ADMINISTRATION OF BLOOD & BLOOD PRODUCTS

Noraliza Salazar, MSN, RN, CCRN, CCNS Critical Care Nurse Educator UCSF Medical Center Asst. Clinical Professor UCSF Graduate School of Nursing

Who can Donate Blood

Age: 17th 71st birthday (regular donor) 17th 61st birthday (first time donor)

Weight: At least 50 kg (110 lbs) Hemoglobin: Must meet requirements Donation Frequency: Minimum of 56 days in between donations Health: In good health and feeling well. Screening: At time of donation, a number of questions are asked to determine donor eligibility, e.g.: If donor has had a: Donor must wait before donating for Dentists visit: 3 days after visit Cold, flu or sore throat: Full recovery Ear/ body piercing or tattooing: 6 months

What is an Apheresis Donation?

Apheresis involves the use of machines to selectively collect a blood component (red cells, platelets, white cells, or plasma). The components that are not required are returned to the donor. Advantages: relatively large amounts of the component can be selectively collected Apheresis donors' donations go through additional typing called Human Leukocyte Antigen (HLA) typing to ensure that the match between donor and recipient is as close as possible.

TYPE & CROSSMATCH

TYPE - To determine ABO type & Rh (steps 1 & 2) SCREEN To screen for antibodies (step 3) CROSSMATCH To determine compatibility of a donated unit of blood for its intended recipient (step 4) Step 1 Recipients ABO type & Rh are determined Step 2 Donor blood of same ABO & Rh is chosen Step 3 General antibody screening on both recipient and donor blood is done. Step 4 If antibody screening (+), more specific antibody identification is done. a. Recipient or donor serum is combined with a panel of RBC samples each with a known antigen. Antibody-antigen rx is observed. b. Recipient and donor bloods are combined (CROSSMATCHED) and observed for antibodyantigen rx. If no rx donors blood compatible with recipients blood

Type & Crossmatch vs Type & Screen Only

Type & crossmatch Takes up to 1 hour to complete Good only for 72 hrs due to possibility of recipient developing antibodies in response to recent blood transfusion

Type & screen only Involves ABO & Rh and general antibody screening only May be done in 20 minutes Sometimes prescribed if there is only a small possibility of pt needing blood or if blood needs to be transfused during an emergency

Each Unit of Donated Blood is Tested For:

ABO type, Rh (+ or-), and for any unexpected RBC antibodies HIV-1 and HIV-2 Antibody (Anti-HIV-1 and Anti HIV-2) HTLV-I/II Antibody (Anti-HTLV-I and Anti HTLV-II) Hepatitis C Virus Antibody (Anti-HCV) Hepatitis B Surface Antigen (HBsAg) Hepatitis B Core Surface Antibody (Anti-HBc) Serologic test for syphilis (RPR) Nucleic acid amplification testing (NAT) HIV and HCV test for genetic material of these two viruses

Whole Blood Is Separated Into Different Components:

Red blood cells which are used for accident victims, surgery patients, and people who have anemia. Plasma which is used to treat people with deficiency in clotting factors, burn victims and shock. Cryoprecipitate which is derived from frozen plasma and used as a source of fibrinogen and Von Willebrand factor, treats patients with hemophilia. Platelets which are used to aid blood clotting such as in people who have cancer White blood cells which are used to help fight infection and protect the body from invasion by foreign substances such as bacteria, fungi and viruses.

BLOOD TRANSFUSIONS
Homologous
from donors to another individual bag is labeled volunteer donor

Autologous
from intended recipient (from self) prior to planned surgery salvaged during surgery bag is labeled autologous

Designated (directed) donor (family/friends) designated by recipient bag is labeled directed

WHAT IS BLOOD MADE OF?

WHOLE BLOOD
Has plasma, WBCs, platelets, & RBCs Plasma has: plasma proteins (e.g. antibodies) clotting factors 63 ml of anticoagulant/ preservative

~ 450 ml plus 63 ml anticogulant per unit 1 unit will Hct by 3% and Hb by 1 g/dL

PACKED RBCs
Plasma removed PRBCs with Adenine-saline (AS) as additive solution with preservative + diluent to shelf life (45 days) and viscosity. Volume ~ 300 - 350 ml. PRBCs with CPDA-1 as additive solution with preservative only (no diluent). Volume ~ 250 - 300 ml. Preservative can be removed or unit can be divided into smaller bags (1 quad pack unit = 75 ml) for pts. who cannot tolerate extra volume Infusion time should not exceed 4 hrs

LEUKOCYTE-REDUCED RBCs vs LEUKOCYTE-POOR RBCs WBCs removed from a unit of PRBCs Indications: To prevent recurrence of febrile, non-hemolytic, urticarial, and anaphylactic rxs. caused by donor WBC antigens reacting with recipients WBC antibodies to risk of alloimmunization to transmission of CMV infection Bag is labeled Leukocyte-reduced PRBCs if leukocytes have been pre-filtered in Blood Bank If leukocyte-poor RBCs is ordered (i.e. not pre-filtered by Blood Bank), a leukocyte removal filter for RBCs (not for platelets!) MUST be used in conjunction with standard blood tubing and filters. Do not flush filter with saline post transfusion (will flush leukocytes into pt)!

SALINE-WASHED RBCs
Whole blood or RBCs that have been washed with 1L - 2 L of saline manually or in an automated cell washer. Contain 10 to 20% less RBCs than the original units hence more washed units may be required to alleviate symptoms. Washed units have a HCT of 70% and have been depleted of 99% of plasma proteins and 85% of WBCs. Residual K+ is 0.2 mEq/L. Other RBC metabolites are almost entirely removed. Washing also removes cytokines that cause febrile rxs. Must be used within 24h since original collection bag has been entered, which breaks the hermetic seal and possibility of bacterial contamination. Removal of anticoagulant-preservative solution also limits cell viability and function.

IRRADIATED BLOOD PRODUCTS

Bld. products exposed to radiation preventing donor WBCs from replication To prevent transfusion-associated graft-vs-host reactions in pts. receiving bld. products with WBCs Given in Hodgkins lymphoma, acute leukemia, bone marrow transplants, congenital immunodeficiencies Bag is labeled Irradiated

Carries no radiation risk to transfusionist or to pt.

PLATELET CONCENTRATES (a.k.a. pooled random donor platelets) Each bag has platelets collected from 3-5 donors Prophylaxis for plt count < 10,000 - 20,000 Contain few RBCs hence ABO compatibility not required Stored for max. of 5 days Use leukocyte-poor platelets if with hx of febrile, nonhemolytic rxs. 1 unit platelet count by ~ 5,000

APHERESED PLATELETS (a.k.a. single-donor platelets) Contains platelets equivalent to 5 to 6 pooled random donor units Collected from a single donor by apheresis 200 - 400 ml total volume Single donor plts transfusion-transmitted diseases and HLA antibody formation

LEUKOCYTE-REDUCED PLATELETS vs LEUKOCYTE-POOR PLATELETS

WBCs removed from a unit platelets Bag is labeled Leukocyte-reduced platelets if leukocytes have been pre-filtered in Blood Bank If leukocyte-poor platelets is ordered (i.e. not pre-filtered by Blood Bank), a leukocyte removal filter for platelets (not for RBCs!) must be used in conjunction with standard blood tubing and filters. Do not flush filter with saline post transfusion (will flush leukocytes into pt)!

HLA-MATCHED PLATELETS
Pheresed platelet units collected from an HLAmatched single-donor Indicated for patients who have evidence of HLA antibodies and have become refractory to random donor platelets. To premature destruction of transfused plts by HLA antibodies. Check platelet counts 15 minute after platelet infusion. A poor 15 minute count may be indicative of HLA antibodies. A good 15 minute count but poor 24 hour count is more suggestive of platelet consumption - fever, sepsis, drugs, etc., and not an indication for HLA matched platelets.

GRANULOCYTES (WBCs)
Indication: Documented severe bacterial infection unresponsive to 24-48 hours of appropriate antibiotic therapy in a patient with severe neutropenia/neutrophil dysfunction Granulocytes are suspended in 200-400 ml plasma and contain some RBCs and platelets. Infused through a standard blood administration set filter over 1-2 hours. Premedication with antihistamine, steroid, acetaminophen, and/or meperidine to prevent rxs (chills, fever, hypotension, resp. distress) Transfused daily until the patient's infection clears or until the neutrophil count exceeds 500/l.

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FRESH FROZEN PLASMA

To clotting factors to correct prolonged PT/PTT FFP is platelet-poor plasma that is separated from red cells within 6 hours of blood collection and frozen in a dedicated freezer (at or below 20 C). Contains all coagulation factors and plasma proteins (such as albumin). One unit of FFP is defined as that obtained from a single whole blood transfusion bag (approximately 250 ml).

CRYOPRECIPITATE
Concentrated source of von Willebrand factor, fibrinogen, factor VIII, and factor XIII. Produced by slow-thawing of FFP, followed by centrifugation. Proteins that precipitate are maintained in 15 - 30 ml of plasma. Each unit = 15 30 ml 10 units will fibrinogen level of a 70 kg pt to 70 mg/dl. Indications: low fibrinogen levels bleeding from excessive anticoagulation massive hemorrhage disseminated intravascular coagulation Hemophilia A (factor VIII deficiency) Von Willebrands disease (Von Willebrand factor deficiency)

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BLOOD ADMINISTRATION GUIDELINES

VS before transfusion and 15 min post initiation At the end of transfusion, check VS, complete BTR, dispose bag + tubing in biohazard wastes container If possible, avoid transfusion if with fever Premedicate as ordered Do not infuse meds or use any other solution except NS Use 19 g or > IV or > 3.5 Fr PICC line for RBCs A filter can be used for more than one unit of blood if: a. filter is not clogged and infuses easily b. filter has not and will not be hanging for > 4 hours. Pressure-transfusing device (no > 300 torr) Blood warmer PRN (to risk of arrhythmias/cardiac arrest with rapid, massive transfusions of cold blood)

BLOOD/BLOOD PRODUCTS ADMINISTRATION: CRITICAL POINTS Administered by an RN upon order of an MD/NP/PA Consent must be in pts chart before transfusion (except in emergency situations). Blood should not be ordered from Blood Bank until consent has been obtained (except in emergency situations). ? Pre-filtered blood products will be delivered in syringes. Unfiltered blood products will be delivered in bags. Blood may be returned to Blood Bank within 30 min if it will not be administered. Nursing unit will be charged for the cost of blood if not returned within 30 minutes. Patient may not leave unit with blood products running, unless accompanied by an RN and only in emergency situations or pre-procedure, i.e., Head CT to r/o bleeding or for central line placement. Recheck CBC may be sent 15 min after transfusion.

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DO NOT...
forget to label & sign 10 cc lavender top type & crossmatch specimen tube. Blood Bank will request a check specimen of 1-2 ml in a lavender tube, if needed, which must be drawn at a separate time from the original type and cross store blood on nursing unit keep blood out of Bld Bank for > 30 minutes prior to tx warm blood in water bath/sink or microwave oven transfuse remaining volume in bag after 4 hrs administer any bld/component without a filter use same filter for more than 4 hours add meds or infuse meds through same administration set as blood/component use any other solution except NS

BEDSIDE CHECK BEFORE START OF TRANSFUSION

Must be done by 2 individuals (one of whom is the RN or MD who will hang the blood, and the 2nd is an RN or MD or PCA or Surgery Tech). Both sign BTR after the check. 1. Check MD order for type of blood component, volume to be infused, length of infusion, premeds, and special considerations/issues, i.e., CMV, antibody negative, irradiated, autologous, designated donor. Compare name and hospital # on pt's wristband with name and hospital # on blood bag. Compare ABO, Rh and ID number on the labels attached to both front and back of blood bag to the Transfusion Record. These must be identical. Verify that blood product has not expired.

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BLOOD ADMINISTRATION RATES

Whole blood 1 unit = ~ 500 ml; in under 4 hrs or ~ 42 drops/min PRBCs 1 unit = ~ 250 ml; in under 4 hrs or ~ 21 drops/min Platelets 5 units = ~ 200-250 ml; as fast as possible FFP 1 unit = 200-250 ml; may be given as fast as possible Cryoprecipitate 1 unit = ~ 50 cc; as fast as possible Single-donor products (e.g. HLA-matched platelets) Vary in volume (check with Bld Bank for rate)

HEMOLYTIC REACTION
Antibodies in recipient's plasma directed against antigens on donor's RBCs Results in rapid intravascular hemolysis of donor RBCs (hemoglobinemia, hemoglobinuria, DIC, renal failure, and cardiovascular collapse) ABO incompatibility due to clerical error - most frequent cause These patients usually have been exposed to antigen through previous pregnancies, transplantation, or transfusions. Antibody titers often are too low to be detected through routine antibody screening, but production of antibodies becomes amplified with reexposure.

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NON-HEMOLYTIC FEBRILE REACTIONS

Nonhemolytic febrile reactions have been thought to be due to recipient antibodies formed against donor WBCs or platelets. More recently, these reactions have been postulated to stem from formation of cytokines (mediators of inflammation) during the storage of blood. These reactions seldom proceed to hypotension or respiratory distress

ANAPHYLACTOID REACTION

Proteins in the donor plasma can cause minor allergic reactions. This is an anaphylactoid reaction and is observed more frequently with components containing large amounts of plasma, such as whole blood, pooled platelets, and fresh frozen plasma.

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ACQUIRED INFECTIOUS DISEASES

Hepatitis B Hepatitis C HIV-1 HIV-2 Cytomegalovirus (CMV) West Nile virus Syphilis Lyme disease Malaria

TRANSFUSION-RELATED ACUTE LUNG INJURY

May be caused by transfusing any plasmacontaining blood product. It is caused by the interaction between the recipient's WBCs and preexisting donor antileukocyte antibodies. This results in complement activation and increased pulmonary vascular permeability. In addition, cytokines (mediators of inflammation) that form while the blood is in storage are also felt to be contributory.

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MASSIVE TRANSFUSIONS COMPLICATIONS

Defined as replacement of entire blood volume within a 24-hr period or replacement of 10 units of blood over course of a few hours. Coagulopathy - caused by dilutional effect on the host's clotting factors and platelets, as well as the lack of platelets and clotting factors in PRBCs. Volume overload Hypothermia Hyperkalemia - caused by lysis of stored RBCs and is in irradiated RBCs. Metabolic acidosis and hypoK+ - caused by transfusion of large amount of citrated cells. Hypocalcemia due to citrate toxicity may occur in those with hepatic failure, CHF, or other low-output states.

TRANSFUSION REACTION
S & S of hemolytic reactions, allergic or febrile reactions, and fluid overload: CP, SOB, stridor, laryngospasm Severe back or flank pain Hematuria S & S of shock Urticaria, rash, or pruritus in temp of 10 C with or without chills Headache, nausea, feeling cold Rales, frothy sputum in pulse rate, BP, CVP Unusual level of anxiety

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TRANSFUSION REACTION
1. Stop infusion immediately and call MD who will determine if a Transfusion Reaction Report is required. Open normal saline to keep line open. Do not flush blood product remaining in line into patient! Check the patient's VS and symptoms. Recheck ID numbers on blood bag and pt's wrist band. Treat pt symptomatically per MD order. Continue transfusion if ordered to do so by physician.

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TRANSFUSION REACTION
6. 7. Notify Blood Bank (x31313) immediately If a transfusion reaction has occurred, complete the upper portion of the Report of Transfusion Reaction form and send to Blood Bank along with: a. All blood bags, IV solutions and administration sets (remove any needles) used for the transfusion b. Lavender top specimen of pts blood labeled post transfusion reaction Send 1st post transfusion urine specimen to Specimen Processing Department Document transfusion reaction in the progress notes.

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