Module 7 Part 2 - Blood Transfusion Therapy Flashcards
We rarely give __ blood unless indicated?
whole blood
Blood is 1% RBC and 99% ___
plasma
Plasma is mostly ___
water
What is the bottom line regarding blood volume and what takes priority?
We always want to protect and reestablish circulating volume!
Without it we cannot get the functions of plasma
Major Functions of Blood Plasma
Maintenance of Blood volume
It suspends cellular elements like RBC, WBC, PLT
O2 and CO2 transport
Nutrient exchange
Hormone transport
Waste evacuation
Temperature regulation
There are at least __ different antigens on RBCs
80
ABO System
Way of designating blood as having A antigens, B antigens, both, or neither
How does dominance work in the AB System?
A and B are dominant over O
However, they are codominant to each other
Rh Factor System
Way of designating possession of the rH antigen or not
Positive = have the rH antigen
Negative = not present
How does dominance work for the rH system?
Positive rH is dominant over negative rH
Antibodies are in __; Antigens are on ___
Antibodies are in PLASMA and Antigens are on RBC!!!
If a person has A blood what kind of antibody is in their plasma? B blood? O Blood? AB Blood?
A = Anti B Antibody
B = Anti A Antibody
AB = No Antibody
O = Both A and B antibody
What are the rules for giving rH + and - blood?
We can give + blood people more + blood, but we cannot give a - person + blood since the - person will recognize the rH antigen on the transfusion as foreign and make antibodies against it
We can give rH - blood to positive and negative people because there is no antigen present to make antibodies against
What pattern of genetic inheritance can rH + blood be?
Homozygous dominant or Heterozygous
What pattern of genetic inheritance can rH - blood be?
Homozygous Recessive
Most common blood type? Least common blood type?
Common = O+
Least Common = AB-
This can make it hard to get the rarer blood types transfusions
Transfusion
Blood component therapy
Administration of whole blood or blood components directly into the bloodstream
What regulates the processes of blood products and transfusions?
The federal government through the American Association of Blood Banks (AABB) who have stringent requirements on collection, testing, storage, and distribution (not available in every country)
What are some options for blood transfusions?
- Homologous Blood
- Autologous Blood
- Designated (Directed) Blood
Homologous Blood Transfusion
transfusion of blood from random volunteer donors
There are rigid checks for risk factors
ex: blood drive
Autologous Blood Transfusion
Blood collected from the intended recipient (yourself) prior to a planned procedure or accident - OR - salvaged during surgery via “cell saver”
It eliminates the risk of alloimmunization, immune mediated transfusion reactions, and transmission of viral diseases
Alloimmunization
Risk for a transfusion reaction from blood of someone in the same species (ex: Human to Human)
Designated (Directed) Blood
Blood collected and transfused from a donor designated and picked by the recipient
ex: a family member of a proper blood type
Blood Components that are Available for Transfusion?
Whole Blood
Packed RBC
Modified RBC - Leukocyte-poor (Washed) or Irradiated
Platelets
Granulocytes
Fresh Frozen Plasma
Cryoprecipitate Antihemophilic Factor (AHF)
Coagulation Factor Concentrates
Albumin, Plasma Protein Fraction
Immune system globulin
Whole Blood
RBC, plasma (plasma proteins, globulins, antibodies), stable clotting factors, and an anticoagulant/preservative
It is the entirety of blood with a conservative that is given in emergency situations
Indications for Whole Blood Use
- (Sometimes) Symptomatic Anemia and Major Volume Deficit
2. Massive Hemorrhaging with hypotension, tachycardia, SOB, pallor, low Hgb and Hct
Whole blood is ___ required and often medically ___
Whole blood is RARELY REQUIRED and often medically unnecessary
What could occur if whole blood is given to someone that does not need it?
Circulatory overload
Before giving blood products always…
check for ABO and Rh factor compatibility - TYPE AND CROSS
How should Whole blood be administered?
- Initiate it slowly (70cc/hr) for 15 minutes at first
2. If there is no transfusion reaction then you can increase the rate and infuse for 2-4 hours
What is the exception to starting slow with the whole blood infusion?
It can be pushed as fast as tolerated in massive blood loss or shock scenarios
Tolerance depends on comorbidities and other conditions - for example someone with Progressive Heart Failure cannot handle pushing whole blood usually unless it is dire
What is the cardinal rule of giving blood transfusions?
NEVER RUN WITH ANYTHING BUT NORMAL SALINE (not antibiotics, dextrose solution, electrolyte solution) because of interactions that can occur
Equipment needed to Transfuse Whole Blood
- Needle (19 gauge or larger; 23 in peds - bigger number = smaller lumen)
- Standard straight or Y type blood infusion set with a 170 micron filter
- 0.9% saline
Expected Outcomes of Giving Whole Blood
- Resolution of symptoms and hypovolemic shock and anemia
2. increase in Hct and Hgb depending on number of units given
How much does 1 unit of whole blood increase Hct and Hgb?
1 unit = Hct increase by 3% and Hgb by 1 g/dL
If someone is given 3 units of whole blood what changes will be seen in their Hct and Hgb?
Hct will increase 9% and Hgb will increase byt 3 g/dL
Potential Complications from Whole Blood
Hemolytic Rxn
Allergic Rxn (There is WBC in here)
Hypothermia (from giving cold blood)
Electrolyte Disturbances
Citrate Intoxication
Infectious Disease (Small but potential)
Citrate Intoxication
Citrate is a preservative in blood products that will metabolize to a base in the body
If 5 units is given you could cause something like Metabolic Acidosis
You only have a __ hour window for use of blood products
4 hour window
Rules For Whole Blood Compatibility
- since it has both RBC and antibodies (plasma) these are the rules *
1. There is no universal donor or recipient
2. An ABO type must be given to the same ABO type (a to A, B to B, AB to AB, O to O)
3. Rh- blood can be given to Rh+ or Rh- blood, but Rh+ blood can only be given to Rh+ people
What sort of reaction occurs if someone is given the whole ABO or Rh blood?
A hemolytic transfusion reaction (They will attack one another)
Packed Red Blood Cells
RBCs centrifuged from whole blood with 80-90% of the plasma (antibodies and hidden viruses) removed
Preservatives are added to increase viscosity (Hct increases) and increase shelf life
We give Packed RBCs to…
do the job of RBCs - getting increased oxygen carrying capability
2 Types of Packed RBC
- Citrate Phosphate Dextrose Adenine (CPDA)
2. Additive Solution (100 mL) (AS-1, AS-3, or AS-5)
Indications to give Packed RBC
Increase O2 carrying capacity in symptomatic anemia d/t nutritional deficiencies or acute/chronic blood loss
*This is only if they are without a need for volume expansion
What cases do NOT need packed red blood cells?
- Need for volume expansion
- Wound healing (albumin needed here)
- General Wellbeing
First thing to do when you’re going to administer Packed RBC
Check ABO and Rh compatibility - cross and test
How is Packed RBC administered?
- Initially start slow (about 70 cc/hr) for 15 minutes
- Increase rate as tolerates and infuse in 2-4 hours (never over 4)
* you can subdivide it into aliquots
* may need dilution with NS
Aliquots
A unit of the entire unit of blood we give (it is the same donor and blood product split into portions)
It can be given to ease administration rate and is often used in Pediatric patients who cannot handle quick administration or heart failure patients
Why do we start infusing transfusions slow for 15 minutes?
To check if there is a transfusion reaction (we can tell because they will get a fever)
Equipment for Administering Packed RBC
- Needle (19 gauge or larger; 23 gauge for peds)
- Standard straight or Y type blood infusion set with 170 micron filter
- 0.9% NS
Never do what with blood and other solutions?
never add medications or mix blood with other solutions
Expected outcome of Packed Red Blood Cell transfusion?
- Resolution of Symptoms of Anemia
2. 1 Unit of blood will increase Hct by 3% and Hgb by 1 g/dL
Complications from Packed Red Blood Cell
Infectious Diseases
Hemolytic Reaction
Allergic Reaction (still a little plasma/WBC in here)
Hypothermia
Electrolyte Disturbances
Citrate Intoxication
If we give 250 mL of packed red blood cells, and 500 mL of whole blood, is the patient receiving the same amount of RBC?
Yes, there is 250 mL in RBC in packed red blood cells, and in the whole blood it is 250mL of plasma and 250mL of RBC
Rules for Packed Red Blood Cell compatibility
- It is only cells here, no plasma antibodies*
1. O is a universal donor (no antigens on it)
2. AB is a universal recipient (no antibodies in their plasma to attack things)
3. A can be given to A, B can be given to B
4. Rh - can be given to Rh + or -, but Rh + can only be given to Rh +
Why is it a big problem to give an Rh- woman Rh+ blood?
The body will become sensitive to that agent, and if it does not cause a transfusion rxn now it can have impacts on if that woman has an Rh+ child later on (Erythroblastosis Fetalis)
Leukocyte Poor Red Blood Cells
A type of RBC given where WBC (responsible for allergic rxns) and plasma are washed out of the transfusion product to prevent further reactions
It prevents alloimmunization
When is Leukocyte Poor RBC indicated?
If the patient has a history of blood transfusion reactions - non hemolytic allergic reactions (fever, rash, anaphylaxis)
Why is Leukocyte Poor RBC not just given to everyone if it can prevent allergic reactions?
It is very expensive
When and How is Washing Performed for Leukocyte Poor RBC ?
Washing is done at collection time
It removes 80-95% of WBC and virtually all plasma
It also removes potassium (K)
Requites 1 hour to be processed
Must be transfused within 24 hours if not frozen
What is storage like for Leukocyte Poor Red Blood Cells?
It is often frozen within 6 days of collection and has a high storage time of 10 years!
Thawing and removal of cryoprotectant (glycerol) eliminates virtually all plasma and 99% of WBCs
Needs 90 minutes to process and must be used in 24 hours
Alloimmunization
A transfusion reaction from receiving blood from the same species (ex: Human-Human) that could carry something like Cytomegalovirus
Expected Outcome of Leukocyte Poor Red Blood Cells
Prevention of rxn caused by infusion of WBCs and foreign proteins
Removal of more (99.9%) of leukocytes may also decrease risk of alloimmunization and transmission of CMV
Complications from Leukocyte Poor RBC that can happen
Hemolytic Rxn (if not type and crossed)
Hypothermia
Electrolyte Disturbances
Citrate Intoxication
Infectious Disease (Still a very small risk)
Irradiated Red Blood Cells
RBC product exposed to a measured amount of ironizing (non harmful) radiation that stops donor lymphocytes from replicating and kill anything that could attack the recipient (viruses, bacteria, WBC, donor T cells, etc)
When is Irradiated RBC used?
Babies and Immunocompromised People
In order to use Irradiated RBC the bag must be labeled …
IRRADIATED
Irradiated RBC carries no risk of what?
Radiation risk to transfusionist or recipient
What is the main goal of giving irradiated RBC?
to prevent Graft v Host Disease (Donor Attacks Receiver)
Indications for Irradiated RBC Use?
To prevent post transfusion graft v host disease
Hodgkin’s or Non Hodgkin’s Lymphoma (Cancers)
Acute Leukemia
Congenital Immunodeficiency Disorders
Low birth weight neonates
Intrauterine Transfusions
Bone marrow transplants
Expected Outcome of Irradiated RBC use?
Prevention of GVHD
Complications that can occur from Irradiated RBC use?
Hemolytic Rxn (if wrong type and cross)
Hypothermia
Electrolyte Disturbances
Citrate Intoxication
Infectious Disease
Platelet (Blood Product)
Removed form whole blood
Still contains some RBCs (so it still must be type and crossed)
Given to thrombocytopenic patients
Can be gathered from pooled blood or apheresis (allowing it all to come from different people)
How many units of whole blood is needed to get one unit of platelets?
4-6 units of whole blood
Types of Platelet Transfusion
Random-Donor
Single-Donor
HLA-Matched (Human Leukocyte Antigen matched - still needs cross and test)
Indications to give Platelets
Thrombocytopenia (Chemotherapy induced too)
Platelet Dysfunction
PLT <10-20,000 or Active bleeding with PLT <50,000
Signs and Symptoms of PLT < 10-20,000
Petechiae
Gum Bleeding
Ecchymosis
Hematuria
Bloody Stool
Contraindications to give platelets?
Immune Thrombocytopenic Purpura
Prophylaxis with massive blood loss or CABG
Why do we not give platelets to ITP patients?
The marker on the PLTs are “not you” and will be attacked
What should we give instead of PLTs to ITP patients
Steroids to increase immune response
Why do we not give PLT to massive blood loss patients?
It can actually decrease bone marrow function if too much- we do not want it to perceive there being enough platelets and to stop working
Monitor baby reticulocyte count because..
we should not give products like platelets if the bone marrow is able to make it itself - unless absolutely needed
Platelet Administration
ABO testing not necessary, but usually done
Infuse at a rate of 10 mL/min and finish infusing within 4 hours
Platelets should not be …
refrigerated
The max storage for platelets is ..
5 days
Equipment for a Platelet Transfusion
DO NOT USE AN RBC FILTER, use component with 170 micron filter from the blood bank (leukocyte poor filter) to catch leftover RBC and WBC
19 gauge or larger needle (like others)
0.9% NS!!
Expected Outcomes for Platelet Transfusion?
Prevention or resolution of bleeding d/t thrombocytopenia or PLT dysfunction
How often should we be rechecking PLT count with a PLT transfusion?
Within the first hour and every hour after to ensure the numbers rise
How does 1 unit of PLT change PLT count levels?
It increased PLT by 5000 cells/microL
If a patient has a PLT count of 5000, how many units of PLT will they need to get back to the 20,000 level?
3 units
Complications that can occur from PLT Transfusion
Infectious Diseases
Allergic Rxns
Febrile Rxns
(Hemolytic is unlikely cause there are not really any RBC, but these are still possible from the RBC or WBC left)
Fresh Frozen Plasma (FFP)
Plasma very rich in clotting factors V, VIII, and IX with the platelets removed
it is 91% water, 7% proteins, 2% carbohydrates
Freezing it within 6 hours of collection preserves the clotting factors
Factor __ works with Factor ___ to turn prothrombin into thrombin
Factor V works With factor X
Low Factor V levels can mean what?
Inability to get a clot through the cascade
Low Factor VIII leads to?
Hemophilia A
Low Factor IX leads to?
Hemophilia B
Indications for Fresh Frozen Plasma Use?
A demonstrated deficiency of clotting factors: DIC, liver disease, coagulopathies, prior to invasive procedures
PT or PTT >1.5 x the normal value
Clotting factors are made in the ___
liver
What is FFP NOT used for?
- Volume expansion (use NS or albumin)
- Nutritional Supplementation
- Prophylaxis with massive blood loss or CABG
What value do we check if the patient is on Heparin ?
PTT
Albumin is a plasma protein that …
maintains oncotic pressure - it helps pull fluids back to the vasculature at the venous end - this is why we need sufficient amounts of albumin
Administration of FFP
It contains no RBCs, but you must administer ABO and Rh compatible plasma after doing a cross and test because it is plasma (with antibodies in it) [Important to consider this because there are Rh antibodies in here an if we give Rh+ antibodies to a mom she could have an immune response against an Rh- baby later)
Must be transfused within 24 hours of thawing
Infused slower if there is risk for circulatory overload (200 mL/hour)
Only give with NS
Why do we given a Mom Rogan mid pregnancy?
It gives metabolizable antibodies that will not be memorized by the immune system and thus can help prevent erythroblast fetalis
Equipment for FFP Transfusion
Do NOT use RBC filter
Use component set with 170 micron filter obtains from Blood Bank
19 gauge or larger needle
0.9% NS (NEVER GIVE MEDS OR A DILUENT)
Expected outcome of FFP use
PT and PTT come down because we gave clotting factors
Specific factor assays should be done to check specific levels
Complications from FFP
Allergic Rxn (WBC in plasma)
Febrile Rxn (WBC in plasma)
Circulatory Overload (biggest risk if done too fast)
Infectious Disease
What is the biggest risk complication for FFP use?
Circulatory Overload
Plasma Compatibility rule for FFP?
AB is now the universal donor (no antibodies) and O is the universal recipient (both antibodies)
Rh factor matters less, you can give Rh+ to + or - and vice versa because that antigen is usually on the RBC - exposure matters more
A goes to A and B goes to B
Cryoprecipitate Antihemophilic Factor (AHF)
Lyophilized concentrate containing Factor VIII and VI, Fibrinogen, and mostly Factor XIII needed for the clotting cascade
It is made from large pools of donor plasma
What is done to eliminate risk for viral transmission when using AHF?
It is heated or a solvent-detergent treatment is used
Lyophilization
Freeze Dried
Indications for AHF use
Factor VIII Problem: Hemophilia A (deficiency), von Willebrand’s Disease, Hypofibrinogenemia, Factor XIII Deficiency
Factor IX Problem: Hemophilia B (Deficiency)
Why does von Willebrand’s Disease get AHF?
Factor VIII is carried by the von willebrand factor - without it the platelets cannot become sticky to form a clot
Factor XIII Deficiency
A rare autosomal recessive disorder that makes fibrin stabilizing factor deficiency - the clot will form without stabilizing fibrin so the clot will break down and bleeding will occur
AHF is only used …
in life threatening emergencies when factor 13 concentrate is not available
Administration of AHF
- Dose is calculated based on plasma volume
- 8-10 bags supply 2g fibrinogen (hemostatic dose)
- Repeated doses may be needed to attain satisfactory serum levels
Rate of infusion is quick here! because this is only really used in emergency scenarios (1-2mL per minute with 4 units (60 mL) in 15 minutes
Equipment for AHF administration?
Blood component administration set with 170 micron filter obtained from blood bank
19 gauge or larger needle
0.9% NS
NEVER add anything to the NS
You must be familiar with what when giving blood?
Policies and procedures of your institution
Expected Outcomes after AHF treatment?
Hemostasis d/t increased levels of deficient factor
Correction of factor and fibrinogen deficiencies
Cessation of bleeding
Lab values are needed to assess effectiveness of treatment
Complications of AHF use
Allergic Rxns
Hepatitis potentially
Caused by WBC or IgA
What are the rules of compatibility for AHF?
Same as with Fresh Frozen Plasma -
AB is now the universal donor (no antibodies) and O is the universal recipient (both antibodies)
Rh factor matters less, you can give Rh+ to + or - and vice versa because that antigen is usually on the RBC - exposure matters more
A goes to A and B goes to B
Albumin Product
Products taken from plasma - 96% Albumin with 4% other plasma proteins and globulins
Plasma Protein Product
Products taken from plasma (like the Albumin Product) - 83% Albumin and 17% globulins
2 Available Forms of Albumin
- 5% Iso Oncotic
2. 25% Solution
5% Iso-oncotic Albumin Solution
Solution w/ the same oncotic pressure as blood in a healthy person
when given there will be no net movement of fluids unless there was very low albumin to begin with
Albumin controls oncotic pressure!
25% Albumin Solution
Solutions 4x the oncotic pressure of the bloods normal oncotic pressure - because of this it pulls a lot more
So be careful using this, can use with isotonic electrolyte solutions if there are not enough fluids (NS or Lactated ringers)
Indications to use Albumin and Plasma Protein Fraction
- Volume Expansion (Protein exchange, shock, massive hemorrhage)
- Acute Liver Failure (not making proteins)
- Burns (everything is lost)
- Hemolytic disease in the newborn
What may need to be given alongside Albumin and Plasma Protein Fraction until adequate circulating volume is established?
A diuretic
Since Albumin and Plasma Protein Fraction pulls fluids back into the vascular space what must we know?
KIDNEY FUNCTION
Hemolytic Disease in the Newborn
Immature baby liver leads to low albumin and plasma proteins, and d/t hemolysis you get RBC destruction leading to increased bilirubin levels
The liver cannot conjugate the bilirubin in this state, so we give albumin to pull from the interstitial spaces in order to get rid of bilirubin and prevent newborn Jaundice (which can be dangerous)
Albumin and Plasma Protein Fraction Administration?
PPF is given 1-10 mL/min
Albumin - 5% is given 1-10mL/min, but can be given faster; 25% is given slower at 0.2-0.4 mL/min\
ABO and Rh are not a factor in administration of this as there is no RBC or Plasma
When can 5% Albumin be given faster?
When the person is in shock with hypotension
Why is 25% albumin given much slower than 5%?
Its concentration
It will cause significant increase in blood volume and blood pressure as it is given
Where can the RN find Albumin and Plasma Protein Fraction products?
NOT in the pharmacy and blood bank like other products
It is already pasteurized, meaning any infectious disease causing things are dead, so it is in normal storage
Equipment for giving an Albumin or Plasma Protein Fraction Transfusion
19 gauge or larger needle
Standard IV infusion set
May require a specific filter
Set and filter may be supplied alongside the solution in storage
Expected outcome of Albumin and PPF administration?
Acquire and maintain adequate BP and volume support
Complications of Albumin and PPF
Circulatory overload (a big one)
Febrile Rxn (still possible regardless of pasteurization, so check vitals)
Compatibility does not matter in this cause and CANNOT transmit hepatitis or HIV since pasteurization process used to prepare products destroy viruses
Fluid overload is a big problem, and if we give transfusions too quickly we can end up getting the signs and symptoms of…
heart failure
ISG - Immune Serum Globulins
Concentrated aqueous solution of gamma globulin containing a higher titer of antibodies
It gives passive immunity via transfusion, but we also make this product with the liver (a large amount of this can be found in our plasma)
2 Types of ISG
Specific ISG
Non Specific ISG
Non Specific ISG
Type of ISG obtained from a large pool of random donors
It is used to increase Gamma Globulin levels and enhance the immune response via passive immunity
Specific ISG
Type of ISG prepared from donors with high antibody titer to known antigens
(ex: Hep B Immune Glob (HBIG), Rh (D) Immune Glob (RhIG - RhoGAM), Varicella-Zoster Immune Glob (VZIG))
Why does ISG only give passive immunity
We give antibodies so the receiver does not have to and no memory cells are made as a result and eventually these will be metabolized - leaving no long lasting immunity
So a snake or raccoon bite may need this
What is the downfall of ISG v a Vaccine for something like Hep B?
You will need more ISG if you are exposed again, but a vaccine can allow you to make your own antibodies in repeated exposure
Indications for ISG Transfusion
Passive Immune Protection against HBIG, RhIG, and VZIG
Treatment for Hypogamma-globulinemia
HBIG
Immunoglobulin given following HBV exposure (Hep B)
RhIG
Immunoglobulin given following exposure to Rh (D) antigens through transfusion or pregnancy to prevent antibody development
VZIG
immunoglobulin given to immuno-compromised patients exposed to chicken pox
What sort of patient may get RhIG ISG?
A pregnant Rh - patient exposed to Rh+ blood
Who should not receive ISG?
Patients with a history of severe allergic reactions to plasma should not receive ISG
What can and cannot be transmitted via ISG?
Neither HIV nor Hep B is transmitted by ISG, however some IV gamma globulin solutions have been reported to transmit HEPATITIS C
Administration of ISG
Mostly given IM but IV also available
Never give IM prep to IV d/t anaphylaxis risk
Read package inserts carefully
Give ISG prior to, or as soon after, exposure as possible
IM ISG Injections may be what and require what in response?
Painful and result in local irritation - they need a warm compress on the area
When must RhIG and VZIG be given to achieve optimal effect?
Within 72 hours of exposure
Administration of IV ISG
administer ONLY IV using a filter
Do NOT administer with other medications
Begin infusion within 2 hours of reconstitution
Most transfusion reactions result from …
error, so know your stuff and double check
Expected Outcome of ISG Transfusion
Transient correction of gamma globulin deficiency OR prevention of disease through the passive administration of the antibody
Granulocyte Product
1 Unit: 10^10 granulocytes (WBC), variable amounts of lymphocytes (<10%), 30-50 mL of RBC, 100-400 mL of plasma, 6-10 units of platelets (optional)
Volume w/ PLT is 200-400 mL, without is 100-200 mL
It basically is WBC solution with basophils, neutrophils, and eosinophils
What is Granulocyte Product usually for?
A last ditch effort to stop infection
Indications for Granulocyte Transfusion
- Acquired neutropenia from radiation or chemotherapy
- Congenital WBC dysfunction
- Serious infection unresponsive to conventional antibiotics
What about granulocyte product use is questionable?
its long term therapeutic benefit
How can we tell is Granulocyte product helped with an infection?
We cannot measure WBC count changes after giving, so the only way to know if it worked is if there is resolution of the infection (leading to its long term therapeutic use being questionable)
Granulocyte Administration
1 Unit is given daily and slowly over 1-4 hours
It has a short survival time so it must be infused as soon as available (within 24 hours)
*IT IS COLLECTED AND GIVEN QUICKLY/IMMEDIATELY
Equipment for Granulocyte Administration
Standard blood component set with 170 micron filter obtained from the blood bank
19 gauge of larger needle
0.9% saline
DO NOT USE DEPTH TYPE MICROAGGREGATE OT LEUKOCYTE DEPLETION FILTER
Why should we not use microaggregate or leukocyte depletion filters with Granulocyte product?
Because it can trap WBC during infusion and then we are not giving what we are supposed to
With granulocyte product administration we have a very high risk for what?
Allergic and Febrile Reaction (so we must pre medicate)
What do we use to premedicate with before giving Granulocyte Product?
Antihistamine
Acetaminophen
Steroids
Meperidine
Expected outcome of Granulocyte transfusion
Improvement in or resolution of infection
No increase in peripheral WBC is seen in adults, but could be seen in children
Improvement in clinical condition is the only measurement of treatment effectiveness
Complications of Granulocyte Product Transfusion
Rash
Febrile Reactions*
Hepatitis
*increased incidence of febrile, non hemolytic reactions with transfusion of granulocytes means you should infuse slowly and watch the patient closely
Pulmonary Insufficiency if given with Amphotericin B
Amphotericin B
Antifungal
CANNOT BE GIVEN WITH GRANULOCYTES AS WITHIN 4 HOURS OF INFUSION THERE CAN BE A RISK FOR PULMONARY INSUFFICIENCY
Compatibility Rules for Granulocytes
Since there is a little RBC in it, it follows packed RBC rules
O is the universal donor
AB is the universal receiver
Rh- can be given to either Rh but Rh+ can only go to +
A to A and B to B
Transfusion Reaction
Antigens on the transfused product can be read and an antibody could be provided and produced causing an immune response and dangerous reaction
2 Categories of Transfusion Reactions
Acute v Chronic
Examples of Acute Transfusion Reactions
Acute Hemolytic Reaction
Febrile Non Hemolytic Reaction (Most common)
Mild allergic reaction
Anaphylactic Reaction
Circulatory Overload
Sepsis
Transfusion Related Acute Lung Injury (TRALI)
Examples of Chronic Transfusion Reactions
Delayed hemolytic
Hepatitis B
Hepatitis C
HIV-1 (AIDS virus) infection
Iron overload
Graft-versus-host disease (GVHD)
Other:
CMV, HTLV-I, malaria
What are some of the General Manifestations of a Transfusion reaction
Fever (up 1-2 degrees C)
chills
muscle aches and pain
back pain
chest pain
headache
heat at site of infusion or along vein
What are some of the Nervous System Manifestations of a Transfusion reaction
apprehension
sense of impending doom
tingling
numbness
What are some of the respiratory Manifestations of a Transfusion reaction
respiratory rate changes - tachy or bradypnea
dyspnea
cough
wheezing
rales
What are some of the GIl Manifestations of a Transfusion reaction
nausea
vomiting
pain, abdominal cramping
diarrhea (may be bloody)
What are some of the renal Manifestations of a Transfusion reaction
changes in urine volume (oliguria, anuria, renal failure)
Changes in urine color (dark, concentrated, shades of red brown and amber, may indicate the presence of Hgb or RBC in urine)
What are some of the cardiovascular Manifestations of a Transfusion reaction
heart rate - tachy or bradycardia
BP changes - hypotension and shock, hypertension
Peripheral circulation - cyanosis, facial flushing
Temp changes - cool and clammy or hot, flushed and dry
Bleeding - generalized (DIC) or oozing at a surgical site
What are some of the integumentary Manifestations of a Transfusion reaction
rashes
hives (urticaria)
swelling
itching
diaphoresis
What are some of the Manifestations of a Transfusion reaction in an UNCONSCIOUS PATIENT
weak pulse
fever
hypotension
visible hemoglobinuria
increased operative bleeding (oozing at surgical site)
vasomotor instability (tachycardia, bradycardia, hypotension)
oliguria or anuria
Reactions from different causes can exhibit similar manifestations, so…
every symptom should be considered potentially serious and transfusion should be discontinued until the cause is determined
Assume the worse for safety reasons!!!
Its important to get what before doing transfusions and during them?
Baseline vitals and 15 min in vitals and hourly after that maybe
If a transfusion reaction begins, never do what?
Allow IV access to go away
If a transfusion reaction begins what equipment needs to go back to the lab for testing?
Every piece of equipment: left over blood, tubing, urine, everything
What to do when a transfusion reaction begins?
- Stop Transfusion and keep the IV open with 0.9% NS
- report rxn to both transfusion services and attending physician ASAP
- Do clerical check at bedside of identifying tags and numbers
- treat symptoms pre physicians orders and monitor vital signs
- send blood bag with attached administration set and labels to the transfusion service
- collect blood and urine samples and send to lab
- document THOROUGHLY on transfusion reaction form and in the patients chart
Acute Hemolytic Reaction
Acute Transfusion Rxn
This occurs because of ABO INCOMPATIBLE whole blood, RBCs, or components containing 10 mL or more RBCs
Antibodies in the recipients plasma attach to the antigens on transfused RBCs and cause RBC destruction
Manifestations of an Acute Hemolytic Reaction
Chills and Fever
LOWER BACK PAIN
Flushing
Tachycardia
Tachypnea (comes with hypotension)
Hypotension (comes with hypotension)
Vascular Collapse
Hemoglobinuria
Hemoglobinemia
Bleeding
Acute renal failure
Shock
Cardiac arrest
Death
What are the most common symptoms of Acute Hemolytic Reaction? What is one of the unique symptoms?
Common: Fever and Chills
Unique: Lower Back Pain
How to manage an Acute hemolytic Reaction
treat shock if its present (priority is given to vascular stability always)
Draw blood samples for serologic testing - do it slowly to prevent hemolysis
send urine to the lab
maintain BP with IV colloid solutions
give diuretics as prescribed to maintain urine output (renal could fail in this case so maintain it)
insert indwelling catheter or measure hourly input
dialysis if renal failure occurs
DOCUMENT!!!
What not to do after an Acute Hemolytic Reaction?
DO NOT TRANSFUSE RBC CONTAINING COMPONENTS UNTIL TRANSFUSION SERVICE PROVIDES NEW CROSSMATCHED UNITS
How to prevent Acute Hemolytic Reaction
Meticulously verify and document patient ID form sample collection to component transfusion
Febrile Non Hemolytic Reaction
Acute Transfusion Reaction
It is due to sensitization to donor WBC, PLTs, or plasma proteins
RBC ARE NOT DESTROYED
More common that Hemolytic reaction
Manifestations of Febrile Non Hemolytic Reactions
Sudden chills
Fever (increase more than 1 degree C)
Headache
flushing
anxiety
muscle pain
How to manage a febrile non hemolytic reaction?
give antipyretics as prescribed
AVOID aspirin in thrombocytopenic patients
DO NOT restart transfusion
Who is at highest risk for a Febrile Non Hemolytic Reaction
Anyone that has gotten a transfusion in the past
Prevention for Febrile Non Hemolytic Reactions
Consider leukocyte poor blood products (filtered, washed, or frozen)
Mild Allergic Reaction
Acute Transfusion rxn
Sensitivity to foreign plasma proteins
Manifestations of a Mild Allergic Reaction
Flushing
itching
Urticaria (Hives)
NO FEVER
Management for a Mild Allergic Reaction
Give antihistamine as directed
If symptoms are mild and transient, transfusion may be restarted slowly (w/ benadryl)
DO NOT restart transfusion if fever or pulmonary symptoms develop
Prevention for Mild Allergic Reaction
Treat prophylactically with antihistamines
Anaphylaxis and Anaphylactic Shock
Acute Transfusion reaction
Caused by infusion of IgA proteins to IgA deficiency recipients who has developed an IgA antibody
Very rare (1 in 40000 to 270000 transfusions)
more severe - it is a massive histamine release
What type of person may have an anaphylactic reaction?
IgA is low in people, so if they had a plasma transfusion before they could have made IgA antibodies causing this reaction
A transfusion rxn in the past would set them up for a shock reaction now
IgA
An immunoglobulin not found in great abundance in people
it is in the GI tract, saliva, tears, body fluids
Due to anaphylaxis, it is important to always as a transfusion patient…
If they have had a transfusion reaction in the past
Manifestations of Anaphylaxis
Anxiety
Urticaria
Wheezing
Throat Swelling
Progresses to Shock - Cyanosis, Shock, Possible Cardiac Arrest
Management for Anaphylactic Reaction
- Initiate CPR if indicated
- Have EP ready for injection (0.4 mL subQ or 0.1 mL diluted in 10 mL NS for IV)
- DO NOT RESTART THIS TRANSFUSION
Why is EP good for anaphylaxis?
EP can stop the mass histamine release that is occurring
Prevention Measures for Anaphylactic Reaction
Transfuse extensively washed RBC products, from which all plasma has been removed
Use blood from an IgA DEFICIENT DONOR (so no antibodies occur)
Ask if they’ve had a reaction or transfusion before
Circulatory Overload
Acute Transfusion Reaction
Fluid is administered faster than the circulation can accommodate causing this reaction
More common in kids and smaller people
Circulatory overload causes ___ symptomology
Lung
Manifestations of Circulatory Overload
Cough
dyspnea
pulmonary congestion (rales)
HA
HTN
tachycardia
distended neck veins
Management for Circulatory overload
place patient upright with feet in dependent position to get fluid more to the periphery
administer prescribed diuretics, oxygen, and morphine (to help breathing and dilate the venous system)
Phlebotomy may be indicated (remove blood)
Do an assessment every hour
Next time, blood must be given in aliquats
Crackles in the lung indicate…
pulmonary edema
Prevention of Circulatory Overload
adjust transfusion volume and flow rate based on patient size and clinical status
have transfusion service divide units into smaller aliquots for better spacing of fluid input
may need to give a diuretic between units if more than 1 unit is being given
Sepsis
Acute transfusion reaction
this is transfusion of contaminated blood components
Manifestations of Sepsis
Rapid onset of chills
high fever
vomiting
diarrhea
marked hypotension! (d/t going into shock)
shock
What 3 important things need to be documented due to sepsis reactions?
- That blood is not expired
- That blood was not sitting around for a long time
- That we have not exceeded the 4 hour time frame
Management of Sepsis
Obtain culture of patients blood and send bag with remaining blood to transfusion service for further study (to find the antibiotic against a specific organism needed)
Treat septicemia as directed: antibiotics, IV fluids, vasopressors (increase BP to treat shock), steroids
Prevention of Sepsis
Collect, process, store, and transfuse blood products according to blood banking standards and infuse them within 4 HOURS OF STARTING TIME
TRALI
Acute transfusion reaction
“Transfusion Related Acute Lung Injury”
It occurs when transfused donor WBCs react with recipient WBCs resulting in agglutination and aggregation in the lungs and thus pulmonary damage
Where does TRALI occur?
the lungs
Manifestations of TRALI
dyspnea
wheezing
fever
chills
bronchospasms
crackles
restlessness
non productive cough
pulmonary infiltrates
HTN or Hypotension
systemic inflammatory symptoms
What is TRALI NOT a sign of?
CHF or Volume Overload
When unhooking a blood product what should be done for flushing?
The whole line should not be flushed because it still has product in it, it should be unhooked at site of insert
Management of TRALI complications
- STOP infusion and maintain patent IV line
- Place in supine position
- maintain open airway - mechanical ventilation if necessary (may need intubation)
- Obtain VS and record
- notify physician
- administer fluids and EP, steroids, and diuretics per orders
- Administer O2
- Monitor VS and urine output (renal failure can occur with a perfusion problem)
- Document event thoroughly
how many cases of TRALI are fatal regardless of aggressive supportive care?
5-10 %
(luckily PP of CO2 returns to pre transfusion levels in 48-96 hours and CXR returns normal in 98 hours so 90-95% of cases end well)
Delayed hemolytic Reaction
Delayed Transfusion Reaction
Causes RBC breakdown slowly leading to bilirubin wastes building up - can occur as early as 3 days to several months , but it is d/t the destruction of transfused RBCs by alloantibodies no detected during crossmatch
HCT will drop from RBC lysis
Usually occurs 1-2 weeks post transfusion
Manifestations of Delayed hemolytic reaction
fever
mild jaundice (waste - bilirubin buildup)
decreased HCT
Treatment for Delayed Hemolytic Reaction
generally, no acute treatment is required
hemolysis that is severe enough can warrant further transfusions
Hepatitis B
Delayed Transfusion Reaction involving inflammation of the liver (from elevated liver enzymes (AST and ALT) dying.
Manifestations of Hep B
elevated liver enzymes (AST and ALT)
anorexia
malaise
nausea and vomiting
fever
dark urine (increased from hemolysis occurring releasing heme)
jaundice (increased bilirubin)
Treatment for Hep B
usually resolve spontaneously within 4-6 weeks
chronic carrier state can develop and can result in permanent liver damage though
it should be treated symptomatically
You can get passive IG for this but you can also get a vaccine for active immunity
Hepatitis C
Delayed transfusion reaction
Similar to Hep B (liver inflammation)
How is Hep C different from Hep B?
Hep C usually has less severe symptoms (but could cause chronic liver disease and cirrhosis thus warranting a liver biopsy every 4-5 years)
Treatment for Hep C
Before, anti-HCV test accounted for 90-95% of all post transfusion hepatitis - but now risk is low
Treat symptomatically (treatment is worse for this than in B)
HIV-1 (AIDS Virus) Infection
Delayed Transfusion reaction
Can be asymptomatic for up to several years, with flu like symptoms 2-4 weeks after exposure, and alter symptomology and AIDS far out
Later S/S of HIV-1
weight loss
diarrhea
fevers
lymphadenopathy
thrush
pneumocystis pneumonia
What is the current estimated risk of infection with HIV-1 from a blood transfusion?
1:30,000 to 1:1,500,000 depending on geographic area
Iron Overload
Delayed transfusion reaction
This is an increase in iron when you are NOT bleeding
RBC is begin destroyed and heme is going to the liver and will be deposited around the body causing harm
What is a potential cause for Iron Overload?
constant blood transfusions (like in chronic anemia or chronic renal patients)
Manifestations of Iron Overload
congestive heart failure
arrhythmias
impaired thyroid and gonadal function
diabetes
cirrhosis
commonly occurs in patients receiving >100 units for chronic anemia
Treatment for Iron Overload
Treat Symptomatically
One medicine is Deferoxamine (Desferal) which chelates and removes accumulated iron via the kidneys and can be administered IV or subQ
Graft V Host Disease
Delayed Transfusion Reaction
It is when the transfusions WBC attacks the receiver (unlike host v graft disease) - result of replication of donor lymphocytes (graft) in the transfusion recipient (host) that attack the recipient’s RBC
Common occurrence in an immunocompromised persons
Manifestations of GVHD
fever
rash
diarrhea
hepatitis
Treatment for GVHD
there is no effective therapy so prevention is crucial with this
How to prevent GVHD
- Irradiate blood products intended for babies or immunocompromised patients
- May want to use first degree family members donations
What is one of the most important things to know when administering blood products?
KNOW HOSPITAL POLICY
What must be gathered before any blood transfusion can occur?
INFORMED CONSENT (you as the nurse must gauge their understanding and obtain and record baseline vitals while the physicians gets the consent)
What may need to be done to prepare for transfusion?
Get vitals
Premedicate with prophylactic meds per physicians order
Prep infusion site and start IV 0.9% NS
Use appropriate needle size, filter, and administration set
What sort of Special Administration Devices are needed for Blood Component Administration?
Electromechanical Infusion Devices (only if approved)
External Pressure Infusion Cuffs (DO NOT USE BP CUFFS)
Blood Warmers
What is the benefit of blood warmers?
they decrease incidence of arrhythmias or cardiac arrest associated with massive infusion of cold blood components
should be used rather than microwave, hot tap water, unmonitored water bath, etc
If mult blood components are indicated…
check with the physician to establish an order of priority based on the situation
also may need lasix to prevent pulmonary edema
What to verify about components you want to transfuse?
- Get from transfusion service and check for abnormalities - should be a deep red color
- record name of person issuing blood, person to whom blood is issued, and date/time of issue
- Read instruction on product label, check expiration date and time
- recheck physicians order sheet to verify component ordered
- compare ABO group and Rh type on the patients chart to that on bag tag and bag label
LOTS OF CHECKING AND YOU NEED CONSENT
What to do after doing checks for blood transfusion?
- 2 qualified individuals should verify patient ID and documentation (most transfusion errors are a result of error in patient or component ID, so check name on bag bracelet, and have them say it)
- Do NOT proceed until all comparisons match EXACLTY - contact transfusion service if any discrepancies
- Sign transfusion form immediately prior to transfusion
- document date and time transfusion started
- keep all ID attached to blood container if paper
BE METICULOUS
What should be done upon Administration of blood components?
Start slow and observe closely for the first 15 minutes - educate patient and family what s/s to watch for
Repeat vitals at 15 minutes and compare to baseline, can adjust flow if everything is ok
monitor and record vitals per institution policy
record this in the permanent record
return empty blood containers and leftover product to transfusion service (never put it in fridges or freezers no monitored by them)
can get plasma derivatives from storage and pharmacy/central stores
What things should be record on transfusion permanent record?
patient name and ID #
component and component #s
initial of individuals verifying ID and starting/ending transfusion
start and end times
volume transfused and immediate response
Who can confirm a transfusion?
2 people:
2 RNs
OR
1 RN and an LPN
OR
1 RN and 1 Physician
Blood Administration Pitfalls to Avoid
Do NOT store component in nursing unit or other unmonitored refrigerator
Do NOT keep blood out of a monitored refrigerator for more than 30 minutes before beginning transfusion
Do NOT warm blood in an unmonitored bath or sink, or microwave oven
Do NOT administer any blood component without a blood filter
Do NOT use the same blood filter for more than 4 hours
Do NOT transfuse a unit of blood for over 4 hours
Do NOT add medications, including those intended for intravenous use, to blood or components or infuse through the same administration set as the blood component
Do NOT allow any solution other than 0.9% Normal Saline to come in contact with the blood component or the administration set
Universal Precautions
All patients should be assumed to be infectious for blood-borne pathogens
Gloves MUST be worn when handling a patient’s body fluids
Protective mask, eye goggles, and gown should also be worn if there is the potential for splash from or mucous membrane exposure to blood or other body fluids
Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices
NEVER recap needles
ALWAYS dispose of needles immediately in a biohazard container
Immediately & thoroughly wash hands and other skin surfaces that are contaminated with blood, body fluids containing visible blood, or other body fluids to which universal precautions apply
Review your institutional guidelines for observing universal precautions
VERY IMPORTANT DURING THE COVID-19 PANDEMIC!!
