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   involves transfusing whole blood or blood components (specific

portion or fraction of blood lacking in patient). One unit of whole blood consists of 450 mL of
blood collected into 60 to 70 mL of preservative or anticoagulant. Whole blood stored for
more than 6 hours does not provide therapeutic platelet transfusion, nor does it contain
therapeutic amounts of labile coagulation factors (factors V and VIII).


1. Avoids the risk of sensitizing the patients to other blood components.
2. Provides optimal therapeutic benefit while reducing risk of volume overload.
3. Increases availability of needed blood products to larger population.
1. Whole blood transfusion
 Generally indicated only for patients who need both increased oxygen -carrying
capacity and restoration of blood volume when there is no time to prepare or obtain
the specific blood components needed.
2. Packed RBCs
 Should be transf used over 2 to 3 hours; if patient cannot tolerate volume over a
maximum of 4 hours,
3. Platelets
 Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit
of platelets should raise the recipient¶s platelet count by 6000 to 10,00 0/mm3.
4. Granulocytes
 May be beneficial in selected population of infected, severely granulocytopenic
patients (less than 500/mm3) not responding to antibiotic therapy and who are
expected to experienced prolonged suppressed granulocyte production.
5. Plasma
 Fresh frozen plasma should be administered as rapidly as tolerated because
coagulation factors become unstable after thawing.
6. Albumin
 Indicated to expand to blood volume of patients in hypovolemic shock and to elevate
level of circulating albumin in patients with hypoalbuminemia. The large protein
molecule is a major contributor to plasma oncotic pressure.
7. Cryoprecipitate
 Indicated for treatment of hemophilia A, Von Willebrand¶s disease, disseminated
intravascular coagulation (DIC), and uremic bleeding.
8. Factor IX concentrate
 Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it
requires pooling from many donors.
9. Factor VIII concentrate
 Indicated for treatment of hemophilia A; heat-treated product decreases the risk of
hepatitis and HIV transmission.
10. Prothrombin complex -Indicated in congenital or acquired deficiencies of these factors.

1. Clinical manifestations of transfusions complications vary depending on the precipitating
2. Signs and symptoms of hemolytic transfusion reaction include:
 low back pain
 flank pain
 hemoglobinuria (cola -colored urine)
3. Clinical signs and laboratory findings in delayed hemolytic reaction include:
 mild jaundice
 gradual fall of hemoglobin
 positive Coombs¶ test
4. Febrile non-hemolytic reaction is marked by:
 Temperature rise during or shortly after transfusion
5. Signs and symptoms of septic reaction include;
 Rapid onset of high fever and chills
 marked hypotension
6. Allergic reactions may produce:
 generalized pruritus
 wheezing or anaphylaxis (rarely)
7. Signs and symptoms of circulatory overload include:
 jugular vein distention
8. Manifestations of infectious disease transmitted through transfusion may develop rapidly
or insidiously, depending on the disease.
9. Characteristics of GVH disease include:
 skin changes (e.g. erythema, ulcerations, scaling)
 hair loss
 hemolytic anemia
10. Reactions associated with massive transfusion produce varying manifestations
1. Ineffective breathing pattern
2. Decreased Cardiac Output
3. Fluid Volume Deficit
4. Fluid Volume Excess
5. Impaired Gas Exchange
6. Hyperthermia
7. Hypothermia
8. High Risk for Infection
9. High Risk for Injury
10. Pain
11. Impaired Skin Integrity
12. Altered Tissue Perfusion
1. Help prevent transfusion reaction by:
 Meticulously verifying patient identification beginning with type and cross match
sample collection and labeling to double check blood product and patient
identification prior to transfusion.
 Inspecting the blood product for any gas bubbles, clothing, or a bnormal color before
 Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely,
particularly during the first 15 minutes (severe reactions usually manifest within 15
minutes after the start of transfusion).
 Transfusing blood within 4 hours, and changing blood tubing every 4 hours to
minimize the risk of bacterial growth at warm room temperatures.
 Preventing hypothermia by warming blood unit to 37 C before transfusion.

2. On detecting any signs or symptoms of reaction:

 Stop the transfusion immediately, and notify the physician.
 Disconnect the transfusion set -but keep the IV line open with 0.9% saline to provide
access for possible IV drug infusion.
 Send the blood bag and tubing to the blood bank for repeat typing and cultur e.
 Draw another blood sample for plasma hemoglobin, culture, and retyping.
 Collect a urine sample as soon as possible for hemoglobin determination.
1. The patient maintains normal breathing pattern.
2. The patient demonstrates adequate cardiac output.
3. The patient reports minimal or no discomfort.
4. The patient maintains good fluid balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin integrity, with no lesions or pruritus.
8. The patient maintains or returns to normal electrolyte and blood chemistry values.

Postural Drainage Therapy

Postural drainage therapy (PDT) is a component of bronchial hygiene therapy. It consists of
postural drainage, positioning, and turning and is sometimes accompanied by chest
percussion and/or vibration.
Cough or airway clearance techniques are essential components of therapy when postural
drainage is intended to mobilize secretio ns. Postural drainage therapy is often used in
conjunction with aerosol administration and other respiratory care procedures.
This procedure has be en commonly referred to a
chest physiotherapy,
chest physical therapy,
postural drainage and percussion, and
percussion and vibration.
Postural drainage therapy is designed to improve the mobilization of bronchi al secretions
and the matching of ve ntilation and perfusion, and to normalize functional r esidual capacity
(FRC) based on the effects of gravity and external manipulation of the thorax. This includes
turning, postural drainage, percussion, vibration, and cough.
2.1 Turning
Turning is the rotation of the body around the longitudinal axis to promote unilateral
or bilateral lung expansion and improve arterial oxygenation. Regular turning can be
to either side or the prone position, with the bed at any degree of inclination (as
indicated and tolerated). Patients may turn themselves or they may turn by the
caregiver or by a special bed or device.
2.2 Postural Drainage
Postural drainage is the drainage of secretions, by the effect of gravity, from one or
more lung segments to the central airways (where they can be removed by cough or
mechanical aspiration). Each position consists of placing the target lung segment(s)
superior to the carina. Positions should generally be held for 3 to 15 minutes (longer
in special situati ons). Standard positions are modified as the patient's condition and
tolerance warrant.
2.3 External Manipulation of the Thorax
2.3.1 Percussion
Percussion is also referred to as cupping, clapping, and tapotement. The purpose of
percussion is to intermittently apply kinetic energy to the chest wall and lung. This is
accomplished by rhythmically striking the tho rax with cupped hand or mechanical
device directly over the lung segment(s) being drained. No convincing evidence
demonstrates the superiority of one me thod over the other.
2.3.2 Vibration
Vibration involves the application of a fine tremorous action (manu ally performed by
pressing in the direction that the ribs and soft tissue of the chest move during
expiration) over the draining area. No conclusive evidence supports the efficacy of
vibration, the superiority of either manual or mechanical methods, or an optimum
Although PDT can be used with neonates, infants, childrens, and adults, this Guideline
applies primarily to older children and adults. PDT can be performed in a wide variety of
3.1 Critical care
3.2 In-patient acute care
3.3 Extended care and skilled nursing facility care
3.4 Home care
3.5 Outpatient/ambulatory care
3.6 Pulmonary diagnostic (bronchoscopy) laboratory
4.1 Turning
4.1.1 inability or reluctance of patient to change body position. (eg, mechanical
ventilation, neuromuscular disease, drug -induced paralysis)
4.1.2 poor oxygenation associated with position(eg, unilateral lung disease)
4.1.3 potential for or p resence of atelectasis
4.1.4 presence of artificial airway
4.2 Postural Drainage
4.2.1 evidence or suggestion of difficulty with secretion clearance difficulty clearing secretions with expectorated sputum production greater
than 25-30 mL/day (adult) evidence or sugges tion of re-tained secretions in the presence of an artificial
4.2.2 presence of atelectasis caused by or suspected of being caused by mucus
4.2.3 diagnosis of diseases such as cystic fibrosis, bronchiectasis, or cavitating lung
4.2.4 presence of foreign body in airway
4.3 External Manipulation of the Thorax
4.3.1 sputum volume or consistency suggesting a need for additional manipulation
(eg, percussion and/or vibration) to assist movement of secretions by gravity, in a
patient receiv ing postural drainage
The decision to use postural drainage therapy requires assessment of potential benefits
versus potential risks. Therapy should be provided for no longer than necessary to obtain the
desired therapeutic resul ts. ˜ 


5.1 Positioning
5.1.1 All positions are contraindicated for intracranial pressure (ICP) > 20 mm Hg(59,60) head and neck injury until stabilized (A) active hemorrhage with hemodynamic instability (A) recent spinal surgery (eg, laminectomy) or acute spinal injury acute spinal injury or active hemoptysis empyema bronchopleural fistula pulmonary edema associated with congestive heart failure large pleural effusions pulmonary embolism aged, confused, or anxious patients who do not tolerate position changes rib fracture, with or without flail chest surgical wound or healing tissue
5.1.2 Trendelenburg position is contraindicated for intracranial pressure (ICP) > 20 mm Hg(59,60) patients in whom increased intracranial pressure is to be avoided (eg,
neurosurgery, aneurysms, eye surgery) uncontrolled hypertension distended abdome esophageal surgerY recent gross hemoptysis re-lated to recent lung carcinoma treated surgically
or with radiation therapy(59) uncontrolled airway at risk for aspiration (tube feeding or recent meal)
5.1.3 Reverse Trendelenburg is contraindicated in the presence of hypotension or
vasoactive medication
5.2 External Manipulation of the Thorax
In addition to contraindications previously listed
5.2.1subcutaneous emphysema
5.2.2 recent epidural spinal infusion or spinal anesthesia
5.2.3 recent skin grafts, or flaps, on the thorax
5.2.4 burns, open wounds, and skin infections of the thorax
5.2.5 recently placed transvenous pacemaker or subcutaneous pacemaker
(particularly if mechanical devices are to be used)
5.2.6 suspected pulmonary tuberculosis
5.2.7 lung contusion
5.2.8 bronchospasm
5.2.9 osteomyelitis of the ribs
5.2.10 osteoporosis
5.2.11 coagulopathy
5.2.12 complaint of chest-wall pain