Fundamentals of Nursing

BLOOD TRANSFUSION THERAPY

Blood Transfusion
Therapy
• Blood transfusion therapy involves
transfusing whole blood or blood
components (specific portion or fraction of
blood lacking in patient). One unit of whole
blood consists of 450 mL of blood collected
into 60 to 70 mL of preservative or
anticoagulant. Whole blood stored for more
than 6 hours does not provide therapeutic
platelet transfusion, nor does it contain
therapeutic amounts of labile coagulation
factors (factors V and VIII).
Blood components include:
1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of
plasma originally present in one unit of whole blood), indicated to
increase the oxygen-carrying capacity of blood with minimal
expansion of blood.
2. Leukocyte-poor packed RBCs, indicated for patients who have
experience previous febrile no hemolytic reactions.
3. Platelets, either HLA (human leukocyte antigen) matched or
unmatched.
4. Granulocytes ( basophils, eosinophils, and neutrophils )
Blood components include:
5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the
labile factors).
6. Single donor plasma, containing all stable coagulation factors but reduced levels of
factors V and VIII; the preferred product for reversal of Coumadin-induced
anticoagulation.
7. Albumin, a plasma protein.
8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and
fibronectin.
9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling,
fractionating, and freeze-drying large volumes of plasma.
10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling,
fractionating, and freeze-drying large volumes of plasma.
11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor
XI.
Advantages of blood component therapy
1. Avoids the risk of sensitizing the patients to other blood
components.
2. Provides optimal therapeutic benefit while reducing risk of volume
overload.
3. Increases availability of needed blood products to larger
population.
Principles of blood transfusion therapy
• WHOLE BLOOD TRANSFUSION
• Generally indicated only for patients who need both increased
oxygen-carrying capacity and restoration of blood volume when there
is no time to prepare or obtain the specific blood components
needed.
• PACKED RBCS
• Should be transfused over 2 to 3 hours; if patient cannot tolerate
volume over a maximum of 4 hours, it may be necessary for the blood
bank to divide a unit into smaller volumes, providing proper
refrigeration of remaining blood until needed. One unit of packed red
cells should raise hemoglobin approximately 1%, hemactocrit 3%.
Principles of blood transfusion therapy
• PLATELETS
• Administer as rapidly as tolerated (usually 4 units every 30 to 60
minutes). Each unit of platelets should raise the recipient’s platelet
count by 6000 to 10,000/mm3: however, poor incremental increases
occur with alloimmunization from previous transfusions, bleeding,
fever, infection, autoimmune destruction, and hypertension.
• GRANULOCYTES
• May be beneficial in selected population of infected, severely
granulocytopenic patients (less than 500/mm3) not responding to
antibiotic therapy and who are expected to experienced prolonged
suppressed granulocyte production.
Principles of blood transfusion therapy
• PLASMA
• Because plasma carries a risk of hepatitis equal to that of whole
blood, if only volume expansion is required, other colloids (e.g.,
albumin) or electrolyte solutions (e.g., Ringer’s lactate) are preferred.
Fresh frozen plasma should be administered as rapidly as tolerated
because coagulation factors become unstable after thawing.
• ALBUMIN
• Indicated to expand to blood volume of patients in hypovolemic
shock and to elevate level of circulating albumin in patients with
hypoalbuminemia. The large protein molecule is a major contributor
to plasma oncotic pressure.
Principles of blood transfusion therapy
• CRYOPRECIPITATE
• Indicated for treatment of hemophilia A, Von Willebrand’s disease,
disseminated intravascular coagulation (DIC), and uremic bleeding.
• FACTOR IX CONCENTRATE
• Indicated for treatment of hemophilia B; carries a high risk of
hepatitis because it requires pooling from many donors.
Principles of blood transfusion therapy
• FACTOR VIII CONCENTRATE
• Indicated for treatment of hemophilia A; heat-treated product
decreases the risk of hepatitis and HIV transmission.
• PROTHROMBIN COMPLEX-Indicated in congenital or acquired
deficiencies of these factors.
Objectives
1. To increase circulating blood volume after surgery, trauma, or
hemorrhage
2. To increase the number of RBCs and to maintain hemoglobin levels
in clients with severe anemia
3. To provide selected cellular components as replacements therapy
(e.g. clotting factors, platelets, albumin)
Nursing Interventions
1. Verify doctor’s order. Inform the client and explain the purpose of
the procedure.
2. Check for cross matching and typing. To ensure compatibility
3. Obtain and record baseline vital signs
4. Practice strict Asepsis
Nursing Interventions
5. At least 2 licensed nurse check the label of the blood transfusion
• Check the following:
• Serial number
• Blood component
• Blood type
• Rh factor
• Expiration date
• Screening test (VDRL, HBsAg, malarial smear) – *this is to ensure that the
blood is free from blood-carried diseases and therefore, safe from
transfusion.
Nursing Interventions
6. Warm blood at room temperature before transfusion to prevent
chills.
7. Identify client properly. Two Nurses check the client’s identification.
8. Use needle gauge 18 to 19. This allows easy flow of blood.
9. Use BT set with special micron mesh filter. To prevent
administration of blood clots and particles.
Nursing Interventions
10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes.
Adverse reaction usually occurs during the first 15 to 20 minutes.
11. Monitor vital signs. Altered vital signs indicate adverse reaction.
12. Do not mix medications with blood transfusion. To prevent adverse effects
13. Do not incorporate medication into the blood transfusion
14. Do not use blood transfusion lines for IV push of medication.
15. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with
dextrose. Dextrose causes hemolysis.
16. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets,
cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be
destroyed.
17. Observe for potential complications. Notify physician.
Complications of Blood Transfusion
1. Allergic Reaction – it is caused by sensitivity to plasma protein of
donor antibody, which reacts with recipient antigen.
• Assessments:
• Flushing
• Rush, hives
• Pruritus
• Laryngeal edema, difficulty of breathing
Complications of Blood Transfusion
2. Febrile, Non-Hemolytic – it is caused by hypersensitivity to donor
white cells, platelets or plasma proteins. This is the most
symptomatic complication of blood transfusion
• Assessments:
• Sudden chills and fever
• Flushing
• Headache
• Anxiety
Complications of Blood Transfusion
3. Septic Reaction – it is caused by the transfusion of blood or
components contaminated with bacteria.
• Assessment:
• Rapid onset of chills
• Vomiting
• Marked Hypotension
• High fever
Complications of Blood Transfusion
4. Circulatory Overload – it is caused by administration of blood volume at a
rate greater than the circulatory system can accommodate.
• Assessment:
• Rise in venous pressure
• Dyspnea
• Crackles or rales
• Distended neck vein
• Cough
• Elevated BP
Complications of Blood Transfusion
5. Hemolytic reaction. It is caused by infusion of incompatible blood products.
• Assessment:
• Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible
blood.
• Chills
• Feeling of fullness
• Tachycardia
• Flushing
• Tachypnea
• Hypotension
• Bleeding
• Vascular collapse
• Acute renal failure
Planning and Implementation
• Help prevent transfusion reaction by:
✓Meticulously verifying patient identification beginning with type and
cross match sample collection and labeling to double check blood
product and patient identification prior to transfusion.
✓Inspecting the blood product for any gas bubbles, clothing, or
abnormal color before administration.
✓Beginning transfusion slowly ( 1 to 2 mL/min) and observing the
patient closely, particularly during the first 15 minutes (severe
reactions usually manifest within 15 minutes after the start of
transfusion).
Planning and Implementation
✓Transfusing blood within 4 hours, and changing blood tubing every 4 hours
to minimize the risk of bacterial growth at warm room temperatures.
✓Preventing infectious disease transmission through careful donor screening
or performing pretest available to identify selected infectious agents.
✓Preventing GVH disease by ensuring irradiation of blood products
containing viable WBC’s (i.e., whole blood, platelets, packed RBC’s and
granulocytes) before transfusion; irradiation alters ability of donor
lymphocytes to engraft and divide.
✓Preventing hypothermia by warming blood unit to 37 C before transfusion.
✓Removing leukocytes and platelets aggregates from donor blood by
installing a microaggregate filter (20-40-um size) in the blood line to
remove these aggregates during transfusion.
Planning and Implementation
• On detecting any signs or symptoms of reaction:
✓Stop the transfusion immediately, and notify the physician.
✓Disconnect the transfusion set-but keep the IV line open with 0.9%
saline to provide access for possible IV drug infusion.
✓Send the blood bag and tubing to the blood bank for repeat typing
and culture.
✓Draw another blood sample for plasma hemoglobin, culture, and
retyping.
✓Collect a urine sample as soon as possible for hemoglobin
determination.
Planning and Implementation
• Intervene as appropriate to address symptoms of the specific reaction:
✓Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and
renal failure associated with RBC hemolysis and hemoglobinuria.
✓Febrile, nonhemolytic transfusion reactions are treated symptomatically with
antipyretics; leukocyte-poor blood products may be recommended for
subsequent transfusions.
✓In septic reaction, treat septicemia with antibiotics, increased hydration, steroids
and vasopressors as prescribed.
✓Intervene for allergic reaction by administering antihistamines, steroids and
epinephrine as indicated by the severity of the reaction. (If hives are the only
manifestation, transfusion can sometimes continue but at a slower rate.)
✓For circulatory overload, immediate treatment includes positioning the patient
upright with feet dependent; diuretics, oxygen and aminophylline may be
prescribed.
Nursing Interventions when complications
occurs in Blood transfusion
1. If blood transfusion reaction occurs. STOP THE TRANSFUSION.
2. Start IV line (0.9% Na Cl)
3. Place the client in fowler’s position if with SOB and administer O2
therapy.
4. The nurse remains with the client, observing signs and symptoms
and monitoring vital signs as often as every 5 minutes.
Nursing Interventions when complications
occurs in Blood transfusion
5. Notify the physician immediately.
6. The nurse prepares to administer emergency drugs such as
antihistamines, vasopressor, fluids, and steroids as per physician’s
order or protocol.
7. Obtain a urine specimen and send to the laboratory to determine
presence of hemoglobin as a result of RBC hemolysis.
8. Blood container, tubing, attached label, and transfusion record are
saved and returned to the laboratory for analysis.
Evaluation
1. The patient maintains normal breathing pattern.
2. The patient demonstrates adequate cardiac output.
3. The patient reports minimal or no discomfort.
4. The patient maintains good fluid balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin integrity, with no lesions or pruritus.
8. The patient maintains or returns to normal electrolyte and blood
chemistry values.