Transcript ADULT & PEDIATRIC TRANSFUSION THERAPY 2010

ADULT & PEDIATRIC
TRANSFUSION THERAPY
2010
Annual Review for
Registered Nurses & other Transfusionists
Purpose

This learning activity will update and
reaffirm essential safe practices related to
transfusion therapy at Kaleida Health*.
*Refer to Policy CL.53 Adult & Pediatric Transfusion Therapy
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Objectives
Upon completion of this activity, the RN
and other Transfusionists will be able to:
 Discuss the process for obtaining an
ordered blood product.
 Recite the steps involved in checking and
administering blood products.
 Describe the signs, symptoms and nursing
interventions for common transfusion
reactions, according to KH policy.
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To ALL transfusionists:
In this program, the terms ‘Transfusion Record’ and
‘bag tag’ are used interchangeably.
To the Transfusionists in the Operating Rooms:
(i.e. Anesthesia, Perfusionists) there are 2 new
protocols available for your review in Policy CL.53:
o
Normovolemic Hemodilution Protocol for
o Transfusion of Autologous Blood
o Platelet Rich Plasma
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Process
Once there is an order to transfuse a patient with
a blood product, the transfusion process
begins…in a nutshell, you must:
1.
2.
3.
4.
5.
6.
7.
8.
Check the MD order for transfusion
Assess the patient
Obtain informed transfusion consent
Draw blood sample for Blood Bank testing
Obtain the blood product
Check the blood product
Administer the blood product
Document patient assessment at assigned intervals
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More about each step in the
transfusion process
STEPS 1 & 2. Check the MD order for transfusion
and assess the patient:
Review the MD order in the chart

Assess the patient for:
~History of previous transfusion reaction
~Pre-transfusion symptoms that could be confused with
a transfusion reaction (e.g. fever, chills)
~Any objections to transfusion therapy

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More about each step in the
transfusion process
STEP 3. Obtain informed transfusion consent.

If there is no consent for a transfusion, be sure
to obtain it prior to the issuance of the blood
product from the Blood Bank.
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More about each step in the
transfusion process
STEP 4. Draw blood sample for Blood Bank testing.



Blood is needed for a type and cross match.
Obtain the blood sample from the patient.
Note: To prevent a transfusion error-a label MUST be
affixed to the tube of blood BEFORE leaving the patient’s
BEDSIDE with:
 Initials - of the person who drew the sample
 Date - sample drawn
 Time - sample drawn
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Mis-labeled pre-transfusion samples

Did you know that in one study, 59% of
transfusion errors occurred with
mis-labeled pre-transfusion samples!

On follow-up, 16% showed a different
blood group with repeated testing.
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More about each step in the
transfusion process
STEP 5. Obtain the blood product:
Remember at Kaleida Health, the RN, GN, or UAP
(PCA) are the only authorized hospital employees
to pick up blood products from the Blood Bank.
Volunteers, Student Nurses and LPNs may NOT go to the
Blood Bank to pick up blood.
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More about each step in the
transfusion process
STEP 6. Checking the blood product at the bedside
of the patient:
This means, once the blood is available on the
nursing unit, the transfusionist….
CHECKS:
Physician order
Consent
Blood Product with attached Transfusion Record (bag tag)
Patient and ID band
Vital Signs –TPR & BP (take immediately before the start of the
transfusion)…document VS on bag tag.
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Checking the blood product
Next, two authorized healthcare professionals
must check the following on the blood product’s
attached transfusion record (bag tag)
at the bedside:
–
–
–
–
–
Patient name
Patient identification number/MR number
Patient date of birth
Patient blood type
Donor blood type, unit expiration date, unit number
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Checking the blood product*
*This checking process is done for:
whole blood
packed red blood cells
plasma
platelets
white blood cells
cryoprecipitate
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KEYPOINT
Keep the Transfusion Record (bag tag)
attached to the blood product at all times
until an uneventful transfusion is
completed.
This piece of paper links the patient to the
specific unit of blood.
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Checking the blood product
The two authorized healthcare professionals must
compare the information on the blood product
(Transfusion Record also known as the bag tag)
against the information on the patient ID band—
AT THE BEDSIDE
All information MUST match!
– Patient name
– Patient identification number/MR number
– Patient date of birth
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Checking the blood product
One more thing to check…..
ABO and Rh group of the donor MUST match or
be compatible with the patient’s information.
 If the ABO & Rh of the donor does not match
the patient’s ABO and Rh, check Blood
Compatibility Table on the back of the
Transfusion Record.

Questions? Call the Blood Bank….
before transfusing.
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Checking the blood product

If all information matches, both healthcare
professionals (authorized to transfuse)
place their signatures and date on the bag
tag at the commencement of the
transfusion.
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Signatures of 2 transfusionists
on the Transfusion Record
verifies that--“We verify that prior to starting this transfusion we have:
1.
2.
3.
4.
Confirmed that this blood product was ordered for transfusion
to this patient.
Reviewed the patient transfusion consent form.
Confirmed that the unit has not expired.
Confirmed the identity of the patient and the unit
information and that there are no discrepancies
between this unit, the tag attached to this unit and the
patient identification.”
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More about each step in the
transfusion process
STEP 7. Administering the blood product
This is one of those steps that should be initiated before sending
someone to pick up the blood product from the Bank.


IV access- be sure patient has patent IV access that will be dedicated
for the transfusion-(Adult patient:18-20 gauge, Pediatric patient: 2224 gauge) for good blood flow)
Set up tubing for blood administration.
 Use of a IV pump is highly recommended.*

Change blood tubing after each unit unless consecutive blood
products are ordered. See policy CL.53 for specifics on this point.
*You can safely transfuse adult patients PRBC, WB and FFP (plasma) using safety
software/drug library on Hospira IV pump. In the neonatal setting, use of a pump is
expected practice. In the pediatric setting, use of a pump is also highly recommended.
In emergencies (urgent need, high desired flow rate), use of a pump may be optional.
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More about each step in the
transfusion process
STEP 7. (continued) Administering the blood product
Keypoints:
 Only normal saline (0.9% sodium chloride) may be
infused in the same IV line with most blood products;
otherwise you may risk hemolysis.
 No medications may be administered through the same
line as the blood.
 Hang time: once a unit of blood is dispensed from the
blood bank, you have only 4 hours to administer
it…otherwise the risk of bacterial growth is too great to
use it safely.
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Administering the blood
product—New for 2010
NEW for 2010-infusion
rates for blood products
changed:
have
For NON-EMERGENT transfusions in ADULTS, infuse blood SLOWLY during
the initial phase of transfusion=
 Transfuse 2 mL/min for the first 15 minutes while you are observing the
patient for any adverse reactions. Once you are sure the patient can
tolerate the transfusion-- REASSESS patient and document this set of vital signs on the bag tag.
 Then adjust the flow rate as in the table on slide 23.
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New for 2010—Rates for Peds
NEW for 2010-infusion
rates for blood products have changed
For NON-EMERGENT transfusions in NEONATES/
PEDIATRICS, infuse blood SLOWLY during the initial
phase of transfusion=
 The order to transfuse from the physician must include a
rate of transfusion.
 Observe the patient carefully for adverse reactions
during first 15 minutes. Once you are sure the patient
can tolerate the transfusion-- REASSESS patient and document this set of vital signs
on the bag tag.
 Then continue transfusion at the flow rate specified in
the physician order (see the following table for
guidelines).
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New suggested* transfusion rates
after first 15 minutes:
Component
Red Blood Cells
Fresh Frozen Plasma
Platelets
Cryoprecipitated AHF
Granulocytes (WBC)
Adult
150-300 mL/hr
200-300 mL/hr
200-300 mL/hr
As rapidly as tolerated
75-100 mL/hr
Pediatric
2-5 mL/kg/hr
60-120 mL/hr
60-120 mL/hr
As rapidly as tolerated
65-100 mL/hr
(* Suggested rates for blood components in non-emergency settings AABB 2008)
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Administering the blood product
Also NEW for 2010…….

The transfusionist should remain near the patient during
the first 15 minutes of the transfusion.
Rationale—to closely monitor the patient for a transfusion
reaction, so prompt interventions can be initiated if
necessary.
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Administering blood products
Vital Signs

Intrauterine transfusions are not exempt from vital sign

On completion of all uneventful (reaction-free)
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
monitoring. Maternal VS should be recorded at the same
intervals as all other transfusions.
transfusions, the patient must be REASSESSED, and vital
signs documented one last time.
If the blood product was infused rapidly (within 15
minutes) take and document vital signs twice
(immediately before and 15 minutes later).
Then, cross off the last time frame on the Transfusion
Record, so it is clear that the blood was given rapidly, for
an emergent reason.
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Transfusion Process-uneventful
At the end of a transfusion, make one final check:
 Are all vital signs written in the appropriate spaces on bag tag?
 Are there 2 signatures in the verification area on the bag tag?
 Is there a date and time indicated for start and end of the
transfusion?
If you answered YES to all of the above, detach the bag tag from the
blood product and place it in the medical record.
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Keeping Vigilant
It is important that the nurse remain vigilant and
observes for the development of any adverse
reactions both during and after the completion
of a blood transfusion.
 Reactions can be potentially life threatening and
most commonly occur within 10-15 minutes of
initiating a transfusion.
 If you suspect a patient is having a reaction,
refer to the Transfusion Record (bag tag) for
signs, symptoms and interventions or refer to
the policy CL.53 Appendices C & D.
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Common Transfusion Reactions
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Allergic (mild)
Allergic (moderate to severe)
Febrile (mild to moderate)
Acute Hemolytic
Fluid Overload
– (fluid overload is more often encountered in neonatal,
pediatrics and geriatrics)
For a complete list of possible signs and symptoms
of a reaction see CL.53 appendix C.
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Transfusion Reaction
Scenario 1
While assessing your patient during a transfusion,
you discover that he has hives on his chest.
Referring to the back of the Transfusion Record or
the policy, you find the ‘Clinical Action’ to take to
intervene
You confirm that he is having what is considered
an mild allergic reaction with signs and
symptoms of hives and/or pruritis.
What are your interventions?
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Transfusion Reaction
Scenario 1 continued
According to policy (and the Transfusion Record)
the interventions you should take for
a mild allergic reaction are:
Turn off the blood product. (temporarily interrupt the transfusion)
Keep IV line open with NS
2.
Recheck patient, blood product information and the attached bag
tag for clerical discrepancies.
3.
Assess VS
4.
Call Physician (using SBAR), ask for an order for antihistamine.
5.
Restart transfusion if symptoms resolve, with MD order.
6.
Monitor for subsequent reactions.
If there is no improvement in 30 minutes treat as a moderate to severe
reaction.
1.
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Transfusion Reaction
Scenario 1 continued
Your patient with the hives (mild allergic reaction) received
an ordered antihistamine, but 30 minutes later, the hives
have spread from his chest to his neck, face and back.
His blood pressure has dropped from 138/84 to 100/68.
According to the policy (and the bag tag) your patient’s
reaction has progressed from mild to the moderate to
severe level.
What is your next intervention?
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Transfusion Reaction
Scenario 1 continued
You should:

1. Discontinue the blood transfusion. Keep IV line open with 0.9%
sodium chloride.
Note the volume of unit infused on bag tag, also for I&O
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2. Call physician* for further orders…. e.g. antihistamines, epinephrine,
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3.Continue to closely monitor the patient.
4. Complete Adverse Reaction Section on front of bag tag
5. Document change in patient condition in progress notes!
6. Call Transfusion Services/Blood Bank to report reaction.
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vasopressors may be ordered as needed to treat symptoms.
*Note in some cases, it may be necessary to call the Rapid Response Team
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For All Other Transfusion Reactions
(other than Hives)
You should:
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1.
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Stop the transfusion, Keep IV open with 0.9% sodium chloride
Recheck patient, blood product information and the attached bag
tag for clerical discrepancies.
Call MD for further direction
Treat symptoms as ordered by MD
Document symptoms on bag tag
Call Transfusion Service/Blood Bank to report reaction
ASAP Draw and send a fully labeled EDTA lavender or pink tube of blood
to Transfusion Service/Blood Bank
Hand deliver* unit with remaining product and administration set to Blood
Bank (remove all needles, cap tubing with a port protector)
*Do not send through the mail or pneumatic tube.
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Transfusion Reaction
Scenario 2
It is 2000, while making hourly rounds, a PCA
discovers that a patient (who is receiving a unit
of PRBCs) has chills and is complaining of
itching. She reports this to you.
When assessing the patient, you look at the vital
signs (on bag tag) that had been taken at the
start of the transfusion and 15 minutes later:
1800-T=99.6, P= 84, R=20, B/P=107/72
1815-T=99.1, P=72, R=18, B/P=104/68
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Transfusion Reaction
Scenario 2
You immediately recheck his vital signs:
T=101.3, P=132, R=16, B/P 175/95.
In summary, he is febrile, hypertensive, has
a rapid pulse, has generalized itching and
states that he feels ‘funny’. His wife is
concerned, says he has received blood
before, but never looked like this.
Only ½ of the unit has been transfused.
What are your interventions?
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Transfusion Reaction
Scenario 2
You will:
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1.
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Stop the transfusion, Keep IV open with 0.9% sodium chloride
Recheck patient, blood product information and the attached bag
tag for clerical discrepancies.
Call MD for further direction
Treat symptoms as ordered by MD
Document symptoms on bag tag
Call Transfusion Service/Blood Bank to report reaction
ASAP Draw and send a fully labeled EDTA lavender or pink tube of blood
to Transfusion Service/Blood Bank
Hand deliver* unit with remaining product and administration set to Blood
Bank (remove all needles, cap tubing with a port protector)
*Do not send through the mail or pneumatic tube.
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Blood has been called “a gift of life”.
For patients with critical medical and surgical
conditions, a blood transfusion can literally mean
the difference between life and death.
Let’s make sure we administer this gift safely…
Sure…. there is a lot of checking and rechecking
with a transfusion---but it is worth it!
Do the right thing!
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