Blood Transfusion Therapy and Nursing Care

Overview of Blood Products and Transfusion Components

• Whole-Blood Transfusions   - These transfusions are currently not approved by the U.S. Food and Drug Administration (FDA) for civilian use.   - The primary reason for this lack of approval is the inability to complete required infectious disease testing before the product must be used.   - When a whole-blood donation occurs, it is typically centrifuged upon arrival at the blood-banking facility to separate it into specific components.   - Components are transfused based on the individual needs of the patient.

Interprofessional Collaboration in Transfusion Services

• Expert Roles in the Blood Bank   - The blood bank may also be referred to as the transfusion center or transfusion services.   - Nurses collaborate with certified experts categorized by the Association for the Advancement of Blood and Biotherapies (2023):     - Specialist in Blood Banking Technology (SBB): Capable of performing all operations from routine testing to leadership. Responsibilities include supervising staff, providing professional education, and conducting research.     - Technologist in Blood Banking (BB): Performs general operations within the blood bank.     - Donor Phlebotomy Technician (DPT): Specializes in the collection of blood from donors.
• Collaboration Points   - Nurses work with these experts to obtain ordered blood, resolve questions or concerns regarding received blood, and manage transfusion reactions.   - Utilizing unique and complementary abilities of team members optimizes patient care according to the Interprofessional Education Collaborative (IPEC) Expert Panel.

Red Blood Cell (RBC) Transfusions

• Indications and Packaging   - RBCs are administered to replace cells lost due to trauma or surgery.   - They are also used for patients with conditions that destroy RBCs or impair their maturation.   - Packed RBCs (PRBCs): These are supplied in $250\,mL$ bags and are a concentrated source of RBCs.
• Compatibility Requirements   - Donor and recipient blood must be matched to prevent lethal reactions.   - Compatibility is determined by two antigen systems:     - Rh factor (Rhesus factor).     - ABO blood group (A, B, AB, or O).

Platelet Transfusions

• Indications and Counts   - Administered when platelet counts fall below $10,000/mm^3$ ($10 \times 10^9/L$).   - Given to patients with thrombocytopenia who are actively bleeding or scheduled for invasive procedures.
• Donor Types and Volume   - Pooled Platelets: Can be collected from up to $10$ donors. Infusion bags contain approximately $300\,mL$.   - Single-Donor Platelets: Prescribed for patients undergoing hematopoietic stem cell transplantation (HSCT) or those needing multiple transfusions to reduce allergic reactions. Infusion bags contain approximately $200\,mL$.   - Platelets do not necessarily have to be the same blood type as the patient.
• Administration Specifics   - Platelets are fragile and must be infused immediately, usually over a $15$- to $30$-minute period.   - A special transfusion set with a smaller filter and shorter tubing is required.   - Nursing Safety Priority (Action Alert): Do not use a standard blood administration set for platelets; longer tubing increases platelet adherence to the lumen, reducing the amount the patient receives.
• Pre-medication   - Patients with a history of reactions may receive diphenhydramine and acetaminophen before the transfusion to minimize fever and severe chills (rigors).

Plasma Transfusions

• Fresh-Frozen Plasma (FFP)   - Often frozen immediately after donation to preserve clotting factors.   - Must be infused immediately after thawing while factors are active.
• Compatibility and Infusion   - ABO compatibility is required because plasma contains donor antibodies that could react with the recipient's antigens.   - Bags contain approximately $200\,mL$.   - Infusion should be as rapid as the patient tolerates, typically $30$ to $60$ minutes.   - Administration uses a regular Y-set or straight filtered tubing.

Granulocyte (White Blood Cell) Transfusions

• Indications and Risks   - Rare; used for neutropenic patients with infections.   - High risk for severe reactions because WBC surfaces have many antigens recognized as non-self.
• Administration Protocols   - Suspended in $400\,mL$ of plasma.   - Infused slowly over $45$ to $60$ minutes.   - Monitoring is stricter; vital signs may be required every $15$ minutes throughout the entire transfusion.   - A health care provider may need to be present on the hospital unit.
• Drug Interactions   - Amphotericin B: Infusion must be separated from WBC transfusions by $4$ to $6$ hours because it can hemolyze blood cells and mask reaction symptoms.

Massive Transfusion Protocol (MTP)

• Definition and Purpose   - Used for continuing heavy blood loss and hemorrhage.   - Uses all blood components to restore volume, clotting ability, and oxygen-carrying capacity.
• Balanced Delivery   - Protocols often mimic whole blood by delivering PRBCs, plasma, and platelets in specific proportions (e.g., $1:1:1$ or protocols with twice as much plasma and PRBCs as platelets).
• Risks   - Infusion is more rapid than standard protocols.   - Risk for reaction is increased due to the high volume of products.

Nursing Responsibilities: Pretransfusion

• Order and Consent   - Ensure the provider has discussed benefits/risks with the patient.   - A prescription must specify the component type, volume, and special conditions.   - Separate informed consent is usually required.
• Testing and Verification   - A specimen is taken for type and crossmatch.   - Two Registered Nurses must check:     - Patient identification (Name and Date of Birth).     - Health record number.     - ABO and Rh types.     - Expiration date.     - Inspection: Check for discoloration, gas bubbles, or cloudiness (indicators of bacterial growth or hemolysis).   - Nursing Safety Priority: The nurse infusing the blood must be one of the two professionals performing the check.
• Equipment and Solutions   - A blood filter (approximately $170$ microns) is mandatory to remove sediment.   - Only Normal Saline ($0.9\%\,NaCl$) is used. Ringer's lactate or Dextrose in water are prohibited as they cause clotting or hemolysis.   - Never add other drugs to blood products.

Nursing Responsibilities: During and After Transfusion

• Monitoring Baseline and Initial Infusion   - Assess vital signs and temperature immediately before starting.   - Remain with the patient for the first $15$ to $30$ minutes; severe reactions often occur within the first $50\,mL$ of blood.   - Vital signs recorded $15$ minutes after start.
• Rates and Continued Care   - If no reaction, rate may increase to transfuse $1$ unit in $2$ to $4$ hours.   - Vital signs are typically taken every hour thereafter.
• Post-Transfusion Tasks   - Discontinue infusion and dispose of materials in hazardous waste.   - Compare final vital signs to baseline.   - Documentation: Include product type, number, volume, duration, assessments, adverse reactions, and patient response in the electronic health record (EHR).

Transfusion Considerations for the Older Adult

• Pre-assessment: Check circulatory, kidney, and fluid status.
• Needle Size: Use no larger than a $20$-gauge needle.
• Blood Age: Use blood less than $1$ week old if possible to avoid fragile cells and potassium release.
• Vital Signs: Monitor every $15$ minutes throughout.   - Indicators of Fluid Overload: Rapid bounding pulse, hypertension, swollen superficial veins.   - Indicators of Transfusion Reaction: Hypotension, rapid thready pulse, cyanosis, ash-gray appearance.
• Timing: Infuse slowly over $2$ to $4$ hours. Allow $2$ hours between units if possible. Change tubing after every $2$ units.

Acute Transfusion Reactions and Interventions

• Acute vs. Delayed   - Acute: Occurs within $24$ hours.   - Delayed: Occurs after $24$ hours and up to $30$ days.
• Emergency Management Protocol   - First Step: Immediately stop the transfusion.   - Remove blood tubing. Do not flush the remaining blood in the tubing into the patient.   - Keep access open with normal saline.   - Initiate the Rapid Response Team (RRT).   - Notify the blood bank; for hemolytic/bacterial reactions, return the bag, labels, and all tubing to the lab.   - Medications: Oxygen, IV diphenhydramine. For shock: Vasopressors and fluid resuscitation. For rigors: Meperidine.

Specific Potential Transfusion Reactions

Autologous Blood Transfusions

• Definition: Infusion of the patient's own blood; eliminates compatibility problems and disease transmission risk.
• Types:   - Preoperative Autologous Donation: Whole blood collected and stored. RBCs can be stored for $40$ days; frozen for $10$ years.   - Acute Normovolemia Hemodilution: Whole blood withdrawn just before surgery and replaced with volume expanders. Reinfused within $6$ hours. Not for patients with anemia or poor kidney function.   - Intraoperative Autologous Transfusion: Recovery of blood from operative field. Must be reinfused within $6$ hours.   - Postoperative Blood Salvage: Collection of blood from surgical drains for filtered reinfusion.

Questions & Discussion

• Patient Identification Safety Goals   - Room number is NOT an acceptable form of identification.   - Use two methods: Name and Date of Birth.   - Bar code-point of care (BC-POC) systems are used in some facilities to reduce errors.
• Health Equity Note   - TRALI and TACO risks increase when donor and recipient are from different ethnicities due to minor red blood cell antigens not caught in standard screenings.   - Increasing donor population diversity is essential for reducing severe reactions.
• NCLEX Challenge 34.4   - Scenario: Patient with absolute neutrophil count (ANC) < $1000$ and fever of $101.8^{\circ}F$ ($38.7^{\circ}C$) with mouth sores.   - Correct Interventions:     - Administer acetaminophen for fever.     - Wear a mask when entering the room.     - Remind staff to wash hands often.     - Collaborate with a registered dietitian nutritionist (RDN) regarding diet.