BLOOD-TRANSFUSION

Definition & Purpose of Blood Transfusion

  • Blood transfusion = intravenous administration of donated whole blood or specific blood components.
    • Goal: replace circulatory volume or individual components that have fallen below safe physiologic levels.
  • Typical clinical scenarios requiring transfusion
    • Acute blood loss: trauma, peri-operative bleeding.
    • Chronic losses/production failure: various types of anemia.
    • Hematologic/oncologic diseases: sickle-cell disease, selected cancers, bone-marrow failure syndromes.
    • Congenital / acquired coagulopathies: hemophilia, anticoagulant reversal, platelet defects.

Indications & Examples

  • Injury or surgery ⇒ rapid volume replacement.
  • Anemias (iron-deficiency, aplastic, megaloblastic, etc.) ⇒ increase Hb\text{Hb} / Hct\text{Hct} to improve oxygen delivery.
  • Malignancy (especially marrow infiltrative cancers) ⇒ correct cytopenias caused by chemotherapy or disease.
  • Hemophilia & other clotting-factor deficiencies ⇒ provide missing factors (often via Fresh Frozen Plasma or specific concentrates).
  • Sickle-cell disease ⇒ exchange or simple transfusion to reduce percentage of sickled cells and prevent vaso-occlusion.

ABO / Rh Compatibility Cheat-Sheet

  • Universal donor for red cells = O−\text{O}^-; universal recipient = AB+\text{AB}^+.
  • Acceptable donor units by recipient type:
    • O+\text{O}^+ ⇐ O+\text{O}^+ or O−\text{O}^-.
    • O−\text{O}^- ⇐ O−\text{O}^- only.
    • A+\text{A}^+ ⇐ A+, A−,\text{A}^+,\,A^-, or O+, O−\text{O}^+,\,O^-.
    • A−\text{A}^- ⇐ A−\text{A}^- or O−\text{O}^-.
    • B+\text{B}^+ ⇐ B+, B−,\text{B}^+,\,B^-, or O+, O−\text{O}^+,\,O^-.
    • B−\text{B}^- ⇐ B−\text{B}^- or O−\text{O}^-.
    • AB+\text{AB}^+ ⇐ Any ABO/Rh type (RBCs from all +/-).
    • AB−\text{AB}^- ⇐ All ABO types that are Rh-negative.
  • Compatibility always double-checked with type & screen + crossmatch prior to issue.

Blood Components: Description & Clinical Use

  • Packed Red Blood Cells (PRBC)
    • Most plasma removed; 1 unit≈250−300 mL1\,\text{unit}\approx250{-}300\,\text{mL}.
    • Restores oxygen-carrying capacity in acute/chronic anemia, GI bleeds, trauma.
  • Whole Blood
    • 1 unit≈450 mL1\,\text{unit}\approx450\,\text{mL} containing RBC, WBC, platelets, plasma.
    • Reserved for massive bleeding (≥1 blood volume), neonatal total exchange, cardiopulmonary bypass.
  • Platelet Concentrate
    • “1 pack” ≈ 50 mL50\,\text{mL}; should raise platelet count by 5−8×103/μL5{-}8\times10^3/\mu\text{L}.
    • Indications: active bleeding, diffuse petechiae, severe thrombocytopenia.
  • Leukocyte-Poor Red Cells
    • ≥90%\ge90\% of donor WBC removed; 1 unit≈200−250 mL1\,\text{unit}\approx200{-}250\,\text{mL}.
    • Decreases febrile non-hemolytic reactions, CMV transmission; used in leukemia, prior reactions, potential renal transplant.
  • Washed RBC
    • Near-complete removal of WBC & plasma proteins; 1 unit≈300 mL1\,\text{unit}\approx300\,\text{mL}.
    • Same indications as leukocyte-poor but for patients with severe recurrent reactions; costlier.
  • Fresh Frozen Plasma (FFP)
    • Contains coagulation factors II, V (heat-labile), VII, IX, X, XI, XII, XIII.
    • 1 unit≈150−250 mL;1\,\text{unit}\approx150{-}250\,\text{mL}; requires ≈1 hr to thaw.
    • Uses: emergent warfarin reversal, documented/suspected coagulopathy, factor replacement when specific concentrates unavailable.
  • 5 % Albumin / 5 % Plasma Protein Fraction
    • Colloid volume expanders derived from plasma.
    • Used for hypovolemia following acute blood loss.
  • 25 % Albumin
    • Concentrated colloid drawing extravascular fluid intravascularly; \approx\burns, severe hypoalbuminemia, oncotic support.

Recognizing Transfusion Reactions

  • Acute signs & symptoms (may appear within minutes):
    • Sudden fever, chills
    • Tachycardia, hypotension → may progress to shock
    • Back or chest pain, headache
    • Diaphoresis, flushed skin
    • Hypersensitivity: hives (urticaria), pruritus, wheezing/dyspnea
  • Delayed reactions can occur hours-days later ⇒ continue surveillance post-infusion.

Immediate Management of Suspected Reaction

  1. STOP transfusion immediately.
  2. Keep IV line patent with normal saline (PNSS) at KVO rate.
  3. Monitor & document vital signs plus urine output (hemoglobinuria ↔ hemolysis).
  4. Save blood bag & tubing for lab re-type, crossmatch, cultures.
  5. Pharmacologic adjuncts
    • Mild febrile → antipyretic (e.g., acetaminophen).
    • Urticarial → diphenhydramine 50 mg50\,\text{mg} IV/PO.
  6. Severe hemolytic reaction → maintain renal perfusion (IV fluids, diuretics) to prevent acute tubular necrosis.

Legal & Ethical Foundations

  • RA 7719 (National Blood Service Act of 1994, Philippines)
    • Promotes voluntary, non-remunerated donation.
    • Ensures adequate, safe, equitable blood supply.
    • Nurses should educate clients & families on community benefit & personal safety of donation.
  • Nursing responsibility includes informed consent, accurate identification, meticulous documentation to avoid ‘wrong-blood’ events (rare but catastrophic).

Step-by-Step Nursing Procedure (Intravenous Therapy Standards)

  1. Verify physician’s order; prepare treatment card per hospital policy.
  2. Observe the “10 Rules” for blood/component preparation & administration (patient identity, right product, right dose, etc.).
  3. Explain procedure + rationale to patient/support system; obtain signed consent; elicit prior transfusion history.
  4. Discuss voluntary donation benefits & legal framework (RA 7719).
  5. Request ordered component from blood bank, including typing, crossmatch, infectious-disease screen.
  6. Retrieve unit on clean, lined tray.
  7. Wrap blood bag in clean towel; keep at room temperature (never warm externally unless per protocol).
  8. Dual check (MD + RN): compare patient ID, ABO/Rh, serial no., expiration, compatibility sheet, additional labs.
  9. Obtain baseline vitals; report abnormalities.
  10. Administer any prescribed pre-medications (e.g., antihistamine, antipyretic, steroid) 30 min pre-start.
  11. Perform hand hygiene pre/post procedure.
  12. Gather equipment:
    • IV tray, compatible blood administration set with built-in 170-200 µm filter.
    • Large-bore IV catheter (adults 18-19G; pediatrics 22G).
    • Plain normal saline solution (only acceptable compatible fluid for priming & flushing).
    • Tourniquet, gloves, sterile gauze, tape, IV hook/pole.
  13. If current maintenance fluid contains dextrose, start separate IV site with PNSS (dextrose can cause hemolysis).
  14. Aseptically spike blood bag; fill drip chamber ≥½; prime tubing—expel all air.
  15. Disinfect Y-port of primary PNSS line; connect blood tubing; secure.
  16. Keep PNSS at KVO during transfusion to maintain vein patency.
  17. Initiate transfusion at 10–15 gtt/min (≈2 mL/min) for first 15 min ⇒ critical reaction window; then adjust to prescribed rate (usual adult max ≤5 mL/kg/h\leq5\,\text{mL}/\text{kg}/\text{h}; entire unit within 4 h).
  18. Remain with patient first 10–15 min, watching closely.
  19. Ongoing monitoring: look for flushed skin, chills, fever spike, pruritus, urticaria, dyspnea.
    • If any appear → STOP transfusion, keep saline running, notify MD.
  20. Gently swirl bag hourly to remix cells & plasma; prevents settling/clotting.
  21. Upon completion: close blood clamp, disconnect, resume PNSS per order.
  22. Continue monitoring for late reactions (vitals, respiratory status, skin, urine) for several hours.
  23. Post-transfusion labs: repeat Hb, Hct,\text{Hb},\,\text{Hct}, bleeding time, platelet count within institution-specified window to evaluate efficacy.
  24. Dispose of blood bag, tubing, sharps using biomedical waste protocols.
  25. Document: start/stop times, product ID, volume infused, vitals trends, patient response, nursing actions, physician notifications.
  26. If multiple units given, remind prescriber to order IV calcium gluconate; citrate in stored blood can chelate calcium causing hypocalcemia.

Equipment Anatomy (Y-Type Blood Tubing)

  • Two spikes → one for blood, one for saline.
  • Upper clamps control each fluid branch.
  • Drip chamber with micro-filter removes clots & aggregates.
  • Main roller clamp adjusts infusion rate; slide clamp for quick stop.
  • Y-injection site allows medication or alternate fluid access (rarely used during transfusion to avoid incompatibility).
  • Adapter connects to IV catheter.

Safety, Quality, & Patient Education Points