NURS 370 Med Surg: Module 6: Blood Products and Transfusion Reactions

Blood Product Functions

1. Restore volume

2. Improve oxygenation

3. Replace platelets

4. Replace granulocytes

5. Replace clotting factors

Indications for Blood Products

1. Acute blood loss

2. Anemia

3. Thrombocytopenia

4. Coagulopathy, DIC

5. Neutropenia/infection unresponsive to antibiotics

Type ABlood

Has A antigens on red cells and anti-B antibodies in plasma. Can receive blood from A and O.

Type B Blood

Has B antigens and anti-A antibodies. Can receive blood from B and O.

Type AB Blood

Has both A and B antigens and no anti-A or anti-B antibodies, making it a universal recipient.

Type O Blood

Has no A or B antigens but both anti-A and anti-B antibodies, making it a universal donor (can only receive from O).

Rh Factor

(D antigen)

1. If the "D" antigen is present, the blood is Rh positive (Rh+).

2. If the "D" antigen is absent, the blood is Rh negative (Rh-).

3. About 85% of people have the "D" antigen, making them Rh positive.

4. People do not naturally have antibodies against the "D" antigen; these only form if an Rh negative person is exposed to Rh positive blood by transfusion or during pregnancy.

Blood Transfusion Compatibility: Red Blood Cells

Patients receive RBCs matching their ABO and Rh type or from universal donors (O type, Rh matched).

Blood Transfusion Compatibility: Plasma

Compatibility depends on antibodies; AB plasma is universal, while type O plasma is less compatible.

Blood Transfusion Compatibility: Whole Blood

Must match both ABO and Rh group for safety.

Testing Requirements: Whole Blood, RBCs

Require ABO typing, Rh typing, and cross-matching.

Testing Requirements: Platelets, Plasma

Require ABO (and Rh for platelets) typing, no cross-matching.

Testing Requirements: Granulocytes

Require ABO and Rh, cross-matching, and HLA typing.

Testing Requirements: Cryoprecipitate

No special ABO/Rh compatibility needed.

Whole Blood

1. Contains all components (RBCs, Plasma, Platelets) Combined with anti-coagulant during collection, otherwise unprocessed

2. Requires cross match to avoid hemolytic transfusion reactions

3. There is an increased risk of circulatory overload with whole blood transfusion because of its volume and composition.

4. NOT first choice for resuscitation; packed RBCs or other components are typically preferred.

5. Expiration date short compared to other blood products.

Packed Red Blood Cells

1. Preferred transfusion product.

2. First choice for correcting anemia and improving oxygen-carrying capacity.

3. One unit typically increases hematocrit by about 3-4% and hemoglobin by roughly 1 g/dL.

4. Often leukocyte-reduced to minimize immunologic reactions.

5. Irradiated version is used for immunosuppressed patients to prevent transfusion-associated graft-versus-host disease.

Platelet Transfusions

1. Generally do not require cross-matching unless the product contains a significant amount of red blood cells.

2. They are commonly indicated for conditions like:

A) Alloimmune disorders

B) Heparin-induced thrombocytopenia

C) Surgical or consumptive thrombocytopenia

D) Malignancy or chemotherapy-related consumption disorders

E) Hemophilia.

3. Infusions are usually administered over 30 minutes, with a 170-micron filter to remove aggregates.

4. May be given by syringe, especially in certain pediatric or rapid-infusion scenarios, instead of standard tubing. This practice helps ensure safe administration and minimizes complications during transfusion.

Granulocyte (WBC) Transfusions Composition

Granulocyte transfusions contain concentrated granulocytes, plus some lymphocytes, platelets, and a small amount of RBCs suspended in 200-300 mL plasma.

Granulocyte (WBC) Transfusions Indications

Given for congenital WBC dysfunction, severe neutropenia, or inability to control infection with antibiotics.

Granulocyte (WBC) Transfusions Administration

1. Infuse over 1-2 hours.

2. There is a high incidence of non-hemolytic febrile reactions.

Granulocyte (WBC) Transfusions Prevention of Reactions

1. Premedicate with diphenhydramine, steroids, and non-aspirin antipyretics.

2. Use a slow transfusion rate to minimize adverse responses.

Cryoprecipitate Composition

1. Is given as ABO-compatible.

2. Contains concentrated clotting factors: VIII, XIII, von Willebrand factor, and fibrinogen.

Cryoprecipitate Indications

Used for congenital deficiency or acquired disseminated intravascular coagulation (DIC), massive transfusions, factor VIII deficiency, and uremia.

Cryoprecipitate Administration

Infused at 1-2 mL per minute using y-set tubing with a 170-micron filter.

Fresh Frozen Plasma (FFP)

1. Provides clotting factors and is not intended for volume resuscitation.

2. It is primarily used for patients with bleeding disorders and those who are pre-surgery.

3. When administering FFP, follow the same precautions as for whole blood and packed red blood cells (PRBCs).

Albumin

1. Is a plasma protein that makes up 80% of plasma's colloid oncotic activity and is derived from donor plasma.

2. It is used to expand volume because it pulls extravascular fluid into the circulation.

3. Indications include shock, trauma, burns, and sepsis, and it can be used to induce diuresis (often with furosemide).

4. Is supplied as 25% and 5% solutions in various volumes and is administered from glass bottles using special albumin tubing. The infusion rate is 2-4 mL/minute.

5. Caution is needed in patients with heart failure due to the risk of extracellular volume expansion.

Types of Transfusions

1. Homologous

2. Autologous

3. Designated Donation

Homologous

Volunteer donation unknown to recipient

Autologous ("auto" = "self")

1. Transfusion of one's own blood

2. Collected pre-operatively

3. Collected intra-operatively (salvage)

Designated donation

Volunteer donation specified for a particular recipient

Potential Risk & Harm in Transfusion

1. The RN is responsible for the safety of the patient during all aspects of blood transfusion therapy.

2. Assessment must occur pre-transfusion, during transfusion, and after transfusion.

3. Legal aspects of informed consent:

A) The physician conducts the initial conversation about risks and benefits.

B) The RN is responsible for verifying that the patient was informed and that signed consent was obtained.

Principles & Methods: Blood Administration

1. Review agency's protocols, policies, and procedures.

2. Verify the recipient's informed consent and document it in the chart.

3. Confirm authorized prescriber's prescription for the transfusion.

4. Pre-transfusion: Ensure proper venous access with the minimum required gauge and appropriate equipment.

Catheter Gauge Recommendations for Blood Transfusions

1. Adults: 22-14 gauge catheters are acceptable; size may need adjustment depending on rate of infusion.

2. Infants and toddlers: 24-22 gauge catheters are acceptable; may require infusion through a pump or syringe.

Principles & Methods: Blood Administration

1. Review agency's protocols, policies, and procedures.

2. Verify recipient's informed consent (chart documentation).

3. Verify authorized prescriber's prescription.

Principles & Methods: Blood Administration Pre-transfusion

1. Ensure venous access of the minimum required gauge, with proper equipment.

2. Perform assessment: labs, vital signs with temperature, breath sounds, urine output, history of transfusion reaction.

3. Administer pre-meds if prescribed.

4. Educate the patient regarding the steps of infusion.

Verifying Correct Product/Patient

To verify the correct blood product and patient before transfusion, check all blood bag and label elements:

1. Unit number: Unique identification for tracking.

2. Blood product: Type of product (e.g., packed red blood cells).

3. Preservative: Solution used to store the blood.

4. Type of donor: (e.g., volunteer donor).

5. Expiration date: Must not be passed before transfusion.

6. Blood type and Rh: Match this to the patient's documentation and wristband.

Initiating the Transfusion Set Up

1. Use NS (normal saline) to prime the blood tubing.

2. Set up filters and controller pumps according to agency policy (only use pumps designated for blood to prevent hemolysis).

3. Connect the blood line to the patient and verify patent venous access, typically using an 18-22 gauge needle.

4. Provide patient and family education:

A) Explain length of infusion and monitoring assessments.

B) Review symptoms to report (give general guidelines, not graphic details).

Initiating the Transfusion Retrieval and Starting

1. Retrieve blood from the blood bank:

A) Transfusion must begin within 30 minutes of removing blood from the refrigerator.

B) Maximum hang time for blood is 4 hours.

2. After the 2-RN check:

A) Spike the bag.

B) Close NS, open the blood product.

C) Initiate infusion at 50 mL/hour.

D) Stay with the patient.

E) Reassess in 15 minutes for transfusion reactions or changes in vital signs.

Completing the Transfusion

1. Clear the IV line with 0.9% normal saline.

2. Repeat assessments as needed.

3. Document transfusion on the slip and in the medical record.

4. Dispose of blood bag and tubing per agency policy (usually sent back to the blood bank due to possible delayed reaction occurrence).

5. Ensure one copy of the transfusion record is kept in the patient's chart and one copy is returned to the blood bank (with the blood bag as required by agency).

Potential Transfusion Reactions

1. Allergic

2. Febrile

3. Acute Hemolytic

4. Delayed Hemolytic

Transfusion Reaction Delayed Hemolytic

(Incompatible non-ABO factors)

1. Onset: Over 2 days after transfusion

2. Cause: Incompatibility due to factors other than ABO blood type

Transfusion Reaction Delayed Hemolytic Signs and Symptoms

1. Drop in hemoglobin/hematocrit (H/H)

2. Low-grade temperature

3. Malaise

Transfusion Reaction Acute Hemolytic Transfusion Reaction

(Incompatible RBCs)

1. Onset: Usually immediate

2. Cause: Infusion of ABO incompatible blood

Transfusion Reaction Acute Hemolytic Transfusion Reaction Signs & Symptoms

1. Burning sensation in vein, pain in flank/back/chest

2. Fever, chills, shock (increased HR, decreased BP)

3. Dyspnea, cyanosis

4. Oozing blood at IV site (may signal Disseminated Intravascular Coagulation)

Transfusion Reaction Febrile (Non-Hemolytic) Transfusion Reaction

1. Rise of 1°C during infusion

2. Onset: Immediately to 1-2 hours after initiation

3. Cause: Antibodies to leukocytes or platelets

Transfusion Reaction Febrile (Non-Hemolytic) Transfusion Reaction Signs & Symptoms

1. Fever

2. Chills

3. Headache

4. Malaise

Transfusion Reaction Allergic Transfusion Reaction

1. Onset: Immediately, up to 1 hour after initiation

2. Cause: Antibodies against plasma proteins

Allergic Transfusion Reaction Signs & Symptoms

1. Mild: Itching, urticaria, dyspnea, wheezing

2. Anaphylaxis: Generalized flushing, itching, urticaria, stridor, respiratory distress, hypotension, bronchoconstriction, dyspnea, loss of consciousness, nausea, vomiting

Response to Transfusion Reactions

1. Stop transfusion immediately and open normal saline (NS) at "to keep open" (TKO).

2. Immediate assessment: Check vital signs and temperature, breath sounds, skin, and urine output.

3. Notify the physician and the blood bank; complete an unusual occurrence form per agency protocols.

4. Be prepared to provide urine and blood samples; return the remaining blood in the bag (with tubing) to the blood bank.

5. Complete all hospital paperwork thoroughly.

6. Document all steps and findings.

Transfusion-Associated Circulatory Overload (TACO)

Volume overload. Pathophysiology: Pulmonary edema due to increased hydrostatic pressure.

Transfusion-Associated Circulatory Overload (TACO) Symptom Onset

During transfusion or 2-6 hours after transfusion

Transfusion-Associated Circulatory Overload (TACO) Clinical Manifestations Respiratory

1. Tachypnea

2. Dyspnea

3. Cough

4. Pulmonary crackles (rales)

5. Decreased O₂ sats

Transfusion-Associated Circulatory Overload (TACO) Clinical Manifestations Cardiovascular

1. Tachycardia

2. Hypertension

3. Increased central venous pressure (CVP),

4. Jugular venous distention (JVD)

5. Widened pulse pressure

Volume Overload (TACO) Actions

1. Stop blood product infusion and maintain IV access.

2. Stop other IV infusions (keep TKO line).

3. Position the patient in high-Fowler's position.

4. Administer oxygen.

5. Verify blood product match to rule out transfusion reaction.

6. Consult the physician regarding diuretic therapy.

Potential Transfusion Reactions Potassium toxicity

Can occur with stored or aged blood, as potassium leaks from cells over time.

Potential Transfusion Reactions Hypocalcemia

Citrate in blood products binds calcium, reducing free calcium levels.

Potential Transfusion Reactions Hypothermia

Risk increases when transfusing multiple units or giving rapid infusions of cold blood.

Potential Transfusion Reactions Infections

Transfusion-transmitted infections include

Hepatitis B

Hepatitis C

HIV

Cytomegalovirus

Malaria

West Nile Virus.

Blood Products Administration: Key Take-Aways Catheter size

Follow evidence/principles—18-22 gauge is standard.

Blood Products Administration: Key Take-Aways Saline prime

Common practice but not strictly required.

Blood Products Administration: Key Take-Aways Tubing

Can be used for up to 4 hours (multiple units permitted).

Blood Products Administration: Key Take-Aways Blood out of refrigerator

Must be started within 30 minutes.

Blood Products Administration: Key Take-Aways Initial 15 minutes

Infuse no faster than 50 mL/hour.

Blood Products Administration: Key Take-Aways Most common reactions

Allergic and febrile.

Blood Products Administration: Key Take-Aways Rapid/multiple transfusions

Citrate binds calcium—monitor for hypocalcemia.

Stored RBCs leak potassium—monitor for hyperkalemia.

Blood Products Administration: Key Take-Aways Blood warmers

Use for rapid infusions and/or if cold agglutinins present.