Lab: Blood transfusions

function of blood

• link between body & organs - carries O2 and waste products

• consists of plasma and cells

plasma components

• 50-60% of blood

• 90% water

• lightest portion of blood

• Composed of proteins, albumin, globulin, fibrinogen and clotting factors, electrolytes, waste products and nutrients

  
  
  

cells in blood

• produced where

• red blood cells (erythrocytes)

• white blood cells (leukocytes)

• platelets (thrombocytes)

• produced in bone marrow of flat and irregular bones (skull, ribs,
  vertebrae, humerus, femur and pelvis)

functions of plasma 5

• clotting factors (prothrombin and fibrinogen are
  synthesized by the liver and circulate in the blood until activated)

• albumin (synthesized by the liver and responsible
  for maintaining blood volume and pressure)

• alpha/beta globulins (synthesized by the liver antibodies
  produced by the lymphocytes) responsible for fighting infection

• Helps maintain temperature (carries heat and is warmed as it circulates)

• Helps maintain pH 7.35-7.45 by buffering

erythrocyte function

• factors that determine blood carrying capacity

• o2 sat measures ?

• carry oxygen bonded to iron in hemoglobin (Hgb) transport O2 from lungs to tissues

• Oxygen-hemoglobin is formed in the pulmonary capillaries where hemoglobin combines with O2 in the lungs

• Amount of hemoglobin, iron and # of RBCs are factors in determining blood carrying capacity

• o2 sat = oxygen carrying capacity of RBCs

RBC lifespan

• days ? phagocytized by?

• what is the forming process ? in utero vs after birth

• where does iron go

• where does heme go

• what causes jaundice / increase bilirubin?

• 120 days - phagocytized by cells in liver, spleen and bone marrow

• Hematopoiesis - process by which blood cells are formed. Liver and spleen do the job in utero and the bone marrow takes over after birth

• Iron is returned to bone marrow for new hemoglobin or stored in the liver

• “Heme” part of hemoglobin is converted to bilirubin-(bile) out through feces

• When diseases cause an increase or premature destruction of RBC’s you see increased serum bilirubin and jaundice

bone marrow is the ?

• red vs yellow

• compensation?

• primary site of hematopoiesis

• red marrow - cells , yellow marrow - fat

• In disease states the liver and the spleen will compensate and help with production

N/C of bone marrow biopsy

• positon

• monitor

• pain

• specimen collection ?

• sidelying fetal position

• monitor site - small amount of drainage expected

• comfort - painful procedure

• irretrievable specimen - extremely difficult, painful, risky, or impossible to collect a second time (someone must phycsically walk down to lab )

blood donation contraindications and parameters

• Donors may not have

• history of hepatitis,

• having received a blood transfusion within the past year,

• untreated syphilis or malaria,

• drug abuse,

• possible exposure to HIV

• skin infections, recent tattoo,

• cancer

• Caution if on aspirin

• Parameters for weight, H and H etc

complications from blood donation

• Weakness/ fainting

• Bleeding

• Angina - must reassess , could be a serious issue

autologous donations

• collected when ?

• advantages vs disadvantages

• Patients own blood is collected for future: ex: elective surgeries, ortho surgeries

• Collected about a month before

• Advantages: Can be frozen and safe to use up to 10 years & less chance of reaction

• Disadvantages: Expensive procedure if needless, may not be enough for emergency

intraoperative blood salvage

• common in Vascular-orthopedic and thoracic surgeries

• During procedure – blood lost in a sterile cavity is suctioned into
  machine, washed & filtered and returned to the patient

hemodilution

• Removal of 1 or 2 units of blood (right before or after anesthesia) and replaced with a colloid or crystalloid solution. (albumin, NS)

• The blood obtained is re-infused after surgery

blood processing

• done when

• tested for ?

• how can we limit reactions

• done immediately

• Tested for HIV, hepatitis, syphilis, West Nile virus

• Typed ABO and Rh

• some centers filter the leukocytes to diminish the possibility of the recipient forming antibodies to antigens found on the leukocytes (small amount attach to RBCs)

Blood type

• refers to antigens on surface of RBCs

• ABO and RH (+) or (-)

Type A

• antigen A on RBCs

• B antibodies in plasma (fights off B antigens = bad reaction)

Type B

• antigen B on RBC

• A antibody in plasma (fights off A antigens = bad reaction)

Type AB

• both antibodies on RBC

• no antibodies in plamsa (universal recipient AB+)

Type O

• neither antigens on RBC

• both A and B antibodies in plasma

Rh factor

• presence or absence of Rh factor

• Rh + can receive both (+) and (-) blood

• Rh - can only receive (-) blood

Pre - procedure of blood transfusion

• what do we need to know

• assessments?

• what tests needed

• what do we need from provider and from pt

• IV gauge?

• fluid ?

• what kind of tubing ? what are we doing before calling blood bank

• know pt history - any reactions in the past ?

• baseline vitals - lung sounds , edema, any rashes BEFORE administering

• type and cross needed (O- if there is no time to test, screen is only good for 3-4 days )

• order and written consent needed

• IV access - over 22 gauge preferred, must check pantency before getting the blood (only good for 30 min, don’t want to risk not making sure you have access)

• gather NS - always given with blood

• Y-type tubing - prime and fill chamber with NS first , then call the blood bank for blood

during procedure

• after ? call for blood

• double check ?

• looking at blood for ?

• must be given within ?

• infusion rate?

• how long do we stay with pt - what are we reassessing

• total administration time should not exceed ? if blood is not finished ?

• after IV is started, patent and tubing primed call for blood

• double check labels with another nurse (ABO and Rh compatibility, label, expiration date)

• check for bubbles and cloudiness (could be bacteria)

• must be given within 30 minutes after they leave the lab refrigerator

• infuse slowly - 25-50ml over first 15 minutes

• stay with patient for 15 minutes observing for any adverse reactions (SOB, itching, rashes, crackles, temp, BP) - any deviations form baseline ?

• total administration time should not exceed 4 hours - must report if all of blood is not used and sent back down to lab (could be from kink , clot etc.)

post procedure

• how often do we change tubing

• what is asses

• to line ?

• document ?

• bad reaction?

• tubing changed every 2 units of blood

• vital signs, lung sounds and skin recorded and compared to baseline

• flush line to get everything In the pt

• document how pt tolerated procedure

• if pt has a bad reaction - bag must be sent back down to lab

transfusion of platelets and fresh frozen plasma

• gauge ? transfused when ?

• how long do we infuse for FFP vs platelets

• same procedure as PRBCs, but 22 cause is ok (thinner) & must be transfused immediately after getting from blood bank

• FFP infuse each unit over 30-60 minutes

• Platelets infuse as quickly as patient can tolerate

febrile nonhemolytic reaction

• is

• cause

• what is given

• Chills with fever more than 1 degree Celsius elevation

• Cause: antibodies to donor leukocytes that remain in the unit of blood or blood component

• Accounts for approx 90% of reactions

• Tylenol or antihistamine given if occurs – not rec before (may mask serious reaction)

acute hemolytic reaction

• Most dangerous - Life threatening!

• Common Cause: incompatibility ABO or Rh

• RBCs are destroyed

• Fever, chills, low back pain, nausea, chest tightness/ SOB, anxiety

• May lead to hypotension, bronchospasms, acute renal failure and DIC

• immediately stop transfusion

allergic reaction

• s/s?

• cause?

• tx? when do we stop?

• urticarial – hives

• Itching – generalize

• Flushing

• Cause: sensitivity to a plasma protein in the blood

• Mild and antihistamines usually help unless accompanied by
  bronchospasms and dyspnea - must stop is occurs

circulatory overload

• cause ?

• who’s at risk

• what may be ordered

• signs to watch

• what else can we give

• too much too quick

• at risk: HF, kidney failure, elderly

• Sometimes diuretics are ordered between or after
  transfusion for prevention for at risk patients

• Dyspnea, orthopnea, tachycardia, sudden anxiety (*can lead to pulmonary
  edema) watch for coughing & pink frothy sputum

• O2 and morphine may be needed

bacterial contamination

• may be from

• what blood product is at greatest risk

• s/s?

• what do you do

• May be from organisms on the donor’s skin

• Platelets are at greatest risk b/c they are stored at room temp

• Never hang blood longer than 4 hours & change tubing every 2 bags

• May see fever, chills and hypotension

• DISCONTINUE TRANSFUSION, keep line open for antibiotics

• Call physician and return bag and tubing to the blood bank

other reactions

• Transfusion-Related Acute Lung Injury – rare

• Delayed Hemolytic reaction – 2 weeks after transfusion. Usually mild – jaundiced and anemic

• Long term Transfusion – infection, become more sensitive
  to donor antigens – multiple donors, iron overload

Nursing implications for transfusion reactions

• when do we stop

• what do we assess

• what do we do with blood

• If hemolytic or bacterial is suspected?

• Stop the transfusion if pt is having dyspnea, SOB, low BP + notify MD and stay with pt and assess

• Keep IV line open or access available

• Assess respirations and compare vital signs with baseline vitals

• Assess change in mental status?, Chills?

• JVD? Cardio/Respiratory/Renal status?

• Call MD with findings - always have current vitals

• Return blood and tubing to blood bank if ordered

• If hemolytic or bacterial is suspected, obtain a urine culture, blood cultures and possibly CXRay

pediatric considerations

• same exact thing just smaller amount of blood

• Infuse first 50 ml slowly and remain with child for 15 minutes

• Amount may vary depending on age of child

• always use infusion pump child or adult