention steps:(8)

· STOP the transfusion · Keep IV open: Hang and infuse new tubing & NS (0.9% sodium chloride) · Assess the client and continue to monitor closely · Notify pHCP or emergency response team, and then the blood bank · 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. If the reaction was mild (low grade fever, flushing) after notifying PHCP, they may order an antipyretic (Tylenol) &/or antihistamine (Benadryl) and continue the transfusion.

Blood Transfusion Objectives:

· increase circulating blood volume (trauma, GI bleed), · increase # of RBCs to maintain hemoglobin levels (anemia), · provide selected cellular components (clotting factors, platelets, albumin)

During & After the Procedure:(8)

• Use Y tubing with filter and hang only with NS • Initiate within 30 minutes of receiving from blood bank • Start slow (25-50 units/hr) increase after 15 minutes if no s/s of complication • Stay with client first 15 minutes • Assessment of Respiratory, skin, cardiac, & VS: -before, -after 15 minutes, -then every 30 minutes if no s/s of complication, -again when completed • Remind client you do not expect any complications but to report anything unusual to you immediately • Do not exceed 4 hours for unit of blood product or for y tubing -Remain alert and continue to assess for any s/s of transfusion reaction.

Initiating a Blood Transfusion Steps:(7)

• Verify order from PHCP • Ensure Type and Crossmatch have been done (client banded?) • Obtain Informed Consent and ensure 20g or larger IV • Pre transfusion assessment of client, including: -does pt know the reason for the transfusion, have they ever had a transfusion before, if so have they ever had a transfusion reaction? -temperature, pulse, respiration, blood pressure and assess fluid volume status (e.g., auscultate lungs, assess for jugular venous distention) to serve as a baseline for comparison during transfusion. • Verify with another nurse (one nurse must be an RN): -PHCP order, Consent signed, Right client, Right blood product and blood group, expiration date, Check all info against client ID band and medical record usually the client will have a separate ID band from the Blood Bank with their number on it to check also. • Before beginning the transfusion teach client s/s to report to you: -fever, chills dizziness, flank pain, and monitor carefully during and after the transfusion. • If even a minor discrepancy exists, do not give the blood; notify the blood bank immediately to prevent infusion errors.