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True or False
Any unexpected signs, symptom or change during or after admin of blood products should be assumed to be suspect for transfusion reactions

True

What are the signs of a transfusion reaction?

Anxiety/restlessnes
HYPOtension
Fever/chills/diaphoresis
lumbar pain
dyspnea/resp. distress/cyanosis
hemoglobinemia/hemoglobinuria
Hives/itching/cough
abd cramps
headache

What are the types of transfusion reactions?

Acute Hemolytic Transfusion Rxn (AHTR)
Febrile Non-Hemolytic (FNHTR)
Transfusion Related Acute Lung Injury (TRALI)
Uriticarial (Mild allergic)
Bacterial contamination (septic)
Transfusion-assoc. circulatory overload (TACO)

What are the AHTR symptoms by system?
Systemic
Heart
Vascular
Chest
Tranfused vien
Lumbar
Urinary

Systemic = chills/fever
Heart = incr. HR
Vascular= HYPOtension, uncontrolled bleeding
Vein = heat sensation
Chest = constricting pain
Lumbar = pain
Urinary = hemoglobinuria/hyperbilirubinemia

What are the 3 physiologic steps to AHTR?

Transfusion
Agglutination & complement binding
Hemolysis

What are potential causes of AHTR?

antigen/antibody rxn d/t ABO incompatibility
80% d/t clerical errors in labeling

What is the onset of AHTR?

10-15min
*can occur in amts of blood 1-2mL +
*potentially fatal

True or False
AHTR is considered a sentinel event and a medical emergency

TRUE

sensitivity to donor WBC, platelets or plasma proteins

Non-hemolytic transfusion rxn

Temp. incr of 1*
Sx onset 30min-2hrs after transfusion start

Non-Hemolytic transfusion rxn

True or False
Leukoreduction will INCREASE the likelihood of reaction

FALSE

What pre-medication measures might we consider prior to transfusions?

antihistamine and/or acetaminophen

What is the first thing we do if we notice a transfusion rxn?

STOP THE TRANSFUSION

Ok, after stopping the tranfusion in a rxn, then what?

Pt. assessment
Call Response team
support pt sx's
call provider
notify blood bank
keep IV line open w/ 0.9% NS
*new tubing + bag
VS frequently
check pt. ID/unit ID
tx sx's per provider order
collect samples
return blood bag w/ tubing + fluids
document

What is the solution we keep running in the IV after we stop the transfusion?

0.9% NS w/ new tubing + bag

True or False
The only antigens on RBC's are ABO

FALSE
Tons of others but are universal and so antibodies don't react to them

If the pt.'s blood has been screened and no antibodies to the universal RBC antigens are found what kind of blood can they get?

ABO-compatible

What if the pt's blood is screened and unexpected antibodies are found?

pt. must have crossmatched blood

What kind of RBC antigens are present on people with type A? What antibodies?

A- RBC antigens
anti-B

Type _____ blood has RBC type _____ antigens and has anti-A antibodies

B
B

What blood type doesn't have plasma antibodies?

AB

What blood type doesn't have RBC antigens?

Type O

What blood type has both Anti-A & Anti-B plasma antibodies?

Type O

What are the two most common blood types in the US?

O pos = 38%
A pos = 34%

What are the top two most common Rh negative blood types in the US?

O-neg = 7%
A-neg = 6%

Rh +/- is determined by what antigen?

+ Anti-D = Rh +
- Anti-D = Rh -

What types of blood products does Rh compatibility NOT apply to?

Plasma
Platelets
Cryoprecipitate

_________ must lack the ANTIGENS to which the pt has the antibody

RBC

___________ must lack the ANTIBODIES that would react with the patients ANTIGEN

PLASMA

Rh _________ pts can recieve Rh-neg blood

Rh +

Who should receive only Rh - blood?

Rh - people

What the breakdown of blood composition

Plasma = 55%
RBC = 44%
WBC <1%
PLT <1%

What can donor whole blood be broken down into?

RBC's - Platelet-rich plasma
then
Platelet-rich plasma = Plasma + Platelets
then
Plasma can be broken down to cryoprecipitate

Who should get RBC's?

Hct <24%
Hgb <7
Sx Anemia

What will one unit of blood infusion do to Hct?

increase Hct 2-4%

One unit =

1 bag

What is the non-emergent RBC infusion rate?

2-4 mL/kg/hr
1 unit / 1.5-2hrs
*Can infuse for up to 4hrs

RBC transfusion requires what testing first?

crossmatch compatibility

Who gets platelet infusion?

Thrombocytopenia
PLT dysfx
PLT <50,000 mm3

What will one unit of PLT do to an adult?

Increast PLT count 26,000mm3

What is the rate of PLT infusion in a non-emergency?

4-8mL/kg/hr
1 unit/20min - 1hr

What testing must be done prior to PLT transfusion?

Hx of ABO

Who gets plasma infusion?

INR <1.6 = reversal of anti-coag

What will one unit of plasma do to an adult?

Increase clotting factor 2-5%

What is the rate of non-emergent plasma transfusion?

2-4mL/kg/hr
1 unit / 1.5-2.0 hrs
*up to 4hrs

What testing is required prior to plasma transfusion?

Hx of ABO

Who gets cryoprecipitate?

Fibrinogen <100mg/dL

What is the effect of one-6 pooled unit on an adult?

increases Fibrinogen 45mg/dL

One bag of cryoprecipitate = ___________ unit

6 pools unit

What is the non-emergent rate of cryoprecipitate infusion?

4-8mL/kg/hr
1 unit / 30min-1hr

What testing must be done prior to cryoprecipitate infusion?

Hx of ABO

Name the test:
no testing performed

Hold

determines blood type and Rh

ABO type

determines blood type and Rh as well as antibodies

Type and Screen
(ABO type and screen)

what tests assures that the intended donor unit selected and tested with pt. sample to determine compatibility

Type and Crossmatch
(Type and screen and crossmatch)

Aside from the 2 pt. identifiers what other standard checks must we perform before administering blood products?

Check transfusion report to bag label

What is involved in verifying transfusion report to bag label?

Kind of component (RBC, PLT, etc.)
Unit #
ABO type
Expiration of unit
Expiration of crossmatch

What other admin. responsibilities does the Nurse have for admin. of blood prods?

Assure IC is signed
assure the transfusion is clinically indicated
RN is ready to monitor pt closely
We have the appropriate equip.
Pt. edu

How often do we do VS and which ones do we do on our transfusion pts?

Baseline before transfusion
@ 15min into transfusion
At completion
*BP, HR, RR, SaO2, Temp.

How often do we do an assessment and what is included in the assessment?

Baseline before transfusion
min q 30min during transfusion
@ completion
*Skin , Lung, Gen. Assess

What equipment do we need for a transfusion?

IV pumps
Filter
NS
*bloodwarmer not necessary in routine transfusion

What is the ONLY fluid that can be used in line with blood components?

NS

How much whole blood is spun to get 1 unit of PLT?

500mL whole blood = 1 unit PLT = 30-50mL

Why do we need to draw a PLT count 1hr after transfusion?

pooled PLT product varies widely

What is pheresing?

draw blood from single donor, take out the PLT, reinfuse the blood back into the donor
*yeilds 200-400mL platelets + plasma

True or False
PLT can be stored at room temperature

TRUE
*can be stored 1-5 days

What guage needles do we use for blood products?

19-guage or >
*18-guage or 16-guage are used for rapid infusions

Why don't we use lactated ringer's or dextrose soln' for admin of blood prods?

cause RBC hemolysis

PRBC's are prepared from __________ by ______________ process. One unit = ________mL's

Whole blood
sedimentation or centrifugation
250-350mLs

Why are PRBC's preferred to RBC

Less danger of fluid overload
component specific
leukocyte depletion can be done to reduce hemolytic febrile rnxs

Who gets PRBC's?

sever or sx anemia
acute blood loss

One unit RBC gives us an increase in ____ Hgb or ________ increase in Hct

1g/dL Hgb
3% Hct increase

one unit of RBC can replace _______ amt of blood loss

500mL

Frozen RBC's are prepared using __________________ and can be stored for ______yrs @ __________ temp.

glycerol and frozen
stored 10yrs
@ -188.6F / -87C

How soon must frozen RBC's be used once thawed? How do we get out the WBC's and plasma proteins?

Must use w/in 24hrs of thawing
successive washing w/ saline soln'

Why use frozen RBC's?

stockpiling or rare donors for pts w/ alloantibodies

PLT come from ________ w/in _______hrs of collection, one unit of PLT = ______ mL of platelet concentrate?

fresh whole blood
w/in 4hrs of collection
30-60mL

What is the expected PLT rise after infusing one unit? If there isn't a rise what do we suspect?

10,000/microL/U
Fever, sepsis, splenomegaly or DIC

Who do we give PLT to?

bleeding from thrombocytopenia

When are PLT contraindicated except in life-threatening emergency?

thrombotic thrombocytopenic purpura
heparin-induced thrombocytopenia

Fresh frozen plasma is processed by _____________, one unit plasma = ________mL, it can be stored for ______ and must be used _______ after thawing

separated from whole blood and frozen
one unit = 200-250mL
stored 1yr
use w/in 2hrs of thawing

True or False
Plasma contains platelets

FALSE

Use of plasma for hypovolemic shock is being replaced by _______________

albumin
plasma expanders

Who gets plasma?

bleeding d/t clotting factor deficiency:
DIC
hemorrhage
massive transfusion
liver disease
Vit K deficiency
excess warfarin

Albumin is prepared from __________, it can be stored for _______ and comes in what two solutions?

albumin prepared from plasma
stored for 5yrs
available in 5% and 25% soln'

Albumin 25g/100mL is osmotically equal to __________ of plasma

500mL

Albumin is _________ treated to kill virus

heat treated

How does albumin work?

hyperosmolar soln' acts by moving water from extravascualr to intravascula space

Who gets albumin?

Hypovolemic shock
hypoalbuminemia

cryoprecipitates and commercial concentrates are prepared from ______, yielding about ______ mL/bag, it can be stored for ____, once thawed need to use _________

fresh frozen plasma
1 bag = 10-20mL
stored for 1yr
must be used immediately after thawing

Who gets cryoprecipitates?

vonWillebrand's
replacement of: clotting factors esp. factor VIII and fibrinogen

What causes 90% of transfusion rxns?

improper product - to- patient ID

If you do a baseline assessment and the pt. has a fever or any other abnormal VS what do you do?

Call provider to clarify whether you should still give the blood product

The blood should be given to the pt ___________, how long can it be stored on the unit?

give to pt. as soon as brought to pt.
DO NOT REFRIGERATE ON UNIT
If not used w/in 30min send it back to the bank

You should remain with the patient during the first ___________ of the transfusion

15min or 50mL

The rate of infusion w/in the first 15min should be no more than_________

2mL/min

what blood components may be infused over 15-30min?

fresh frozen plasma
PLT

Why don't we infuse for over 4 hours?

increased risk of bacterial growth once it is out of refrigeration

What do you do with blood that has not been infused after 4 hrs?

send back to teh bank

What do we check in addition to the VS previously listed in a transfusion reaction?

BP, HR, RR, SaO2 + URINE OUTPUT

What causes most acute hemolytic reactions?

admin of blood to wrong person
mislabeling specimens

What is the etiology of an acute hemolytic rxn?

antibodies in pt. react w/ antigens in donor RBC - > agglutination - > obstruct capillaries - > hemolysis of RBCs releases Hgb into plasma -> Hgb overloads/blocks kidneys = ARF, DIC, DEATH

What in teh blood and urine at the onset of the rxn show evidence of acute hemolytic rxn?

free Hgb

What is considered a delayed transfusion rxn?

24hrs up to 14d post transfusion

febrile rxn are d/t

leukocyte incompatibility; people who get 5+ transfusions can devlop antibodies to WBC in donor blood, can use addl' filters in tubing, filtered, washed or frozen products can also be used to reduce febrile rxn

How can we do to reduce febrile rxns in pts who get frq transfusions?

pre-med w/ acetaminophen and diphenhyramine 30 min before transfusion

allergic rxn result from the pts sensitivity to ______ in the donor blood and are more common in pts w/ a hx of ____________

plasma proteins
allergies

____________ may be used to prevent allergic rxn and ___________ are used to tx severe allergic rxns

antihistamines
epi or corticosteriods

AHR is caused by __________, has the sx's of __________________

ABO incompatibility
chills/fever
low back pain
flushing/tachycardia
dyspnea/tachypnea
HYPOtension/vascular collapse
hemogloinuria
acute jaunidic
dark urine*
bleeding*
acute kidney injury
SHOCK
cardiac arrest
death

STOP infusion
Tx shock and DIC
draw blood samples*
mtn BP w/ IV colloid soln'
give diuretics*
insert catheter*

What to do about AHR
*draw slowly to avoid hemolysis
*diruetics to mtn urine flow
*catheter to measure output

Sudden chills and fever = rise in temp >1C
headache
flushing
anxiety
vomiting
muscle pain

Febrile non-hemolytic rxn
*sensitization of WBCs, platelets or plasma proteins

give antipyretics*
DO NOT RESTART INFUSION UNLESS ORDERED TO

Tx for Febrile non-hemolytic rxn
*avoid aspirin in thrombocytopenic pts

flushing
itching/uticaria

Mild allergic rxn

antihistamine/corticosteriods
if sx's are mild/transient transfusion may be restarted slowly*

What to do about mild allergic rxn
*DO NOT RESTART if fever or pulmonary sx's are present

anxiety
uticaria
dyspnea/wheezing
cyanosis
bronchospasm
HYPOtension
Shock
possible cardiac arrest

anaphylaxis rxn

initate CPR if indicated
pop with epi

management for anaphylaxis

cough
dyspnea
pulmonary congestion
headache
HYPERtension
tahcycardia
distended neck veins

fluid overload rxn
*fluid admin too fast

place pt upright w/ feet dependent
admin diuretics, O2, morphine
*phlebotomy may be indicated

what to do about fluid overload rxn

rapid onset of chills
high vefer
vomiting
diarrhea
marked HYPOtension
shock

sepsis rxn
*from bacterially infx blood prods

Obtain culture of pts blood an send bag w/ reaming blood and tubing to bank
give antibiotics, IV fluids, vasopressors

treatment for sepsis rxn

rxn btwn transfused antileukoctye antibodies and pts leukocytes which causes pulmonary inflammation and capillary leak

TRALI
transfusion-related acute lung injury

fever
HYPOtension
tachypnea
dyspnea
decr SaO2
frothy sputum

Sx's of TRALI

send bag + tube + blood to bank
draw blood for ABG's
Chest X-ray
give O2
corticosteriods*
initiate CPR if necessary
provide ventilatory and BP support if necessary

tx for TRALI
*diruetics don't work on TRALI

HF
dysrhythmias
impaired thyroid/gonadal fx
tx w/ chelating agents

Iron overload
occurs in people receving >100units of blood for chronic anemia: sickle cell, B-thallassemia

What agent chelates Fe out of the blood and and removes it via the kidneys, is given IV or SQ

deferoxamine (desferal)

What chelating agent is ataken PO

deferasirox (exjade)

True or False
Women can donate PLASMA aphoresis?

FALSE
*Only males can do PLASMA aphoresis b/c females could have HLA's as a result of pregnancy

True or False
Women can donate PLT aphoresis?

TRUE

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