Hemtaologic System (transfusion reactions, sickle cell, DIC)

what does a CBC include?

RBCs, WBCs, and platelets

what is the normal range of RBCs for males and females

males: 4.7-6.1

female: 4.2-5.4

what is a normal WBC count?

5,000-10,000

what is a normal platelet count?

150,000-400,000

what is pancytopenia?

suppression of all blood cells (RBCs, WBCs, and platelets)

what does RBC suppression cause?

anemia

what does WBC suppression cause?

neutropenia

what does platelet suppression cause?

thrombocytopenia

what does a peripheral smear show?

morphology (shape, size, color) of blood cellswhat

what disorders can peripheral smear help diagnose?

sickle cell, leukemia

what does thrombocytopenia increase the risk for?

spontaneous hemorrhage

what does thrombocytosis increase the risk for?

excessive clotting

what blood type is a universal donor?

O-

what blood type is the universal recipient?

AB+

what test determines Rh status?

Coombs test

when are PRBCs used?

for anemia ONLY (NOT actively bleeding)

when are platelets given?

for thrombocytopenia (deficiency of platelets)

when is FFP given?

active bleeding, DIC, coat factor depletion

when is albumin used?

(relative) hypovolemia, hypoalbuminemia

when is cryoprecipitate used?

fibrinogen and clotting factor replacement

what fluid can run with blood products?

ONLY NS 0.9%

why can’t dextrose or LR run with blood products?

it causes hemolysis

how long do you have to start a blood infusion after getting the blood?

30 minutes

what is the maximum infusion time for blood?

4 hours

how fast is blood initially run over the first 15 minutes?

60-120 mL/hr (max 2L/min)

who must check the blood at bedside?

2 RNs

when are vitals taken for a transfusion?

before starting, 15 minutes after, and after completion 

who can do vitals after the first 15 minutes of a transfusion?

UAP- but the RN must do vitals at the 15 minute mark

when do acute transfusion reactions occur?

within the first 15 minutes

what are key signs of a hemolytic reaction?

• fever

• chills

• low back (flank pain)

• tachycardia

• hypotension

• dark urine (hemoglobinuria)

what is the first action after nothing a hemolytic reaction?

STOP the transfusion

what are key signs of a febrile reaction?

• fever

• chills

• headache

• tachycardia

• tachypnea

what are the key signs of a mild allergic transfusion reaction?

hives, rash, flushing

what are they key severe signs of a severe allergic transfusion reaction?

anxiety, wheezing, decreased BP

what is a TACO ?

transfusion associated circulatory overload

what are causes of a TACO?

fluid overload (cardiogenic)

what are s/s of a TACO?

• HTN

• JVD

• crackles in the lungs

• NO FEVER

• increased BNP

what is a TRALI?

transfusion related acute lung injury

what is the cause of a TRALI?

donor antibodies that contain neutrophils which attack and damage the alveoli in the lungs

what are s/s of a TRALI?

• SOB

• hypoxia

• crackles

• FEVER

• HYPOtension

  • occurs within 6 hours

when do delayed transfusion reactions occur?

days to months later

what are s/s of a delayed transfusion reaction?

• fever

• jaunidce

• low Hct & low Hgb

what is the treatment for a TACO?

STOP the transfusion

raise HOB

medications

Are we going to give a TACO diuretics and why?

Yes b/c it helps to get off the extra fluid causing the circulatory overload

are we going to give a TACO fluids and why?

No b/c they are already in circulatory overload and it would worsen their condition

what is the treatment for a TRALI?

STOP transfusion

give O2

intubation/mechanical ventilation if needed

What medications are given to a TRALI?

fluids b/c they may be hypotensive

they need leukocyte reduced blood FOR LIFE

who can recieve cell-salvaged blood?

trauma/surgical patients, Jehovah’s Witnesses

what CANNOT receive stored autologous blood?

Jehovah’s witnesses

what causes sickle cell disease?

genetic disorder where RBCs become sickle-shaped, stiff, and sticky—> block blood flow

which populations are commonly affected with sickle cell?

African American, Sub-Saharan African, Mediterranean

what can trigger a sickling crisis?

• infection (MOST COMMON)

• dehydration

• stress

• high altitude

• low oxygen tension

• pneumonia

what is the number one complication of pneumonia?

infection (PNEUMONIA)

why does infection risk increase?

increased spleen damage —> autosplenectomy —> reduced immune function

what organ problems occur due to repeated infections?

• splenomegaly

• avascular necrosis (bones)

• stroke

• renal failure

• liver damage

• HF

• acute chest syndrome

what occurs during a sickle cell crisis?

sickled cells block vessels —> severe pain, tissue hypoxia, capillary leak, hypovolemia, SHOCK

what are some common locations of infarcts/pain with sickle cell?

• arms

• back

• abdomen

• femurs

what are some key clinical manifestations of sickle cell?

• acute and chronic pain

• fever, sweating

• tachypnea

• HTN

• N/V

• anemia (pallor/jaundice)

• organ dysfunction (splenomegaly, hepatomegaly)

what is a peripheral smear going to show with sickle cell?

sickled cells and hemolysis

why does jaundice occur with sickle cell?

increased bilirubin from a large breakdown of RBCs

what are some expected lab changes with sickle cell?

• decreased H&H

• decreased folate

• decreased reticulocytes

• increased bilirubin

what is the first priority in a sickle cell crisis?

oxygen (“O'“ in HOP)

what does hydration do in sickle cell?

reduces blood viscosity making it easier for the cells to move through the blood vessels and decreases sickling

why is DVT prophylaxis needed with sickle cell?

sickle cell increases risk for clotting

what are the treatments for acute chest syndrome?

• O2

• fluids

• antibiotics

• exchange transfusion

what are the first-line medications for sickle cell pain?

IV opioids (morphine, hydromorphone)

what are the adjunct pain therapies for sickle cell?

NSAIDs, neuropathic meds, nerve blocks, heat, PT/OT

what vaccines are essential with sickle cell?

Pneumococcal, H. influenzane, influenza, hepatitis

what is hydroxyurea used for?

prevents a sickle cell crisis by increasing fetal hemoglobin. NOT for a CRISIS

when is hydroxyurea used?

only preventative NOT a crisis

what is the risk with frequent transfusion in sickle cell?

iron overload

how is iron overload treated in sickle cell?

chelation therapy

what is the only cure for sickle cell disease?

hematopoietic stem cell transplant

what is DIC?

a bleeding a clotting disorder where clotting factors and platelets are consumed —> simultaneous hemorrhage + thrombosis

what is the biggest danger in DIC?

bleeding (because the clotting factors become depleted)

what are some acute causes of DIC?

• shock

• hemolytic processess

• obstetric complications

• malignancies

• tissue damage (trauma, burns, crash injury)

what are chronic causes of DIC?

• liver disease

• SLE

• malignancy

what are some clinical manifestations of DIC?

• pallor, cyanosis, necrosis

• tachypnea, orthopnea, PE, ARDS

• tachycardia, hypotension, EKG changes

• distension, bloody stools, ileus

• oliguria, renal failure

• visual changes, HA, ALOC, irritability

  • bone/joint pain

what labs are increased with DIC?

• PT

• PTT

• aPTT

• D-dimer

what labs are decreased with DIC?

• fibrinogen

• platelets

• antithrombin

• plasminogen

what is a normal PTT?

11-12.5 seconds

what is a normal INR?

0.5-1.1

what is the first priority in treating DIC?

stabilize ABCs and treat the underlying cause

what blood product is used for significant bleeding in DIC?

Fresh frozen plasma (FFP)— to replace clotting factors

why is FFP given with DIC?

they have no clotting factors which is why they are hemorrhaging (it treats the underlying cause)

when might anticoagulants be used with DIC?

in selected chronic DIC cases where clotting is the predominant issue

what are key nursing priorities with DIC?

• continuous VS monitoring

• assess for bleeding

• manage fluids/blood products

• monitor tissue perfusion

• reduce anxiety of the client

• monitor coags (PT, PTT, INR, platelets, Hbg/Hct)