Blood Transfusions: Administration and Patient Safety

Blood Transfusions: Responsibilities and Procedures

• Maintaining patient safety remains a priority, even when not directly administering blood.
• Responsibilities include verifying blood appropriateness, spiking saline bags for RNs, and performing bedside tasks (e.g., administering Biotinamide).
• Monitoring for signs and symptoms (e.g., complications, constipation) and knowing when to stop blood administration is crucial.
• Qualified personnel can insert IV catheters for blood administration below a specified point.
• Priming tubing with normal saline before blood administration is a preparatory step.

Blood Tubing and Priming

• Blood tubing includes two spikes: one for blood and one for saline.
• The process involves spiking with normal saline first to prime the tubing, followed by priming with blood by the RN.

Vital Sign Monitoring

• Vital signs are monitored at specific intervals after starting blood transfusions (e.g., 5-15 minutes, 30-minute increments, hourly).
• Monitoring frequency and infusion rate are adjusted based on patient-specific factors (e.g., cardiac issues, CHF).
• Patients with CHF require lower initial infusion rates, with potential adjustments based on tolerance.

ABO System and Blood Types

• Blood types are differentiated by the presence of antigens, which act as cell identifiers located on the cell surface.
• Antigens determine blood type compatibility.
• O-negative individuals are universal donors, while AB-positive individuals are universal recipients.

Antibodies and Immune Response

• Antibodies are proteins produced by the immune system to detect and neutralize harmful substances (antigens).
• Antigens can be introduced via blood components, bacteria, or viruses.

Blood Components

• Plasma constitutes 55% of blood volume and is composed of 91% water, 7% proteins, and 2% other solutes.
• Blood also contains platelets, leukocytes (white blood cells), and erythrocytes (red blood cells).
• Normal platelet count ranges from 150,000 to 400,000. Too much Coumadin or Heparin would drop this count.

Coagulation and Cross-Matching

• Fibrinogen and prothrombin are crucial components of the coagulation process.
• Cross-matching ensures blood compatibility before transfusion.

Historical Context and Screening

• Significant advancements have occurred in blood screening processes, reducing the risk of disease transmission.
• Stringent screening protocols have minimized the possibility of transmitting infectious agents through blood transfusions.

Hemoglobin Levels and Transfusion Thresholds

• Normal hemoglobin levels are around 14.
• Transfusion is typically considered when hemoglobin levels drop below 7, increasing the risk to the heart and oxygen delivery.
• Low hemoglobin levels (e.g., below 7) can result in inadequate oxygen transport, affecting cellular function and potentially causing confusion or brain injury.
• The lowest recorded hemoglobin level mentioned was 4.5.

Immunological Considerations

• Transfusions always carry a risk of reaction because the body may recognize the new blood as a foreign body.
• Blood transfusions involve complex immunological reactions related to antigens, antibodies, and immune responses.
• Transfusions can be relevant in organ transplants, diagnosis, and prevention of diseases.

Rh Factor

• The Rh factor, or Rhesus factor, indicates the presence or absence of a specific protein on red blood cells.
• Rh incompatibility between mother and fetus requires intervention.

Blood Type Antibodies

• A-positive and A-negative blood types have anti-B antibodies.
• AB-positive and AB-negative blood types have no antibodies.
• B-positive and B-negative blood types have anti-A antibodies.
• O-positive and O-negative blood types have both anti-A and anti-B antibodies.
• A has B antibodies, B has A antibodies, AB has none, and O has both A and B antibodies.

Blood Bag Inspection

• Blood bags must be carefully inspected for patient label details (name, date of birth, MRN), expiration date, and any signs of abnormality.
• The scanning process (patient, bag, expiration date) is crucial for verification.

Poly Solutions

• Poly solutions, also known as volume expanders, include natural (e.g., albumin) and synthetic (e.g., Dextran, Hetastarch) types.
• Albumin solutions (5% and 25%) are examples of natural volume expanders.

Volume Expanders: Considerations

• Volume expanders increase plasma volume, and we should be cautious of raising blood pressure too high.
• Synthetic blood is beneficial for individuals with rare blood types or religious objections to allogenic blood.

Albumin

• Albumin is a natural plasma protein produced by the body.
• It can be extracted from plasma through a process called apheresis, which separates blood components.
• Albumin solutions primarily increase plasma volume in cases of hypovolemia.

Crystalloids

• Crystalloids (e.g., normal saline, lactated Ringer's) are preferred for trauma and blood loss due to their electrolyte content.
• Lactated Ringer's solution contains electrolytes that help restore balance in cases of burns, hemorrhage, or dehydration.

Monitoring During Infusion

• During the first hour of infusion, monitor for hives and reactions.

Adverse Reactions and Interventions

• If a patient experiences an adverse reaction to a blood product, the infusion must be stopped immediately.
• A new bag of saline should be used to maintain IV access, and the physician should be notified.
• For patients with a history of reactions, premedication with Benadryl and dexamethasone may be considered.
• The blood bag and tubing should be sent back to the lab for testing to identify the cause of the reaction (e.g., mislabeling, contamination).

Types of Transfusion Reactions

• Transfusion reactions can manifest differently, ranging from fever and chills to severe anaphylactic responses.

Acute Hemolytic Transfusion Reaction

• Mechanism involves antigen-antibody reaction to incompatible blood.
• Symptoms include fever, chills, nausea, dyspnea, chest pain, back pain, hypotension, and hematuria.
• Back pain may indicate spleen involvement, leading to blood breakdown and blood in the urine.
• Onset typically occurs shortly after starting the transfusion.

Anaphylactic Transfusion Reaction

• This is a severe allergic reaction.

Transfusion-Associated Circulatory Overload (TACO)

• Occurs when the cardiovascular system is unable to manage the additional fluid volume.
• Symptoms include cough, orthopnea, dyspnea, and cyanosis.
• Onset can occur up to 12 hours after transfusion.
• Interventions include stopping the infusion, calling for help, administering oxygen and diuretics.

Delayed Hemolytic Reaction

• Occurs when the patient's body starts to attack the red blood cells. Does not occur immediately but later on.
• Unexplained fever, decreased hematocrit, two to fourteen days after transfusion.
• Transfusion may be required in worst case scenario.

Infusion Rate Calculations

• One liter is a thousand milliliters. To calculate infusion times, use proportional math.
• If the numbers do not work out perfectly, round to the nearest number.

Examples:

• 1 liter of normal saline with a rate of 65
  ewline ml/hr started at 6PM will finish at 3:23 AM.
• 1000 / 65 = 15.3846, which is 15 hourse and 23 minutes. 6PM + 15 hours = 9 AM + 23 minutes.
• 1000 ml of lactated ringers going at 45 ml/hr started at 3 AM will finish at 1:13 AM the following day.
• 1000 / 45 = 22.222, which is 22 hours and 13 minutes.

Flow Rate Example

• 300 ml of normal saline over fifteen minutes. What would you set the pump to.

(300 \text{ ml} / 15 \text{ min}) * (60 \text{ min} / 1 \text{ hour}) = 1200 \text{ ml/hour}

• Remember, the pump only uses mls per hour.