Blood transfusion

ADMINISTRATION OF THE TRANSFUSION

F An 18- or 19-gauge IV needle will be needed to achieve a maximum flow rate of blood products and prevent damage to red blood cells; if a smaller gauge needle must be used, red blood cells may be diluted with normal saline.

F Blood products should be infused through administration sets designed specifically for blood; use a Y-tubing or straight tubing blood administration set that contains a filter designed to trap fibrin clots and other debris that accumulate during blood storage

F Premedicate the client with acetaminophen (Tylenol) or diphenhydramine (Benadryl), as prescribed, if the client has a history of adverse reactions; if prescribed, oral medications should be administered 30 minutes before the transfusion is started, and intravenously administered medications may be given immediately before the transfusion is started.

F Begin the transfusion slowly under close supervision; if no reaction is noted within the first 15 minutes, the flow can be increased to the prescribed rate.

 GENERAL PRECAUTIONS

ü  A large volume of refrigerated blood infused rapidly through a central catheter into the ventricle of the heart can cause cardiac dysrhythmias.

ü  No solution other than normal saline should be added to blood components.

ü  Medications are never added to blood components or piggybacked into a blood transfusion.

ü  To avoid the risk of septicemia, infusions (1 unit) should not exceed 4 hours.

ü  The blood administration set should be changed every 4 to 6 hours, with each unit of blood, or according to institution policy, to reduce the risk of septicemia.

ü  Always check the blood bag for the date of expiration; components expire at midnight on the day marked on the bag unless otherwise specified.

ü  Inspect the blood bag for leaks, abnormal color, clots, and bubbles.

ü  Blood must be administered as soon as possible (within 20 to 30 minutes) from its being received from the blood bank, because this is the maximal allowable time out of monitored storage.

ü  Never refrigerate blood in refrigerators other than those used in blood banks; if the blood is not administered within 20 to 30 minutes, return it to the blood bank.

ü  The recommended rate of infusion varies with the blood component being transfused and depends on the client's condition; generally, blood is infused as quickly as the client's condition allows.

ü  Components containing few red blood cells and platelets may be infused rapidly, but caution should be taken to avoid circulatory overload.

ü  The nurse should measure vital signs and assess lung sounds before the transfusion and again after the first 15 minutes and every hour until 1 hour after the transfusion is completed.

Principles of blood transfusion therapy

1. 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.
2. 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%.
3. 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.
4. 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.
5. 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.
6. 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.
7. Cryoprecipitate
   • Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated intravascular coagulation (DIC), and uremic bleeding.
8. Factor IX concentrate
   • Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors.
9. Factor VIII concentrate
   • Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission.
10. Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors.

Signs of an immediate transfusion reaction

Z  Chills and diaphoresis

Z  Muscle aches, back pain, or chest pain

Z  Rashes, hives, itching, and swelling

Z  Rapid, thready pulse

Z  Dyspnea, cough, or wheezing

Z  Pallor and cyanosis

Z  Apprehension

Z  Tingling and numbness

Z  Headache

Z  Nausea, vomiting, abdominal cramping, and diarrhea

Signs of a transfusion reaction in an unconscious client

ü  Weak pulse

ü  Fever

ü  Tachycardia or bradycardia

ü  Hypotension

ü  Visible hemoglobinuria

ü  Oliguria or anuria

Delayed transfusion reactions

F Reactions can occur days to years after a transfusion.

F Signs include fever, mild jaundice, and a decreased hematocrit level.

Interventions

µ  Stop the transfusion.

µ  Keep the intravenous line open with 0.9% normalsaline.

µ  Notify the physician and blood bank.

µ  Remain with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.

µ  Prepare to administer emergency medications such as antihistamines, vasopressors, fluids, and corticosteroids, as prescribed.

µ  Obtain a urine specimen for laboratory studies.

µ  Return blood bag, tubing, attached labels, and transfusion record to the blood bank.