BLOOD

ADMINISTRATION
Bruno Talerico MSN, RN

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Objectives
■ Discuss indications for transfusion
■ Identify ABO and Rh blood groups
■ Discuss common blood products in critical care setting and
their uses
■ Identify correct procedure for blood transfusion
■ Discuss risks associated with blood transfusions
■ Discuss S/S and management of acute transfusion
reactions

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History of Transfusions

15th century: Stefano Infessura

17th century: Jean-Baptiste Denis
1818: James Blundell
1901: Karl Landsteiner discovered human blood
groups
1902: AB blood type found
Today over 5 million people receive about
30 million transfusions per year
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Blood Therapy
■ Indications
– Significant hypovolemia due to acute blood loss
– Symptomatic anemia
– Decreasing hemoglobin
– Decreasing hematocrit
– To increase oxygen carrying ability
– Decreased clotting factors

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Blood Typing ■ Type O .......… universal recipient 5 ... universal donor ■ Type AB .......

you have B antigens on the surface of your red blood cells and A antibodies in your blood plasma. 6 .ABO Blood Groups Blood group A If you belong to the blood group A. Blood group B If you belong to the blood group B. you have A antigens on the surface of your red blood cells and B antibodies in your blood plasma.

you have neither A or B antigens on the surface of your red blood cells but you have both A and B antibodies in your blood plasma. Blood group 0 If you belong to the blood group 0 (null). you have both A and B antigens on the surface of your red blood cells and no A or B antibodies at all in your blood plasma. Blood group AB If you belong to the blood group AB. 7 .ABO Blood Groups cont..

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Rh Factor ■ Rh positive – Possess D antigen ■ Rh negative – Possess no D antigen – Rh negative patients may develop antibodies to D antigens with exposures to Rh positive blood 9 .

A person with Rh+ blood can receive blood from a person with Rh. whose Rh antigens can trigger the production of Rh antibodies. This is also an antigen and those who have it are called Rh+. 10 . for instance).blood without any problems. Those who haven't are called Rh-.blood does not have Rh antibodies naturally in the blood plasma (as one can have A or B antibodies.Rh Factor Blood Grouping System Many people also have a so called Rh factor on the red blood cell's surface. A person with Rh. But a person with Rhblood can develop Rh antibodies in the blood plasma if he or she receives blood from a person with Rh+ blood.

B-.blood A+ blood A-. O-. AB+. O+ blood 11 .blood O+ blood O-. A+.blood B+ blood B-. B+. O-. O+ blood O. O. O.blood O.blood AB-. A-. B+.blood B-.blood A-. A+.Blood types that match A person who has: Can receive: A. O-. O+ blood AB. Oblood AB+ blood AB-. O+ blood B.

Type and Screen ■ Indications – Sudden blood loss – Anemia – Pre-surgical work-up ■ Procedure – Phlebotomy – Spin and separate – Test for antibodies 12 .

RBCs will agglutinate – Coomb’s test 13 .Cross Match ■ Indications – Specific blood for specific patient ■ Procedure – Incubate donor cells with recipient serum – If incompatible.

Types of Blood Products ● Packed red blood cells – ■ Liquid portion of blood removed Indications ■ Increases Hgb/Hct while minimizing volume increases ■ Promotes oxygen delivery in patients who are actively bleeding ■ Symptomatic anemia unresponsive to conservative management ■ Shelf-life 21-42 days ■ Transfusion based on clinical status of patient – Leukocyte poor/reduced PRBCs – Washed PRBCs Donor & recipient must be ABO/Rh identical & compatible 14 .

must be used within 24 hours ● Indications ●correction of coagulopathies ● supplying deficient plasma proteins ●PT (>17-18 sec) and PTT (>55-60 sec) Cross-matching not required but donor/recipient must be ABO/Rh compatible 15 .Blood Products cont… – Fresh frozen plasma ■ Liquid portion of blood: contains stable coagulation factors & plasma proteins ■ May be stored frozen for one year ■ After thawing.

. ■ Platelets – To control/prevent bleeding due to thrombocytopenia – Platelet deficiency and/or dysfunction – Can be given as pools of random donor (RD) platelets or apheresis (SDAP) ■ Indications – Platelet counts 40-50.000 – Expires 5-7 days after collection 16 .000 before invasive procedure/surgery – Post-surgical counts of 50-90.Blood Components cont.

factor VIII deficiency – Fibrinogen levels < 150mg/dL – May be frozen for one year – Only good 4 hours after thawing Cross – Matching is not required 17 . von Willebrand’s dz.Blood Components cont… ■ Cryoprecipitate – Plasma rich in certain clotting factors removed by freezing and then slow thaw – Factor VIII and Fibrinogen ●Indications – Hemo A.

Blood Components cont… ■ Granulocytes – Severe and persistent neutropenia with infection in patients unresponsive to standard therapy – Suspected/documented fungal infection unresponsive to conventional therapy – Treatment= 1 unit/day for 4 – 5 days – Must be used within 24hours Must be ABO/Rh compatible 18 .

Albumin ■ Largest protein in blood ■ Provides osmotic force to maintain fluid volume within vascular space ■ Strong predictor of health ■ Volume expansion when crystalloids solutions are not adequate ■ Low albumin levels and hypoproteinemia No ABO/Rh antibodies present. compatibility is not a factor 19 .

Newer Trends in Blood ■ Specific coagulation factors manufactured from pooled plasma/recombinant DNA products Products ■ Factor VIII ■ Factor IX ■ Activated protein C ■ Factor VII 20 .

Blood Administration ■ Equipment needed – Patient Consent – Physicians order – Blood typed and cross matched – Venous access (20G or larger) – Filtered administration set – 0.9% NS – Thermometer – BP Cuf 21 .

Transfusion Procedure ■ Preparation of patient – Confirm order for blood – Check patient for ■ Right patient ■ Right blood product ■ Right type – Assess baseline vital signs – Ensure suitable venous access 22 .

Transfusion Procedure ■ Preparation of blood – Check blood for ■ Right patient ■ Right blood product ■ Right type ■ Expiration date – Maintain temperature of blood 23 .

may react 24 .causes clotting Medications .Transfusion Precautions ■ Do not mix blood with – D5W .causes hemolysis – – LR .

9% NS – Start transfusion slowly – Monitor for adverse reaction 25 .9% NS – Cover the administration filter with blood – Connect blood to tubing – Piggyback onto IV line of 0.Transfusion Procedure ■ Procedure – Flush tubing with 0.

Transfusion Rate ■ Procedure – Initially @ rate of 1 ml/min – Evaluate for hemolytic reaction – Monitor vital signs q 15 minutes – After 30 minutes. adjust flow rate – Evaluate for hemolytic reaction – Monitor vital signs q 30 minutes 26 .

60 minutes Less than 2 hours Albumin – – 5% 1-2ml/min 25% 0.2 ml/min Use w/i 6hours of thawing Platelets – – ■ Fresh frozen plasma – – Cryoprecipitate 30.Transfusion Rate ■ Whole blood – 2-3 hours – No more than 4 hours ■ ■ Packed red blood cells – 11/2-2 hours – No more than 4 hours ■ – – 30-60 min Less than 2 hours ■ 1.4ml/min 27 .2-0.

Transfusion Reactions ■ Hemolytic Reaction – Chills/shaking – Fever – Pain – N/V – Chest tightness – Red/black urine – H/A – Flank pain – Shock/renal failure/DIC 28 .

Transfusion Reactions ■ Bacterial Sepsis – – – Rigors/chills Fever Shock ■ Febrile Reactions – – Fever Chills ■ Allergic Reactions – – – – Urticaria Flushing Asthmatic wheezing Laryngeal edema ■ Hypothermia – – – – Chills Low temperature Irregular heartrate Possible cardiac arrest ■ Circulatory Overload – – – – – Dyspnea Rhales Cyanosis Dry cough Distended neck veins 29 .

Transfusion Reaction Treatment – STOP the transfusion! – Maintain IV access with 0.9% NS – Save the remaining blood product – Administer oxygen PRN – Support hemodynamics as needed 30 .

Transfusion Reaction ■ Treatment – Medications ■ ■ ■ ■ – – Benadryl Epinephrine Tylenol Lasix Notify physician Treat for signs and symptoms of shock 31 .

Documentation ■ Record – Baseline vital signs – Time transfusion started – Transfusion flow rate – Patient’s response and ongoing vital signs – Time transfusion ended – Pertinent observations and clinical manifestations 32 .

1999 ■ Lower transfusion thresholds – NIH: Hg 7g/dL – American College of Physicians: Hgb 7-10g/dL – American Society of Anesthesiologists: Hgb 7g/dL – American College of Pathologists: Hgb 5-8g/dL 33 .Trends in Blood Administration ■ TRICC Trials.

Transfusion Risks ■ Infection ■ Transfusion-related Graft-versus-host disease ■ Transfusion Related Immunosuppression –  T killer cell activity/macrophage antigen presentation ■ Transfusion Related Acute Lung Injury (TRALI) – Leading cause of transfusion related mortality in 2003 34 .

TRALI: Definition ■ Bilateral patchy infiltrates on CXR ■ No evidence of left atrial hypertension ■ Hypoxemia with a P/F ratio <300 ■ Onset of symptoms that occur 2-6 hours post-transfusion ■ Carries 5-13% mortality 35 .

TRALI ■ Occurs with all plasma-containing blood and blood components – PRBC – Whole Blood – Random donor platelets – Apheresed platelets – Cryoprecipitate – Granulocytes 36 .

inflammation.TRALI: Etiology? ■ Two proposed reasons for vascular permeability: – Leukocyte specific antibodies – Biologically active substances ■ Two Hit Hypotheses: – 1st condition: primed neutrophils exist first (surgery. infection) – 2nd condition: transfusion of either leukocyte specific antibodies to recipient or from donor 37 .

TRALI Symptoms/Treatment? ■ Usually self-limiting ■ Mild-severe – – – – – Dyspnea Hypotension Cyanosis Hypoxia Tachycardia ■ Mechanical ventilation ■ Hemodynamic support 38 .

Any Questions????? 39 .

and he is bleeding from his nose and upper gastrointestinal tract. and four units of FFP are ordered for an immunocompromised client who is actively bleeding. one unit of single donor platelets.Case Study Two units of packed RBCs. The client's hematocrit is 24%. In what order would you give the blood products and why? 40 .

Case Study cont. What additional precautions might you take giving the blood.. given the patient’s medical history? What medication might also be ordered to prevent fluid overload during blood administration? 41 .

Blood Administration Any Questions??? 42 .

Wells. 73: 138-142.(2004). G.409-417[ 43 . Archives of Surgery 2002. MA. 137: 711-717 Annals of Thoracic Surgery 2002. Blajchman. et al (1999) A multicenter. randomized. N Engl J Med 340.References American Association of Blood Banks. Primer for blood administration. controlled clinical trial of transfusion requirements in critical care. Hebert. PC.