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Blood Transfusion
Instructions for Whole Blood and All Components
• Verify the physician's order for blood transfusion and explain the procedure to the patient before transfusion procedure takes place.
• The intended recipient must be properly identified before the transfusion is started.
• Another nurse must be present during the transfusion procedure to ensure that blood products to be transfused are correctly labeled. The presence of another nurse also ensures that the procedure is performed on the correct patient and is documented properly on the patient's chart.
• Record initial vital signs before blood transfusion is initiated.
• Mix blood components thoroughly before use.
• Do not add or infuse medications or solutions through the same tubing with blood or components except 0.9% sodium chloride. Other solutions intended for IV use may be used in an administration set or added to blood or components under either of the following conditions: 1) They have been approved for this use by the FDA or 2) There is documentation available to show that addition to the component involved is safe and efficacious. ABO-compatible plasma, 5% albumin, or plasma protein fraction or either suitable plasma expanders may be used with approval of the patient's physician.
• Observe universal precautions during blood transfusion since possible contact with blood and other body fluids is involved.
• A special tubing, one that contains a blood filter, is used to screen out fibrin clots and other particulate matter.
• For the first 15 minutes, run the transfusion very slowly, at about 2ml/min and observe the patient carefully for adverse effects. If no ill effects occur during this time, the flow rate is then increased unless the patient is at risk for circulatory overload. Observe the patient frequently throughout the transfusion.
• Completion of the transfusion should be prior to component expiration or within 4 hours, whichever is sooner. If blood or blood components cannot be infused in 4 hours, they should be divided and stored appropriately in the blood bank until needed.
Assessment
Before initiating transfusion therapy, it is important to determine that the blood has been typed and cross-matched and that the ABO group and Rh type on the blood containers are in accordance with the compatibility record. The blood should also be checked for the presence of gas bubbles and any abnormal color or cloudiness. Gas bubbles may indicate bacterial growth, and abnormal color or cloudiness may be a sign of hemolysis. The labels identifying the number and type of the donor blood are noted. Patient identification is confirmed by asking for the patient's name and by checking the identification wrist hand. At the same time, the patient's chart is checked for blood type and number. Temperature, pulse, respiration, and blood pressure are measured to provide a baseline for comparing vital signs at a later time. After the blood transfusion is started, the patient is monitored closely for 15-30 minutes to detect signs of reaction of circulatory overload. Monitoring vital signs is carried out at regular intervals as indicated.
Complications and Nursing Management
Circulatory Overload: Transfuse blood slowly to prevent circulatory overload.
• Signs include dyspnea, orthopnea, cyanosis, or sudden anxiety. If the transfusion is continued, severe dyspnea and coughing of pink, frothy sputum can occur. Neck vein distention, crackles at the base of the lungs, and rise in central venous pressure will occur.
• Position the patient with the feet in a dependent position, discontinue the blood transfusion, and notify the physician. Keep the IV line patent with very slow infusion of normal saline to retain access to the vain in case IV medications are necessary. Phlebotomy or diuretics, oxygen, morphine, and aminophylline may be necessary if improvement does not occur rapidly.
Febrile Reaction: May occur because of the presence of bacterial pyrogens, sensitivity to leukocytes or platelets, hemolytic episodes, or unknown factors. If contaminated blood is infused, the patient develops fever, and shaking chills within 30 minutes, and shock soon follows. Even if the cause of this reaction is recognized early, mortality is high. As soon as the reaction is recognized, the transfusion is discontinued and the IV line is kept open with normal saline. The physician and blood bank are notified and the blood container is returned to the blood bank. The patient's temperature is monitored for 30 minutes after the chill and as indicated thereafter. Antipyretics are administered as prescribed.
Allergic Reaction: Signs and symptoms include urticaria (hives) or generalized itching or, wheezing or anaphylaxis. These reactions are generally mild and respond to antihistamine. If urticaria is the only symptom, the transfusion can sometimes be continued at a slower rate. If the reaction is severe, parenteral epinephrine is used. Future reactions may be prevented by premedication with antihistamines.
Septic Reaction: This is a severe reaction that results from transfusion of blood or components contaminated with bacteria. Preventative measures include administering blood within a 4 hour period before warm room temperatures promote bacterial growth, inspecting blood or components for gas bubbles, clotting, or abnormal color before administration. If the transfusion is contaminated, the patient will respond with rapid onset of chills, high fever, vomiting, diarrhea, and marked hypotension. In such a case the transfusion is discontinued immediately and the IV line kept patent with normal saline. The physician and blood bank are notified, and the blood bag is returned to the blood back. Blood cultures are obtained, and the patient is treated for septicemia with antibiotics, IV fluids, vasopressors, and steroids.
Hemolytic Reaction: This is the most dangerous type of all of the reactions because the donor blood is incompatible with that of the recipient. Antibodies in the recipient's plasma rapidly combines with the donor erythrocytes, and the cells are hemolyzed either in the circulation or in the reticuloendothelial system.
• Symptoms consist of chills, low back pain, headache, nausea, or chest tightness followed by fever and hypotension and vascular collapse. Severe reactions usually start within 10 minutes after the infusion is begun. Hemoglobinuria (blood in urine) appears at the next voiding.
• The reaction most be recognized promptly and the transfusion discontinued immediately. Severity of complications is proportional to the volume infused.
• Treatment: Correct the hypotension and prevent the renal damage that can follow hemoglobinuria. Support patient with IV colloid and give mannitol as an osmotic diuretic to maintain adequate urine flow, glomerular filtration, and renal blood flow. An indwelling catheter may be necessary for accurate measurement of output. If after 24 hours, urine flow cannot be maintained, mannitol is contraindicated because it can be assumed that acute tubular necrosis has occurred. The subsequent management will be that for the renal disorder and will include fluid restriction and possibly dialysis until spontaneous healing takes place.
Delayed Hemolytic Reaction: Occurs at about 2-14 days and is recognized by fever, mild jaundice, a gradual fall in hemoglobin level, and a direct anti-human globulin test. Rarely there is hemoglobinuria, and generally these reactions are not dangerous. Recognition is important, however, because subsequent transfusions may cause an acute hemolytic reaction.
Diseases Transmitted by Transfusion: (e.g., hepatitis, malaria, syphilis, AIDS).
Gerontological Considerations: Assess the elderly patient for signs of circulatory overload since rapid infusions of large volumes can result in congestive heart failure. Nursing care should include careful monitoring of cardiac and pulmonary function and fluid intake and output.
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Whole Blood and Whole Blood Components
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Description
Whole blood contains the red blood cells and plasma components of donor blood. Most of the platelets and/or white blood cells may have been removed during processing; those remaining in stored blood are usually nonviable after a few days.
Actions
Whole blood provides RBCs to oxygen to tissues. It also is a blood volume expander and source of proteins with oncotic and certain nonlabile coagulation.
Indications
Whole blood is indicated only for those patients who have a symptomatic deficit of oxygen carrying capacity combined with hypovolemia of sufficient degree to be associated with shock. If only the former is present, the component of choice is RBCs. Whole blood, less than 7 days old, may be used for exchange transfusion. Whole blood cannot be considered a source of viable platelets or white cells or of therapeutic levels of labile coagulation factors V and VIII.
Contraindications
Do not use whole blood or other RBC components if anemia can be treated with specific medications such as iron, vitamin B12, recombinant erythropoietin or folic acid, and if the clinical condition of the patient permits sufficient time for these agents to promote erythropoiesis. Do not use whole blood when blood volume can be safely and adequately replaced with other volume expanders such as 0.9% sodium chloride, lactated Ringer's; albumin; or plasma protein fraction. Do not use whole blood to correct coagulation deficiencies when they can be treated better by appropriate components and derivatives.
Side Effects and Hazards
See Complications and Nursing Management.