Blood Transfusion Administration

1
Blood Transfusion Administration

• Adapted for use in the Ohio Region by the Nursing
  Education Department

2
Learning Objectives

• Upon completion of this learning module, the
  learner will be able to state
• At least two general principles
• Why red blood cells, cryoprecipitate, FFP,
  albumin and platelets are transfused
• 2 age-appropriate considerations
• Signs and symptoms of blood transfusion reactions
• Supplies needed for specific transfusion types
• Documentation requirements

3
Basic Procedure

• Verify that there is a written order from a
  physician for blood or blood components.
• Verify that there is a signed Consent and Blood
  Transfusion form with the patients name and
  medical record number documented on it.
• Check date. Consent forms are valid for 6 months.
• Identify the patient.
• With another RN (or MD), compare the information
  on the unit of blood or blood product with the
  patient's identification band. This is the
  single-most important step in preventing
  transfusion reactions.

4
Basic Procedure

• The following elements MUST be double-checked
  item-by-item with a second RN (or MD) prior to
  administration of the blood or blood product
• Patients name
• Patients medical record number
• Donor unit identification
• Blood type (ABO Group)
• Rh type
• Donor unit expiration date and when applicable,
  time
• Presence of antibodies and/or agglutinins
• Product type

5
Refer to Ohio Region Policy JR.PC.08
Most major or fatal transfusion reactions result
from type mismatches caused by a clerical error,
administration of blood to the wrong patient, or
incorrect identification of the blood component.

• Administration of Blood and Blood Products

6
Red Blood Cells (RBCs)

• Packed red blood cells (RBCs) are prepared by
  removing approximately 250 ml of the plasma from
  whole blood therefore, there are no significant
  amounts of clotting factors or platelets in RBCs.
  
• Each unit of RBCs contains 250 to 300 ml.
• One unit of RBCs can increase an average adult's
  hemoglobin by 1 g/dl, and hematocrit can increase
  by 2 or 3.
• RBCs are given to increase the oxygen-carrying
  capacity of the circulatory system in the
  presence of acute or chronic blood loss.

7
Red Blood Cells (RBCs) Procedure

• Invert the RBCs gently several times to suspend
  them.
• Rationale Components should be mixed thoroughly
  before administration.
• Close roller clamp on tubing.
• Spike one tail of Y-type tubing with 0.9 normal
  saline solution, and prime the tubing.

8
Red Blood Cells (RBCs) Procedure

• Spike the second tail of the Y-type tubing with
  the RBC bag. Ensure the drip chamber is half full
  and the filter is covered with saline to prevent
  damage to the blood cells.
• Clean the IV port with an alcohol swab, and then
  attach the Y tubing to the patient's IV site and
  open the roller clamp on the RBCs. A gentle
  squeeze on the filter helps start the flow of
  blood.

9
Red Blood Cells (RBCs) Procedure

• Infuse slowly for the first 15 minutes while
  observing the patient for reactions. This step
  allows for assessment to make sure the patient is
  not in need of rapid, life-sustaining
  interventions.
• Rationale Most serious reactions occur during
  this time.

10
Red Blood Cells Procedure

• After 15 minutes, reassess vital signs and adjust
  the flow rate to the desired speed if no signs of
  a transfusion reaction are noted.
• Infusion time should not exceed 4 hours. The
  longer the RBCs are left at room temperature, the
  greater the danger of bacterial proliferation and
  RBC hemolysis.
• Continue the assessments of the patient (always
  include the vital signs) throughout the
  transfusion as needed, according to the patient's
  condition, the number of units being
  administered, and facility policy.

11
Signs and symptoms of transfusion reactions

• Fever (temperature increase of gt 1º C or 2º F,
  with or without chills.
• Shaking chills (rigors), with or without fever.
• Pain at infusion site, or in the chest, abdomen
  or flanks muscle aches.
• Blood pressure changes, usually acute, either
  hypertension or hypotension.
• Respiratory distress, including dyspnea,
  tachypnea, hypoxemia, shortness of breath,
  wheezing, cough or rales.

12
Signs and symptoms of transfusion reactions

• Skin changes, including flushing, urticaria,
  localized or generalized edema.
• Nausea, with or without vomiting
• Bradycardia or tachycardia
• Pruritis, diaphoresis, cyanosis or pallor

13
Signs and symptoms of transfusion reactions

• Headache, apprehension, numbness or tingling.
• Acute onset of sepsis, including fever, severe
  chills, hypotension or high output cardiac
  failure.
• Anaphylaxis

14
Management of a transfusion reaction
Immediately STOP the transfusion once a reaction
has been identified. Disconnect the tubing from
the patient but leave the bag and tubing
attached. Do not discard the blood.
Immediately take the patients vital signs.
15
Management of a transfusion reaction

• Maintain venous access with normal saline.
• Call the patients physician.
• Continue to monitor the patients vital signs.
• Recheck the information on the blood container,
  the requisition and the patients
• armband.

16
If the physician suspects a transfusion reaction

1. Notify the Blood Bank.
2. Complete an Unusual Occurrence Report and return
   to the Blood Bank with completed information on
   the amount of blood product transfused into the
   patient.
3. Collect, label and send the appropriate blood
   samples to the Blood Bank.
4. Return the unit of blood involved in the
   transfusion reaction along with all the tubing
   attached to the Blood Bank.
5. Continue to monitor the patients vital signs as
   ordered, until stable.
6. Record the vital signs and any other necessary
   pertinent information on the Blood Products
   Administration flow sheet.
7. Record the amount of the blood transfusion
   absorbed on the Transfusion Flow Sheet.

17
Albumin

• Albumin is a circulating protein found in both
  the serum and the extravascular area.

18
Albumin

• The primary function of albumin is the
  maintenance of normal colloid oncotic pressure.

• If possible, hold angiotensin-converting enzyme
  (ACE) inhibitors for 24 hours before albumin
  administration. Albumin is very expensive when
  compared with the cost of crystalloid solutions.

19
Albumin

• Albumin solutions are available in 5 and 25
  concentrations.
• Albumin is given to
• replace volume after an acute loss, therapeutic
  phlebotomy, or a plasma exchange
• to correct hypoalbuminemia and
• improve intravascular volume in patients who have
  severe burns or who are developing signs of
  edema.

20
Albumin

• 5 Albumin may also be used in conjunction with a
  diuretic in patients with pulmonary edema or
  adult respiratory distress syndrome.

• Policy Administration of Blood and Blood
  Products JR.PC.08
• Kaiser Ohio Region

21
Albumin Procedure

• Check that the proper solution is being used
  (normal saline solution or dextrose 5 in water
  D5W).
• Spike the bottle with a vented spike, close
  roller clamp on the tubing, and attach IV tubing
  to the vented spike opening. Use of filters
  during albumin administration is determined by
  the manufacturer and institutional policy.
• Squeeze the drip chamber until the chamber is
  one-third full.

22
Albumin Procedure

• Open the regulating clamp and prime the IV
  tubing.
• Attach tubing to the patient's IV access port
  after cleaning with an alcohol swab.
• For treatment of hypovolemic shock, administer
  albumin at 1 to 2 ml/min.
• In other patients, administer at 2 to 4 ml/min
  for 5 albumin solutions and no faster than 1
  ml/min for 25 albumin solutions.

23
Platelets

• Platelets play an important role in blood
  coagulation and thrombus formation.
• One unit of platelets can increase an average
  adult's platelet count by 5000 platelets per
  microliter.

24
Platelets

• Platelets are obtained through centrifugation of
  whole blood.
• They are given to prevent or help control
  bleeding due to thrombocytopenia. Platelets
  should not be administered to patients with
• heparin-induced
• thrombocytopenia (HIT).

25
Platelets Procedure

• Identify the patient and check the platelet blood
  type versus the patient's blood type per
  institutional policy.
• Prime the blood administration set with a 170- to
  220-micron filter with a normal saline solution.
  Do not use filters that were previously used to
  filter whole blood or PRBCs.

26
Platelets Procedure

• Before exposure to Rh-positive platelets,
  administer anti-Rh-immune globulin to Rh-negative
  women who are of childbearing age.
• Hang the platelet bag on one tail of the Y set.
• Close the normal saline-solution line roller
  clamp, and open the platelet line.
• Run the infusion slowly for the first 15 minutes,
  as with other blood products, and watch closely
  for any transfusion reaction.

27
Platelets Procedure

• Assess and document vital signs. After this, the
  infusion rate can be moved up to 4 to 8 ml/kg per
  hour according to the patient's tolerance and
  organizational policy.
• When the platelet pack is empty, close the roller
  clamp, open the normal saline solution, and flush
  the line to infuse all the platelets.

28
Fresh Frozen Plasma (FFP)

• Fresh frozen plasma (also known as FFP, FP, or
  frozen plasma) contains all the components of
  plasma, including clotting factors and
  fibrinogen, of one unit of whole blood.

29
Fresh Frozen Plasma (FFP)

• FFP is given to correct coagulation deficiencies
  for which specific factor concentrates are
  unavailable. FFP is typically not the treatment
  choice for volume expansion.

30
Fresh Frozen Plasma (FFP)

• FFP may also be given for treatment of the
  following conditions
• sickle cell crisis
• a bleeding tendency of unknown cause or one
  associated with liver failure
• coagulopathy and active bleeding, such as may
  occur during massive transfusion or in
  disseminated intravascular coagulation
• reverse warfarin effect.

31
FFP Procedure

• Identify the patient and the blood type.
• Double check the unit of plasma with another
  person to make sure the blood type is correct.
• Document the double-checked data in accordance
  with policy.
• Inspect the bag for leaks and the color of the
  infusion. Thawed FFP should be yellow or light
  green in color and clear in appearance.
• Prime the infusion set with normal saline.

32
FFP Procedure

• Close the roller clamp on the normal saline
  solution and spike the plasma with the other tail
  of the Y set.
• Open up the plasma, and regulate the drip rate.
• Run the infusion slowly for the first 15 minutes,
  as with other blood products, and watch closely
  for any transfusion reactions. Assess and
  document vital signs as required by
  organizational policy.
• Increase rate as prescribed.
• Dosage is usually 10 to 15 ml/kg but may vary
  depending on clinical presentation.

33
General Principles

• No medications or solutions (except normal
  saline) should be added to or transfused
  concurrently with blood components.
• If the integrity of any component is questioned
  on visual inspection, the unit should be returned
  to the blood bank for further evaluation.

• Lactated Ringer's solution or other electrolyte
  solutions containing calcium should never be
  administered concurrently with a blood component
  mixed with an anticoagulant containing citrate,
  because calcium binds to citrate.

• Policy Administration of Blood and Blood Products

• JR.PC.08 Kaiser Permanente, Ohio Region

34
General Principles

• A filter designed to retain blood clots and
  particles must be used for transfusion.
• Components should be mixed thoroughly before
  administration.

• If the blood component container is entered for
  any reason, the component expires after 4 hours
  at room temperature (20 to 24C) or after 24
  hours if refrigerated at 1 to 6C.1

35

• Do not allow RBCs to stand at room temperature
  longer than 30 minutes before administration.

• All blood or blood components not used within 30
  minutes must be stored in a monitored
  refrigerator that has been approved by the blood
  bank.
• Transfusions should be completed within 4 hours
  and before the expiration date/time of the blood
  component.

36
General Principles

• Transfusion reactions can be life threatening and
  occur with exposure to even a small amount of
  blood therefore, transfusions should be started
  slowly and vital signs should be obtained no more
  than 15 minutes after the transfusion is started
  or per organization policy.
• Review Policy Administration of Blood and Blood
  Products, JR.PC.08
• Kaiser Ohio Region Policy

37
Patient Teaching

• Instruct the patient to immediately report any
  chills, itching, feeling of warmth, difficulty
  breathing, pain in the back, the abdomen, the
  chest, or at the IV site.

38
Documentation

• Per organizational Policy
• Component infused and amount
• Unit number and/or expiration date
• ABO and Rh type of component and patient
• Length of infusion time
• Unexpected outcomes or transfusion reactions
• Physician notification of transfusion reactions
• Both RNs double-check signatures

39
Objectives

• The learner should be able to identify proper
  infusion procedures for administering RBCs,
  Albumin, Platelets, and FFP.
• The learner should be able to state the signs and
  symptoms of a transfusion reaction and how to
  respond when a reaction occurs.
• The learner should be able to list the elements
  necessary for patient education and for nursing
  documentation.

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References

• Excerpted and adapted from Emergency Nursing
  Procedures, Fourth Edition, by Jean A. Proehl,
  RN, MN, CEN, CCRN, FAEN, St. Louis Saunders,
  2009.
• American Association of Blood Banks (AABB).
  (2006). Circular of information for the use of
  human blood and blood components.
• Ohio Regional Policy
• Administration of Blood and Blood Products
• JR.PC.08