Catanduanes State Colleges College of Health Sciences NURSING DEPARTMENT Virac,Catanduanes

REPORT in
BLOOD TRANSFUSION

Submitted by: LANON, EMLYN JOSEPHINE M. BSN3A/G3

Submitted to: Ms. MARIA ALMA V. TABIRARA, RN., MAN Clinical Instructor

BLOOD TRANSFUSION THERAPY 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). BLOOD COMPONENTS include: 1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygen-carrying capacity of blood with minimal expansion of blood. 2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions. 3. Platelets, either HLA (human leukocyte antigen) matched or unmatched. 4. Granulocytes ( basophils, eosinophils, and neutrophils ) 5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors). 6. Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation. 7. Albumin, a plasma protein. 8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin. 9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma. 10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma. 11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

ADVANTAGES of blood component therapy 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.

Principles of blood transfusion therapy 1. Whole blood transfusion o 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 o Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%. 3. Platelets o Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipients platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension.

4. Granulocytes o 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 o Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringers lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing. 6. Albumin o 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 o Indicated for treatment of hemophilia A, Von Willebrands disease, disseminated intravascular coagulation (DIC), and uremic bleeding. 8. Factor IX concentrate o Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors. 9. Factor VIII concentrate o 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.

BLOOD TYPES Every person has one of the following blood types: A, B, AB, or O. Also, every person's blood is either Rh-positive or Rh-negative. So, if you have type A blood, it's either A positive or A negative. The blood used in a transfusion must work with your blood type. If it doesn't, antibodies (proteins) in your blood attack the new blood and make you sick. Type O blood is safe for almost everyone. About 40 percent of the population has type O blood. People who have this blood type are called universal donors. Type O blood is used for emergencies when there's no time to test a person's blood type. People who have type AB blood are called universal recipients. This means they can get any type of blood. If you have Rh-positive blood, you can get Rh-positive or Rh-negative blood. But if you have Rh-negative blood, you should only get Rh-negative blood. Rh-negative blood is used for emergencies when there's no time to test a person's Rh type. WHO NEEDS A BLOOD TRANSFUSION? Blood transfusions are very common. Each year, almost 5 million Americans need blood transfusions. This procedure is used for people of all ages. Many people who have surgery need blood transfusions because they lose blood during their operations. For example, about one-third of all heart surgery patients have a transfusion. Some people who have serious injuriessuch as from car crashes, war, or natural disastersneed blood transfusions to replace blood lost during the injury. Some people need blood or parts of blood because of illnesses. You may need a blood transfusion if you have: y A severe infection or liver disease that stops your body from properly making blood or some parts of blood.

y An illness that causes anemia, such as kidney disease or cancer. Medicines or radiation used to

treat a medical condition also can cause anemia. There are many types of anemia, including aplastic, Fanconi, hemolytic, iron-deficiency, and sickle cell anemias and thalassemia (thala-SE-me-a). y A bleeding disorder, such as hemophilia or thrombocytopenia (THROM-bo-si-to-PE-ne-ah). WHAT ARE THE RISKS OF A BLOOD TRANSFUSION? Most blood transfusions go very smoothly. However, mild problems and, very rarely, serious problems can occur. Allergic Reactions Some people have allergic reactions to the blood given during transfusions. This can happen even when the blood given is the right blood type. Allergic reactions can be mild or severe. Symptoms can include: Anxiety Chest and/or back pain Trouble breathing Fever, chills, flushing, and clammy skin A quick pulse or low blood pressure Nausea (feeling sick to the stomach)

y y y y y y

A nurse or doctor will stop the transfusion at the first signs of an allergic reaction. The health care team determines how mild or severe the reaction is, what treatments are needed, and whether the transfusion can safely be restarted. Viruses and Infectious Diseases Some infectious agents, such as HIV, can survive in blood and infect the person receiving the blood transfusion. To keep blood safe, blood banks carefully screen donated blood. The risk of catching a virus from a blood transfusion is very low. Fever You may get a sudden fever during or within a day of your blood transfusion. This is usually your body's normal response to white blood cells in the donated blood. Over-the-counter fever medicine usually will treat the fever. Some blood banks remove white blood cells from whole blood or different parts of the blood. This makes it less likely that you will have a reaction after the transfusion. Iron Overload Getting many blood transfusions can cause too much iron to build up in your blood (iron overload). People who have a blood disorder like thalassemia, which requires multiple transfusions, are at risk for iron overload. Iron overload can damage your liver, heart, and other parts of your body. If you have iron overload, you may need iron chelation (ke-LAY-shun) therapy. For this therapy, medicine is given through an injection or as a pill to remove the extra iron from your body. Lung Injury Although it's unlikely, blood transfusions can damage your lungs, making it hard to breathe. This usually occurs within about 6 hours of the procedure. Most patients recover. However, 5 to 25 percent of patients who develop lung injuries die from the injuries. These people usually were very ill before the transfusion. Doctors aren't completely sure why blood transfusions damage the lungs. Antibodies (proteins) that are more likely to be found in the plasma of women who have been pregnant may

disrupt the normal way that lung cells work. Because of this risk, hospitals are starting to use men's and women's plasma differently.

Acute Immune Hemolytic Reaction Acute immune hemolytic reaction is very serious, but also very rare. It occurs if the blood type you get during a transfusion doesn't match or work with your blood type. Your body attacks the new red blood cells, which then produce substances that harm your kidneys. The symptoms include chills, fever, nausea, pain in the chest or back, and dark urine. The doctor will stop the transfusion at the first sign of this reaction. Delayed Hemolytic Reaction This is a much slower version of acute immune hemolytic reaction. Your body destroys red blood cells so slowly that the problem can go unnoticed until your red blood cell level is very low. Both acute and delayed hemolytic reactions are most common in patients who have had a previous transfusion. Graft-Versus-Host Disease Graft-versus-host disease (GVHD) is a condition in which white blood cells in the new blood attack your tissues. GVHD usually is fatal. People who have weakened immune systems are the most likely to get GVHD. Symptoms start within a month of the blood transfusion. They include fever, rash, and diarrhea. To protect against GVHD, people who have weakened immune systems should receive blood that has been treated so the white blood cells can't cause GVHD PREPARATION FOR BLOOD TRANSFUSION Before a blood transfusion is performed, the doctor will order a blood specimen to confirm the patient's blood type and compatibility with the blood being donated. This test is done even when the patient is donating his own blood. This is done to ensure the patient's safety and health. PLANNING AND IMPLEMENTATION 1. Help prevent transfusion reaction by: o 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. o Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration. o Beginning transfusion slowly ( 1 to 2 mL/min) or 20 drops/min. and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion). o Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures. o Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents. o Preventing GVH disease by ensuring irradiation of blood products containing viable WBCs (i.e., whole blood, platelets, packed RBCs and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide. o Preventing hypothermia by warming blood unit to 37 C before transfusion. o Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion. 2. On detecting any signs or symptoms of reaction: o Stop the transfusion immediately, and notify the physician.

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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 culture. Draw another blood sample for plasma hemoglobin, culture, and retyping. Collect a urine sample as soon as possible for hemoglobin determination.

3. Intervene as appropriate to address symptoms of the specific reaction: o Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria. o Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions. o In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed. o Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.) o For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed. TRANSFUSION PROCEDURE Before the transfusion begins, the patient must sign a consent form. The doctor will then order the patient to take medications, such as antihistamines and acetaminophen, before the transfusion. Before the transfusion begins, two nurses will check the patient's identity. The nurse performing the transfusion will then insert an intravenous line into the patient's arm. 1. Verify doctors written prescription and make a treatment card according to hospital policy. 2. Observe ten (10) Rs when preparing and administering any blood or blood components. 3. Explain the procedure/rationale for giving blood transfusion to reassure patient and significant others and secure consent. Get patients history regarding previous transfusion 4. Explain the importance of the benefits on Voluntary Blood Donation (RA 7719 National Blood Service Act of 1994). 5. Request prescribed blood/blood components from blood bank to include blood typing and X-matching and blood result of transmissible disease. 6. Using a clean lined tray, get compatible blood from hospital blood bank. 7. Wrap blood bag with clean towel and keep it at room temperature. 8. Have a doctor and a nurse assess patients condition. Countercheck the compatible blood to be transfused against the X-matching sheet noting ABO grouping and Rh, serial no. of each blood unit, and expiry date with the blood bag label and other laboratory blood exam as required before transfusion (Hgb and Hct). 9. Get the baseline vital signs BP, RR, temperature before transfusion. Refer to MD accordingly. 10. Give pre-med 30 minutes before transfusion as prescribed. 11. Do hand hygiene before and after the procedure. 12. Prepare equipment needed for BT. IV injection tray, IV catheter/needle G 18/19, plaster, tourniquet, gloves, blood component to be transfused. Plain NSS 500 cc, IV set . sterile 2x2 gauze or transparent dressing. 13. If main IVF is with dextrose 5% initiate an IV line with appropriate IV catheter with Plain NSS on another site, anchor catheter properly and regulate IV drops. 14. Open compatible blood set aseptically and close roller clamp. Spike blood bag carefully; fill the drip chamber at least half full; prime tubing and remove air bubbles (if any). Use needle G 18 or 19 for side drip (for adults) or of 22 for pedia (if blood is given through the Y-injection port, the gauge of needle is disregarded). 15. Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle from BT administration set and secure with adhesive tape. 16. Close roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on.

17. Transfuse the blood via the injection port and regulate at 10-15 gtts initially for 15 minutes and then at the prescribed rate (usually based on the patients condition). 18. Observe patient for 10-15 minutes for any immediate reaction. 19. Observe patient on an on- going basis for any untoward signs and symptoms such as flushed skin, chills, elevated temperature, itchiness, urticaria and dyspnea. If any of these symptoms occurs stop the transfusion, open the roller clamp of the IV line with Plain NSS, and report to doctor immediately. 20. Swirl the bag hourly to mix the solid with the plasma. N.B. one BT set should be used for 1-2 units of blood. 21. When blood is consumed, close the roller clamp of BT, and disconnect from IV lines then regulate the IVF of plain NSS as prescribed 22. Continue to observe and monitor patient post transfusion for delayed reaction could still occur. 23. Re-check Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed &/or per institutions policy. 24. Discard blood bag and BT set and sharps according to Health Care Waste Management(DOH/DENR). 25. Document the procedure, pertinent observations and nursing intervention and endorse accordingly. 26. Remind the doctor about the administration of Ca gluconate if patient had several units of blood transfusion (3-6 or more units of blood) NURSE'S RESPONSIBILITY BEFORE and DURING PROCEDURE The nurse handling the transfusion has a number of responsibilities to ensure that the procedure is performed correctly and to ensure the patient's safety and health.  Before, during and after the transfusion, the nurse will check the patient's temperature, pulse and blood pressure, and will check for any signs of adverse reactions to the transfusion.  While reactions are rare, they are monitored. Symptoms for adverse reactions include breathing problems, chills, fever, itching/hives, rash, nausea, lower back pain, apprehensive feelings, tingling or numbness, heat, pain, or swelling at the site where the IV is inserted. Patients are urged to keep the nurse abreast of any symptoms they experience.  The nurse is responsible for insuring that the right unit of blood is to be administered to the right patient after typing and cross matching by the lab. This is done by checking the lot, serial numbers, blood type, and expiration date with another nurse or qualified lab personnel. Then the unit of blood has to be checked off with another nurse before administration. Only registered nurses are allowed by law to administer blood products.  Before administering the unit, the nurse has to get consent forms signed by the patient or a qualified representative of the patient, except in the cases of trauma or life saving situations if the patient is unable to make that decision. All patients have the right to refuse transfusions.  After consents are signed and the blood is checked by appropriate personnel, the nurse has to take a complete set of vital signs for a baseline.  After starting the transfusion, the vital signs must be checked after 15 minutes, then 30 minutes from then, then at one hour. Then vital signs must be checked every hour, according to hospital protocol. The vital signs are checked this often to monitor for a reaction to the blood. If a reaction occurs, then the transfusion must be stopped immediately and normal saline infused. Blood can only be transfused with normal saline. Some hospitals may give premedications before transfusion to reduce the chance of a reaction. a unit of whole blood (packed red blood cells) must be infused over 3.5-4 hours, but not over 4 hours from the time of the start of the transfusion.

REACTION: CAUSE

CLINICAL SIGNS

NURSING INTERVENTION* 1. Discontinue the transfusion immediately. NOTE: When the transfusion is discontinued, the blood tubing must be removed as well. Use new tubing for the normal saline infusion. 2. Keep the vein open with normal saline, or according to agency protocol. 3. Send the remaining blood, a sample of the clients blood, and a urine sample to the laboratory. 4. Notify the physician immediately. 5. Monitor vital signs. 6. Monitor fluid intake and output. 1. Discontinue the transfusion immediately. 2. Give antipyretics as ordered. 3. Notify the physician. 4. Keep the vein open with a normal saline infusion. 1. Stop or slow the transfusion, depending on agency protocol. 2. Notify the physician. 3. Administer medication (antihistamines) as ordered. 1. Stop the transfusion 2. Keep the vein open with normal saline. 3. Notify the physician immediately. 4. Monitor vital signs. Administer cardiopulmonary resuscitation if needed. 5. Administer medications and/or oxygen as ordered. 1. Place the client upright, with feet dependent 2. Administer diuretics and oxygen as ordered. 3. Notify the physician. 4. Stop or slow the transfusion 1. Stop the transfusion. 2. Send the remaining blood to laboratory 3. Notify the physician. 4. Obtain a blood specimen from the client for culture. 5. Administer IV fluids, antibiotics. 6. Keep the vein open with a normal saline infusion.

1) Hemolytic reaction: incompatibility between clients blood and donors blood 2) Febrile reaction: sensitivity of the clients blood to white blood cells, platelets, or plasma proteins.

Chills, fever, headache, backache, dyspnea, cyanosis, chest pain, tachycardia, hypotension

Fever; chills; warm, flushed skin; headache; anxiety, muscle pain

3) Allergic reaction (mid): sensitivity to infused plasma proteins.

Flushing, itching, urticaria, bronchial wheezing

4) Allergic reaction (severe): antibody-antigen reaction

Dyspnea, chest pain, circulatory collapse, cardiac arrest

5) Circulatory overload: blood administered faster than the circulation can accommodate

Cough, dyspnea, crackles (rales), distended neck veins, tachycardia, hypertension

6) Sepsis: contaminated blood administered

High fever, chills, vomiting, diarrhea, hypotension