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By Kelli Rosenthal, MS, RN, BC, CRNI, ANP, APRN, BC Blood transfusion can be lifesaving therapy for patients with a variety of medical and surgical conditions. Your patient may require transfusion therapy for any of the following reasons: "Transfusion" can refer to the administration of any of several blood products. Let’s first review a brief description of each product, its indications, actions, and contraindications, and some general information about administration. Types of Blood Products Whole Blood: Whole blood contains cells (red blood cells, white blood cells, and platelets), plasma (plasma proteins, antibodies, water, and waste), and electrolytes. Its use is now rare, since most patients receive a blood component specific for their replacement needs. Packed Red Blood Cells: Packed red blood cells (PRBC) are collected from whole blood by either centrifugation or sedimentation, after drawing off about 250 ml of plasma and platelets from the donor unit. Packed red blood cells have a hematocrit between 70% and 80%, so they are among the most viscous of the blood products to transfuse. PRBC transfusions are usually administered to increase the oxygen-carrying capacity in anemic patients. One unit of packed red blood cells has the same amount of oxygen carrying red blood cells as a unit of whole blood. For each unit of RBCs transfused, the average 70 kg adult’s hemoglobin will usually increase by 1 g/dL the and their hematocrit by 2-3 percent. When administering PRBC, infuse the first 25 ml slowly over 15 minutes, staying with the patient to observe for any signs and symptoms of adverse reactions. Once you’re sure the patient is tolerating the transfusion, a unit of red blood cells can generally be infused over a period of 1 1/2 hours. Infusion rates are based on the patient’s blood volume, cardiac status and hemodynamic condition. Patients with who have lost a lot of their blood volume can tolerate blood administered as quickly as possible. Otherwise healthy adults with chronic anemia can be given red blood cells safely at a rate of 3-4 ml per kilogram per hour, while patients with cardiovascular compromise may tolerate rates of no more than 1 ml per kilogram per hour. Monitoring lung sounds for rales (or "crackles") is a good tool to observe for fluid overload. Infusion of PRBC must be completed within four hours after they are removed from the refrigerator, due to the potential for bacterial growth. Due to viscosity, it is sometimes difficult to administer PRBCs through a small catheter within the 4 hour time limit, especially if using a PICC catheter or a small tunneled catheter. Check with the blood bank to see if a unit can be split into two smaller bags, or use a pump. Many hospitals have the policy of inserting at least a 20 ga. peripheral I.V. catheter to infuse PRBCs because of the length of time it will take to administer them through a smaller cannula )although it does not harm the cells themselves to give it through a smaller catheter if the patient’s veins will not allow insertion of a larger one). PRBCs should be administered through a filter specifically for that purpose, and the tubing and filter should be primed with normal saline (this is necessary to make the filter function properly). A Y-type blood administration set is often used to facilitate priming the tubing and filter with normal saline. PRBC should not be concurrently infused with any solutions other than 0.9% normal saline, 5% albumin, plasma protein fraction, or compatible plasma. Because most of the plasma is removed from PRBCs, most of the anti -"A" or anti- "B" antibodies are also removed, allowing group "O" cells to be given to patients with "A" ,"B", or "AB" types more safely. So, in emergency situations, when time does not permit ABO determination, group "O" red blood cells may be given. Patients who are Rh negative or whose Rh status is unknown may only receive Rh negative PRBCs. Rh-positive patients may receive either Rh-positive or Rh-negative cells. Platelets: Platelets are available in two preparations; random donor concentrates made from single units of whole blood, and single donor concentrates obtained from a single donor. Platelet products also contain plasma (especially factor III, necessary for coagulation), some red cells and some white cells. Platelet transfusions are administered to control or prevent bleeding associated with deficiencies in platelet number or function. Each unit of platelet concentrate should increase the average adult patient’s platelet count by about 5,000 platelets/µL. Platelets should be infused within four hours, or by the expiration time on the unit label, whichever comes sooner, due to the risk of bacterial contamination. As with other types of blood components, a 170-260 micron filter (standard in most blood administration sets) should be used to administer the platelets. For most adults, platelet concentrates do not require ABO crossmatching before infusion, but patients who have had numerous platelet transfusions (like some oncology patients) may become refractory to pooled donor platelets, and respond better to donor-matched platelets from a single donor. For infants and small children, ABO compatible or reduced-volume ABO incompatible platelets must be given. While platelets contain an insufficient number of red cells to cause an incompatibility reaction, there are enough red cells for an Rh-negative person to develop Rh antibodies if they receive Rh-positive platelets. Fresh Frozen Plasma (FFP): Fresh frozen plasma contains all the normal components of blood plasma, including clotting factors. It is removed from whole blood and frozen within 8 hours of collection. FFP should be used as soon as possible after it is thawed and always within 24 hours after thawing. A hanging unit must be infused within 6 hours, due to the risk of bacterial contamination. FFP may be ordered for patients with documented clotting deficiencies who are actively bleeding or are about to undergo an invasive procedure where bleeding is likely. Patients may have coagulation deficiencies for several reasons, including congenital deficiency, liver disease, anticoagulation with warfarin (Coumadin) or massive transfusion with red cells and crystalloid/colloid solutions. Because FFP is an isotonic volume expander, patients receiving more than one unit must be monitored closely for signs of overload. As with other blood components, FFP should be filtered with a standard filter (170-260 microns) in the tubing. Since FFP is not as viscous as whole blood or PRBCs, a blood component recipient set is often used, which is shorter than the standard Y-type tubing and has a smaller filter. The advantage of using this type of administration set is its smaller residual volume and smaller volume filter chamber. Thus, there’s less FFP left in the tubing at the end of the transfusion. FFP must be ABO compatible; however, Rh antibody status is irrelevant. For information on IVIG, another blood-derived product, please see Intravenous Immunoglobulin. About ABO and Rh Compatibility Whether or not your patient can receive a certain type of blood depends on the combination of 1) their blood type and 2) whether the donor has antibodies that can attack their blood type. Anti-"A" antibodies develop in Type "O" and Type "B" people, who don’t have the "A" molecule (so it's foreign to them). Anti-"B" antibodies develop in Type "O" and Type "A" people, who don’t have the "B" molecule (Type "O" simply has no corresponding molecule, so there is no such thing as "anti-’O’" antibodies). Anti-Rh antibodies arise in Rh-negative people. ABO antibodies develop naturally starting at approximately 3 months of age, whereas antibodies against Rh occur in Rh negative individuals only after exposure to Rh positive blood. When assessing the compatibility of blood and components, both patient and donor antigens and antibodies must be considered. ABO Antigens/Antibodies
Rh Antigens
Transfusion – the Nurse’s Responsibility Nurses must be knowledgeable about blood products, their safe administration, and how to monitor patients during and after transfusion therapy. The safety of your patient also depends on your adherence to the rules governing transfusion. Assure that informed consent has been obtained before starting a transfusion. In many institutions this is obtained by the physician. Appropriate information to include in patient education includes the benefits, risks and alternatives to transfusion. Letting your patient know that transfusion is generally a safe and simple procedure is important and can help reassure a frightened patient, too. At the same time, patients should be told that reactions to blood components can occur. Instructing your patient to alert you to any unusual sensations he or she might experience during or after the infusion will help ensure that symptoms of a possible reaction are promptly reported. Document all patient education regarding transfusion therapy, and the responses of patients and family members after teaching. When assessing your patient before a transfusion, you should obtain important medical history information, review pertinent lab values, and perform a physical assessment. Find out whether your patient has ever been transfused and if so, if he or she experienced any adverse reactions. A female patient’s history of pregnancy might indicate if a patient is more likely to experience a reaction due to previous sensitization by the father’s blood type being expressed in the fetus. A history of heart disease or renal disease may indicate the need for a slower rate of infusion. (A slower rate of infusion may also be necessary for geriatric or pediatric patients.) Review the laboratory studies that prompted the transfusion order to double-check why the physician has ordered the transfusion. Reviewing the physician order, including any special processing requested, provides an opportunity to be sure the blood component was properly ordered and dispensed. The patient’s electrolyte and fluid balance should also be assessed. A baseline physical assessment should include vital signs and assessment for skin rashes, shortness of breath, wheezing, pain, chills, itching or nausea. In patients with cardiopulmonary disease, listen to the lungs to establish a baseline for the presence of any rales (crackles). When you receive the delivery from the blood bank, you should receive both the product and the transfusion record that corresponds to it. Once you have them, inspect for the following:
If there are any abnormalities in appearance, they should be reported and the unit returned to the blood bank for replacement. Prior to starting the transfusion, perform the following verification process to ensure the correct blood is being given to the correct patient. Remember, most transfusion reactions occur because of errors in patient or component identification.
Once unit and patient identification are confirmed, assess the patency of the patient’s vascular access, and spike and prime the transfusion as described. Obtain the patient’s temperature, pulse, respiration, and blood pressure and record. Recheck vital signs 15 minutes after starting the transfusion and as appropriate based on the patient’s condition, until the transfusion is complete. Record a final set of vital signs at the completion of the transfusion. Administer the blood or component at the recommended rate, based on the patient’s condition. Stay with the patient for the first few minutes of the transfusion (for about the first 25 ml.), and review signs and symptoms of what the patient should report to you. If the patient experiences any symptoms of a reaction to the transfusion (See below, “What to Do if You Suspect a Transfusion Reaction”), discontinue it immediately and call for assistance. Finally, document the transfusion in the patient’s chart. The “Chart Record” portion of the Transfusion Report should be placed in the patient chart as a permanent record. Continue to monitor your patient for any signs and symptoms of reaction for at least one hour after the transfusion. Obtain any ordered post-transfusion laboratory studies. What to Do if You Suspect a Transfusion Reaction Acute hemolytic transfusion reactions (AHTR) are rare, but can cause serious consequences, including death. When they do occur, it is usually because of ABO incompatibility between patient and donor during transfusion of red cells. Since most cases of ABO incompatibility occur as a result of clerical error at some point in the transfusion process, it is vital that nurses and all others responsible for every facet of the transfusion procedure assure accuracy when drawing laboratory samples for typing and crossmatching. It is also critical to ensure that the intended recipient is getting the intended unit at the time of transfusion. AHTR signs and symptoms will usually appear within the first 5-15 minutes after the transfusion is started, but can happen anytime during the transfusion. Symptoms you might see during an acute hemolytic transfusion reaction include: Should any of these symptoms occur, discontinue the unit immediately, hang normal saline (on a new tubing) to maintain vascular access, and call for assistance. Closely monitor the patient’s vital signs and symptoms. Notify the physician and obtain further orders to address the patient’s symptoms. Recheck the patient’s identifying information against the transfusion record and blood bag. All bags, tubings, filters, and paperwork should be retained and forwarded per hospital policy. The U.S. Food and Drug Administration now requires the use of machine-readable information on blood product container labels to help reduce transfusion errors. References American Association of Blood Banks. Standards for Blood Banks and Transfusion Services, 19th ed. Arlington, VA: 1999. Vengelen-Tyler, V, ed. For the American Association of Blood Banks. Technical Manual, 13th ed. Arlington, VA: 1999. Weinstein, S. Plumer’s Principles and Practices of IV Therapy, 7th Ed. Ch. 17. Philadelphia: Lippincott, Williams & Wilkins, 2001. Intravenous Nurses Society: "Infusion Nursing Standards of Practice," Journal of Intravenous Nursing. 23(6S), S70-71. 2000. FDA. Bar code label requirements for human drug products and biological requirements (Final Rule) Federal Register, 21 CFR Parts 201, 606, and 610. Published February 26, 2004.
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