Blood or Blood Component Transfusions

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Blood or Blood Component Transfusions
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Blood Transfusion

• Blood and Blood product administration is an area
  where the potential for mistakes can be very
  high.
• Following the policies exactly can help prevent
  mistakes

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Blood Transfusion

• JCAHO and the FDA monitor errors in blood
  administration.
• The goal is to administer these products safely
  and not harm a patient nor have to report any
  errors.
• Every effort should be made to assure safe
  administration.

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Why do we transfuse RBCs?

• Red blood cells contain hemoglobin and serve to
  transport oxygen through the bloodstream and to
  the tissues.
• Whole blood or red blood cells are given to
  increase patients oxygen carrying capacity.

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Competency Check-off

• RNS and LVNs criteria for competency
• Attending orientation
• Blood Exam grade of 85 or better
• check-off completed in Blood Administration with
  preceptor
• LVNs Need to take IV concepts class within the
  first year of employment

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PROCEDURE

• A physician or licensed independent
  practitioner will initiate the order, utilizing
  EDITH.
• The order must include any special instructions
  or requirements. (Example- if irradiated blood
  is required ONCOLOGY)

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BLOOD TRANSFUSE PROCEDURE

• Check the electronic chart for a consent or
  refusal form. If no forms are found, explain
  the procedure to patient and complete a Consent
  for Transfusion of blood or Refusal to Permit
  Transfusion of Blood and Blood Components if the
  patient refuses a transfusion. Scan the consent
  in CPRS.

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BLOOD TRANSFUSE PROCEDURE

• Refer to text.

Please refer to the pages in your orientation
manual and review these forms. These forms are
scanned into EDITH
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BLOOD TRANSFUSE PROCEDURE

• A phlebotomist or nurse will draw and label the
  type and crossmatch specimen,
• apply red blood band to patient.
• Nurse draws are allowed in ICU/CCU ER
  OR PACU/POCU

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PROCEDURE for IDENTIFYING BLOOD SAMPLE AND PATIENT

• Secure the Hollister I-denta-blood labels and
  red blood arm band.
• (form on next slide)
• Note that the form stickers all have the same
  R. This will be used for all testing on that
  specimen and any products prepared for this
  patient)

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LRW
6/14/07 1540 LRW
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PROCEDURE for IDENTIFYING BLOOD SAMPLE AND PATIENT

• Fill out the specimen label ( located in the
  upper right hand corner of the page) and
• armband insert (Located at the bottom of the
  form) to contain only the following
• Date and time specimen was drawn
• Initials of person drawing the sample
• Apply label to tube and armband to patient before
  leaving the patients bedside.

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PROCEDURE for IDENTIFYING BLOOD SAMPLE AND PATIENT

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PROCEDURE for IDENTIFYING BLOOD SAMPLE AND PATIENT

• Draw sample into a red topped tube (For adults
  MINIMUM of 3 cc, however a full 10 cc tube is
  best)
• (For infants and children ask the lab how much
  specimen is needed)
• After applying label to specimen tube, send it
  along with the remaining blood tab label sheet to
  the lab.

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PROCEDURE for IDENTIFYING BLOOD SAMPLE AND PATIENT

• NOTE A computer generated label may be utilized
  with additional information added so that all
  required information is available. The computer
  generated label can be applied to the Hollister
  specimen label. (The Hollister label may not be
  placed on top of a computer label. The lab will
  reject a specimen with that type of label.)

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To Obtain Blood Products

• Either the blood bank will call when the blood is
  ready or you can check the computer for the
  order and a notification that component testing
  is complete.
• Check (CPRS) EDITH for a completed, signed, and
  scanned patient Consent to Transfuse form.

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To Obtain Blood Products

• Obtain a Component Requisition Slip (on next
  slide)
• take to patient room and verify that the patient
  has a red blood band on.
• Complete the following
• name
• Medical record number,
• R and
• component requested on the requisition slip from
  the information on the patient blood band and
  patient ID band.
• Do not take the information from the patients
  chart.

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To Obtain Blood Products

• Confirm that the patient has a patent IV with a
  catheter of sufficient size to allow the blood
  to drip without damaging the cells.
• Make sure that all necessary supplies are
  available
• Blood Administration set
• 0.9 Normal Saline (Prime tubing with saline)
• Transfusion Administration Record form (see next
  slide)

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To Obtain Blood Products

• Send or take the completed requisition slip to
  the blood bank located in the basement of the
  hospital.
• Only hospital employees may pick up blood
  components from the lab. (Note Nursing students
  working as nurse techs may pick up blood when
  working as a nurse tech, but if they are here as
  a student, they may not pick up blood)

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To Obtain Blood Products

• Give the component requisition slip to the blood
  bank technician who will secure the component
  from the blood bank refrigerator
• Confirm the following with the blood bank
  technician
• Patient Name (Including middle initial if
  available)
• R Number
• Blood Component Number
• Component type/Rh
• Type of component
• Component expiration date

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To Obtain Blood Products

• If all the information correlates between
• the Component Requisition Slip,
• the component label,
• the cross-match report and
• the blood bank computer,
• the hospital employee will sign the Cross match
  Report slip on the Received by line.
• The blood bank technician will sign on the
  Issued By line

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To Obtain Blood Products

• By signing the component requisition form, each
  person has verified that the above information is
  correct. The date and time issued are those of
  the blood bank computer.
• If for any reason, there are items that do not
  match, the process stops until the problem is
  identified and resolved.

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Blood Products in cooler

• For some areas, when more than one unit of
  components are requested, the units will be
  issued in a cooler.
• Inside the cooler is a thermometer and a SIGN
  OUT SHEET FOR BLOOD PRODUCTS REMOVED FROM BLOOD
  BANK TRANSPORT COOLER AT MMH form. (see
  orientation manual)

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Blood Products in cooler

• The SIGN OUT SHEET FOR BLOOD PRODUCTS REMOVED
  FROM BLOOD BANK TRANSPORT COOLER form is to be
  completed as the component is removed from the
  cooler.
• Document the following information
• Unit number
• Component (type)
• Temperature when removed from Cooler
• Signature of person removing component
• Time removed from cooler

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Blood Products in cooler

• SIGN OUT SHEET FOR BLOOD PRODUCTS REMOVED FROM
  BLOOD BANK TRANSPORT COOLER form (cont.)
• The last space is utilized by the blood bank if
  the component is returned to the blood bank.
• After completion, the form is returned to the
  cooler and sent to the blood bank. (An example
  of the form is in the orientation book)

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Transfusing the component

• The blood component is then taken immediately to
  the patients room where two licensed nurses (one
  must be an RN) will verify
• Patient name with middle initial if available
• Medical Record
• R and
• complete the Patient Identification Infusion
  Record on the Crossmatch Report Slip.
• ALL MUST MATCH EXACTLY

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Transfusing the component

• Compare the R Number on the patients red blood
  band with the R Number on the blood component and
  the Crossmatch Report Slip. All must match
  exactly.
• Document the R number on the Blood
  Administration Record
• Compare the component unit number on the
  component label and the cross match report slip.
  All must match exactly.

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Transfusing the component

• Compare the ABO/Rh on the component label and the
  Cross match Report Record-All must match exactly.
• After all information has been checked and
  verified by the two licensed nurses, both must
  initial the information and sign the Patient
  Identification Infusion Record (on the Cross
  match Report Slip)
• If at any point there are mismatches, the process
  stops immediately, the component is returned to
  the blood bank for correction.

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Transfusing the component

• The primary nurse will take a complete set of
  vital signs and record on the Blood
  Administration Record.
• Complete vital signs include
• Temperature
• Blood Pressure
• Pulse
• Respirations
• (Refer to the Orientation Booklet to review the
  Blood Administration Record form)

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Transfusing the component

• Carefully spike the blood bag,
• (Note The best method of spiking the bag is to
  hang the blood bag, then insert the spike into
  the bag very carefully. Holding the bag while
  spiking, seems to be connected with increased
  incidence of spiking through to puncture the
  bag. This causes the unit to be wasted)
• mix in the saline and begin the transfusion,
• Begin transfusion at a rate of 120 cc/hr for the
  first 15 minutes
• while observing the patient for potential signs
  of a transfusion reaction.
• Document the time the transfusion is started on
  the Blood Administration Record and on the
  Crossmatch Slip.(See a copy of the Blood
  Administration Record in your orientation book)

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Transfusing the component

• You must stay with the patient for the first 15
  minutes of the transfusion in case of a reaction.
• Most ABO incompatibilities occur in the first
  fifteen minutes.

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Transfusing the component

• the blood component must be started within 30
  minutes or returned immediately to the blood bank
• EXCEPTION storing component in a red blood bank
  transport cooler which has been set up by the lab
  with the proper documentation forms and a
  thermometer.

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Transfusing the component

• After the first 15 minutes have passed and no
  reaction noted,
• take and record a second set of vital signs
• increase the rate of infusion.
• (Once started, the transfusion must be completed
  within 4 hours. .
• If for some reason it does not appear possible to
  finish in 4 hours, the blood bank should be
  consulted. A doctors order is needed to possibly
  divide the unit into two equal parts )

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Transfusing the component

• Every 30 minutes until the transfusion is
  completeThe nurse is to physically return to the
  patients room to
• assess the patient,
• take and document another complete set of vital
  signs
• (While an automatic blood pressure machine may
  be utilized, the nurse is to rely on a physical
  assessment)

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Transfusing the component

• When the transfusion is complete, take a full set
  of vital signs, document on the Blood
  Administration Record form, discontinue the blood
  tubing and resume IVs as per physician order.

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Transfusing the component

• Complete the information on the Crossmatch slip
  which has been left on the blood bag during the
  transfusion, and place the Crossmatch report on a
  piece of paper and scan into CPRS under the
  appropriate title.

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Transfusing the component

• Dispose of the used blood bag and IV Tubing into
  a red biohazard bag and place the red bag into a
  red biohazard tub. (Blood bags and tubing are
  the exception to the hazardous waste rule and are
  considered hazardous waste)

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Transfusing the component

• One hour post transfusion, the nurse physically
  returns to the patients room to reassess the
  patient, take and record the final set of vital
  signs for this transfusion process.

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Transfusing the component

• Who should receive Rh immunoglobulin?
• The Rh(D) negative patient who has either
  Received Rh positive platelets Is a female
  under 50 who has received Rh positive
  FFP Is a postpartum patient who has
  delivered an Rh positive baby. (Must be given
  within 72 hours of delivery or termination of
  pregnancy).

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Transfusion Reactions
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Clinical Signs and symptoms ( of a blood
transfusion reaction )

• Increased pulse Hypertension
• Hypotension Congestive Heart Failure
• Cyanosis Chills
• Dyspnea Fever (a 2rise is
  considered a
• Chest pain febrile reaction)
• Nausea Hemoglobinuria
• Vomiting Rash
• Back pain Heat or pain along the
• Flushing vein of transfusion
• Urticaria
• Other symptoms that would cause concern to the
  nurse or patient

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Transfusion Reaction

• In the event of a transfusion reaction, the nurse
  administering the blood will initiate the
  following interventions
• Stop the transfusion by discontinuing the blood
  as close to the IV Cannula as possible

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Transfusion Reaction

• Keep the IV open with 0.9 normal saline (Secure
  a fresh IV tubing and bag of saline. --- Do not
  open the saline side of the Y Blood tubing or
  you could potentially give the patient an extra
  bolus of 50 or more ccs)

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Transfusion Reaction

• Report the reaction to the physician.(The final
  decision to diagnose a transfusion reaction is
  made by the physician) In addition notify the
  Blood Bank, the charge nurse and House
  Supervisor/Nurse Manager of the potential
  reaction)(Monday-Friday, 8 AM to 4 PM the nurse
  managers/division directors fulfill the function
  of the house supervisor. After 4 PM daily and
  all day on weekends, a house supervisor is in
  house and should be notified.)

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Transfusion Reaction

• Perform a clerical check at the bedside by
  comparing the patient information on the
  Hollister armband with the cross match report
  slip. Make sure that all information matches
  exactly.

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Transfusion Reaction

• Treat symptoms per physicians order and monitor
  patient vital signs.
• Document thoroughly on Transfusion Reaction
  Report note in CPRS. This must be completed
  whether or not the MD calls it a true reaction.
• (The Blood Bank requests a Transfusion Reaction
  Report be completed as a tracking device even if
  the physician does not diagnose the symptoms
  seen as a transfusion reaction )

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Transfusion Reaction

• If diagnosed by the physician, order a
  transfusion reaction workup in the computer.
• Send the blood with attached administration set
  to the blood bank.
• ( Refer to your orientation book for an example
  of the Transfusion Reaction Report note.)

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Transfusion Reaction

• Hemolytic transfusion reaction
• The destruction of transfused red cells. The
  most common cause of acute hemolytic reactions is
  transfusion of ABO incompatible blood, resulting
  from identification errors occurring at some
  point(s) in the transfusion process. Type and
  cross matches are done to try to prevent this
  type of reactions.
• Acute hemolytic reaction
• Characteristically begin with an increase in
  temperature and pulse rate symptoms may include
  chills, dyspnea, chest or back pain, abnormal
  bleeding or shock. Instability of blood pressure
  is frequent, the direction and magnitude of
  change depending upon the phase of the
  antigen-antibody event and the magnitude of
  compensatory mechanisms

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Transfusion Reaction

• Delayed Hemolytic reactions
• Occur in previous alloimmunized patients in
  whom antigens on transfused red cells provokes
  anamnestic production of antibodies that reaches
  a significant circulating level while the
  transfused cells are still present in the
  circulation
• the usual time frame is 2 to 14 days after
  transfusion.
• Signs may include unexplained fever,
  development of a positive direct antiglobulin
  test, an unexplained fall in hemoglobin/hematocrit
  . Hemaglobinemia and hemoglobinuria are
  uncommon, but elevation of LDH or bilirubin may
  be noted. Most delayed hemolytic reactions have
  a benign course and require no treatment.

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Transfusion Reaction

• Febrile non-hemolytic reaction
• Typically manifested by a temperature
  elevation of 1C or 2F occurring during or
  shortly after a transfusion and in the absence of
  any other pyrexic stimulus.
• (At MMH a 2 rise in temperature is considered a
  febrile reaction).
• This may reflect the action of antibodies against
  white blood cells or the action of cytokines,
  either present in the transfused component or
  generated by the recipient in response to
  transfused elements.
• Febrile reactions may accompany about 1 of
  transfusions they occur more frequently in
  patients alloimmunized by transfusion or
  pregnancy and in patients immune dysfunction due
  to neoplasm or autoimmunity.
• Patients who experience repeated, severe febrile
  reactions may benefit from receiving luekocyte
  reduced components.
• Allergic Reactions
• Usually occurs as urticaria, but may also
  include wheezing or angioedematous reactions.

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Transfusion Reaction

• ABO Compatibilities
• THE ABO group of all red cell-containing
  components must be compatible with the ABO
  antibodies in the recipients plasma. Whole blood
  must be ABO identical with the recipient. Red
  Blood Cells which contain a much reduced volume
  of antibody containing plasma, need not be ABO
  identical. Refer to the following charts which
  delineate what types are compatible.
• Notice O NEGATIVE is the universal donor
  type.
• (Refer to the compatability charts on
  page 131 of the Orientation Book)

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Transfusion Reaction

• EMERGENCY TRANSFUSIONS
• Except in cases when any delay in transfusion
  will be life-threatening, serologic compatibility
  must be established before any red-cell-containing
  component is transfused. MMH will release type
  specific or uncross matched blood in an
  emergency upon receipt of a completely filled out
  EMERGENCY TRANSFUSION SLIP .
• (A Licensed Nurse is allowed to take a verbal
  order to initiate the process to get type
  specific or uncross matched blood in an
  emergency. The form must be taken to the blood
  bank or they will not release the blood product.
  The blood bank must have a way of tracing all
  products)
• Refer to the Emergency Release of Blood
  Components form in your orientation book.

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