Blood Administration: Key Terms and Definitions for Medical Practice

Blood components

• RBC/WBC/Platelets= 45%

• Plasma= 55%

Uses of blood

• Restoring volume and oxygen-carrying capacity

• Providing clotting factors/platelets

• Manage hematologic diseases

• HOWEVER, MUST FIX THE UNDERLYING PROBLEM

Autologous blood transfusion

• Donation of client's own blood before a scheduled procedure

• Reduces risk of disease transmission & transfusion complications

• Donation can be made every 3 days as long as hemoglobin remains in safe range

• Donations should begin 5 weeks before and end no later than 3 days before transfusion date

• Still requires a filter

Blood salvage transfusion

• Type of autologous donation done during procedures

• Suctioning blood from body cavity, joint spaces, or other closed body sites

• May need to be "washed" to removed tissue debris

Designation donor transfusion

• Homologous or allogenic donor

• Recipients select their own compatible donor

• Does not reduce risk of disease transmission, but there is comfort in knowing where the blood comes from

Compatibility

• Type and crossmatch sample drawn from client

• Recipient ABO type & Rh type are identified

• Antibody screen done to determine presence of antibodies other than anti-A and anti-B

• Crossmatching is done using recipient serum & Coomb's serum to ensure no RBC agglutination = COMPATIBILITY

Blood types

• Type A, B, AB, or O is determined by presence of antigens

• Antibodies develop on RBC that do not have the corresponding antigen

  • Type A has A antigens and B antibodies

  • Type B has B antigens and A antibodies

  • Type AB has both A and B antigens and NO antibodies

  • Type O has no antigens and both A and B antibodies

Rh- positive is determined by?

Present D antigen

Rh- negative is determined by?

Absent D antigen

Human Leukocyte Antigen (HLA) system

• Genes and protein products located on surface of WBC

• Involved in immune regulation

• If HLA is found on WBC, can lead to hypersensitivity to even organ failure so we give irradiated RBCs

A negative can receive from

Only a negative

A positive can receive from

Both a negative and a positive

Packed red blood cells

• Used to replace erythrocytes

• Infuse within 4 hours of initiation

• Each unit increases the hemoglobin by 1 g/dL and hematocrit by 3%

  • Change in lab values takes at least one hour after completion

• Requires type & cross-match

Leukocyte- poor or reduced PRBC

• Leukocytes, proteins, plasma are removed or reduced

• Used to restore oxygen-carrying capacity & intravascular volume

• Replaces RBCs while preventing febrile, nonhemolytic transfusion reactions

Washed PRBC

• Depleted of plasma, platelets, leukocytes

• Given to those with history of transfusion reactions or hematopoietic stem cell transplants

Irradiated PRBC

• Replaces RBCs while preventing transfusion-associated graft-versus-host disease (TA-GvHD)

  • PRBCs exposed to a special dose of gamma radiation

  • Radiation inactivates donor lymphocytes

• Used in immunodeficient patients

  • Bone marrow transplants

  • Hematologic malignancy

• Any blood component can be irradiated

Whole blood

• Replaces red cell mass and plasma volume

  • When you need EVERYTHING replaced

  • Complete replacement

• Infuse within 4 hours of initiation

• Each unit increases the hemoglobin by 1 g/dL and hematocrit by 3%

  • Change in lab values takes at least one hour after completion

• Requires type & cross-match

Platelets

• Used to treat thrombocytopenia & platelet dysfunctions

• Volume in each unit varies

• Requires type but not cross-match since there are no RBC but… is usually done anyway

• Administer rapidly within 6 hours of pooling – over 15-30 minutes

• Evaluate effectiveness passed on platelet count at 1 hour and again at 18-24 hours after administration

  • Each unit of platelets should yield a 5,000-10,000 mm3 increase

Giving platelets requires

Type but not cross-match

How do you administer platelets?

Administer rapidly within 6 hrs of pooling- over 15-30 mins

Evaluate effectiveness passed on platelet count at

1 hr and again at 18-24 hrs after adminstration

Fresh Frozen Plasma

• Used to replace all clotting factors without RBC or platelets & control bleeding when replacement of coagulation factors is needed (e.g., DIC).

  • Patient is actively bleeding / about to bleed / clotting factors are low

• Contains no platelets

• Infuse within 2 hours of thawing, while clotting factors are still viable

• Infuse over 15-30 minutes

• Evaluate effectiveness by coagulation studies (PT, PTT) & resolution of hypovolemia

• Requires type & cross-match

How to infuse fresh frozen plasma?

• Infuse within 2 hrs of thawing while clotting factors are still viable

• Infuse over 15-30 minutes

How do you evaluate the effectiveness of fresh frozen plasma given?

By coag studied (PT, PTT) & resolution of hypovolemia

Cryoprecipitate

• Prepared from FFP

• Used to replace only certain clotting factors

• Given often with Factor VIII & low fibrinogen (r/t massive bleeding)

• Can be stored for 1 year but once thawed must be used

• Infuse over 15-30 minutes

• Evaluate effectiveness by coagulation studies

• PT, PTT & fibrinogen

• Requires type & cross-matching since prepared from FFP

Cryoprecipitate can be stored for how long?

1 year but must be used once thawed

Cryoprecipitate is infused over?

15-30 minutes

Granulocytes

• Type of White Blood Cell (WBC)

• Can be transfused in a client with sepsis or neutropenic and unresponsive to antibiotics

• Evaluate effectiveness by WBC & differential counts

• Rare

What evaluates the effectiveness of granulocytes?

WBC and differential counts

Large volume of refrigerated blood can cause?

Cardiac dysrhythmias

Equipment

• All RBC require a straight or Y-type set with 170-260-micron filter specially designed to prevent hemolysis and trap fibrin clots & debris

• Administer with infusion pump or pressure infuser not to exceed 300 mmHg

• Blood warmer – prevents hypothermia & adverse reactions

  • Warms blood to near-body temperature (37* C)

  • Large volumes of refrigerated blood can cause cardiac dysrhythmias

General precautions

• No solution other than normal saline

• Never add med to or piggyback into a blood transfusion

• 1 unit over 4 hrs at a time to prevent complications

• Never exceed 4 hrs

• Change tube with each unit

• Administer within 20-30 min of receiving from blood bank

• Have client void before initiating transfusions

• Measure VS & assess lungs sounds before initiation, then 15 min, then 30 min, and every hour after that until 1 hr after the transfusion

Client assessment

• Cultural or religious belief

• Obtain informed consent

• Assess vital signs, renal, circulatory, respiratory status

  • Notify provider of elevated temperature – may delay transfusion & may mask transfusion reaction

• Have client void before initiating

Blood bank precautions

• Must bring facility required documentation with client demographic info

• One client at a time to prevent wrong blood product to wrong client

• One unit at a time, even if multiple are ordered

Client identity and compatibility

• Check the provider prescription

• CRITICAL STEP

  • Confirm product compatibility, client identity, expiration data on product

• Two licensed nurses (according to policy) to check blood products & client identity AT THE BEDSIDE – scan barcodes when possible

• Verify blood bag tag, label, requisition for ABO & Rh type compatibility

  • Return blood to blood bank if any inconsistencies

Transfusion administration

• Maintain standard & transmission-based precautions

• 20 gauge or larger peripheral IV (18 gauge is preferred)

• Largest port on central line

• Check the volume on the bag

• Premedicate the client 30 minutes before with PO acetaminophen or diphenhydramine if / as prescribed

  • IV medications can be given immediately before

• Instruct client to report anything unusual immediately

• Begin transfusion slowly (2 mL/min) & stay with client for first 15 minutes

• Can increase rate after first 15 minutes if no reaction noted

  • ABO incompatibility & severe allergic reaction is usually evident in first 50 mL

Reactions to transfusions

• Stop the transfusion – DO NOT THROW ANYTHING AWAY

• Change the IV tubing down to the site

• Keep the IV open with a new bag of normal saline

• Notify the provider

• Do not leave the client alone – monitor VS q5 minutes & watch for any life-threatening symptoms

• Obtain blood & urine samples

• Return blood bag, tubing, attached labels, transfusion record, blood & urine sample to blood bank

• Document

Circulatory overload is caused by

The infusion of blood at a rate too rapid for the client to tolerate

What to assess for when a patient is in circulatory overload?

• Cough, dyspnea, chest pain, wheezing

• Headache

• Hypertension, tachycardia, bounding pulse, distended neck veins

Interventions to help a patient who has circulatory overload?

• Place client in upright position with feet in dependent position

• Notify provider

• Administer oxygen, diuretics, morphine sulfate as prescribed

• Monitor for dysrhythmias

Septicemia occurs when

The transfusion of microorganism-contaminated blood

What to assess for in a patient with septicemia?

• Rapid onset of chills and high fever

• Vomiting/diarrhea

• Hypotension, shock

Interventions to help a client with speticemia?

• Notify provider

• Obtain a blood culture and cultures of blood products

• Admin O2, IV fluids, antibiotics, vasopressors, and corticosteroids as prescribed

Iron overload occurs when

A delayed transfusion complication that occurs in a client who received multiple blood transfusions (anemia & thrombocytopenia)

What to assess for in a patient with iron overload?

• Vomiting/diarrhea

• Hypotension

• Altered hematological values

Interventions to take with iron overload

• Deferoxamine IV or subcutaneously – removes accumulated iron via the kidneys

• Turns urine red as iron is excreted

• Continue until serum iron levels return to normal

Hypocalcemia due to a blood transfusion

• Citrate in transfused blood binds with calcium & is excreted

• Assess serum calcium before & after transfusion

• Monitor for signs of hypocalcemia

• Slow transfusion & notify provider if signs of hypocalcemia occur

Hyperkalemia due to a blood transfusion

• Stored blood releases potassium through hemolysis

• The older the blood, the greater the risk

  • Administer fresh blood in presence of renal insufficiency or renal failure

• Assess the date on the blood & serum potassium before & after transfusion

• Monitor the potassium level & for signs and symptoms of hyperkalemia

• Slow the transfusion & notify the provider if signs of hyperkalemia occur

Citrate toxicity

• Citrate, the anticoagulant used in blood products, is metabolized by the liver

• Rapid administration of multiple units of stored blood may cause hypocalcemia & hypomagnesemia when citrate binds calcium and magnesium → citrate toxicity → myocardial depression & coagulopathy

Who is more at risk of Citrate toxicity?

Pts w liver dysfunction & neonates with immature liver function

Treatment for citrate toxicity

• Slow or stop the transfusion to allow the citrate to be metabolized

• Treat hypocalcemia & hypomagnesemia with replacement therapy

Immediate febrile non-hemolytic reaction (FNHTR)

• Most common type

• Occurs in first 30 minutes up to 2 hours post-transfusion

• Antibodies attack donor WBC's

• Fever 1°C or 2°F above baseline

• Continue transfusion unless it becomes severe

Immediate acute hemolytic transfusion reaction

• ABO incompatibility

• Severe flank pain, flushing of face, burning sensation along a vein, headache, chills, fever, lumbar pain, abdominal pain, chest pain, N/V, blood in urine, hypotension, ↑HR, dyspnea

• Occurs in first 15 minutes

• Can lead to acute kidney injury, shock, DIC, death

• Emergency

• Acute hemolysis = Aggressive hemolysis

Transfusion reactions in an unconscious patient

• Weak pulse

• Fever

• Tachycardia or bradycardia

• Hypotension

• Visible hemoglobinuria

• Oliguria or anuria

Delayed transfusion reactions

• Transfusion-Associated Graft-versus-Host Disease (rare and fatal) - Donor cells attack recipient tissue-organ failure

  • Donor cells attack recipient tissue-organ failure

• Can occur days to years after a transfusion

  • If the patient is exposed to same antigen

• Fever, mild jaundice, decreased hematocrit level

• Highest risk in immunocompromised clients

• Death due to bleeding or infection in 3 weeks

• Should receive irradiated products moving forward

Mild allergic reaction to a blood transfusion

• Antibodies react against donor proteins

• Urticaria, itching, wheezing, angioedema, hives, facial flushing

• Can occur anytime during up to one hour after

Anaphylactic reaction to a blood transfusion

• Severe

• Recipient antibodies interact with allergenic proteins

• Severe hypotension, ↑HR, flushed skin, urticaria, chills, loss of consciousness, shock state, bronchospasm