LPN IV Series: Blood and Blood Products Transfusion

The most common type of blood is O+. Anyone with Rh+ blood can receive O+ blood; this includes O+, A+, B+, and AB+. Technically, three out of four people can benefit from this blood type.

Patients with O+ can only receive O+ or O- blood (NHSBT, 2018).

Patients with O+ who are negative for cytomegalovirus (CMV) are known as heroes as it is the safest for immune-deficient newborns who need blood transfusions (American Red Cross, n.d.).

About one out of every seven patients have O- blood, or 8% of the population. It is far less common than O+ blood.

Patients with this blood type are called "universal donors" as they can give blood to anyone. Type O- blood is usually carried on ambulances/emergency vehicles for emergency purposes. It is often used when the patient's blood type is not known. Because it can always be used, it is difficult to keep stock of this type of blood.

It is important to note that patients with O- blood can only receive O- blood (NHSBT, 2018).

About 1 in 3 people have A+ blood, making it pretty common. It is essential to keep a good supply of this blood type because of how common it is.

Patients with A+ blood can give blood to patients with A+ and AB+. However, they can receive blood from A+, A-, O+, and O- patients.

A+ platelets are also commonly used in hospitals (NHSBT, 2018).

Around one in every 14 patients is A-, or about 8% of the population. Patients with A- blood can donate to A-, A+, AB+, and AB-. Patients with this type can receive blood from A- and O- patients.

A- platelets can be given to all patients; therefore, they are called "universal platelets" (NHSBT, 2018).

Around 8% of the population has B+ blood. Patients with B+ blood can give blood to patients with B+ or AB+. However, they can receive blood from B+, B-, O+, and O-.

B+ is essential in treating thalassemia and sickle cell disease, where blood transfusions are more common.

Approximately 2% of the population has B+ blood with a Ro subtype, which is in high demand (NHSBT, 2018).

B- is one of the rarest types of blood there is. Only 2% are B-. Patients with B- can donate to patients with B-, B+, AB-, and AB+ blood. However, they can only receive blood from B- or O- patients.

It is essential to raise awareness about the necessity of these rare blood types (NHSBT, 2018).

Another rare blood type is AB+; just 2% of patients have this type of blood.

Patients with AB+ blood can only donate to others with this type of blood. However, they can receive blood from any blood type.

There is an increased need for AB+ plasma; however, this fresh frozen plasma is only taken from male patients. Females, especially those who have recently had a child, can develop antibodies and, when given to others, can prove life-threatening (NHSBT, 2018).

AB- is the rarest type of blood; only about 1% of the population has AB- blood. Finding donors can be challenging.

Patients with this type of blood can give to others who are AB- or AB+. However, they can receive blood from AB-, O-, A-, and B- (NHSBT, 2018).

Autologous transfusion is the transfusion of the patient's own blood. Autologous transfusion eliminates the risks of alloimmunization, immune-mediated transfusion reactions, and disease transmission, making it the safest transfusion choice.

Before elective procedures, the patient may donate blood to be set aside for a later transfusion. Autologous RBCs can also be salvaged during some surgical procedures or after trauma-induced hemorrhage using automated cell-saver devices or manual suction equipment. Autologous blood products must be clearly labeled and identified (Zhou, 2016).

There are different ways autologous transfusions can be performed. They include cell salvage, preoperative autologous donation, and acute normovolemic hemodilution. Cell salvage will be discussed later, as it is the most common type. Preoperative autologous donation is where blood is collected before a procedure (non-emergent), stored in a blood bank, and then given back to the patient when it is genuinely needed. Acute normovolemic hemodilution is where blood is collected right before surgery, and blood volume is restored by colloids or crystalloids. Once hemostasis has been achieved, blood is transfused back to the patient.

Patient safety is critical, no matter what transfusion is being performed. Autologous blood transfusions come with a high incidence of risks and adverse effects and a high cost. It should not be used unless there is  >20% blood loss. However, this form of transfusion does have its advantages. It is the best choice when significant blood loss is expected. Disadvantages include a complex process that can result in complications. Also, the salvaged blood could contain cell debris (Machave, 2000; Zhou, 2016).

By far the most common option, volunteer donors' blood products are assigned randomly to patients; this is a homologous transfusion. Before donation, volunteer donors receive information about the process, potential adverse reactions, tests that will be performed on the donated blood, post-donation instructions, and education regarding the risk for human immunodeficiency virus (HIV) infection and signs and symptoms. Donors are screened against eligibility criteria designed to protect all patients (Sansom, 1993).

In a directed transfusion, blood products are donated by an individual for transfusion to a specified recipient. Directed transfusions may be used in certain circumstances (e.g., a parent providing sole transfusion support for a child), but there is no evidence that directed donation reduces transfusion risks (Wadge et al., 2021).

Erythropoietin or iron can be taken to avoid transfusion in some cases, but it takes days to months to replace blood cells. Antifibrinolytic drugs can decrease the amount of bleeding during surgery but cannot replace lost platelets or clotting factors.

Volume expanders: These help maintain adequate fluid in the blood. They are non-blood-based but contain plenty of minerals and water. There are different types of volume expanders:

• Dextrans: These are composed of sugar molecules. They are commonly found in plaque located in the mouth. When purified and given IV, it can help expand the blood volume. It is often given in critical situations when the blood pressure becomes too low. These molecules are so large that they cannot get through the walls of blood vessels. Since they are osmotic, they maintain water within the blood vessels, helping to normalize blood pressure levels.
• Saline and Ringer's solutions: These also expand the volume of blood in critical situations where patients have low blood pressure. Saline is full of sodium or salt. Ringer's solution also has sodium, but it also has calcium and potassium. Both solutions, given IV, expand and dilute the blood volume. They pass through blood vessels and into surrounding tissue; this ensures that blood pressure levels are maintained adequately for extended periods. These solutions are lost in urine; however, they can cause edema if given to patients with poor kidney functioning.
• Hetastarch and pentastarch: These are also comprised of sugar molecules. They work similarly to dextrans; they hold water in the blood vessels, expanding the blood volume and maintaining blood pressure (American Cancer Society, 2016; Tsai et al., 2015).

Growth Factors: Growth factors already exist in the body; they cause the bone marrow to create blood. However, man-made versions of growth factors exist, and they are for patients who have low blood cells. These growth factors stimulate RBC and WBC production, as well as platelets.

However, they should only be used for specific patients with certain circumstances:

• Growth factors are not as quick to help out as blood transfusions are. It can take days-weeks for growth factors to increase blood counts, so this is not ideal for patients who are in critical situations and are actively bleeding.
• Patients with bone marrow diseases may not respond to the effects of growth factors as they already have a limited capability to increase blood production.
• Some growth factors can cause specific cancer cells to grow faster. Examples include breast or cervical cancer, multiple myeloma, head or neck cancer, lymphocytic leukemia, and lung cancer. Because of this, growth factors are often avoided in patients with cancer. If they are used, it is for short-term purposes.
• Growth factors are costly, much more than a blood transfusion (American Cancer Society, 2016; Civinini et al., 2010). 

Blood salvage: Blood salvage is performed by a device in surgery. It offers the option of using one's own blood versus someone else's. Blood salvage collects the blood loss during surgery using suction, removes the broken cells, cleans the rest, and returns it to the patient. Up to 80% of lost RBCs can be returned (American Cancer Society, 2016; Vieira et al., 2021).

The ABO blood group system is clinically significant because A and B antigens elicit the strongest immune response. The presence or absence of A and B antigens on the RBC membrane determines the individual's ABO group. The ability to make A or B antigens is inherited. Antibody formation in the absence of specific exposures to antigens is unique to the ABO system. An antibody directed against the missing antigen(s) is produced by the age of 3 months in neonates (Nettina, 2019).

Antibodies (immunoglobulins) are proteins produced by B-lymphocytes. The interaction of antibodies and ABO antigens trigger an immune response. The extent of the immune response depends on the quantity of antibodies and antigens.

When mismatching occurs, antibodies against the A and B antigens attach to the surfaces of the recipient's RBCs, leading to a hemolytic reaction (Nettina, 2019).

Non-ABO antigen-antibody reactions usually do not produce powerful, immediate hemolytic reactions, but several have clinical significance. After A and B, D is the most immunogenic antigen. It is part of the Rhesus system, which includes C, D, and E antigens. D (Rh)-negative individuals do not develop anti-D without specific exposure. Still, antibody development (alloimmunization) is high after exposure to D. Two common methods of sensitization to these RBC antigens are transfusion or fetomaternal hemorrhage during pregnancy and delivery. Anti-D can complicate future transfusions and pregnancies. For the D (Rh)-negative individual, exposure to D should be avoided by using Rh-negative blood products. In the case of Rh-negative mothers and Rh-positive fetuses, exposure to D can be treated using Rh immunoglobulins, preventing anti-D formation.

Exposures to RBC antigens from other antigenic systems (such as Lewis, Kidd, or Duffy) may also cause alloimmunization; this may become clinically significant in individuals receiving multiple blood products over a long period (Nettina, 2019).

Acute hemolytic reactions: this is caused by the immune destruction of RBCs by the recipient's antibodies. These antibodies would have developed after a previous transfusion, such as with pregnancy. Other causes include improper storage, infusing blood with incompatible medications, the overgrowth of bacteria, and the use of improper tubing. Hemolytic transfusion reactions result because antibodies in the recipient's plasma react with antigens in donor RBCs. It leads to donor cell agglutination (clumping) and capillary occlusion (clot), blocking oxygen and blood flow to vital organs. Eventually, the red cells break down and release free hemoglobin into plasma and urine. The free hemoglobin may block the renal tubules resulting in renal failure.

Acute hemolytic reactions occur within the first 24 hours after infusion. Hemolysis can be intravascular or extravascular, but extravascular is more common. Extravascular hemolysis occurs when the donated RBCs are attacked by the liver or spleen. Symptoms can include fever, chills, nausea and vomiting, rigors, hypotension, excess bleeding, anuria, infusion site pain, and pain in the chest and back. These symptoms can advance, causing kidney failure with the need for dialysis, significant anemia, DIC, and even death.

Acute hemolytic reactions, though they do occur, are rare. One to five reactions per 50,000 transfusions encompasses the incidence rate. Scanning bar codes and ensuring patient identification is correct does decrease the rate of these reactions (Harewood et al., 2022).

Allergic reactions: Although the mechanism of an allergic transfusion reaction is unknown, it probably results from the reaction of allergens in the donor's blood with antibodies in the recipient's blood. A bacterial transfusion reaction is a contamination of donor blood, usually by gram-negative organisms (Nettina, 2019).

These reactions can be mild to severe. Itching and hives may be the only symptoms during mild allergic reactions. Life-threatening allergic reactions may result in anaphylaxis. Anaphylaxis will have accompanying symptoms of stridor, bronchospasms, hypotension, and gastrointestinal symptoms. Up to 3% of patients will experience an allergic reaction during or after a transfusion.

There are ways to try and prevent allergic reactions from occurring. RBCs and platelets can be washed to remove plasma in patients who have an IgA deficiency. However, observing the patient for at least the first fifteen minutes during a transfusion is best (Suddock & Crookston, 2022).

Transfusion-related acute lung injury: This injury is from pulmonary edema causing acute hypoxia. It usually occurs within six hours of the transfusion. Male-dominant plasma has helped to decrease the mortality rate associated with this reaction (Cho et al., 2022).

Febrile nonhemolytic transfusion reactions: Febrile transfusion reaction occurs because the recipient is sensitive to the donor leukocytes or platelets. It is defined as a rise in body temperature of at least 1.8°F above the average body temperature of 98.6°F within 24 hours post-transfusion. The patient may also feel discomfort and have chills and rigors. The leukoreduction process has helped decrease rates of febrile nonhemolytic transfusion reactions. Leukoreduction removes WBCs from the donor's blood. Febrile nonhemolytic transfusion reactions mainly occur with platelet transfusions versus RBC transfusions (Suddock & Crookston, 2022).

It can be challenging to diagnose these reactions; research has proven that cytokines, such as interleukin-6 and interleukin-8, may contribute to their occurrence. It is a diagnosis of exclusion.

Transfusion-associated circulatory overload: this results from rapid transfusions of blood volumes that are more than the circulator system can handle. Patients are at an increased risk of this type of overload if they are infants or elderly or have a history of renal failure or anemia. Signs and symptoms of transfusion-associated circulatory overload include cough, fast heart rate, difficulty breathing, hypertension, and cardiac complications. Pulmonary edema and cardiomegaly can often be seen on x-rays (Nettina, 2019).

Clinical diagnosis is possible, but lab work, such as brain natriuretic peptide levels, may assist with the diagnosis (Semple et al., 2019).

Transfusion-associated graft-versus-host disease: this delayed reaction results from lymphocyte proliferation of the donor, causing an immune response in the recipient that attacks the organs and tissues. More than 90% of the time, it is a fatal diagnosis. Immunocompromised and immunocompetent patients are more at risk for this condition. Other risk factors include Hodgkin's disease and those with a history of stem cell transplants, chemotherapy, intrauterine transfusions, premature infants, cytotoxic drugs, and a history of taking fludarabine. Symptoms of transfusion-associated graft-versus-host disease include fever, diarrhea, rash, liver dysfunction, and pancytopenia (lower than normal number of RBCs and WBCs, and platelets). The reaction typically occurs one to six weeks post-transfusion. Gamma irradiation of blood can help prevent this delayed reaction (Kopolovic et al., 2015).

Delayed hemolytic transfusion reactions (DHTRs): This reaction occurs 3-10 days after transfusions. It occurs in patients alloimmunized to RBC antigens during previous transfusions, such as in pregnancy. Unfortunately, this type of reaction cannot be identified with pretransfusion testing. Extravascular hemolysis can cause death.

DHTRs are characterized by a drop in hemoglobin or less than expected rise in hemoglobin after transfusion. It is usually diagnosed days to weeks after transfusion. Symptoms include fever and chills, malaise, jaundice, back pain, and sometimes, renal failure. Sometimes, the symptoms are similar to sickle cell disease, and the diagnosis can be missed.

Specific treatment is not often warranted. Transfusion should be avoided unless the patient is severely anemic. In that case, transfusion of RBCs may be necessary even though alloantibodies may not have formed. Before transfusion, the risk versus benefits should be weighed (Omer et al., 2020).

Post-transfusion purpura (PTP): This is a rare reaction when a patient develops thrombocytopenia or a low platelet count 7-10 days after a blood transfusion. Symptoms include bleeding from mucous membranes and the gastrointestinal and urinary tracts. If death does occur, it is often due to bleeding in the brain. Thrombocytopenia usually lasts at least two weeks.

Patients who have a history of sensitization are more likely to develop PTP. Females are more often affected than males.

Immunoglobulin should be given IV 1g/kg; doses should be repeated as necessary. Plasma exchange and steroids can be used in patients without improvement (Hawkins et al., 2019).

If you suspect a transfusion reaction (Nettina, 2019):

1. STOP the transfusion immediately!
2. Change the tubing.
3. Start a normal saline infusion at 10cc/hr.
4. Notify the blood bank, the physician, and the nursing supervisor.
5. Monitor the patient's vital signs every 10-15 minutes or more frequently, depending on the severity of the symptoms.
6. Insert a foley catheter and monitor urinary output every hour for oliguria and anuria.
7. Collect a urine specimen.
   1. For the first post-transfusion urine, mark "possible blood transfusion" on the specimen. The lab tests this specimen for hemoglobin presence, indicating a hemolytic reaction.
8. Obtain an order for BUN, creatinine, and bilirubin, which will indicate renal damage.
9. Return remaining blood, tubing, and normal saline to the blood bank for repeat compatibility testing.
10. Administer medications per physician's order:
    1. Subcutaneous epinephrine to counteract the allergic response
    2. Mannitol (osmotic diuretic) to decrease the risk of kidney damage
    3. Bicarbonate IV alkalizes urine and helps prevent and decrease the precipitation of hemoglobin
11. Make the patient as comfortable as possible and provide reassurance.

If a transfusion reaction is anticipated, prophylactic treatment with antihistamines and/or antipyretics may be given preceding blood administration.

1. Time and date of transfusion reaction.
2. Type and amount of blood infused.
3. Clinical signs and symptoms of reaction in order of occurrence.
4. Complete set of vital signs and frequency.
5. Specimens to the lab.
6. Any interventions provided.
7. Patient response to interventions.
8. Complete transfusion reaction form.
9. Date and time the physician was notified and orders received (Nettina, 2019).

Routine laboratory testing is performed to assess the compatibility of a particular blood product with the recipient before releasing the blood product from the blood bank. These tests include:

• ABO group and Rh type: determines the presence of A, B, and D antigens on the surface of the patient's RBCs.
• Direct Coombs' test: determines the presence of antibodies attached to the patient's RBCs.
• Cross-match (compatibility test): detects agglutination of donor RBCs caused by antibodies in the patient's serum.
• Indirect Coombs' test: identifies the presence of lower molecular weight antibodies (IgG) directed against blood group antigens (Basavaraju et al., 2021).

Routine laboratory testing is performed to identify antigens or antibodies in donor blood that may indicate prior exposure to specific blood-borne diseases. Screening is designed to decrease the risk of disease transmission via blood products, including the use of volunteer donors, the exclusion of high-risk populations, and the screening of donors via health and social history. Specific conditions screened for include:

• Hepatitis: tests for the presence of hepatitis B surface antigen and, most recently, hepatitis C, the most common non-A, and non-B hepatitis.
• Syphilis: tests for the presence of antibodies against the spirochete.
• Bacteria: contamination of blood products with bacteria may occur during and after the collection of blood.
  • The risk is managed by maintaining sterile technique during phlebotomy and blood processing procedures, correct storage techniques, visual inspection of blood products, and limiting the shelf life.
• CMV: tests for the presence of antibodies against CMV.
  • Approximately 50% of blood donors have been exposed to CMV, and 10% carry the CMV virus in WBCs.
  • Patients with impaired immune function (e.g., bone marrow dysfunction, organ transplant recipients, and premature babies) are at risk for CMV infection from transfused blood.
• HIV tests for the presence of antibodies against HIV, which indicates prior exposure to the virus.
  • All blood products in the United States have been screened since the test first became available in 1985.
  • Because antibodies to the virus are not produced until at least six weeks after exposure, donor screening and exclusion of high-risk groups (e.g., homosexual men, intravenous drug abusers, prostitutes, and sexual partners of high-risk individuals) remain important parts of preventing transmission of HIV via blood products.
  • A low risk of HIV transmission (estimated to be 1/100,000 units of blood) remains.
• Trypanosoma cruzi (anti-T. cruzi): It is also called Chagas. The particular parasite is endemic to Latin America; however, other cases have been reported worldwide, leading to more routine screenings for this parasite. However, most cases that have been reported have been from unscreened samples. An Enzyme-Linked Immunosorbent Assay (ELISA) detects this parasite in blood samples (Dhingra & Kitchen, 2014).

1. Blood administration set - primed
2. Normal saline
3. Informed consent
4. Venipuncture equipment - 18-22 gauge for routine transfusions in adults, 16-18 gauge for rapid transfusions in adults, and 22-25 gauge for pediatrics
5. Blood filter - primed 

1. Validate the physician's order.
2. Ensure informed consent is obtained before blood from the lab and before the transfusion, except in extreme emergencies.
3. Explain the procedure to the patient and provide patient education.
4. Start an IV.
   1. Avoid using anything smaller than a 20 gauge except in the neonatal population.
   2. Attach normal saline to the needle hub and start the infusion at 10cc/hr.
5. Get a complete set of vital signs before blood infusion begins.
   1. A temperature of greater than 100°F should be called to the physician before proceeding with the transfusion.
6. Obtain blood/blood product from the blood bank.
   1. Check the expiration date.
   2. Observe for abnormal color, red cell clumping, gas bubbles, and extraneous material.
   3. Return abnormal/outdated blood to the blood bank.
7. Verify all information and documentation with another healthcare professional.
   1. Compare the name and number on the patient's ID bracelet with that on the blood bag label.
   2. Check blood bag ID number and ABO and Rh compatibility.
8. Begin transfusion within 30 minutes of obtaining the product from the blood bank.
9. Begin transfusion slowly, approximately 20ggts/minute in the first 15-30 minutes.
   1. Observe for signs and symptoms of transfusion reactions.
   2. Take a complete set of vital signs after 15 minutes into the transfusion.
   3. If there are no signs of transfusion reaction, increase the rate to the ordered rate.
   4. Take a complete set of vital signs 30 minutes into transfusion.
10. Complete the transfusion within four hours.
    1. Take a complete set of vital signs.
    2. Flush the main line with normal saline to clear the tubing and IV catheter.
    3. Discontinue the blood bag and dispose of it according to hospital policy (Nettina, 2019). 

• Signatures verifying blood on blood confirmation slip.
• Date, time of transfusion.
• Type and volume of product infused.
• Patient response.
• Any interventions done for transfusion reactions (Nettina, 2019). 

• Obtain the blood product just before transfusion. Never use the unit refrigerator for storage until ready. Remember, you have 30 minutes from blood bank pick up until the initiation of infusion. If the 30 minutes is exceeded, return the unit to the blood bank.
• Use only normal saline solution. Dextrose solutions cause RBCs to clump, swell, and hemolyze.
• Use appropriate in-line filters. Replace the filters and administration set after each unit.
• A blood filter is a device attached to a unit of blood or components between the bag and the patient, designed to retain blood clots, white cells, and debris. The blood bank will provide the appropriate blood filter if needed.
• Filter use is recommended during rapid, massive transfusions of whole blood or packed RBCs to prevent pulmonary complications. Filters may also decrease the incidence of febrile transfusion reactions by removing many of the leukocytes. Special leukocyte-depletion filters with platelet products remove 80% to 95% of leukocytes and retain 80% of the platelets.
• Transfusions must be infused within four hours. The minimum transfusion is two hours, except in an emergency.
• Provide psychological support, explain all procedures, and reassure the patient and their family.
• The nurse should be in the room for at least the first 15 minutes, as this is usually when reactions occur.
• The transfusion rate can be increased if there are no signs of a transfusion reaction after the first 15 minutes.
• If a reaction does happen, the transfusion should be discontinued immediately. Ensure the blood tubing is disconnected from the patient. The provider of care should be immediately notified, the nurse should stay with the patient, and everything should be documented.
• Once the transfusion is finished, the Y tubing should be flushed with normal saline, and the tubing should be disposed of properly.
• Soreness at the insertion or puncture site can be normal after the procedure (Lotterman & Sharma, 2022; Nettina, 2019; Sahu et al., 2014).