Blood Admin Protocols

Protocol Prior to admin: Type & Crossmatch

T&C

• takes ab 45 min

• blood drawn to check for blood type, antigens & antibodies

  • blood band PLACEMENT

• blood bank will match recipient blood w donor

• Know Blood type & Rh Factor

If Rh (+) person is exposed to Rh (-) blood, what reaction would occur?

• no Rh incompatability rx would occur

  • bc Rh (-) = NO antigen

If an Rh (+) mother becomes pregant for the 1st time what kind of exposure would the child recieve?

What would occur with the 2nd pregnancy?

1st pregnancy = 1st exposure→ sensitizes

2nd pregnancy= 2nd exposure→ possibly fatal (fetal hemolysis)

What does HLA testing determine?

performed on recipient to determine if any antibodies would target donated organ or tissue

measures possible incompatabilites prior to donation of blood.

Human leukocyte Antigen (HLA) testing indications?

• multiple tranfusions over time

• freqeuent transfusions over short time

Box 34.8 Best Practice for Pt safety: responsibilities r/t Transfusion Therapy

Before Infusion

• Explain procedure to pt

• assess lab values to make sure blood transfusions are allowed

• Verify the type & compatibility of blood component (s) w pt ID, HRN, DOB

  • check providers order for type, dose, & duration of transfusion; the blood itself for expiration date, discoloration, gas bubbles, or cloudiness

• Check VS, UO, skin color & ANY hx of transfusion reactions to be proactive

• establish or use venous access w/ a 20-gauge needle or catheter to prevent cath occlusion or damage to RBC

• prepare to admin blood products only w IV NS (other IV solut. may cause hemolysis)

During Transfusion

• After receiving products transfuse soon after to prevent bacterial growth or product deterioration

• infuse blood at ordered rate for transfusion type to avoid FVO

• stay & closely monitor pt for 1st 15-30 min of infusion (hemolytic transfusion rx tend to occur during this time)

• After 15-30 min→ check VS & pt condition based on agency to identify early indication of AE

After Transfusion

• once completed, discontinue infusion & dispose of bad & tubing to prevent spread of bloodborne pathogens

• Recheck VS & compare to baseline

• Document all aspects of tranfusion

  • type, product, product number, volume infused, duration, VS & assessments during infusion, ANY adverse reaction [s]

34.9 Patient safety: OA receiving a Transfusion

• assess pt circulatory, kidney & fluid status before starting

• use a needle no larger than 20-gauge

• Take VS q15 min throughout the duration of transfusion. **Changes can indicate FVO & may be the only indicators of Adverse reactions

  • rapid, bounding pulse

  • HTN

  • transfusion reaction

  • hypOtension

  • rapid, thready pulse

  • inc pallor/ashen gray appearance

• admin blood slowly, taking 2-4H for each unit of whole blood, PRBC or plasma

• admin should NOT exceed 4H due to r/o bacterial growth

• Avoid concurrent fluid admin into any other IV site

• Allow for 2H in between infusions of 1 unit before admin of next

• Change blood tubing every 2 units transfused

Normal Hg range

12-18 mg/dl

What should a pt report during an infusion?

• any change in physical or emotional status such as new-onset

  • joint

  • back

  • chest

  • abd pain

  • chills, nausea, feeling unwell or uneasy

NI: transfusion reaction

• stop transfusion & remove blood tubing

• return all components, labs & tubing to blood bank

• Call RRT

• If no other IV access→ keep access & flush with NS

  • Do NOT flush contents of blood tubing→ may exacerbate reaction

• Apply O2 therapy + Diphenhydramine [IV Push]

• Presence of shock→ fluid resuscitation & hemodynamic monitoring needed**

• BP support→ pressors (Epi, norepi, dopamine)

**Table 34.6 Potential tranfusion rx & NI (857)

Whole blood [indications & risks]

• contains: RBC, platelets & plasma. 500 mL

Indications

• rarely used-PRBC preferred

• massive hemorrhage >25% of BV

Risks

• FVO

• stored whole blood is high in K→ hyperkalemia

PRBC (contains, indications & risks)

1 unit contains

• 200 mL RBC

• 100 mL additive solut.

• 30 mL plasma

• NO clotting F

  • Total volume= 250-350 mL/unit

• High viscosity→ needs NS to dilute

• Completion of admin w/in 4H

1 uniy PRBC→ Increases Hg by 1G & Hct 3-4%

Indications

• To help increase o2 carrying capacity→ anemia & malignancies

• to help increase colloidal oncotic pressure

Leukocyte-Poor/Reduced PRBC

Contain < 5 × 10^6 WBC/bag

Indications

• prevent rebrile nonhemolytic transfusion rx

• persons receiving multiple transfusion over time

• immunocompromised

• prevent transmission of CMV

Washed PRBC

• washed w NS→ removes plasma proteins, WBC & platelets

Indications

• IgA- deficient w IgA antibodies→ exposure→ anaphylaxis

• multiple transfusions w febrile rx

• urticarial rx

Irradiated PRBC

Radiation stickers on blood indciate radiation status

Cross matching: Special circumstances based on clinical urgency

Clinical urgency

• Immediate→ Group O- PRBC

• Minutes→ ABO & Rh D type→ group specific blood

• W/in an Hour→ ABO & Rh D type→ complete crossmatch

NI

• get written consent from HCP if using blood w/out crossmatch

• Complete crossmatch after blood admin

Hemolytic Reaction

Recipient product is destroying donor’s blood.

Mistyped

Complications

• DIC

• Renal failure

S/S

• fever

• chills

• anxiety

• back/chest pain

• Inc HR, Low BP

• hemoglobinuria

Febrile Reaction (nonhemolytic)

Platelet admin (rate, indication & NI)

ABO & Rh

IV bolus w special filter rate @ 1-2 ml/min [Total dose over 15-30min]

VS→ before, 15 m after starting & at completion

NI: Tranfuse quickly, w/in 30 min of receiving bc platelets tend to clump.

Indications

• control active bleeding

• Platelet <10,000

• Thrombocytopenia, Leukemia

• DIC

FFP (contains, rate, indications, NI)

• derived from plasma removed from donated WB

Contains

• clotting F & fibrinogen, NO platelets

• 150-300 ml

ABO type required

NI: admin w/in 4H of receiving

• infuse immed after thawing (20-25 m to defrost)

  • clotting f still active

  • rapid tranfuse over 30-60 min

  • use reg Y-set (blood) / straight filtered tubing

Risks

• FVO→ FFP inc colloidal oncotic pressure

• Hypocalcemia→ Rx: calcium gluconate

Indications

• replace clotting factors

• replace plasma volume (hypovolemia)

• DIC

• liver disease

• Active hemorrhage [PT or PTT >1.5x normal]

Granulocyte (WBC) Tranfusion** (NI)

rarely used

MUST be ABO compatible→ contains 30 ml RBC

MUST be irradiated→ to deactivate donor T-lymphocytes [prevent TAGVHD]

NI

• Closely monitor pt for severe rx→ VS Q15 min during

• Infuse slowly (45-60 min)

Indications

• Neutropenic w infections

  • Criteria

    • WBC <500. Fever >20-48H

    • + Bacterial/fungal culture w no response to Abx

Albumin

derived from plasma & heat tx for viral inactivation

Admin w/in 4H bc contains no preservatives

No ABO antibodies→ so no risk for transfusion reaction

NI

• Monitor FVO

• C/I severe anemia & dehydration

Indications

• malnutrition, cirrhosis, renal conditions

• Volume expansion→ from burns/trauma

• BP support→ hypotensive episodes

Albumin 5% solution

Albumin 25% solution

5% [5 Gm/100 ml; isotonic]

Available→ 250 OR 500 mL

Admin→ 2-4 ml/min

Expands plasma volume by 4-5x

Indications

• volume expander treatment → hypovolemic shock (trauma or surgery)

• Svr hypotension

• Maintain oncotic pressure→ treat 3rd spacing

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25% [25 Gm/100 ml; hypertonic]

Available→ 25, 50 or 100 mL units

Admin→ 1 mL/min for rapid fluid shifts

Indications

• Volume expansion→ shift fl from interstitial to intravascular space

Required elements of a transfusion order

• order on the EHR

• blood product to be transfused

• # of products to be transfused

• may include transfusion rate or standard infusion rate

EXAMPLE order

• “Transfuse 2 units Irradiated B+ PRBC over 2H each unit

• IV furosemide 20 mg IVP after each unit

• Repeat CBC (H&H) after each unit

What IV gauge is used for blood admin, what can be administered with it?

18-20 gauge peripheral IV or Central line→ blood is thick, prevent occlusion

Admin ONLY with 0.9% NS

NO admin w lactated ringer/dextrose→ clotting & hemolysis

NO coadmin w other meds→ clotting

What indicates becterial growth/hemolysis of product?

Discoloration

gas bubbles

cloudiness

Forms of ID & verification before admin

Blood product checks

• requires 2 RN

• check armband including→ MRN, ABO group & Rh type

• Blood unit number & donor blood group should match on→ ID armband, bank label/attached to bag

• Check correct blood componenent

Any signs of discrepancies

• DO NOT PROCEED

• Contact→ Blood Bank Lab ASAP

what are the 3 primary NON negotiable blood product checks?

• LABEL

  • exp date

  • ABO + Rh

  • unit number

  • component label

• INTEGRITY

  • leaks

• APPEARANCE

  • color

  • cloudiness

  • abnormalities

  • clots

Setting up Transfusion

• DO NOT SPIKE BAG WHEN HANGING FROM IV POLE

• IV tubing requires filters

  • removes sediments from stored product

  • CHANGE tubing/filters every 4H or every 2 UNITS

• Prime tubing w NS

• Prime w blood

NI & safety checks during blood admin

• stay w pt during first 15 min

• Transfuse at 2ml/min for the first 15

• Monitor→ itching, hives, rash, flushing, SOB

• Recheck VS→ T, HR, BP, RR & SpO2

If NO adverse effects

• transfuse 1 unit over 2H (max <4H)

  • NI: blood cannot hang >4H at room temp

Q1H during transfusion→ VS

Repeat at end of transfusion→ VS

What Cues would indicated STOPPING a TRANSFUSION?

Instruct pt to REPORT what s/s

• Inc Temp by 1 degree** from baseline

• BP change (± 10 mmHg)

• Significant Inc HR

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REPORT

• hives/itching

• fever/chills

• chest/abd pain

• SOB

• restless

• back pain or pain at infusion sitr

• Any alteration in mood

• Blood in Urine (hemoglobinuria)

Actions after transfusion is completed?

• Flush tubing w NS

• Repeat VS

• Document EHR→ pt reaction, s/s, any alterations or adverse effects, how it was tolerated, labs (CBC: H&H), VS.

How many units are ordered at a time?

What should be done prior to admin a second unit?

Clinical reassessment after transfusions

ONE ORDER AT A TIME

Checks before Transfusion

• current Hg level?

• target Hg level?

• would this be achieved by transfusing another unit?

---

Each unit transfused is an independent clinical decision→ Reassessment

• is pt still symptomatic

• is further transfusion indicated?

• only order 1 unit at a time for non-bleeding pt

• Document reason for transfusion each time.

What is the first action/intervention for MOST reactions?

+Following interventions to ensure pt safety

STOP BLOOD TRANS IMMEDIATELY!

• Maintain IV access & flush w NS

  • use NEW IV tubing

  • AVOID removing catheter

  • AVOID flushing contents of blood tubing into pt

• STAY. with patient→ Repeat VS Q5 min

• Notify provider & lab→ send blood tubing, labels, transfusion record & remaining product to lab/bank

• If SOB

  • fowlers position

  • O2 Rx

  • IV benadryl (IVP)

• Monitor pt & Rx→ antihistamines, fluids, pressors, steroids

• UA→ check for presence of HgB (RBC hemolysis)

Cues: Transfusion rx in an unconscious/sedated Patient

• Dec or Inc HR

• Dec BP

• Fever

• Signs of Hg in urine→ cola/wine color

• Oliguria or anuria

• bleeding

Early Complications

<24H

• acute hemolytuc transfusion reaction

• febrile (non-hemolytic)

• Bacterial contamination (rare)

• Anaphylaxis

• Allergic Rxn

• TACO

Delayed Complications

>24H

• infection

• Iron overload (PRBC, WB)

• post-transfusion purpura

• TRALI

• TAGVHD

Acute Hemolytic Rxn & NI

Cause

• ABO/Rh incompatible

  • immediate response

• Commonly bc human error→ preventable

CUES

• occurs w/in 30 min or first 200 mL of admin

• low back pain (FIRST sign)

• chills

• burning along infusion vein & oozing at IV site

• Dec BP & Inc HR, shock

• CP, dyspnea, restless

• Flank pain

• Hemoglobinuria

• Ac Renal failure

• feeling of impending doom

NI

• Stop transfusion

• O2 supp

• IV fluids

• Epi & other pressors

• Monitor→ DIC & renal failure

Allergic/Urticarial/Anaphylactic Rxn

Cause

• allergen in donor blood

CUES

• mild→ hives, flushing, rash, itching

• Severe→ fever, N/V, anaphylaxis/shock (facial swelling, angioedema), dyspnea, cardiac arrest

NI

• Stop transfusion

• Monitor VS

• Antihistamines, epi, steroids

• If pt needs transfusion later→ PRE-MEDICATE

  • use washed/ reduced PRBC +special filters to remove WBC

Febrile (Non-hemolytic) Rxn

Cause

• hypersensitivity to leukocytes, platelets, or plasma proteins

CUES

• occurs w/in 30 min- 2H post transfusion

• mild→ fever, chills

• Severe→ HA, chest tightness, flank pain, INC HR

NI

• Antipyretics for fever

• Antihistamine

• Leukocyte filter for NEXT transfusion

• Leukocyte Reduced/Washed RBC→ for future transfusions

Transfusion-Associated Circulatory Overload (TACO)

Cause

• too rapid transfusion & inc circulatory volume

CUES

• w/in 6H of transfusion

• Dyspnea, crackles, orthopnea

• Inc BP & HR (bounding)

• JVD

• Confusion

• Peripheral edema

NI

• Notify HCP immed

• slow/stop transfusion

• Diuretics

• Oxygen

• bronchodilators

• Monitor BS & SaO2

• UPRIGHT W FEET DEPENDENT

Transfusion Graft vs Host DIsease

Cause

• T-cell lymph attacks host tissues

• rare life threaening

• imuunosuppressed pt

CUES

• w/in 1-2 weeks post admin

• Skin changes (erythema, ulcerations, scaling)

• edema

• Thrombocytopenia

• Hemolytic anemia

• Hair loss

• A/N/V, wt loss

• chronic hepatitis

• recurrent infections

PREVENTION

• Irradiated blood products→ dec T-cell