Blood Tranfusion

Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood, such as red blood cells, white blood cells, plasma, clotting factors, and platelets.

Blood transfusion therapy involves transfusing whole blood or blood components (specific portion or fraction of blood lacking in patient). One unit of whole blood consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant. Whole blood stored for more than 6 hours does not provide therapeutic platelet transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII).

Blood components include:

1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygen-carrying capacity of blood with minimal expansion of blood.
2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions.
3. Platelets, either HLA (human leukocyte antigen) matched or unmatched.
4. Granulocytes ( basophils, eosinophils, and neutrophils )
5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors).
6. Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation.
7. Albumin, a plasma protein.
8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.
9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

Advantages of blood component therapy

1. Avoids the risk of sensitizing the patients to other blood components.
2. Provides optimal therapeutic benefit while reducing risk of volume overload.
3. Increases availability of needed blood products to larger population.

Principles of blood transfusion therapy

1. Whole blood transfusion
• Generally indicated only for patients who need both increased oxygen-carrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed.
2. Packed RBCs
• Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%.
3. Platelets
• Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipient’s platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension.
4. Granulocytes
• May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production.
5. Plasma
• Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringer’s lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing.
6. Albumin
• Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma oncotic pressure.
7. Cryoprecipitate
• Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated intravascular coagulation (DIC), and uremic bleeding.
8. Factor IX concentrate
• Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors.
9. Factor VIII concentrate
• Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission.
10. Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors.

Complications of Blood Transfusion

1. Hemolytic transfusion reaction- is a life-threatening complication occurring from transfusion of donor blood that is incompatible with the recipient’s blood.
2. In hemolytic transfusion reaction, antibodies in the recipient’s plasma combine with antigens on donor erythrocytes, causing agglutination and hemolysis in circulation or in the reticuloendothelial system. Similarly, antibodies in donor plasma combine with antigenon the recipient’s eyhrocytes; however, complications from infusion of incompatible plasma are less severe than those associated with infusion of incompatible erythrocytes. The most rapid hemolysis occurs in ABO incompatibility; Rh incompatibility is often less severe.
3. Delayed hemolytic transfusion reaction –occurs 1 to 2 weeks after transfusion; erythrocytes hemolyzed by antibody are not detectible during crossmatched but are formed rapidly after transfusion. It generally is not dangerous, but subsequent transfusions may be associated with acute hermolytic reaction.
4. In hemolytic reaction, severity of complications correlates with the amount of incompatible blood transfused; chances of fatal reactions are decreased if less than 100 ml of incompatible blood is infused.
5. Febrile, non hemolytic Transfusion reaction, the most common type of reaction, is commonly caused by sensitivity to leukocyte or platelet antigens.
6. Septic reaction is an often serious complication resulting from transfusion if a blood product contaminated with bacteria.
7. Allergic reactions may result from sensitivity to plasma protein or donor antibody, which reacts with recipient antigen.
8. Circulatory overload results from administration at a rate or volume greater than can be accommodated by the circulatory system, precipitating congestive heart failure or pulmonary edema.
9. Several infectious diseases can be transmitted through blood transfusion, including:
• Hepatitis B
• Non-A, non-B hepatitis
• Malaria
• Syphilis
• Acquired immunodeficiency syndrome (AIDS)
10. Graft-versus-host (GVH) disease results from engraftment of immunocompetent lymphocytes in bone marrow of immunosuppressed recipients, which triggers the immune response of the graft against the host.
11. Reactions associated with massive transfusions (>10 units of packed RBCs on 1 or 6 hours) include:
• Hypocalcemia, resulting from binding of recipient’s circulating calcium to anticoagulant (citrate) in packed RBC’s.
• Citrate intoxication due to accumulation of citrate.
• Hyperkalemia, in which stored red cells progressively increase extracellular potassium concentrations.
• Exacerbation of liver disease die to increased ammonia levels in stored blood.
• Hypothermia, in which transfusion of cold blood (below 37 C) at rates >100 mL/min may produce dysrhythmias and cardiac arrest.
• Aggregates of leukocytes and platelets in the lungs, resulting from accumulation of these aggregates during blood storage.
• Hemorrhage resulting from excessive dilution of the recipient’s platelets and clotting factors.

Assessment findings

1. Clinical manifestations of transfusions complications vary depending on the precipitating factor.
2. Signs and symptoms of hemolytic transfusion reaction include:
• Fever
• Chills
• low back pain
• flank pain
• headache
• nausea
• flushing
• tachycardia
• tachypnea
• hypotension
• hemoglobinuria (cola-colored urine)
3. Clinical signs and laboratory findings in delayed hemolytic reaction include:
• fever
• mild jaundice
• gradual fall of hemoglobin
• positive Coombs’ test
4. Febrile non-hemolytic reaction is marked by:
• Temperature rise during or shortly after transfusion
• Chills
• headache
• flushing
• anxiety
5. Signs and symptoms of septic reaction include;
• Rapid onset of high fever and chills
• vomiting
• diarrhea
• marked hypotension
6. Allergic reactions may produce:
• hives
• generalized pruritus
• wheezing or anaphylaxis (rarely)
7. Signs and symptoms of circulatory overload include:
• Dyspnea
• cough
• rales
• jugular vein distention
8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease.
9. Characteristics of GVH disease include:
• skin changes (e.g. erythema, ulcerations, scaling)
• edema
• hair loss
• hemolytic anemia
10. Reactions associated with massive transfusion produce varying manifestations

Possible Nursing Diagnosis

1. Ineffective breathing pattern
2. Decreased Cardiac Output
3. Fluid Volume Deficit
4. Fluid Volume Excess
5. Impaired Gas Exchange
6. Hyperthermia
7. Hypothermia
8. High Risk for Infection
9. High Risk for Injury
10. Pain
11. Impaired Skin Integrity
12. Altered Tissue Perfusion

Planning and Implementation

1. Help prevent transfusion reaction by:
• Meticulously verifying patient identification beginning with type and cross match sample collection and labeling to double check blood product and patient identification prior to transfusion.
• Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.
• Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion).
• Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures.
• Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents.
• Preventing GVH disease by ensuring irradiation of blood products containing viable WBC’s (i.e., whole blood, platelets, packed RBC’s and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide.
• Preventing hypothermia by warming blood unit to 37 C before transfusion.
• Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion.
2. On detecting any signs or symptoms of reaction:
• Stop the transfusion immediately, and notify the physician.
• Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion.
• Send the blood bag and tubing to the blood bank for repeat typing and culture.
• Draw another blood sample for plasma hemoglobin, culture, and retyping.
• Collect a urine sample as soon as possible for hemoglobin determination.
3. Intervene as appropriate to address symptoms of the specific reaction:
• Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria.
• Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions.
• In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed.
• Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.)
• For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed.

Evaluation

1. The patient maintains normal breathing pattern.
2. The patient demonstrates adequate cardiac output.
3. The patient reports minimal or no discomfort.
4. The patient maintains good fluid balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin integrity, with no lesions or pruritus.
8. The patient maintains or returns to normal electrolyte and blood chemistry values.

source: wikipedia, nursingcrib.com