Administration of Blood and Blood Products (LO4)

Question 1

Blood serves the following functions:

Answer 1

Supplies oxygen and nutrients for energy production and for tissue maintenance, growth, and repair

Transports cellular waste, including carbon dioxide, to the organs for elimination

Provides a defense against infection by transporting antibodies

Regulates and equalizes body temperature

Helps to maintain the acid-base balance

Regulates fluid and electrolyte balance

Question 2

Blood is made up of 2 basic components:

Answer 2

Cellular or formed elements

Plasma 

Question 3

Plasma

Answer 3

is a sticky straw-coloured fluid

approximately 90% water.

Dissolved within the plasma are over 100 different solutes including proteins, nutrients, electrolytes, and respiratory gases.

Plasma makes up about 55% of the volume of blood.

Question 4

Erythrocytes

Answer 4

(red blood cells)

constitute approximately 45% of the blood’s volume

have a dedicated role in the transportation of respiratory gases.

Question 5

Leukocytes

Answer 5

white blood cells

make up less than 1% of the entire blood volume

play a major role in defense against infection and disease.

Question 6

Platelets

Answer 6

(also less than 1% of blood volume)

are necessary for the clotting process and circulate in the vasculature, inactive until a blood vessel ruptures or is damaged

Question 7

Blood is group classified based

Answer 7

on the types of antigens present or absent on the surfaces of the red blood cell

Question 8

Pre-transfusion testing includes the following

Answer 8

Blood typing

Antibody detection (and antibody identification if antibody screen is positive)

Crossmatching

Question 9

ABO Group

• A
• B
• AB
• O
• name antigen and the frequency in population

Answer 9

-A
40%

-B
11%

-A and B
4%

-None
45%

Question 10

A patient’s antibodies will do what to red blood cells that have corresponding antigen on their surface

Answer 10

A patient’s antibodies will hemolyze (break down or destroy red blood cells) transfused red blood cells that have the corresponding antigen on their surface.

Question 11

Historically, patients whose blood group was unknown and who required an urgent transfusion were provided with

Answer 11

Group O Rh negative red blood cells (RBC) until the patient’s blood group was determined

Question 12

In situations where the blood group is unknown:

Answer 12

The Transfusion Medicine Laboratory (TML) will usually issue O Rh negative RBC’s for females of child bearing potential (less than 45 years of age) until the patient’s blood group is confirmed.

All males and females past child bearing potential, can receive O Rh positive RBC’s until the patient’s blood group is confirmed

Question 13

Crossmatching 

Answer 13

is the process of determining the compatibility of blood from a donor with that of the recipient before transfusion

Question 14

Whole blood 

Answer 14

contains all components of blood

the clotting factors and platelets quickly lose their function during storage

A unit contains approximately 450 mL of whole blood plus 63 mL of anticoagulant

Question 15

Indications of whole blood

Answer 15

indicated in blood loss

not commonly available from blood banks, and therefore red blood cells are more commonly used for treatment of anemia and acute blood loss

One unit of whole blood can increase the patient’s hemoglobin by approximately 10g/L

Question 16

Infusion Rate of whole blood

Answer 16

The initial transfusion should be slow (5 mL/min for 15 minutes) while assessing the patient for adverse reactions

In the absence of any reactions, the product can be infused as quickly as the patient can tolerate it. 

The transfusion must be completed with the 4-hour window

Question 17

whole blood Compatibility

Answer 17

Normal saline

Question 18

whole blood Special Considerations

Answer 18

Whole blood must be ABO-identical to the recipient’s blood group. (Group O is not universal donor for whole blood.)

Question 19

whole blood Administration Set

Answer 19

The administration set must be a blood tubing set that has a 170–260 micron blood filter.

Question 20

whole blood Storage and Shelf Life

Answer 20

Whole blood cannot be left at room temperature for longer than 4 hours.

As soon as collection from the donor is complete, whole blood must be stored at 1–6° C
the red blood cells will retain their function for up to 21–35 days

Question 21

Whole Blood – Overview

• major uses
• storage and shelf life
• administration

Answer 21

Major Uses

• To replace:
• Fibrinogen: in patients actively bleeding who have a low fibrinogen level

Storage and Expiration

• Frozen
• Shelf life: 1 year
• Once thawed, expires after 4 hours stored at 20–24°C

Administration

• Blood tubing required
• Transfuse as rapidly as tolerated

Question 22

Red Blood Cells

Answer 22

along with normal saline are more commonly used than whole blood for acute blood loss

A unit of red blood cells is 240–340 mL and will be more viscous than whole blood
most red blood cell components today have an additive solution mixed with the red blood cells (e.g., AS-3).

With an additive solution, red blood cells will have the same flow rate as whole blood
Red blood cells have minimal amounts of plasma (and ABO antibodies) so you can give ABO-compatible blood rather than only ABO identical

Question 23

Red Blood Cells indications

Answer 23

Red blood cells units are administered to patients requiring increased oxygen-carrying capacity by increasing the circulating red blood cell mass.

Question 24

Infusion Rate

Answer 24

The initial infusion should be slow for the first 15 minutes to assess for adverse reactions, then administered as quickly as the patient tolerates

A slower rate should be considered for patients at risk for overload.

A unit of red blood cells must be administered within 4 hours.

Question 25

red blood cells Compatibility

Answer 25

Normal Saline

Question 26

red blood cells special considerations

Answer 26

In massive transfusions, if possible warm blood with approved blood warmer prior to transfusion to prevent hypothermia.

Question 27

cAdministration Set

Answer 27

The administration set must be a blood tubing set that has a 170–260 micron blood filter. If administering at a fast rate, 16–18 gauge cathlon is required in small vein patients a 20–22 gauge may be used. 

Question 28

red blood cells shelf life

Answer 28

Depending on the anticoagulant and additive solution used, red blood cell units have a shelf life of 21–42 days.

Question 29

red blood cells Storage

Answer 29

Red blood cells must be stored at 2–6° C. During inter-facility transfers, the blood should be stored in a Canadian Blood Services styrofoam box with ice packs.

Question 30

Red Blood Cells – Overview

Answer 30

Major Uses - Bleeding or anemic non-bleeding patients with signs and symptoms of impaired tissue oxygen delivery: - -Tachycardia - -Shortness of breath - -Dizziness Storage and Expiration -2–6° C in approved refrigerator only   -Shelf life: Maximum 42 days Administration - Blood tubing required - Initiate transfusion slowly for first 15 minutes unless massive blood loss - Transfuse over no more than 4 hours - Typically over 1½–2 hours with slower rates for patients at risk for circulatory overload

Question 31

Fresh Frozen Plasma

Answer 31

- Fresh frozen plasma (FFP) is separated from whole blood by centrifugation or sedimentation and must be frozen within 8 hours of collection - A unit of fresh frozen plasma (FFP) contains approximately 250 mL (minimum 100 mL) of anticoagulated plasma.  

Question 32

Fresh Frozen Plasma Indications

Answer 32

Fresh frozen plasma (FFP) is separated from whole blood by centrifugation or sedimentation and must be frozen within 8 hours of collection A unit of fresh frozen plasma (FFP) contains approximately 250 mL (minimum 100 mL) of anticoagulated plasma.   Fresh frozen plasma is indicated for patients requiring plasma coagulation factors, patients on Coumadin requiring emergency invasive procedures before Vitamin K can reverse its effects, or patients with plasma protein deficiencies.

Question 33

Infusion Rate Fresh Frozen Plasma

Answer 33

Recommended infusion time is 30 minutes to 120 minutes but must be infused within 4 hours. 

Question 34

Compatibility Fresh Frozen Plasma

Answer 34

Normal Saline

Question 35

Special Considerations Fresh Frozen Plasma

Answer 35

FFP should be thawed in a water bath at 30–37° C (in a watertight protective plastic over wrap using gentle agitation); this may take 20–30 minutes. Once thawed, FFP must be used immediately and cannot be refrozen.

Question 36

Administration Set

Answer 36

The administration set must be a blood tubing set that has a 170–260 micron blood filter.

Question 37

Storage and Shelf Life

Answer 37

FFP can be stored up to 12 months at temperatures -18° C and for 24 hours at 1–6° C once thawed.

Question 38

Fresh Frozen Plasma – Overview

Answer 38

``` Major Uses -Liver disease coagulopathy --Massive transfusion --Plasma exchange procedures for certain diseases (e.g., TTP/HUS*) Frozen ``` Storage and Expiration -Shelf life: 1 year; Once thawed, expires after 5 days stored at 1–6° C ``` Administration -Blood tubing required Initiate transfusion slowly for first 15 minutes unless massive blood loss -Transfuse over no more than 4 hours -Typically over 30 minutes–2 hours ```

Question 39

Cryoprecipitate

Answer 39

produced by Canadian Blood Services from fresh frozen plasma An insoluble precipitate, cryoprecipitate, is separated from the plasma and refrozen One unit of cryoprecipitate contains 80IU of Factor VIII and 150 mg of fibrinogen in 5–15 mL of plasma.  

Question 40

Indications of cryoprecipitate

Answer 40

Cryoprecipitate is indicated in patients requiring a source of fibrinogen or Factor VIII. It can only be used as a source of Factor VIII when virally inactivated fractionation products or recombinant Factor VIII (used for Hemophilia A) are not available.

Question 41

Infusion Rate of cryoprecipitate

Answer 41

Recommended infusion time is 10–30 minutes per dose but must be complete within 4 hours. 

Question 42

Compatibility of cryoprecipitate

Answer 42

Normal saline

Question 43

Administration Set of cryoprecipitate

Answer 43

The administration set must be a blood tubing set that has a 170–260 micron blood filter.

Question 44

Storage and Shelf Life

Answer 44

Cryoprecipitate can be stored up to 12 months at temperatures of -18° C and for 4 hours at 20-24° C.

Question 45

Cryoprecipitate – Overview

Answer 45

Major Uses - To replace: - Fibrinogen: in patients actively bleeding who have a low fibrinogen level Storage and Expiration - Frozen - Shelf life: 1 year; Once thawed, expires after 5 days stored at 1–6° C Administration - Blood tubing required - Transfuse as rapidly as tolerated

Question 46

4.1 Rights of Transfusion

Answer 46

1. Patient - Is this the right patient? 2. Product - Is this the right product? Check the blood for any clots, leaks, or discolouration Check the expiry date 3. Amount - Is this the right amount? 4. Rate - Is it set at the right rate? 5. Time - Is it the right time?

Question 47

monitoring of a patient receiving blood products:

Answer 47

Only transport those patients receiving blood products that have been  stable for last 24 hours Ensure that vital sign assessment is performed 15 minutes after the initiation of transfusion Repeat vitals every 30 minutes, including a temperature Repeat vitals more often for patients who are at greater risk of overload or experienced previous reactions Ensure that a physician’s order is present specifying the infusion rate and that the rate is no faster than 2 hours per unit All infusions must be complete within 4 hours of initiation A pressure infuser cannot be utilized unless a physician is present during transport Only normal saline can be infused through the same IV line as a blood product All blood tubing must be changed every 2–4 units of blood

Question 48

Steps Upon Completion of Transfusion

Answer 48

Disconnect blood tubing once infusion is complete, as used tubing can be a breeding ground for bacteria Dispose of used blood tubing and bags in a biohazard bag and return to the hospital Continue to assess patient for symptoms of reactions for 6 hours post transfusion

Question 49

Documentation

Answer 49

include the following on your PCR: Start and finish time of each bag Type of product being infused Blood unit number Rate the transfusion was run at Volume transfused during transport Vital signs and assessment findings Any reactions and treatment provided

Question 50

List Potential Complications of Blood and Blood Product Transfusions

Answer 50

Adverse effects, generally referred to as transfusion reactions, are infrequent and vary in severity. Death due to transfusion is rare AIDS has occurred following transfusion, but blood donors are now tested

Question 51

Adverse reactions can be classified as one of the following:

Answer 51

Immediate transfusion reactions Delayed transfusion reactions

Question 52

deaths from blood transfusion

Answer 52

The majority of deaths are due to severe intravascular hemolysis (the destruction of red blood cells) following the administration of ABO mismatched blood Viral hepatitis is the second most common cause of death related to blood transfusion; the association with transfusion may not be recognized, and the hepatitis may develop many months after the transfusion

Question 53

Immediate Transfusion Reactions

Answer 53

Reactions that occur during or within 24 hours of the infusion of blood products ``` They include the following: Acute hemolytic transfusion reactions Febrile reactions Allergic reactions Air embolism Overload Chills Hypothermia ```

Question 54

Acute Hemolytic Transfusion Reactions

Answer 54

rare usually due to the transfusion of ABO incompatible blood following the improper identification of the recipient, either when the crossmatch specimen is taken or when the blood donor is transfused

Question 55

Signs of acute intravascular hemolysis include

Answer 55

fever, chills, hypotension, hemoglobinuria (the presence of hemoglobin in the urine which may cause a reddish discoloration of the urine), flank pain, and shortness of breath

Question 56

disseminated intravascular coagulation (DIC)

Answer 56

results in abnormal bleeding such as around an IV site

Question 57

Febrile Reactions

Answer 57

during transfusion is the most common adverse reaction following a transfusion

Question 58

Febrile Reactions may be due to

Answer 58

Destruction of transfused red blood cells Destruction of transfused white blood cells Bacterial contamination of the blood Reaction to proteins

Question 59

Urticaria during blood transfusion

Answer 59

(hives) fairly common. Unless extremely severe or accompanied by bronchospasm or other signs of impending anaphylaxis, the development of urticaria is not serious Treatment consists of discontinuing the transfusion of the blood product and keeping the IV line open with normal saline.

Question 60

Anaphylaxis

Answer 60

A life-threatening anaphylactic reaction (hypotension, bronchospasm, flushing, and laryngeal edema) rarely occurs during a transfusion of blood Treatment consists of discontinuing the transfusion of the blood product, keeping the IV line open with normal saline, providing high flow O2, etc.

Question 61

Air Embolism

Answer 61

The use of closed plastic systems for the collection of whole blood and for the preparation of blood components has virtually eliminated air embolism as a complication of blood transfusion deaths have occurred when air has been deliberately introduced into the blood bag, or the administration set, to increase the rate of blood flow to the patient

Question 62

Delayed Transfusion Reactions

Answer 62

a delayed reaction occurs after 24 hours and in some cases is not identified until much later.

Question 63

Delayed Transfusion Reactions include

Answer 63

Hepatitis Sepsis Iron overload Delayed hemolytic reaction Post transfusion purpura Transfusion-associated graft-versus-host disease

Question 64

Transfusion Associated Circulatory Overload (TACO)

Answer 64

The infusion of blood products can cause fluid overload and resultant pulmonary edema Circulatory overload occurs when the rate of infusion is excessive for that patient's cardiovascular status especially in the elderly or very young

Question 65

Transfusion Associated Circulatory Overload (TACO) symptom

Answer 65

These patients complain of shortness of breath (which can also be present with anaphylactic and acute hemolytic reactions)

Question 66

Transfusion Associated Circulatory Overload (TACO) treatment

Answer 66

Treatment consists of discontinuing the transfusion of the blood product and keeping the IV line open with normal saline The patient should also be placed on high flow O2 and placed as high as possible in the sitting position.

Question 67

Chills and treatment

Answer 67

Chills may occur as a result of a febrile reaction or in patients with a normal temperature In either case the transfusion should be discontinued Treatment consists of discontinuing the transfusion of the blood product and keeping the IV line open with normal saline

Question 68

Hypothermia and treatment

Answer 68

Hypothermia may occur if cold blood is rapidly transfused Treatment consists of discontinuing the transfusion of the blood product and keeping the IV line open with normal saline

Question 69

Possible Transfusion Reaction | -Fever, chills, or rigors (shaking)

Answer 69

Bacterial contamination Acute hemolytic transfusion reaction Transfusion related acute lung injury (TRALI) Febrile non-hemolytic transfusion reaction

Question 70

Possible Transfusion Reaction | -Urticaria and other allergic symptoms

Answer 70

Anaphylaxis Minor allergic reaction

Question 71

Possible Transfusion Reaction | -dyspnea

Answer 71

Transfusion related acute lung injury (TRALI) Transfusion associated circulatory overload (TACO) Anaphylaxis Bacterial contamination Acute hemolytic transfusion reaction

Question 72

Possible Transfusion Reaction | -Hypotension

Answer 72

Transfusion associated circulatory overload (TACO)

Question 73

Possible Transfusion Reaction | -Hemolysis, hemoglobinuria

Answer 73

Acute hemolytic transfusion reaction

Question 74

Possible Transfusion Reaction | -Pain

Answer 74

Acute hemolytic transfusion reaction IV site Lumbar Transfusion associated circulatory overload (TACO) Chest

Question 75

Possible Transfusion Reaction | -Nausea and vomiting

Answer 75

Acute hemolytic transfusion reaction Acute anaphylaxis Febrile non-hemolytic transfusion reaction

Question 76

Risk and Description | -Minor Allergic Reaction

Answer 76

1 in 100 Mild allergic reaction to an allergen in the blood component/product.

Question 77

Risk and Description | -Anaphylaxis

Answer 77

1 in 40,000 Potentially fatal reaction caused by an allergen that the patient has been sensitized to.

Question 78

Risk and Description | -Febrile Non-Hemolytic Transfusion Reaction

Answer 78

1 in 300 Mild, usually self-limiting, reaction associated with donor white blood cells or cytokines in the blood component/product. Usually presents with fever and/or rigors.

Question 79

Risk and Description | -Bacterial Sepsis (platelet pool)

Answer 79

1 in 10,000 will become symptomatic 1 in 60,000 will be fatal Potentially fatal reaction caused by bacteria inadvertently introduced into the blood component/product or originating from the donor. More common in platelets due to room temperature storage.

Question 80

Risk and Description | -Bacterial Sepsis (red blood cells)

Answer 80

1 in 250,000 will become symptomatic 1 in 500,000 will be fatal More common in platelets due to room temperature storage.

Question 81

Risk and Description | -Acute Hemolytic Transfusion Reaction

Answer 81

1 in 40,000 Potentially fatal reaction caused by blood group incompatibility. Can also be caused by chemical hemolysis  (e.g. incompatible solutions) or mechanical hemolysis (e.g. improper storage). Can result in renal failure, shock, and coagulopathy.

Question 82

Risk and Description | -Transfusion Related Acute Lung Injury (TRALI)

Answer 82

1 in 12,000 Acute hypoxemia with evidence of new bilateral lung infiltrates on X-ray and no evidence of circulatory overload. Patients often require ventilatory support. Usually occurs within 1–2 hours of start of transfusion and rarely after 6 hours. Usually resolves within 24–72 hours, with death occurring in 5–10%. Cause not fully understood. Postulated to be related to donor or recipient antibodies acquired through pregnancy or transfusion.

Question 83

Risk and Description -Transfusion Associated Circulatory Overload (TACO)

Answer 83

1 in 100 Circulatory overload from excessively rapid transfusion and/or in patients at greater risk for overload (e.g. very young, elderly, impaired cardiac function). Preventative measures include slower transfusion rates and pre-emptive diuretics for patients at risk.

Question 84

Risk and Description | -Hypotensive Reaction

Answer 84

Rare Bradykinin mediated hypotension. Characterized by profound drop in blood pressure, usually seen in patients on ACE inhibitors unable to degrade bradykinin in blood component/product.