BLOOD

ADMINISTRATION
Bruno Talerico MSN, RN

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

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

Blood Typing
Type O

........... universal donor

Type AB ..... universal recipient

ABO Blood Groups

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

ABO Blood Groups cont..

Blood group AB
If you belong to the blood group AB, 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 0
If you belong to the blood group 0 (null), 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.
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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

Rh Factor Blood Grouping

System

Many people also have a so called Rh factor on the red

blood cell's surface. This is also an antigen and those
who have it are called Rh+. Those who haven't are called
Rh-. A person with Rh- blood does not have Rh
antibodies naturally in the blood plasma (as one can have
A or B antibodies, for instance). 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,
whose Rh antigens can trigger the production of Rh
antibodies. A person with Rh+ blood can receive blood
from a person with Rh- blood without any problems.

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Blood types that match

A person who has: Can receive:
A- blood

A-, O- blood

A+ blood

A-, A+, O-,

O+ blood

B- blood

B-, O- blood

B+ blood

B-, B+, O-,

O+ blood

AB- blood

AB-, Oblood

AB+ blood

AB-, AB+, A-,

A+, B-, B+,
O-, O+ blood

O- blood

O- blood

O+ blood

O-, O+ blood

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Type and Screen

Indications
Sudden blood loss
Anemia
Pre-surgical work-up
Procedure
Phlebotomy
Spin and separate
Test for antibodies

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Cross Match
Indications
Specific blood for specific patient
Procedure
Incubate donor cells with recipient serum
If incompatible, RBCs will agglutinate
Coombs test

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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

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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, 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

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Blood Components cont..

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 before invasive
procedure/surgery
Post-surgical counts of 50-90,000
Expires 5-7 days after collection

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Blood Components cont

Cryoprecipitate

Plasma rich in certain clotting factors removed

by freezing and then slow thaw
Factor VIII and Fibrinogen

Indications
Hemo A, von Willebrands dz, factor VIII
deficiency
Fibrinogen levels < 150mg/dL
May be frozen for one year
Only good 4 hours after thawing

Cross Matching is not required

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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

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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
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Newer Trends in Blood

Specific coagulation factors manufactured from pooled
plasma/recombinant DNA products
Products
Factor VIII
Factor IX
Activated protein C
Factor VII

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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

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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

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Transfusion Procedure
Preparation of blood
Check blood for
Right patient
Right blood product
Right type
Expiration date

Maintain temperature of blood

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Transfusion Precautions
Do not mix blood with
D5W - causes hemolysis

LR - causes clotting
Medications - may react

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Transfusion Procedure
Procedure

Flush tubing with 0.9% NS

Cover the administration filter with blood

Connect blood to tubing

Piggyback onto IV line of 0.9% NS

Start transfusion slowly

Monitor for adverse reaction

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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

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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- 2 ml/min
Use w/i 6hours of thawing

Platelets

Fresh frozen plasma

Cryoprecipitate

30- 60 minutes
Less than 2 hours

Albumin

5% 1-2ml/min
25% 0.2-0.4ml/min

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

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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

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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

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Transfusion Reaction
Treatment
Medications

Benadryl
Epinephrine
Tylenol
Lasix

Notify physician
Treat for signs and symptoms of shock

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Documentation
Record
Baseline vital signs
Time transfusion started
Transfusion flow rate
Patients response and ongoing vital signs
Time transfusion ended
Pertinent observations and clinical manifestations

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Trends in Blood
Administration
TRICC Trials, 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

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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

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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

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

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

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TRALI
Symptoms/Treatment?
Usually self-limiting
Mild-severe

Dyspnea
Hypotension
Cyanosis
Hypoxia
Tachycardia

Mechanical ventilation
Hemodynamic support

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Any Questions?????

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Case
Study
Two units of packed RBCs, one unit of single donor platelets, and four
units of FFP are ordered for an immunocompromised client who is
actively bleeding. The client's hematocrit is 24%, and he is
bleeding from his nose and upper gastrointestinal tract.

In what order would you give the blood products

and why?

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Case Study cont..

What additional precautions might you take giving the blood,
given the patients medical history?
What medication might also be ordered to prevent fluid
overload during blood administration?

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Blood Administration

Any Questions???

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

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