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NURS361 - Pathophysiology II > Module 7 Part 2 - Blood Transfusion Therapy > Flashcards

Module 7 Part 2 - Blood Transfusion Therapy Flashcards

1
Q

We rarely give __ blood unless indicated?

A

whole blood

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2
Q

Blood is 1% RBC and 99% ___

A

plasma

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3
Q

Plasma is mostly ___

A

water

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4
Q

What is the bottom line regarding blood volume and what takes priority?

A

We always want to protect and reestablish circulating volume!

Without it we cannot get the functions of plasma

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5
Q

Major Functions of Blood Plasma

A

Maintenance of Blood volume

It suspends cellular elements like RBC, WBC, PLT

O2 and CO2 transport

Nutrient exchange

Hormone transport

Waste evacuation

Temperature regulation

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6
Q

There are at least __ different antigens on RBCs

A

80

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7
Q

ABO System

A

Way of designating blood as having A antigens, B antigens, both, or neither

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8
Q

How does dominance work in the AB System?

A

A and B are dominant over O

However, they are codominant to each other

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9
Q

Rh Factor System

A

Way of designating possession of the rH antigen or not

Positive = have the rH antigen

Negative = not present

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10
Q

How does dominance work for the rH system?

A

Positive rH is dominant over negative rH

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11
Q

Antibodies are in __; Antigens are on ___

A

Antibodies are in PLASMA and Antigens are on RBC!!!

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12
Q

If a person has A blood what kind of antibody is in their plasma? B blood? O Blood? AB Blood?

A

A = Anti B Antibody

B = Anti A Antibody

AB = No Antibody

O = Both A and B antibody

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13
Q

What are the rules for giving rH + and - blood?

A

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

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14
Q

What pattern of genetic inheritance can rH + blood be?

A

Homozygous dominant or Heterozygous

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15
Q

What pattern of genetic inheritance can rH - blood be?

A

Homozygous Recessive

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16
Q

Most common blood type? Least common blood type?

A

Common = O+

Least Common = AB-

This can make it hard to get the rarer blood types transfusions

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17
Q

Transfusion

A

Blood component therapy

Administration of whole blood or blood components directly into the bloodstream

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18
Q

What regulates the processes of blood products and transfusions?

A

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)

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19
Q

What are some options for blood transfusions?

A
  1. Homologous Blood
  2. Autologous Blood
  3. Designated (Directed) Blood
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20
Q

Homologous Blood Transfusion

A

transfusion of blood from random volunteer donors

There are rigid checks for risk factors

ex: blood drive

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21
Q

Autologous Blood Transfusion

A

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

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22
Q

Alloimmunization

A

Risk for a transfusion reaction from blood of someone in the same species (ex: Human to Human)

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23
Q

Designated (Directed) Blood

A

Blood collected and transfused from a donor designated and picked by the recipient

ex: a family member of a proper blood type

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24
Q

Blood Components that are Available for Transfusion?

A

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

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25
Q

Whole Blood

A

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

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26
Q

Indications for Whole Blood Use

A
  1. (Sometimes) Symptomatic Anemia and Major Volume Deficit

2. Massive Hemorrhaging with hypotension, tachycardia, SOB, pallor, low Hgb and Hct

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27
Q

Whole blood is ___ required and often medically ___

A

Whole blood is RARELY REQUIRED and often medically unnecessary

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28
Q

What could occur if whole blood is given to someone that does not need it?

A

Circulatory overload

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29
Q

Before giving blood products always…

A

check for ABO and Rh factor compatibility - TYPE AND CROSS

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30
Q

How should Whole blood be administered?

A
  1. 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

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31
Q

What is the exception to starting slow with the whole blood infusion?

A

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

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32
Q

What is the cardinal rule of giving blood transfusions?

A

NEVER RUN WITH ANYTHING BUT NORMAL SALINE (not antibiotics, dextrose solution, electrolyte solution) because of interactions that can occur

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33
Q

Equipment needed to Transfuse Whole Blood

A
  • 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
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34
Q

Expected Outcomes of Giving Whole Blood

A
  1. Resolution of symptoms and hypovolemic shock and anemia

2. increase in Hct and Hgb depending on number of units given

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35
Q

How much does 1 unit of whole blood increase Hct and Hgb?

A

1 unit = Hct increase by 3% and Hgb by 1 g/dL

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36
Q

If someone is given 3 units of whole blood what changes will be seen in their Hct and Hgb?

A

Hct will increase 9% and Hgb will increase byt 3 g/dL

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37
Q

Potential Complications from Whole Blood

A

Hemolytic Rxn

Allergic Rxn (There is WBC in here)

Hypothermia (from giving cold blood)

Electrolyte Disturbances

Citrate Intoxication

Infectious Disease (Small but potential)

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38
Q

Citrate Intoxication

A

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

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39
Q

You only have a __ hour window for use of blood products

A

4 hour window

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40
Q

Rules For Whole Blood Compatibility

A
  • 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
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41
Q

What sort of reaction occurs if someone is given the whole ABO or Rh blood?

A

A hemolytic transfusion reaction (They will attack one another)

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42
Q

Packed Red Blood Cells

A

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

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43
Q

We give Packed RBCs to…

A

do the job of RBCs - getting increased oxygen carrying capability

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44
Q

2 Types of Packed RBC

A
  1. Citrate Phosphate Dextrose Adenine (CPDA)

2. Additive Solution (100 mL) (AS-1, AS-3, or AS-5)

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45
Q

Indications to give Packed RBC

A

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

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46
Q

What cases do NOT need packed red blood cells?

A
  1. Need for volume expansion
  2. Wound healing (albumin needed here)
  3. General Wellbeing
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47
Q

First thing to do when you’re going to administer Packed RBC

A

Check ABO and Rh compatibility - cross and test

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48
Q

How is Packed RBC administered?

A
  1. Initially start slow (about 70 cc/hr) for 15 minutes
  2. Increase rate as tolerates and infuse in 2-4 hours (never over 4)
    * you can subdivide it into aliquots
    * may need dilution with NS
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49
Q

Aliquots

A

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

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50
Q

Why do we start infusing transfusions slow for 15 minutes?

A

To check if there is a transfusion reaction (we can tell because they will get a fever)

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51
Q

Equipment for Administering Packed RBC

A
  1. Needle (19 gauge or larger; 23 gauge for peds)
  2. Standard straight or Y type blood infusion set with 170 micron filter
  3. 0.9% NS
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52
Q

Never do what with blood and other solutions?

A

never add medications or mix blood with other solutions

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53
Q

Expected outcome of Packed Red Blood Cell transfusion?

A
  1. Resolution of Symptoms of Anemia

2. 1 Unit of blood will increase Hct by 3% and Hgb by 1 g/dL

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54
Q

Complications from Packed Red Blood Cell

A

Infectious Diseases

Hemolytic Reaction

Allergic Reaction (still a little plasma/WBC in here)

Hypothermia

Electrolyte Disturbances

Citrate Intoxication

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55
Q

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?

A

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

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56
Q

Rules for Packed Red Blood Cell compatibility

A
  • 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 +
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57
Q

Why is it a big problem to give an Rh- woman Rh+ blood?

A

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)

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58
Q

Leukocyte Poor Red Blood Cells

A

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

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59
Q

When is Leukocyte Poor RBC indicated?

A

If the patient has a history of blood transfusion reactions - non hemolytic allergic reactions (fever, rash, anaphylaxis)

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60
Q

Why is Leukocyte Poor RBC not just given to everyone if it can prevent allergic reactions?

A

It is very expensive

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61
Q

When and How is Washing Performed for Leukocyte Poor RBC ?

A

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

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62
Q

What is storage like for Leukocyte Poor Red Blood Cells?

A

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

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63
Q

Alloimmunization

A

A transfusion reaction from receiving blood from the same species (ex: Human-Human) that could carry something like Cytomegalovirus

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64
Q

Expected Outcome of Leukocyte Poor Red Blood Cells

A

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

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65
Q

Complications from Leukocyte Poor RBC that can happen

A

Hemolytic Rxn (if not type and crossed)

Hypothermia

Electrolyte Disturbances

Citrate Intoxication

Infectious Disease (Still a very small risk)

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66
Q

Irradiated Red Blood Cells

A

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)

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67
Q

When is Irradiated RBC used?

A

Babies and Immunocompromised People

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68
Q

In order to use Irradiated RBC the bag must be labeled …

A

IRRADIATED

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69
Q

Irradiated RBC carries no risk of what?

A

Radiation risk to transfusionist or recipient

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70
Q

What is the main goal of giving irradiated RBC?

A

to prevent Graft v Host Disease (Donor Attacks Receiver)

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71
Q

Indications for Irradiated RBC Use?

A

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

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72
Q

Expected Outcome of Irradiated RBC use?

A

Prevention of GVHD

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73
Q

Complications that can occur from Irradiated RBC use?

A

Hemolytic Rxn (if wrong type and cross)

Hypothermia

Electrolyte Disturbances

Citrate Intoxication

Infectious Disease

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74
Q

Platelet (Blood Product)

A

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)

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75
Q

How many units of whole blood is needed to get one unit of platelets?

A

4-6 units of whole blood

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76
Q

Types of Platelet Transfusion

A

Random-Donor

Single-Donor

HLA-Matched (Human Leukocyte Antigen matched - still needs cross and test)

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77
Q

Indications to give Platelets

A

Thrombocytopenia (Chemotherapy induced too)

Platelet Dysfunction

PLT <10-20,000 or Active bleeding with PLT <50,000

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78
Q

Signs and Symptoms of PLT < 10-20,000

A

Petechiae

Gum Bleeding

Ecchymosis

Hematuria

Bloody Stool

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79
Q

Contraindications to give platelets?

A

Immune Thrombocytopenic Purpura

Prophylaxis with massive blood loss or CABG

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80
Q

Why do we not give platelets to ITP patients?

A

The marker on the PLTs are “not you” and will be attacked

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81
Q

What should we give instead of PLTs to ITP patients

A

Steroids to increase immune response

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82
Q

Why do we not give PLT to massive blood loss patients?

A

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

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83
Q

Monitor baby reticulocyte count because..

A

we should not give products like platelets if the bone marrow is able to make it itself - unless absolutely needed

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84
Q

Platelet Administration

A

ABO testing not necessary, but usually done

Infuse at a rate of 10 mL/min and finish infusing within 4 hours

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85
Q

Platelets should not be …

A

refrigerated

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86
Q

The max storage for platelets is ..

A

5 days

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87
Q

Equipment for a Platelet Transfusion

A

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!!

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88
Q

Expected Outcomes for Platelet Transfusion?

A

Prevention or resolution of bleeding d/t thrombocytopenia or PLT dysfunction

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89
Q

How often should we be rechecking PLT count with a PLT transfusion?

A

Within the first hour and every hour after to ensure the numbers rise

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90
Q

How does 1 unit of PLT change PLT count levels?

A

It increased PLT by 5000 cells/microL

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91
Q

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?

A

3 units

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92
Q

Complications that can occur from PLT Transfusion

A

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)

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93
Q

Fresh Frozen Plasma (FFP)

A

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

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94
Q

Factor __ works with Factor ___ to turn prothrombin into thrombin

A

Factor V works With factor X

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95
Q

Low Factor V levels can mean what?

A

Inability to get a clot through the cascade

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96
Q

Low Factor VIII leads to?

A

Hemophilia A

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97
Q

Low Factor IX leads to?

A

Hemophilia B

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98
Q

Indications for Fresh Frozen Plasma Use?

A

A demonstrated deficiency of clotting factors: DIC, liver disease, coagulopathies, prior to invasive procedures

PT or PTT >1.5 x the normal value

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99
Q

Clotting factors are made in the ___

A

liver

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100
Q

What is FFP NOT used for?

A
  1. Volume expansion (use NS or albumin)
  2. Nutritional Supplementation
  3. Prophylaxis with massive blood loss or CABG
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101
Q

What value do we check if the patient is on Heparin ?

A

PTT

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102
Q

Albumin is a plasma protein that …

A

maintains oncotic pressure - it helps pull fluids back to the vasculature at the venous end - this is why we need sufficient amounts of albumin

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103
Q

Administration of FFP

A

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

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104
Q

Why do we given a Mom Rogan mid pregnancy?

A

It gives metabolizable antibodies that will not be memorized by the immune system and thus can help prevent erythroblast fetalis

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105
Q

Equipment for FFP Transfusion

A

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)

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106
Q

Expected outcome of FFP use

A

PT and PTT come down because we gave clotting factors

Specific factor assays should be done to check specific levels

107
Q

Complications from FFP

A

Allergic Rxn (WBC in plasma)

Febrile Rxn (WBC in plasma)

Circulatory Overload (biggest risk if done too fast)

Infectious Disease

108
Q

What is the biggest risk complication for FFP use?

A

Circulatory Overload

109
Q

Plasma Compatibility rule for FFP?

A

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

110
Q

Cryoprecipitate Antihemophilic Factor (AHF)

A

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

111
Q

What is done to eliminate risk for viral transmission when using AHF?

A

It is heated or a solvent-detergent treatment is used

112
Q

Lyophilization

A

Freeze Dried

113
Q

Indications for AHF use

A

Factor VIII Problem: Hemophilia A (deficiency), von Willebrand’s Disease, Hypofibrinogenemia, Factor XIII Deficiency

Factor IX Problem: Hemophilia B (Deficiency)

114
Q

Why does von Willebrand’s Disease get AHF?

A

Factor VIII is carried by the von willebrand factor - without it the platelets cannot become sticky to form a clot

115
Q

Factor XIII Deficiency

A

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

116
Q

AHF is only used …

A

in life threatening emergencies when factor 13 concentrate is not available

117
Q

Administration of AHF

A
  • 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

118
Q

Equipment for AHF administration?

A

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

119
Q

You must be familiar with what when giving blood?

A

Policies and procedures of your institution

120
Q

Expected Outcomes after AHF treatment?

A

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

121
Q

Complications of AHF use

A

Allergic Rxns

Hepatitis potentially

Caused by WBC or IgA

122
Q

What are the rules of compatibility for AHF?

A

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

123
Q

Albumin Product

A

Products taken from plasma - 96% Albumin with 4% other plasma proteins and globulins

124
Q

Plasma Protein Product

A

Products taken from plasma (like the Albumin Product) - 83% Albumin and 17% globulins

125
Q

2 Available Forms of Albumin

A
  1. 5% Iso Oncotic

2. 25% Solution

126
Q

5% Iso-oncotic Albumin Solution

A

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!

127
Q

25% Albumin Solution

A

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)

128
Q

Indications to use Albumin and Plasma Protein Fraction

A
  1. Volume Expansion (Protein exchange, shock, massive hemorrhage)
  2. Acute Liver Failure (not making proteins)
  3. Burns (everything is lost)
  4. Hemolytic disease in the newborn
129
Q

What may need to be given alongside Albumin and Plasma Protein Fraction until adequate circulating volume is established?

A

A diuretic

130
Q

Since Albumin and Plasma Protein Fraction pulls fluids back into the vascular space what must we know?

A

KIDNEY FUNCTION

131
Q

Hemolytic Disease in the Newborn

A

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)

132
Q

Albumin and Plasma Protein Fraction Administration?

A

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

133
Q

When can 5% Albumin be given faster?

A

When the person is in shock with hypotension

134
Q

Why is 25% albumin given much slower than 5%?

A

Its concentration

It will cause significant increase in blood volume and blood pressure as it is given

135
Q

Where can the RN find Albumin and Plasma Protein Fraction products?

A

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

136
Q

Equipment for giving an Albumin or Plasma Protein Fraction Transfusion

A

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

137
Q

Expected outcome of Albumin and PPF administration?

A

Acquire and maintain adequate BP and volume support

138
Q

Complications of Albumin and PPF

A

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

139
Q

Fluid overload is a big problem, and if we give transfusions too quickly we can end up getting the signs and symptoms of…

A

heart failure

140
Q

ISG - Immune Serum Globulins

A

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)

141
Q

2 Types of ISG

A

Specific ISG

Non Specific ISG

142
Q

Non Specific ISG

A

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

143
Q

Specific ISG

A

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))

144
Q

Why does ISG only give passive immunity

A

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

145
Q

What is the downfall of ISG v a Vaccine for something like Hep B?

A

You will need more ISG if you are exposed again, but a vaccine can allow you to make your own antibodies in repeated exposure

146
Q

Indications for ISG Transfusion

A

Passive Immune Protection against HBIG, RhIG, and VZIG

Treatment for Hypogamma-globulinemia

147
Q

HBIG

A

Immunoglobulin given following HBV exposure (Hep B)

148
Q

RhIG

A

Immunoglobulin given following exposure to Rh (D) antigens through transfusion or pregnancy to prevent antibody development

149
Q

VZIG

A

immunoglobulin given to immuno-compromised patients exposed to chicken pox

150
Q

What sort of patient may get RhIG ISG?

A

A pregnant Rh - patient exposed to Rh+ blood

151
Q

Who should not receive ISG?

A

Patients with a history of severe allergic reactions to plasma should not receive ISG

152
Q

What can and cannot be transmitted via ISG?

A

Neither HIV nor Hep B is transmitted by ISG, however some IV gamma globulin solutions have been reported to transmit HEPATITIS C

153
Q

Administration of ISG

A

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

154
Q

IM ISG Injections may be what and require what in response?

A

Painful and result in local irritation - they need a warm compress on the area

155
Q

When must RhIG and VZIG be given to achieve optimal effect?

A

Within 72 hours of exposure

156
Q

Administration of IV ISG

A

administer ONLY IV using a filter

Do NOT administer with other medications

Begin infusion within 2 hours of reconstitution

157
Q

Most transfusion reactions result from …

A

error, so know your stuff and double check

158
Q

Expected Outcome of ISG Transfusion

A

Transient correction of gamma globulin deficiency OR prevention of disease through the passive administration of the antibody

159
Q

Granulocyte Product

A

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

160
Q

What is Granulocyte Product usually for?

A

A last ditch effort to stop infection

161
Q

Indications for Granulocyte Transfusion

A
  1. Acquired neutropenia from radiation or chemotherapy
  2. Congenital WBC dysfunction
  3. Serious infection unresponsive to conventional antibiotics
162
Q

What about granulocyte product use is questionable?

A

its long term therapeutic benefit

163
Q

How can we tell is Granulocyte product helped with an infection?

A

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)

164
Q

Granulocyte Administration

A

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

165
Q

Equipment for Granulocyte Administration

A

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

166
Q

Why should we not use microaggregate or leukocyte depletion filters with Granulocyte product?

A

Because it can trap WBC during infusion and then we are not giving what we are supposed to

167
Q

With granulocyte product administration we have a very high risk for what?

A

Allergic and Febrile Reaction (so we must pre medicate)

168
Q

What do we use to premedicate with before giving Granulocyte Product?

A

Antihistamine

Acetaminophen

Steroids

Meperidine

169
Q

Expected outcome of Granulocyte transfusion

A

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

170
Q

Complications of Granulocyte Product Transfusion

A

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

171
Q

Amphotericin B

A

Antifungal

CANNOT BE GIVEN WITH GRANULOCYTES AS WITHIN 4 HOURS OF INFUSION THERE CAN BE A RISK FOR PULMONARY INSUFFICIENCY

172
Q

Compatibility Rules for Granulocytes

A

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

173
Q

Transfusion Reaction

A

Antigens on the transfused product can be read and an antibody could be provided and produced causing an immune response and dangerous reaction

174
Q

2 Categories of Transfusion Reactions

A

Acute v Chronic

175
Q

Examples of Acute Transfusion Reactions

A

Acute Hemolytic Reaction

Febrile Non Hemolytic Reaction (Most common)

Mild allergic reaction

Anaphylactic Reaction

Circulatory Overload

Sepsis

Transfusion Related Acute Lung Injury (TRALI)

176
Q

Examples of Chronic Transfusion Reactions

A

Delayed hemolytic

Hepatitis B

Hepatitis C

HIV-1 (AIDS virus) infection

Iron overload

Graft-versus-host disease (GVHD)

Other:
CMV, HTLV-I, malaria

177
Q

What are some of the General Manifestations of a Transfusion reaction

A

Fever (up 1-2 degrees C)

chills

muscle aches and pain

back pain

chest pain

headache

heat at site of infusion or along vein

178
Q

What are some of the Nervous System Manifestations of a Transfusion reaction

A

apprehension

sense of impending doom

tingling

numbness

179
Q

What are some of the respiratory Manifestations of a Transfusion reaction

A

respiratory rate changes - tachy or bradypnea
dyspnea

cough

wheezing

rales

180
Q

What are some of the GIl Manifestations of a Transfusion reaction

A

nausea

vomiting

pain, abdominal cramping

diarrhea (may be bloody)

181
Q

What are some of the renal Manifestations of a Transfusion reaction

A

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)

182
Q

What are some of the cardiovascular Manifestations of a Transfusion reaction

A

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

183
Q

What are some of the integumentary Manifestations of a Transfusion reaction

A

rashes

hives (urticaria)

swelling

itching

diaphoresis

184
Q

What are some of the Manifestations of a Transfusion reaction in an UNCONSCIOUS PATIENT

A

weak pulse

fever

hypotension

visible hemoglobinuria

increased operative bleeding (oozing at surgical site)

vasomotor instability (tachycardia, bradycardia, hypotension)

oliguria or anuria

185
Q

Reactions from different causes can exhibit similar manifestations, so…

A

every symptom should be considered potentially serious and transfusion should be discontinued until the cause is determined

Assume the worse for safety reasons!!!

186
Q

Its important to get what before doing transfusions and during them?

A

Baseline vitals and 15 min in vitals and hourly after that maybe

187
Q

If a transfusion reaction begins, never do what?

A

Allow IV access to go away

188
Q

If a transfusion reaction begins what equipment needs to go back to the lab for testing?

A

Every piece of equipment: left over blood, tubing, urine, everything

189
Q

What to do when a transfusion reaction begins?

A
  1. Stop Transfusion and keep the IV open with 0.9% NS
  2. report rxn to both transfusion services and attending physician ASAP
  3. Do clerical check at bedside of identifying tags and numbers
  4. treat symptoms pre physicians orders and monitor vital signs
  5. send blood bag with attached administration set and labels to the transfusion service
  6. collect blood and urine samples and send to lab
  7. document THOROUGHLY on transfusion reaction form and in the patients chart
190
Q

Acute Hemolytic Reaction

A

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

191
Q

Manifestations of an Acute Hemolytic Reaction

A

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

192
Q

What are the most common symptoms of Acute Hemolytic Reaction? What is one of the unique symptoms?

A

Common: Fever and Chills

Unique: Lower Back Pain

193
Q

How to manage an Acute hemolytic Reaction

A

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!!!

194
Q

What not to do after an Acute Hemolytic Reaction?

A

DO NOT TRANSFUSE RBC CONTAINING COMPONENTS UNTIL TRANSFUSION SERVICE PROVIDES NEW CROSSMATCHED UNITS

195
Q

How to prevent Acute Hemolytic Reaction

A

Meticulously verify and document patient ID form sample collection to component transfusion

196
Q

Febrile Non Hemolytic Reaction

A

Acute Transfusion Reaction

It is due to sensitization to donor WBC, PLTs, or plasma proteins

RBC ARE NOT DESTROYED

More common that Hemolytic reaction

197
Q

Manifestations of Febrile Non Hemolytic Reactions

A

Sudden chills

Fever (increase more than 1 degree C)

Headache

flushing

anxiety

muscle pain

198
Q

How to manage a febrile non hemolytic reaction?

A

give antipyretics as prescribed

AVOID aspirin in thrombocytopenic patients

DO NOT restart transfusion

199
Q

Who is at highest risk for a Febrile Non Hemolytic Reaction

A

Anyone that has gotten a transfusion in the past

200
Q

Prevention for Febrile Non Hemolytic Reactions

A

Consider leukocyte poor blood products (filtered, washed, or frozen)

201
Q

Mild Allergic Reaction

A

Acute Transfusion rxn

Sensitivity to foreign plasma proteins

202
Q

Manifestations of a Mild Allergic Reaction

A

Flushing

itching

Urticaria (Hives)

NO FEVER

203
Q

Management for a Mild Allergic Reaction

A

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

204
Q

Prevention for Mild Allergic Reaction

A

Treat prophylactically with antihistamines

205
Q

Anaphylaxis and Anaphylactic Shock

A

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

206
Q

What type of person may have an anaphylactic reaction?

A

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

207
Q

IgA

A

An immunoglobulin not found in great abundance in people

it is in the GI tract, saliva, tears, body fluids

208
Q

Due to anaphylaxis, it is important to always as a transfusion patient…

A

If they have had a transfusion reaction in the past

209
Q

Manifestations of Anaphylaxis

A

Anxiety
Urticaria
Wheezing
Throat Swelling

Progresses to Shock - Cyanosis, Shock, Possible Cardiac Arrest

210
Q

Management for Anaphylactic Reaction

A
  1. Initiate CPR if indicated
  2. Have EP ready for injection (0.4 mL subQ or 0.1 mL diluted in 10 mL NS for IV)
  3. DO NOT RESTART THIS TRANSFUSION
211
Q

Why is EP good for anaphylaxis?

A

EP can stop the mass histamine release that is occurring

212
Q

Prevention Measures for Anaphylactic Reaction

A

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

213
Q

Circulatory Overload

A

Acute Transfusion Reaction

Fluid is administered faster than the circulation can accommodate causing this reaction

More common in kids and smaller people

214
Q

Circulatory overload causes ___ symptomology

A

Lung

215
Q

Manifestations of Circulatory Overload

A

Cough

dyspnea

pulmonary congestion (rales)

HA

HTN

tachycardia

distended neck veins

216
Q

Management for Circulatory overload

A

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

217
Q

Crackles in the lung indicate…

A

pulmonary edema

218
Q

Prevention of Circulatory Overload

A

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

219
Q

Sepsis

A

Acute transfusion reaction

this is transfusion of contaminated blood components

220
Q

Manifestations of Sepsis

A

Rapid onset of chills

high fever

vomiting

diarrhea

marked hypotension! (d/t going into shock)

shock

221
Q

What 3 important things need to be documented due to sepsis reactions?

A
  1. That blood is not expired
  2. That blood was not sitting around for a long time
  3. That we have not exceeded the 4 hour time frame
222
Q

Management of Sepsis

A

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

223
Q

Prevention of Sepsis

A

Collect, process, store, and transfuse blood products according to blood banking standards and infuse them within 4 HOURS OF STARTING TIME

224
Q

TRALI

A

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

225
Q

Where does TRALI occur?

A

the lungs

226
Q

Manifestations of TRALI

A

dyspnea

wheezing

fever

chills

bronchospasms

crackles

restlessness

non productive cough

pulmonary infiltrates

HTN or Hypotension

systemic inflammatory symptoms

227
Q

What is TRALI NOT a sign of?

A

CHF or Volume Overload

228
Q

When unhooking a blood product what should be done for flushing?

A

The whole line should not be flushed because it still has product in it, it should be unhooked at site of insert

229
Q

Management of TRALI complications

A
  1. STOP infusion and maintain patent IV line
  2. Place in supine position
  3. maintain open airway - mechanical ventilation if necessary (may need intubation)
  4. Obtain VS and record
  5. notify physician
  6. administer fluids and EP, steroids, and diuretics per orders
  7. Administer O2
  8. Monitor VS and urine output (renal failure can occur with a perfusion problem)
  9. Document event thoroughly
230
Q

how many cases of TRALI are fatal regardless of aggressive supportive care?

A

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)

231
Q

Delayed hemolytic Reaction

A

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

232
Q

Manifestations of Delayed hemolytic reaction

A

fever

mild jaundice (waste - bilirubin buildup)

decreased HCT

233
Q

Treatment for Delayed Hemolytic Reaction

A

generally, no acute treatment is required

hemolysis that is severe enough can warrant further transfusions

234
Q

Hepatitis B

A

Delayed Transfusion Reaction involving inflammation of the liver (from elevated liver enzymes (AST and ALT) dying.

235
Q

Manifestations of Hep B

A

elevated liver enzymes (AST and ALT)

anorexia

malaise

nausea and vomiting

fever

dark urine (increased from hemolysis occurring releasing heme)

jaundice (increased bilirubin)

236
Q

Treatment for Hep B

A

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

237
Q

Hepatitis C

A

Delayed transfusion reaction

Similar to Hep B (liver inflammation)

238
Q

How is Hep C different from Hep B?

A

Hep C usually has less severe symptoms (but could cause chronic liver disease and cirrhosis thus warranting a liver biopsy every 4-5 years)

239
Q

Treatment for Hep C

A

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)

240
Q

HIV-1 (AIDS Virus) Infection

A

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

241
Q

Later S/S of HIV-1

A

weight loss

diarrhea

fevers

lymphadenopathy

thrush

pneumocystis pneumonia

242
Q

What is the current estimated risk of infection with HIV-1 from a blood transfusion?

A

1:30,000 to 1:1,500,000 depending on geographic area

243
Q

Iron Overload

A

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

244
Q

What is a potential cause for Iron Overload?

A

constant blood transfusions (like in chronic anemia or chronic renal patients)

245
Q

Manifestations of Iron Overload

A

congestive heart failure

arrhythmias

impaired thyroid and gonadal function

diabetes

cirrhosis

commonly occurs in patients receiving >100 units for chronic anemia

246
Q

Treatment for Iron Overload

A

Treat Symptomatically

One medicine is Deferoxamine (Desferal) which chelates and removes accumulated iron via the kidneys and can be administered IV or subQ

247
Q

Graft V Host Disease

A

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

248
Q

Manifestations of GVHD

A

fever

rash

diarrhea

hepatitis

249
Q

Treatment for GVHD

A

there is no effective therapy so prevention is crucial with this

250
Q

How to prevent GVHD

A
  1. Irradiate blood products intended for babies or immunocompromised patients
  2. May want to use first degree family members donations
251
Q

What is one of the most important things to know when administering blood products?

A

KNOW HOSPITAL POLICY

252
Q

What must be gathered before any blood transfusion can occur?

A

INFORMED CONSENT (you as the nurse must gauge their understanding and obtain and record baseline vitals while the physicians gets the consent)

253
Q

What may need to be done to prepare for transfusion?

A

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

254
Q

What sort of Special Administration Devices are needed for Blood Component Administration?

A

Electromechanical Infusion Devices (only if approved)

External Pressure Infusion Cuffs (DO NOT USE BP CUFFS)

Blood Warmers

255
Q

What is the benefit of blood warmers?

A

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

256
Q

If mult blood components are indicated…

A

check with the physician to establish an order of priority based on the situation

also may need lasix to prevent pulmonary edema

257
Q

What to verify about components you want to transfuse?

A
  1. Get from transfusion service and check for abnormalities - should be a deep red color
  2. record name of person issuing blood, person to whom blood is issued, and date/time of issue
  3. Read instruction on product label, check expiration date and time
  4. recheck physicians order sheet to verify component ordered
  5. 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

258
Q

What to do after doing checks for blood transfusion?

A
  1. 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)
  2. Do NOT proceed until all comparisons match EXACLTY - contact transfusion service if any discrepancies
  3. Sign transfusion form immediately prior to transfusion
  4. document date and time transfusion started
  5. keep all ID attached to blood container if paper

BE METICULOUS

259
Q

What should be done upon Administration of blood components?

A

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

260
Q

What things should be record on transfusion permanent record?

A

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

261
Q

Who can confirm a transfusion?

A

2 people:

2 RNs

OR

1 RN and an LPN

OR

1 RN and 1 Physician

262
Q

Blood Administration Pitfalls to Avoid

A

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

263
Q

Universal Precautions

A

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!!

NURS361 - Pathophysiology II (20 decks)

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