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Tuesday, April 21, 2009

Fundamentals of Nursing: Blood Administration

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Blood Administration - Presentation Transcript

1. Blood Administration Reference: 1. Only two units per filter. 2. Verify units. 3. Use within four hours after removal from blood bank. 4. Use 20 ga. or larger catheter. 5. Obtain Informed consent. 6. PRBC replaces RBCs only. 7. If more than 6-8 units of PRBC are given then give FFP with every other unit. 8. Give platelets one for every unit of PRBC after eight units. ESSENTIAL INFORMATION: 1. Clinical Pathology and Transfusion Medicine Guide 2. Nursing Department Policy: Infusion of Blood and Blood Components. 3. Department of Transfusion Medicine (DTM) Procedure: Infusion of Non-cryopreserved Cellular Components. 4. Circular of Information For the Use of Human Blood and Blood Components, American Association of Blood Banks. July 1998 (Distributed by DTM) EQUIPMENT: STEPS KEY POINTS Verify physician order for type and crossmatch Draw blood sample for crossmatching Place patient labels on large red top tube Patient label includes patient name and hospital ID#. Use a ballpoint pen and press hard when Blood samples, which are missing any writing: patient name, ID#, date of this information, are rejected. A specimen collected, and initials of person new sample will then need to be collecting specimen. drawn and properly labeled. Identify the patient using at least 2 forms The major cause of acute transfusion- of identification, ex., hospital related death is error in identification. identification bracelet, MAS data, asking Patient identification is the most the patient to state his/her name. Or the important step in the transfusion new picture hospital card. Sign blood procedure. product request form indicating you verified patient Identification. Collect blood specimen in large red top To prevent hemolysis of the blood tube. If venipuncture required, use 20 sample, a 22 gauge needle or larger gauge needle or larger for adults and a should be used to obtain the blood 22 or 23 gauge needle for children. sample. The minimum sample volume needed is 8 ml. Will have to draw one tube for each two units. Keep in mind the expiration dates of The crossmatch sample expires on
2. crosmatches for most hospitals. 11:59 p.m. on the third day after the day it is drawn, i.e. a sample drawn anytime Tuesday the 23rd, will expire at 11:59 p.m. on Friday the 26th. Blood Transfusion Preparation – Verify Order for Blood Product, Identification & Consent Check physician’s order to determine: Allow 30 – 60 minutes for oral a. product to be administered medications, 10 minutes for IV b. number of units or volume to be medications to become effective. administered c. date to be administered d. special processing e. duration of infusion f. pre-medication orders, if indicated For whole blood, red blood cells or granulocytes, verify in the computer or with the blood bank.results of: a. blood grouping b. Rh type c. number of units crossmatched d. number of units set up Verify informed consent has been Consent required for ALL blood obtained and signed in the past year, products. except for emergency transfusions. Ensure the inpatient is wearing hospital Required for ALL blood products. ID bracelet. Ask lucid patients to state full name and date of birth. If not lucid, ask responsible visitor. Establish Line & Check Client’s VS Establish or verify patency of peripheral When infusion pump is used, 20 or central venous access device. gauge needle or larger is recommended to prevent lysis of red blood cells. 23-gauge needle can be used for transfusing pediatric patients. Obtain and record patient’s baseline Febrile patients destroy cells vital signs. Conduct patient teaching and rapidly. If febrile, notify physician to alert staff to the following symptoms: decide if transfusion can wait or if • Chest pain. patient should receive acetaminophen • Flushing. as a pre- medication. • Shivering. • Abdominal discomfort. • Rashes. • Shortness of breath. • Pain in the loins or extremities. • Blood in urine. • A feeling of restlessness or anxiety. • Feeling generally unwell Pick up Blood from Blood Bank
3. When the patient is ready to be There should be a four hour time transfused, take pick up slip to blood lapse between completing infusion of bank to obtain blood. Amphotericin and beginning transfusion of granulocytes or vice versa. It is advisable that all other blood products be separated from Amphotericin by two hours. Blood products must be hung within 30 minutes of leaving the Blood Bank refrigerator. The Blood Bank will usually only release one blood product at a time. However, with physician phone call multiple units may be issued during an emergency. Blood products MUST NEVER be placed in the refrigerator on the patient care unit. Check the appearance of unit for If appearance is suspicious, return it presence of clots, brown discoloration, to Blood Bank, as it may not be clumps or abnormal cloudiness, and appropriate for infusion. integrity of seals. Warming is not normally necessary and blood components should never be put in a bowl of warm water, on a radiator or in a microwave oven: this is dangerous, as it will damage the cells. Two qualified health professionals trained All three records must correspond in blood administration procedures exactly. compare: All identification attached to the a. Blood product received on the unit container must remain attached until to product requested in the the transfusion has been terminated. medical order. b. Blood type and Rh type recorded in computer with the container bag and container label ensuring that they are either identical or compatible. c. The blood product number on the blood container with the product number on the blood container tag. d. Compare the expiration date and time, if present, on the blood container label to the current date and time. Immediately before the transfusion, The major cause of acute transfusion- in the presence of the recipient, two related death is error in identification. qualified health professionals identify the Proper patient and unit identification patient using at least 2 forms of is one of the most important steps in identification: the transfusion process. If any a. Verify the patient’s name and discrepancy is noted, notify Blood medical record number on the Bank at once and return the blood blood unit with the information on product until the discrepancy is
4. the recipient’s identification resolved. bracelet and the information recorded in the patient record. Identify patients with patient hospital b. Ask the patient to state his/her ID band or hospital label and ask the name. patient to state their name. Correlate c. Verify the information on the this information with blood patient wristband and blood unit. component’s tag. Start the Infusion Set Prime the administration set with the Use of other IV solutions damages blood product or 0.9% Sodium Chloride. blood components. a. Add a three-way stopcock onto the During a reaction, 0.9% Sodium end of the blood administration Chloride may be administered set. Have 0.9% Sodium Chloride through the stopcock without infusing solution and IV tubing unopened the additional blood product in the and available in room for tubing emergency use or attached to Leukocyte depletion filter may be stopcock. used to prevent repeat febrile b. If a leukocyte-depletion filter is reactions, decrease the risk of CMV indicated, follow the transmission, and decrease the risk manufacturer’s and blood Bank of alloimmunization. Do not flush instructions for set up. filter with saline. Leukocyte depletion filters are not to be used when administering granulocytes. Connect the blood administration set to During a blood transfusion, it is the IV extension set either directly or recommended that no intravenous through the intermittent infusion cap via drugs are added to the same cannula needleless system. or giving set, because of the risk of interactions Adjust the rate of flow for first few . minutes A volumetric infusion pump may be For adults: used to administer blood products. • Platelets or plasma - 2-5 Symptoms of an immediate adverse cc/min for 5 minutes reaction are usually manifested • Whole blood, RBC or during infusion of the initial 50 cc. If granulocytes - 2cc/min for 15 an incompatible transfusion is minutes terminated early, acute renal necrosis Patient should be observed closely for the and death may be prevented. first 15 minutes. For pediatric patients, volume of For pediatric patients: blood products (excluding • transfuse 5% of the total volume granulocytes) to be transfused should ordered in the first five minutes be ordered based on the child’s of platelet or plasma infusion weight, i.e. 10 - 15 ml/kg. • first 15 minutes of whole blood, RBC’s or granulocyte infusion. Remain with the patient for the first 15 minutes after the start of the infusion. Monitoring for Adverse Reaction At the end of the first 15 minutes, The desirable rate of infusion
5. obtain and record TPR and BP. If vital depends upon patient’s blood volume, signs are within normal range and the cardiac status, and hemodynamic patient has no signs/symptoms of an condition. Suggested rates for adults adverse reaction, change the rate to are: infuse the unit within the time period PRBCs: 100-230 cc/hr specified in the physician’s order. Granulocytes: 75-100 cc/hr Plasma/platelets: 200 – 300 cc/hr The volume of a plateletpheresis bag varies from 120 cc to 400 cc. The entire platelet product should be given within one hour, if possible. Continue to monitor the patient for signs . and symptoms of adverse reaction during Adverse transfusion reactions can transfusion and 1 hour post- transfusion. occur anytime during or after the If patient experiences a transfusion transfusion. reaction while transfusion is in progress, For treatment of adverse transfusion immediately stop the transfusion. reactions: see Clinical Pathology and Maintain patency of line with normal Transfusion Medicine Guide \"Adverse saline and notify MD. Reactions to Transfusions\". Complete transfusion as ordered not to Increased possibility of contamination exceed four hours. and decreased viability of cells if prolonged. Tubing sets can be used for second unit of blood if used within four hours. As there is a possibility of delayed transfusion reactions, some hospitals require empty transfusion packs to be kept to enable testing if required. Packs should only be stored for the required time as they are a source of infection in themselves if left for extended periods. At the conclusion of a blood product Do not flush leukocyte filters with transfusion in which no adverse reaction saline. occurred: a. Obtain 10 - 60 minute post transfusion CBC for post-count as indicated. b. Flush the blood administration set with 0.9% Sodium Chloride until the tubing is clear. c. Obtain and record vital signs. d. Disconnect and discard the empty blood product container in a contamination red bag. Adverse Reactions Pyrexia A temperature of more than 38 C might be due to: • n Pyrogens resulting from bacterial contamination. • n Reaction to white cells or platelets which can • also be accompanied by chills or rigors. • n Haemolytic blood reaction (see below). The appropriate action is to stop the transfusion and to seek medical advice.
6. Allergic reaction Allergic reactions can present as an urticarial rash or a mild pyrexia. This can also develop into oedema around the eyes or larynx and cause dyspnoea. Full anaphylaxis is uncommon. The appropriate action is to stop the transfusion and to seek medical advice. (Subsequent transfusions might require pre-medication with a prescription for an antihistamine and paracetamol.) Infection Although donated blood is screened for major viruses and bacteria (including HIV, hepatitis B, hepatitis C and syphilis), infections, although very rare, do occasionally occur. Much more common, however, is local phlebitis which occurs if a cannula remains in situ for too long: the most commonly isolated bacteria are staphylococci or corynebacteria. Platelets are stored at room temperature and so can act as an ideal medium for bacterial growth. The appropriate action is to check cannula insertion sites regularly for inflammation and infection, and to change the insertion site routinely every 72 hours. When using platelets, bags should be checked for discolouration, which may indicate the presence of bacteria. Haemolytic reaction A haemolytic reaction is caused by destruction of the donor red blood cells by antibodies in the recipient’s plasma. It can occur after only a few millilitres of blood are transfused, although a delayed reaction can occur up to two hours later. Haemolytic reactions can be fatal and as such, a suspected haemolytic reaction must always be responded to as a medical emergency. A haemolytic reaction is indicated by: • Breathlessness. • Collapse. • Tachycardia. • Hypertension followed by hypotension. • Chest or loin pain. • Subsequently, the patient might develop: • Disseminated intravascular coagulation (DIC). • Circulatory and respiratory failure. • Renal failure. The appropriate actions are: 1. stop the transfusion 2. disconnect the pack and giving set 3. maintain the intravenous line with normal saline 4. seek urgent medical advice. This is an emergency, life-threatening situation. Haemolytic reaction is most likely to be due to a patient receiving the wrong blood from one or more errors in the chain of events from taking a cross-match sample, the laboratory processes, the collection of blood for transfusion and administration into the recipient. All blood must be returned to the blood bank and an investigation must be carried out to ascertain the source(s) of the error. Circulatory overload Circulatory overload causes less of a problem now that concentrated red cells are used more frequently than whole blood. Problems can occur with older people, neonates or patients with megaloblastic anaemia. The action to take is to give diuretic therapy as prescribed, slow the rate of transfusion and observe closely for pulmonary and peripheral oedema. Iron overload Patients who receive multiple transfusions have an increased serum ferritin. At a level greater than 1,000mg per litre, the iron infiltrates organs such as the liver, heart and kidneys, which can lead to organ failure or even be fatal. In patients on multiple transfusion programmes, an iron chelater such as desferrioxamine can be prescribed to regulate the level of serum ferritin.

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