Chapter 27: Blood and Blood Products

Albumin

*protein in blood; maintains the proper amount of water in the blood* *Purpose:* Expands circulating blood volume by exerting oncotic pressure *Therapeutic Uses:* -hypovolemia -hypoalbuminemia -burns -adult respiratory distress [ARDs] -cardiopulmonary bypass -hemolytic disease in newborns *Types of Reactions:* -fluid volume overload -pulmonary edema

Whole Blood

*refers to the mixture of both plasma and formed elements* *Purpose:* Increase circulating blood volume *Therapeutic Uses:* -replacement therapy for acute blood loss due to traumatic injuries or surgical procedures -volume expansion in pt who have extensive burn injury, dehydration, shock *Type of Reactions* -ALL 8

Febrile [FEVER] Nonhemolytic Reaction

Most COMMON reaction *S/S:* Sudden chills or fever, headache -Fever: increase in temp greater than 1 degree C from baseline *Nursing Consideration:* -observe for manifestations of reaction and STOP transfusion, keep IV line open with 0.9% sodium chloride -notify provider immediately -administer *acetaminophen* for fever

Blood Groups and Compatibilities

The most important blood groups are ABO and RhD. Transfusion with ABO incompatible blood can lead to severe and potentially fatal transfusion reactions. RhD is highly immunogenic and can lead to red cell haemolysis in certain settings.

Rhesus D (RhD) Antigen

There are more than 40 different kinds of Rh antigens. The most significant Rh antigen is RhD. When RhD is present on the red cell surface, the red cells are called RhD positive. Antibodies to RhD develop only after an individual is exposed to RhD antigens via transfusion, pregnancy or organ transplantation. Anti RhD (or anti-D) antibodies destroy RhD positive red cells and can lead to haemolytic transfusion reactions. This is of particular importance in pregnancy where anti-D antibodies can cross the placenta from mother to unborn child and lead to haemolytic disease of the newborn. As a general rule, RhD negative individuals should not be transfused with RhD positive red cells, especially RhD negative girls and women of childbearing age. When a transfusion is given, it is preferable for patients to receive blood and plasma of the same ABO and RhD group.

Complications & Reactions [8]

i. Acute Hemolytic Reaction ii. Febrile Nonhemolytic Reaction iii. Anaphylaxis iv. Mild Allergic Reaction v. Fluid Overload vi. Sepsis vii. Hyperkalemia viii. Transfusion-Associated Graft vs Host Disease

White Blood Cells (leukocytes)

White blood cells protect the body from infection. They are much fewer in number than red blood cells, accounting for about 1 percent of your blood. The most common type of white blood cell is the neutrophil, which is the "immediate response" cell and accounts for 55 to 70 percent of the total white blood cell count. Each neutrophil lives less than a day, so your bone marrow must constantly make new neutrophils to maintain protection against infection. Transfusion of neutrophils is generally not effective since they do not remain in the body for very long. The other major type of white blood cell is a lymphocyte. There are two main populations of these cells. T lymphocytes help regulate the function of other immune cells and directly attack various infected cells and tumors. B lymphocytes make antibodies, which are proteins that specifically target bacteria, viruses, and other foreign materials.

Contraindications/Precautions

Contraindicated in pt who have hypersensitivity reactions observe culturally sensitive or religious issues regarding blood transfusion, such as pt who is Jehovah's Witnesses. -infusing colloids and other plasma expanders can be acceptable

Hyperkalemia

*Due to the lysis of blood cells* *S/S:* -bradycardia -hypotension -irregular heartbeat -paresthesia of extremities -muscle twitching -potassium level >5.0 mEq/L *Nursing Considerations:* -lysis of blood cells is more likely in products that were previously frozen or older than 1 week -check potassium before transfusion for baseline -notify provider immediately if hyperkalemia occurs Paresthesia: an abnormal sensation, typically tingling, pricking ("pins and needles") or burning, caused chiefly by pressure on or damage to peripheral nerves. Usually felt in the hands, arms, legs, or feet, but can also occurs in other parts of the body. The sensation, which happens without warning, is usually painless and described as tingling or numbness, skin crawling, or itching. Most people have experienced temporary paresthesia- a feeling of "pins and needles"- at some time in their lives when they have sat with legs crossed for too long, or fallen asleep with an arm crooked under their head. It happens when sustained pressure is placed on a nerve. The feeling quickly goes away when the pressure is relieved.

Packed RBCs (PRBCs)

*Purpose:* Increase the number of RBCs *Therapeutic Uses:* -Most common use is severe and symptomatic anemia -Can also be used with hemoglobinopathies, erythroblastosis fetalis and medication induced hemolytic anemia *Hemoglobinopathy*: a hereditary condition involving an abnormality in the structure of hemoglobin *Erythroblastosis fetalis*: hemolytic disease of the fetus and newborn that occurs when the immune system of an Rh-negative mother produces antibodies to an antigen in the blood of an Rh-positive fetus which cross the placenta and destroy fetal erythrocytes and that is characterized by an increase in circulating erythroblasts (an immature erythrocyte, containing a nucleus- a nucleated cell in bone marrow that develops into an erythrocyte) and by jaundice *Hemolytic Anemia*: a disorder in which RBCs are destroyed faster than they can be made. (hemolysis: destruction of RBCs, anemia: lower than normal amount of RBCs) *Type of Reactions:* All but FLUID OVERLOAD

Anaphylactic Reaction

*S/S:* -Anxiety -Urticaria: (Hives) characterized by the development of raised welts or hives, angioedema (swelling) or both at once. -Wheezing -Shock -Cardiac Arrest *Nursing Considerations:* -if manifestations occur, STOP transfusion, keep IV line open with 0.9% sodium chloride -initiate CPR -have *epinephrine* ready for IM or IV injection

Circulatory Overload [Fluid Overload]

*S/S:* -cough -SOB -crackles -HTN -tachycardia -distended neck veins *Nursing Observation:* -in older adults or pt at risk for fluid overload, transfuse 1 unit of PRBCs over 2-4 hrs, avoiding any concurrent fluid infusion into another IV site. -monitor VS every 15 min throughout transfusion. -if possible, wait at least 2 hrs between units of blood if multiple units are prescribed -if manifestations occur, STOP transfusion, place pt in a sitting position with legs DOWN, and notify provider -administer diuretics and oxygen as appropriate -monitor I&O -prior to any transfusion, asses kidney, respiratory, and cardiovascular function for risk of overload

Mild Allergic Reaction

*S/S:* Flushing, itching, urticaria *Nursing Considerations:* -note that a pt who has a hx of allergic reaction to blood transfusion or has undergone a stem cell transplant might receive a prescription for *washed [leukocyte poor] RBCs* to prevent allergic reaction -if manifestations occur, STOP transfusion, keep IV line open with 0.9% sodium chloride -if manifestations are mild and there is no respiratory compromise, *antihistamines* may be prescribed and the transfusion restarted slowly

Sepsis

*S/S:* rapid onset of chills and fever, vomiting, diarrhea, hypotension, shock *Nursing Considerations* -ensure IV access, have equipment prepared prior to removing blood product from refrigeration -inspect blood product for gas bubbles, discoloration, or cloudiness [can indicate bacterial contamination] and return to blood bank if abnormalities are seen -transfuse unit of blood within 4 hrs after removal from refrigerator -observe for sepsis during and following transfusion -stop transfusion; keep line open with 0.9% NS -notify provider immediately -obtain blood culture, send transfusion bag for analysis for possible contaminants, and treat sepsis with *antibiotics, IV fluids, vasopressors, and steroids*

Complete Transfusion within Specific Time

*Whole Blood, PRBCs*: About 250 mL/unit; infuse within 2-4 hrs *Platelet Concentrate:* About 300 mL/unit; infuse within 15-30 min/unit *FFP:* About 200 mL/unit; infuse over 30-60 min/unit *White Blood Cells:* About 400 mL/unit; infuse over 45 min to 1 hr *Albumin:* -5%: 250 to 500 mL bottle; infuse 1 to 10 mL/min -25%: 50 to 100 mL bottle; infuse 4 mL/min

Fresh Frozen Plasma (FFP)

*plasma rich in clotting factors; desired effect is decrease in prothrombin time* *Purpose:* Replace coagulation factors *Therapeutic Uses:* -active bleeding or massive hemorrhage -extensive burns -shock -disseminated intravascular coagulation -antithrombin III deficiency -thrombotic thrombocytopenic purpura -reversal of anticoagulation effects of warfarin -replacement therapy for coagulation factors [II, V, VII, IX, X, XI] *Disseminated Intravascular Coagulation (DIC)*: is a condition in which blood clots form throughout the body's small blood vessels. These blood clots can reduce or block blood flow through the blood vessels, which can damage the body's organs *Thrombotic Thrombocytopenic Purpura (TTP)*: is a rare blood disorder that causes blood clots to form in small blood vessels. The clots can limit or block the flow of oxygen-rich blood to the body's organs. The increased clotting that occurs in TTP also uses up platelets in the blood. Platelets are blood cell fragments that help form blood clots. These cell fragments stick together to seal small cuts and breaks on blood vessel walls and stops bleeding. This leads to a low platelet count (thrombocytopenia). With fewer platelets available in the blood, bleeding problems can occur. People with TTP may bleed inside their bodies, underneath the skin, or from the surface of the skin. When cut or injured, they also may bleed longer than normal. (Purpura: refers to purple bruises caused by bleeding under the skin) *Antithrombin Deficiency*: is a disorder of blood clotting. People with this condition are at higher than average risk for developing abnormal blood clots, particularly a type of clot that occurs in the deep veins of the legs (DVT). Affected individuals have an increased risk of developing a pulmonary embolism (PE). *Types of Reactions:* All except Hyperkalemia and Graft vs Host

Platelet Concentrate

*platelets removed from unrefrigerated fresh whole blood and stored for transfusion* *Purpose:* Increase platelet counts *Therapeutic Uses:* -indicated in thrombocytopenia for platelet counts less that 20,000/mm (usually caused by aplastic anemia or chemotherapy) -active bleeding [platelet count less than 50,000/mm] *Thrombocytopenia*: deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury. *Aplastic Anemia*: deficiency of all types of blood cells caused by failure of bone marrow development *Chemotherapy*: the treatment of disease by the use of chemical substances, especially the treatment of cancer by cytotoxic and other drugs *Types of Reactions:* Nonhemolytic fever Mild allergic reactions Sepsis

Complete Blood Count (CBC)

A complete blood count (CBC) test gives your doctor important information about the types and numbers of cells in your blood, especially the red blood cells and their percentage (hematocrit) or protein content (hemoglobin), white blood cells, and platelets. The results of a CBC may diagnose conditions like anemia, infection, and other disorders. The platelet count and plasma clotting tests (prothombin time, partial thromboplastin time, and thrombin time) may be used to evaluate bleeding and clotting disorders. Your doctor may also perform a blood smear, which is a way of looking at your blood cells under the microscope. In a normal blood smear, red blood cells will appear as regular, round cells with a pale center. Variations in the size or shape of these cells may suggest a blood disorder.

Blood and Blood Products Uses:

Blood and Blood products are used to -increase intravascular volume -replace clotting factors and other components -replace blood loss -improve oxygen carrying capacity

Where Do Blood Cells Come From?

Blood cells develop from hematopoietic stem cells and are formed in the bone marrow through the highly regulated process of hematopoiesis. Hematopoietic stem cells are capable of transforming into red blood cells, white blood cells, and platelets. These stem cells can be found circulating in the blood and bone marrow in people of all ages, as well as in the umbilical cords of newborn babies. Stem cells from all three sources may be used to treat a variety of diseases, including leukemia, lymphoma, bone marrow failure, and various immune disorders.

Blood Basics

Blood is a specialized body fluid. It has four main components: plasma, red blood cells, white blood cells, and platelets. Blood has many different functions, including: -transporting oxygen and nutrients to the lungs and tissues -forming blood clots to prevent excess blood loss -carrying cells and antibodies that fight infection -bringing waste products to the kidneys and liver, which filter and clean the blood -regulating body temperature The blood that runs through the veins, arteries, and capillaries is known as whole blood, a mixture of about 55 percent plasma and 45 percent blood cells. About 7 to 8 percent of your total body weight is blood. An average-sized man has about 12 pints of blood in his body, and an average-sized woman has about nine pints.

Acute Hemolytic Reaction

Hemolytic: r/t or involving the rupture or destruction of RBCs *S/S:* Chills, fever, LOW BACK PAIN, tachycardia, tachypnea, hypotension -Low back pain due to passage of hemolyzed blood cell through kidneys *Nursing Considerations:* -asses VS at baseline and during the first 15-30 min. Stay with pt during that time. Continue to take VS at least hourly. -*acute hemolytic reaction usually occurs during the first 50 mL of infusion* [but onset can be delayed] -if manifestations occur, STOP INFUSION IMMEDIATELY, *keeping IV line open with 0.9% sodium chloride and NEW IV tubing [don't hook up saline with old tubing-pushing blood in tubing into pt]

Components of Blood Products

Include whole blood and components of blood: i. Whole Blood ii. Packed RBCs [PRBCs] iii. Platelet Concentrate iv. Fresh Frozen Plasma [FFP] v. Pheresed Granulocytes vi. Albumin

Red Blood Cells (Erythrocytes)

Known for their bright red color, red cells are the most abundant cell in the blood, accounting for about 40 to 45 percent of its volume. The shape of a red blood cell is a biconcave disk with a flattened center - in other words, both faces of the disc have shallow bowl-like indentations (a red blood cell looks like a donut). Production of red blood cells is controlled by erythropoietin, a hormone produced primarily by the kidneys. Red blood cells start as immature cells in the bone marrow and after approximately seven days of maturation are released into the bloodstream. Unlike many other cells, red blood cells have no nucleus and can easily change shape, helping them fit through the various blood vessels in your body. However, while the lack of a nucleus makes a red blood cell more flexible, it also limits the life of the cell as it travels through the smallest blood vessels, damaging the cell's membranes and depleting its energy supplies. The red blood cell survives on average only 120 days. Red cells contain a special protein called hemoglobin, which helps carry oxygen from the lungs to the rest of the body and then returns carbon dioxide from the body to the lungs so it can be exhaled. Blood appears red because of the large number of red blood cells, which get their color from the hemoglobin. The percentage of whole blood volume that is made up of red blood cells is called the hematocrit and is a common measure of red blood cell levels.

General Nursing Considerations

Obtain baseline labs and VS -Hgb, Hct, platelet count, total protein, albumin levels, PT, PTT, fibrinogen, potassium, pH, serum calcium Obtain informed consent Assess orders, labs, patient and IV patency -ensure that a 20-gauge or larger IV catheter is used to avoid hemolysis of blood cells Obtain the blood product from the blood bank just before beginning transfusion (no more than 30 min between taking unit of PRBCs from blood bank refrigerator and beginning transfusion). Ensure transfusion is complete at least 4 hrs after product taken from refrigerator. Use blood tubing with filter, only hang with NS -change tubing after every 2 units to prevent bacterial sepsis -for platelet transfusion, use a specialized platelet filter with shorter tubing. Platelets stick onto the standard blood administration filter and to the longer tubing so it it important to use a platelet filter. Check blood with a trained partner Stay with patient during the first 15-30 minutes Do not give other medications in same IV line as the blood Complete within the specified time frame -Document blood type, blood bank number of product, total volume infused, time of start and completion, VS, and any adverse effects as well as actions taken

Transfusion-Associated Graft vs Host Disease

Rare, and occurs 1-2 weeks after transfusion. *S/S:* -n/v -weight loss -hepatitis -thrombocytopenia *Thrombocytopenia*: deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and SLOW blood clotting after injury. *Nursing Considerations:* -can be prevented by using irradiated blood products that contain decreased T-cells and cytokines

In the event of a REACTION...

Stop the transfusion and notify the provider immediately Do not flush the line with the saline that is hanging with the blood (why? do not want to push blood in line into the body) Document start & stop times, volume given and pt's reaction Stay with pt and monitor VS and urine output Notify blood bank and return the blood Obtain and send urine and other ordered labs

ABO Antigens & Antibodies

The ABO blood group is the most important of all the blood group systems. There are four different ABO blood groups determined by whether or not an individual's red cells carry the A antigen, the B antigen, both A and B antigens or neither. Normal healthy individuals, from early in childhood, make red cell antibodies against A or B antigens that are not expressed on their own cells. These naturally occurring antibodies are mainly IgM immunoglobulins. They attack and rapidly destroy red cells carrying the corresponding antigen. For example, anti-A attacks red cells of Group A or AB. Anti-B attacks red cells of Group B or AB. If ABO incompatible red cells are transfused, red cell haemolysis can occur. For example if group A red cells are infused into a recipient who is group O, the recipient's anti-A antibodies bind to the transfused cells. An ABO incompatible transfusion reaction may result in overwhelming haemostatic and complement activation, resulting in shock, renal failure & death

Plasma

The liquid component of blood is called plasma, a mixture of water, sugar, fat, protein, and salts. The main job of the plasma is to transport blood cells throughout your body along with nutrients, waste products, antibodies, clotting proteins, chemical messengers such as hormones, and proteins that help maintain the body's fluid balance.

Platelets (thrombocytes)

Unlike red and white blood cells, platelets are not actually cells but rather small fragments of cells. Platelets help the blood clotting process (or coagulation) by gathering at the site of an injury, sticking to the lining of the injured blood vessel, and forming a platform on which blood coagulation can occur. This results in the formation of a fibrin clot, which covers the wound and prevents blood from leaking out. Fibrin also forms the initial scaffolding upon which new tissue forms, thus promoting healing. A higher than normal number of platelets can cause unnecessary clotting, which can lead to strokes and heart attacks; however, thanks to advances made in antiplatelet therapies, there are treatments available to help prevent these potentially fatal events. Conversely, lower than normal counts can lead to extensive bleeding.

Pheresed Granulocytes

specialized transfusion -given within 24 hours from when collected *Purpose:* Replaces neutrophils/granulocytes *Neutrophils*: type of WBC. Most of the WBCs that lead to the immune system responses are neutrophils. Neutrophils are not limited to a specific area of circulation. They can move freely through the walls of veins and into the tissues of the body to immediately attack all antigens. *Granulocytes*: a category of WBC characterized by the presence of granules in their cytoplasm- a WBC with secretory granules in its cytoplasm. i.e. a neutrophil, basophil, or eosinophil *Therapeutic Uses:* -severe neutropenia (absolute neutrophil count < 500/mm) -life-threatening bacterial/fungal infection NOT responding to antibiotics -neonatal sepsis -neutrophil dysfunction *Neutropenia*: the presence of abnormally few neutrophils in the blood, leading to increased susceptibility to infection. *Types of Reactions:* All except Hyperkalemia and Graft vs Host