Safe Blood Transfusions

• Key steps to safe transfusions of blood products and components are important because a patient's life may depend on it.
• Education is vital to understanding blood product function and safe administration.
• The article reviews what you need to know about transfusion therapy.

Indications, Actions, and Contraindications

• Review the indications, actions, and contraindications for each blood product type.
• Discuss general information about how to administer these blood products.

Whole Blood

• Contains red blood cells (RBCs), white blood cells (WBCs), platelets, plasma (plasma proteins, antibodies, water, and waste), and electrolytes.
• RBCs carry oxygen to the body's tissues.
• It is a blood volume expander and source of proteins that promote coagulation.
• Colloid or crystalloid intravenous (I.V.) solutions are alternatives to expand volume.
• They can't improve the blood's oxygen-carrying capacity and tissue oxygenation.
• It is rarely used today, blood components specific to a patient's individual replacement needs are more common.
• Patients who need rapid, massive replacement of lost blood (usually more than 25% of their blood volume) and have symptoms of hypoxia, or patients who need an exchange transfusion are candidates.

Points to note when using Whole Blood

• Prime the tubing and filter with 0.9% sodium chloride before hanging whole blood.
• Filters have a maximum hang time of 4 hours, so be sure to use a new one for each unit to be transfused.
• A Y-type blood administration set is often used to make it easier to prime the tubing and filter with 0.9% sodium chloride.
• Once you remove it from the refrigerator, administer it within 4 hours because of the risk of bacterial growth beyond this time.
• Infuse the first 25 ml of blood slowly over 15 minutes to watch for any adverse reactions.
• Once you're sure the patient can tolerate the transfusion, you can usually infuse one unit of red blood cells over 1½ hours.
• Monitor the patient's lung sounds for crackles to check for fluid overload; infusion rates are based on the patient's blood volume, cardiac status, and hemodynamic condition.
• Patients who've lost a lot of blood volume can tolerate rapid replacement.
• Healthy adults with chronic anemia can safely be given RBCs at a rate of 3 to 4 ml/kg/hour.
• Patients with cardiovascular compromise generally can't tolerate rates of more than 1 ml/kg/hour.
• Because of the risk of hemolysis, whole blood cannot be administered in the same line with most other infusions, except 0.9% sodium chloride, 5% albumin, plasma protein fraction, or compatible plasma.
• It is type specific and must be ABO- and Rh-compatible to prevent reactions.
• Blood is matched based on ABO compatibility, which depends on the presence or absence of A or B antigens and antibodies.
• ABO antibodies develop naturally at about 3 months of age.
• Antibodies against Rh occur in Rh-negative individuals only after exposure to Rh-positive blood.

Packed Red Blood Cells (PRBCs)

• Cells collected from whole blood by either centrifugation or sedimentation, with plasma and platelets drawn off.
• The concentration of RBCs remains the same as in whole blood, with about 25% of the original plasma retained.
• PRBCs have a hematocrit between 70% and 80%, making them viscous.
• One unit has the same amount of oxygen-carrying RBCs as a unit of whole blood.
• Each unit transfused will generally increase the average 70 kg adult's hemoglobin by 1 g/dl; hematocrit will usually rise by 2% to 3%.
• A patient who has an iron deficiency normally receives supplemental iron, not PRBCs.
• Patients with a folate or vitamin B12 deficiency: Folate and vitamin B12 supplements are the treatment; however, if one of these patients is severely anemic, PRBCs would be given to improve hemoglobin level and oxygenation.
• PRBCs are generally administered as blood replacement during surgery and to increase the oxygen-carrying capacity of blood in anemic patients.

Rules for administering PRBCs

• Like whole blood, PRBCs should be administered through a filter specifically designed for that purpose.
• The tubing and filter should be primed with 0.9% sodium chloride, which is needed to make the filter function properly.
• A Y-type blood administration set is often used to make priming easier.
• A unit should not hang for more than 4 hours after removing it from the refrigerator.
• Due to viscosity, PRBCs can be difficult to administer through a small catheter within the 4-hour time limit, especially when 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 a policy that PRBCs must be infused through at least a 20-gauge peripheral I.V. catheter.
• The cells themselves won't be harmed if they're given through a smaller catheter because the patient's veins won't accommodate the larger cannula.
• The concern is the length of time it'll take to administer blood through the smaller-diameter cannula.
• As with whole blood, PRBCs shouldn't be concurrently infused with any solution other than 0.9% sodium chloride, 5% albumin, plasma protein fraction, or compatible plasma.
• In processing, most of the plasma is removed from PRBCs, so most of the anti-A or anti-B agglutinins (or both) are gone.
• This allows type O blood to be given to patients with other blood types, particularly in emergencies, when time doesn't permit ABO typing.
• Rh-positive PRBCs should be given only to patients known to be Rh-positive; Rh-negative PRBCs should be given to patients who are known to be Rh-negative or who have an unknown Rh status.
• Modified PRBCs are similar to PRBCs; one type is washed in 0.9% sodium chloride and is intended for neonatal or intrauterine transfusion or when patients have repeated or severe allergic reactions to plasma proteins.
• Frozen deglycerolized packed cells are used for the same indications.
• Leukocyte-filtered PRBCs are given to patients who've had repeated febrile reactions to transfusions.
• Even neonates can receive PRBCs if the cells are modified, as in washed in 0.9% sodium chloride.

Platelet Products

• They are available in two preparations: random-donor concentrates made from single units of whole blood and single-donor concentrates obtained from plasmapheresis of a single donor.
• Platelet products also contain plasma (especially factor III, necessary for coagulation), some RBCs, and some WBCs (leukocytes).
• Platelets are transfused to control or prevent bleeding associated with deficiencies in platelet number or function and to aid in the coagulation process.
• Each unit of platelet concentrate should increase the average adult patient's platelet count by about 5,000 platelets/microliter.
• Patients with immune thrombocytopenic purpura shouldn't receive platelet infusions, unless life-threatening bleeding occurs.
• Because of their coagulating properties, platelets shouldn't be given prophylactically to patients who've received high concentrations of heparin (such as those on cardiopulmonary bypass) or large volumes of citrate (such as following a massive blood transfusion).
• Platelets should be infused either within 4 hours of being removed from the refrigerator or by the expiration time on the unit label, whichever comes first, due to the risk of bacterial contamination.
• A filter should be used, and as with other blood components, platelets should be administered through a standard 170- to 260-micron filter.
• Avoid filters that were used to filter whole blood or PRBCs; red cell debris already accumulated in the filter might trap the platelets.
• Platelet concentrates don't require ABO crossmatching before infusion for most adults.
• Patients who've had numerous platelet transfusions may become resistant to pooled donor platelets and may respond better to donor-matched platelets from a single donor.
• Infants and small children must receive either ABO compatible or reduced-volume ABO incompatible platelets.
• The number of red cells in platelets isn't high enough to cause an incompatibility reaction, but there are enough red cells for an Rh-negative child to develop Rh antibodies if he receives Rh-positive blood products.

Fresh Frozen Plasma (FFP)

• Contains all the normal components of blood plasma, including clotting factors and 200 to 400 mg of fibrinogen.
• It’s removed from whole blood and frozen, generally within 8 hours of collection.
• May benefit actively bleeding patients with documented clotting deficiencies, such as from congenital deficiency, liver disease, anticoagulation with warfarin (Coumadin), or massive transfusion with red cells and crystalloid/colloid solutions.
• It may also be ordered for patients about to undergo an invasive procedure where bleeding is likely.
• Each unit transfused will increase the level of any clotting factor by 2% to 3% in the average adult.
• Laboratory tests should be used to monitor the patient with a suspected clotting disorder.
• For FFP transfusion is rarely indicated if prothrombin time (PT) and partial thromboplastin time (PTT) are less than 1.5 times normal.
• Because FFP is an isotonic volume expander, patients receiving more than one unit must be monitored closely for signs of overload.
• Also, because of its coagulation properties, FFP shouldn't be administered as a volume expander or as a prophylactic measure in patients who've had a massive blood transfusion or a protracted cardiopulmonary bypass.
• FFP should be used as soon as possible after it's been thawed, and always within 24 hours of thawing.
• A hanging unit must be infused within 6 hours due to the risk of bacterial contamination.
• Use a standard filter (170 to 260 microns) in the tubing when filtering FFP because it isn’t as viscous as whole blood or PRBCs.
• A blood component recipient set is often used as it is shorter than the standard Y-type tubing and has a smaller filter, with the advantage of Less FFP being left in the tubing at the end of the transfusion.
• FFP must be ABO compatible, but Rh-antibody status is irrelevant.

Key Steps for All Blood Products

• Make sure the patient has signed an informed consent form before starting the transfusion.
• You can educate the patient by talking about the benefits, risks, and alternatives to blood transfusion, reassure him that transfusion is generally a safe and simple procedure, but that reactions to blood components can occur.
• Instruct him to alert you to any unusual sensations he might experience during or after the infusion so that symptoms of a possible reaction are promptly reported. Document all patient education about transfusion therapy, as well as the responses of patients and family members after teaching.
• When assessing your patient before a transfusion, review their medical history and pertinent lab values and perform a physical assessment. Find out whether he's had transfusions in the past, and if so, whether he's had any adverse reactions. A female patient with a history of pregnancy might be more likely to experience a reaction due to previous sensitization. A history of heart or renal disease may indicate the need for a slower infusion rate, also true of geriatric or pediatric patients.
• Review the lab studies to confirm the reason for the transfusion and assess the patient's fluid and electrolyte balance. Then check the transfusion order to ensure that the blood component was properly ordered.
• As you perform a baseline physical assessment, check the patient's vital signs and assess for skin rashes, shortness of breath, wheezing, pain, chills, itching, or nausea.
• You generally won't administer blood if the patient's temperature is too high, as specified by your facility's policy.
• In patients with cardiopulmonary disease, listen to the lungs to establish a baseline for the presence of crackles.The blood bank should send you both the unit of blood or component ordered and the corresponding transfusion record.

Blood Product Inspections

• The blood bank should send you both the unit of blood or component ordered and the corresponding transfusion record.
• Once you have the blood or component, inspect the labels for the expiration date, ABO/Rh label, unit number, the component label, and any special processes (such as irradiation or leukocyte-depleted).
• Check integrity of the unit by pressing lightly on the unit and invert it to ensure that all bag segments and seams are free from leaks and that port covers are in place.
• For appearance, look for uniformity of color between bag segments and the main part of the bag. RBCs should not be appreciably darker than the bag segments and the remaining plasma should not be murky, purple/blue, brown, or reddish. Platelets should be clear to yellow straw to light strawberry color, without obvious aggregates. Thawed FFP should be clear, with the color varying from yellow straw to light green to orange.
• If a newborn needs an exchange transfusion of whole blood, make sure the blood is less than 5 days old, as Potassium leaks out of the cells and into the plasma during the time that whole blood is stored, boosting the potassium concentration.

The verification process:

• Recheck the prescriber's order to verify that you've received the component ordered and that any ordered special processing was completed.
• Two qualified individuals should verify the patient and unit identification. The two people verifying the patient/unit identification should sign the transfusion report Record the date and time the transfusion begins Keep the unit record attached to the unit until the transfusion is complete
• After you've confirmed the unit and patient identification, assess the patency of the patient's vascular access and spike and prime the transfusion as described earlier.
• Record the patient's temperature, pulse, respirations, and blood pressure.
• Record a final set of vital signs at the completion of the transfusion. Administer at the recommended rate, based on the patient's condition.
• Stay with the patient for the first few minutes of the transfusion, and be alert for any problems.
• If the patient experiences symptoms of a transfusion reaction, immediately discontinue the transfusion and call for help
• If no complications occur, document the transfusion in the patient chart, noting the date, time, type of infusion, the patient's vital signs, and how he tolerated the procedure.

Transfusion reactions

• Acute hemolytic transfusion reactions (AHTR) can cause serious, potentially fatal consequences and are usually the result of ABO incompatibility. Most cases of ABO incompatibility result from clerical error during the transfusion process.
• Signs and symptoms of AHTR usually appear 5 to 15 minutes after the transfusion begins, but they can develop anytime during the transfusion.
• Should any of these symptoms occur (temperature increase of more than 2° F (1° C); bloody urine; chills; hypotension; severe low back, flank, or chest pain; low or absent urine output; nausea and vomiting, dyspnea, wheezing; anxiety, sense of impending doom, diaphoresis and generalized bleeding, especially from punctures and surgical wounds) immediately discontinue the transfusion and hang 0.9% sodium chloride to maintain vascular access (be sure to use new tubing)
• Closely monitor the patient's vital signs and symptoms, notify the primary care provider and obtain 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 facility policy.