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 $\text{Hb}$ / $\text{Hct}$ 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 = $\text{O}^-$; universal recipient = $\text{AB}^+$.
• Acceptable donor units by recipient type:
  • $\text{O}^+$ ⇐ $\text{O}^+$ or $\text{O}^-$.
  • $\text{O}^-$ ⇐ $\text{O}^-$ only.
  • $\text{A}^+$ ⇐ $\text{A}^+,\,A^-,$ or $\text{O}^+,\,O^-$.
  • $\text{A}^-$ ⇐ $\text{A}^-$ or $\text{O}^-$.
  • $\text{B}^+$ ⇐ $\text{B}^+,\,B^-,$ or $\text{O}^+,\,O^-$.
  • $\text{B}^-$ ⇐ $\text{B}^-$ or $\text{O}^-$.
  • $\text{AB}^+$ ⇐ Any ABO/Rh type (RBCs from all +/-).
  • $\text{AB}^-$ ⇐ 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; $1\,\text{unit}\approx250{-}300\,\text{mL}$.
  • Restores oxygen-carrying capacity in acute/chronic anemia, GI bleeds, trauma.
• Whole Blood
  • $1\,\text{unit}\approx450\,\text{mL}$ containing RBC, WBC, platelets, plasma.
  • Reserved for massive bleeding (≥1 blood volume), neonatal total exchange, cardiopulmonary bypass.
• Platelet Concentrate
  • “1 pack” ≈ $50\,\text{mL}$; should raise platelet count by $5{-}8\times10^3/\mu\text{L}$.
  • Indications: active bleeding, diffuse petechiae, severe thrombocytopenia.
• Leukocyte-Poor Red Cells
  • $\ge90\%$ of donor WBC removed; $1\,\text{unit}\approx200{-}250\,\text{mL}$.
  • Decreases febrile non-hemolytic reactions, CMV transmission; used in leukemia, prior reactions, potential renal transplant.
• Washed RBC
  • Near-complete removal of WBC & plasma proteins; $1\,\text{unit}\approx300\,\text{mL}$.
  • 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.
  • $1\,\text{unit}\approx150{-}250\,\text{mL};$ 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 $50\,\text{mg}$ 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 $\leq5\,\text{mL}/\text{kg}/\text{h}$; 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 $\text{Hb},\,\text{Hct},$ 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