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128 terms

Blood transfusion

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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