BLOOD TRANSFUSION Objectives: Replace circulating blood volume Increase the O2 carrying capacity of blood Prevent infection: if there

ere is a decrease in WBC Prevent bleeding: if there is platelet deficiency BLOOD and BLOOD COMPONENTS A single unit (u) of blood contains 450mL of blood and 50mL anticoagulant. It is more economical, appropriate and practical to separate blood into its primary components: RBC, Platelet and Plasma BLOOD and BLOOD COMPONENTS Whole Blood provides all components (Hct = 40%) Complications: volume overload, transmission of hepatitis or AIDS, transfusion reaction, infusion of excess potassium & sodium, infusion of anticoagulant (citrate) used to keep stored blood from clotting, calcium binding & depletion (citrate) in massive transfusion therapy Packed Red Blood Cell (PRBC) Provide almost twice the amount of Hct than whole blood With little plasma, some platelets and WBCs residuals Indicated in cases of blood loss, pre-op & post-op client & those with incipient congestive failure Complication: transfusion reaction (less common than with whole blood: due to removal of plasma protein) Fresh Frozen Plasma Contains all coagulation factors including V & VIII Can be stored frozen for 12 months; takes 20 minutes to thaw Hang immediately upon arrival to unit (loses its coagulation factor rapidly) Platelets Will raise recipients platelet count by 10,000/mm3 Pooled from 4-8 units of whole blood Single-donor platelet transfusion may be necessary for clients who have developed antibodies; compatibilities testing may be necessary Factor VIII Fractions (Cryoprecipitate) contains von Wilebrand factor, factor VIII, XIII & fibrinogens Granulocytes Do not increase WBC: increase marginal pool (at tissue level) rather than circulating pool Premedication with steroids, antihistamine & acetaminophen Respiratory distress with shortness of breath, cyanosis & chest pain may occur; requires cessation of transfusion & immediate attention Shaking chills or rigors common, require brief cessation of therapy, administration of meperdine IV until rigors are diminished & resumption of transfusion when symptoms relieved BLOOD DONATION To protect both recipient and donor, all prospective donors are screened. Donors are typically required to give consent for the process and this requirement means that minors cannot donate without parental consent. The donor's race or ethnic background is sometimes important since certain blood types, especially rare ones, are more common in certain ethnic groups. Donors should not have any present or history of the following: Viral Hepatitis Received a BT or infusion of any blood derivative within 12mos Untreated Syphilis or Malaria Drug abuse Exposure to HIV Recent asthma attack Urticaria Allergy to medications

 Skin infection Pregnant Tooth extraction or oral surgery 72h prior to donation Untreated exposure to infectious dse. Within the past 3 weeks Recent immunizations Recent tattoo Cancer Diagnosis of hemochromatosis Whole blood donation within the past 56 days DISEASES TRANSMITTED BY BT Viral Hepatitis AIDS (HIV and HTLV) Cytomegalovirus (CMV) Graft versus Host Disease (GVHD) Creutzfeldt-Jakob Disease (CJD) Cytomegalovirus (CMV) A virus that infects most people worldwide. CMV spreads from person to person by direct contact. Although CMV infection is usually harmless, it can cause severe disease in persons with weakened immune systems. There is no treatment for CMV infection. Prevention centers on good personal hygiene, especially frequent hand washing. Graft versus Host Disease (GVHD) A rare disorder that can strike persons whose immune system is suppressed and have either received a blood transfusion or a bone marrow transplant. Symptoms may include skin rash, intestinal problems similar to colitis, and liver dysfunction. Clinically, graft-versus-host-disease is divided into: acute or fulminant form is normally observed within the first 100 days post-transplant chronic form normally occurs after 100 days. Creutzfeldt-Jakob Disease (CJD) CJD a dementing disease of the brain caused by an unconventional, transmissible agent (prion). Symptoms of CJD include forgetfulness, nervousness, jerky trembling hand movements, unsteady gait, muscle spasms, chronic dementia, balance disorder, and loss of facial expression. Most cases occur randomly (sporadic), but inherited forms exist. There is neither treatment nor cure for CJD. POTENTIAL DONORS Donors should be asked if he/she has taken any ASA or ASA containing medications within the past 3 days. He/she may pass the requisites for donation Requisites: Body wt. is > 50kg (110lbs.) for a 450mL donation Age 17 above Oral temperature should not exceed 37.5oC PR should be regular and between 50-100 bpm. BP is within 90/50 to 180/100 mmHg. Hgb level is at least 12.5g/dL (F); 13.5g/dL (M) TYPES OF BLOOD DONATION Directed friends or family members of the patient donates the blood considered not safe than random donations Standard Phlebotomy is done Standard precautions are observed Donor is on semi-recumbent position Skin prep is done Tourniquet is applied

Venipuncture is performed Withdrawal of 450mL of blood (takes lees than 15 mins) After removal of needle, donors are asked to hold arm straight up and firm pressure is applied with sterile gauze for 2-3 mins until bleeding stops. Firm bandage is applied. Donor stays recumbent until he/she feels able to sit up. Health teachings are given. After blood donation: Before leaving, relax for 1015 minutes and enjoy some snacks and beverages. Keep arm pressure wrap in place for about an hour. Avoid smoking for 30 minutes after donating. Avoid strenuous activity or heavy lifting for about 4 hours, as it may cause bruising. Double fluid intake for the next 24 hours. Water and fruit juices are best and avoid caffeine. Avoid alcoholic beverages for 1224 hours or until after you have eaten a full meal. After donating, and experienced: Bruising (hematoma): Apply cold, wet compresses for the first 1224 hours; then use warm, wet compresses thereafter. Discoloration (blue, black or green) will be visible on arm for 710 days and experience discomfort/tenderness. Bleeding: Elevate arm above your head and reapply direct pressure over the donation site. Apply a clean bandage when bleeding has stopped. Light-headed & dizziness: Sit down and place head between knees or lie down and elevate feet about 12 inches. Do not drive or operate heavy machinery. TYPES OF BLOOD DONATION Autologous process of donating one's own blood indicated for an elective surgical or medical procedure in which the likelihood of a blood transfusion is high. Such procedures include surgery on the heart, blood vessels, bones, and chest. Advantages: Blood is an exact match to his or her blood type, thereby avoiding transfusion reaction. No risk of inadvertently transmitting infectious agents. Supplement the community blood supply. Promotes blood cell production by bone marrow. The patient is often reassured by the knowledge that his or her own blood will be used if a blood transfusion becomes necessary. Disadvantages: Contamination of autologous blood with infectious agents is possible. possibility that a patient's blood will be mislabeled or that allogeneic blood will be inadvertently transfused. Costs more to process and store. Unused units are usually disposed of; approximately 44% of autologous donations remain unused after surgery. Intraoperative blood salvage also known as autologous blood salvage procedure involving recovering blood lost during surgery and re-infusing it into the patient. used frequently in cardiothoracic, vascular and spinal surgery, in which blood transfusions and the use of blood products have traditionally been high. Hemodilution transfusion method that may be done after induction of anesthesia. about 1-2 u of blood are removed from the patient through a venous or arterial line and simultaneously replaced with a colloid or crystalloid solution. blood obtained is then re-infused after surgery

COMPLICATIONS OF BLOOD DONATION Excessive bleeding at venipuncture site. Fainting Anginal chest pain Seizures BLOOD PROCESSING After donation, blood is tested for antibodies to: HIV 1 and 2 Hepatitis B, C Human T-call lymphotropic virus type 1 Blood is also tested for Hepa B surface antigen and for syphilis. Accurate determination of blood type is done Rh and ABO system is used to determine if the blood is safe for transfusion. ABO system the most important blood type system (or blood group system) in human blood transfusion. it identifies which sugars are present on the membrane of a persons erythrocytes. There are four possible blood groups in the ABO system: AB, A, B, O. Individuals with type A blood (having A antigen on the surface of their RBCs, and blood serum containing IgM antibodies against the B antigen) can receive blood from donors of type A and type O blood. Individuals with type B blood (having the B antigen on the surface of their RBCs, and blood serum containing IgM antibodies against the A antigen) can receive blood from donors of type B and type O blood. Individuals with type AB blood (have both A and B antigens on the surface of their RBCs, and their blood serum does not contain any antibodies against either A or B antigen) can receive blood from any blood group Individuals with type O blood (do not have either A or B antigens on the surface of their RBCs, but their blood serum contains IgM anti-A antibodies and anti-B antibodies against the A and B blood group antigens) can receive blood from donors of only type O. Rh system Rh antigens are transmembrane proteins with loops exposed at the surface of red blood cells. Rh antigens together are proteins of 417 amino acids. These proteins cross the red cell membrane 12 times. 85% of the population is Rh positive (RhD) 15% lack D antigen and termed as Rh negative the process of transferring blood or blood-based products from one person into the circulatory system of another INDICATIONS: massive blood loss due to trauma blood loss during surgery severe anemia or thrombocytopenia blood diseases like hemophilia or sickle-cell disease Blood transfusions can be grouped into two main types depending on their source: Homologous transfusions Autologous transfusions Donor units of blood must be kept refrigerated to prevent bacterial growth and to slow cellular metabolism. The transfusion must begin within 30 minutes after the unit has been taken out of controlled storage. Blood can only be administered intravenously. It therefore requires the insertion of a cannula of suitable caliber. A unit (up to 500 ml) is typically administered over 4 hours. Acetaminophen and/or an antihistamine are sometimes given before the transfusion to prevent other types of transfusion reactions. Purpose: RBC: Improve O2 transport Whole Blood, Plasma, Albumin: volume expansion Fresh Frozen Plasma, Albumin, Plasma Protein Fraction: provision of proteins Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole Blood: provision of coagulation factors Platelet Concentration, Fresh Whole Blood: provision of platelets PRINCIPLES OF BLOOD TRANSFUSION Proper refrigeration

a. Expiration of packed RBC is 3-6 days b. Expiration of platelet is 3-5 days c. Proper typing and cross matching d. Type O: universal donor e. Type AB: universal recipient f. 85% of population is RH positive Aseptically assemble all materials needed for BT a. Filter set b. Gauge 18-19 needle c. Isotonic solution (0.9 NaCl / plain NSS): to prevent hemolysis Ask another RN to re check the following a. Client name b. Blood typing & cross matching c. Expiration date d. Serial number Check the blood unit for bubbles cloudiness, sediments and darkness in color a. Never warm blood: it may destroy vital factors in blood. b. Warming is only done: during emergency situation & if you have the warming device c. Emergency rapid BT is given after 30 minutes & let natural room temperature warm the blood. BT should be completed less than 4 hours Avoid mixing or administering drugs at BT line: to prevent hemolysis Regulate BT 10-15 gtts/min or KVO rate or equivalent to 100 cc/hr: to prevent circulatory overload Monitor strictly vital signs before, during & after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period

BT PROCEDURE Verify doctors order. Observe ten (10) Rs when preparing and administering any blood or blood components. Explain the procedure/rationale for giving blood transfusion to reassure patient and significant others and secure consent. Request prescribed blood/blood components from blood bank to include blood typing and X-matching and blood result of transmissible disease. Using a clean lined tray, get compatible blood from hospital blood bank. Wrap blood bag with clean towel and keep it at room temperature. 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). Get the baseline vital signs BP, RR, temperature before transfusion. Refer to MD accordingly. Give pre-med 30 minutes before transfusion as prescribed. Do hand hygiene before and after the procedure. Prepare equipment needed for BT. 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. 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 Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle from BT administration set and secure with adhesive tape. Close roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on. Transfuse the blood via the injection port and regulate at 10-15 gtts initially for 15minutes and then at the prescribed rate. Observe patient for 10-15 minutes for any immediate reaction. Observe patient on an ongoing basis for any untoward signs and symptoms 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.

When blood is consumed, close the roller clamp of BT, and disconnect from IV lines then regulate the IVF of plain NSS as prescribed. Continue to observe and monitor patient post transfusion for delayed reaction could still occur. Re-check Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed &/or per institutions policy. Discard blood bag and BT set and sharps according to hospital policy. Document the procedure, pertinent observations and nursing intervention and endorse accordingly. TRANSFUSION REACTIONS

TRANSFUSION REACTIONS

TRANSFUSION REACTIONS

Nursing Management Upon identifying that there is a transfusion reaction the nurse should: Stop BT Notify physician Flush with plain NSS Administer isotonic fluid solution: to prevent shock and acute tubular necrosis Send the blood unit to blood bank for re-examination Obtain blood sample & send to laboratory for re-examination Monitor vital signs & I&O Administer medications as ordered Anti Histamine (Benadryl): if positive to hypotension, anaphylactic shock: treat with Epinephrine

Administer medications as ordered Antipyretic Antibiotic Administer medications as ordered Loop diuretic (Lasix) NURSING RESPONSIBILITY Assess client for history of previous blood transfusions & any adverse reaction Ensure that the adult client has an 18-19 gauge IV catheter in place Use 0.9% sodium chloride At least two nurse should verify the ABO group, RH type, client & blood numbers & expiration date Take baseline V/S before initiating transfusion Start transfusion slowly (2 ml/min) Stay with the client during the first 15 min of the transfusion & take V/S frequently Maintain the prescribed transfusion rate: Whole Blood: approximately 3-4 hr RBC: approximately 2-4 hr Fresh Frozen Plasma: as quickly as possible Platelet: as quickly as possible Cryoprecipitate: rapid infusion Granulocytes: usually over 2 hr Volume Expander: volume-dependent rate Monitor for adverse reaction Document the following: Blood component unit number (apply sticker if available) Date of infusion starts & end Type of component & amount transfused Client reaction & vital signs Signature of transfusionist PHARMACOLOGIC ALTERNATIVES TO BT Growth Factors Erythropoietin Granulocyte-Colony Stimulating Factor Granulocyte-Macrophage Stimulating Factor Thrombopoietin Erythropoietin a glycoprotein hormone produced by the kidney, that controls erythropoiesis, or red blood cell production. Available forms as biomedicine Epoetin (Procrit (also known as Eprex) or NeoRecormon) Darbepoetin (Aranesp) Epoetin delta (Dynepo) Methoxy polyethylene glycol-epoetin beta (Mircera) by Roche Erythropoietin is associated with an increased risk of adverse cardiovascular complications in patients with kidney disease if it is used to increase hemoglobin levels above 13.0 g/dl. Granulocyte-Colony Stimulating Factor Used to increase the number of hematopoietic stem cells in the blood of the donor before collection by leukapheresis for use in hematopoietic stem cell transplantation. It may also be given to the receiver, to compensate for conditioning regimens. Brand Name: Neupogen Granulocyte-Macrophage Stimulating Factor a protein secreted by macrophages, T cells, mast cells, endothelial cells and fibroblasts. stimulates stem cells to produce granulocytes (neutrophils, eosinophils, and basophils) and monocytes. Trade Name: Leukine Thrombopoietin stimulates the production and differentiation of megakaryocytes, the bone marrow cells that fragment into large numbers of platelets Thrombopoietin shares its first 153 amino acids with erythropoietin