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Contact hours for LPNs in any state are earned by completing this course. This is part of a series of 24 contact hours of courses to prepare for LPN IV Certification in Florida. Florida certification participants must schedule a 6-hour live presentation and return demonstration to complete IV Certification. The live presentation is not provided by CEUFast.com.
Participants will be able to manage patients receiving blood and blood components, including the identification of adverse reactions, and indications and contraindications for use.
Upon completion of this course, the participant will be able to:
Transfusions of blood and blood products may be necessary to treat severe thrombocytopenia, leucopenia, and anemia resulting from a disease process or from treatment. Whole blood, packed red blood cells and other blood products replenish volume, oxygen-carrying capacity, platelet volume, and clotting factors. This life-saving procedure can be life-threatening if not carefully performed in accordance with facility policy and safe nursing practice.
Because of the potentially life-threatening consequences of blood incompatibility and the safety concerns about disease transmission through blood products, transfusion therapy has been limited to occasions when it is absolutely necessary. In addition, various techniques before transfusion have been instituted to reduce the chance of error. The Food and Drug Administration (FDA), Joint Commission (JC), and the American Association of Blood Banks (AABB) regulate blood product procurement, storage, preparation, and testing.
Whole Blood consists of red blood cells (RBC), plasma, plasma proteins, and about 60 mL anticoagulant/preservative solution in a total volume of about 500 mL.
Packed RBCs consists primarily of RBCs, a small amount of plasma, and about 100 mL anticoagulant/preservative solution in a total volume of about 250 to 300 mL/unit. RBCs restore or maintain oxygen carrying capacity while preventing fluid overload, and reducing the risk of metabolic complications from whole blood transfusion. The average adult dose administered is 2 units; pediatric doses are generally calculated as 5 to 15 mL/kg. Packed RBCs are typically contaminated with white blood cells (WBC) that may increase the risk of minor transfusion reactions and alloimmunization. WBCs are also called leukocytes.
Leukocyte poor RBCs have 70% of WBCs removed by washing or freezing the product in the blood bank or using a small-pore filter during administration. This product prevents febrile reactions from leukocyte antibodies.
WBCs (granulocyte concentrates) consist of a minimum of 1 X 1010 granulocytes, variable amounts of lymphocytes (usually less than 10% of the total number of WBCs), 6 to 10 units of platelets, 30 to 50 mL RBCs, and 200 to 400 mL plasma. It is obtained via apheresis, generally of multiple donors. The dosage is usually 1 unit daily for approximately 5 to 10 days, discontinuing if no therapeutic response. The process for WBC transfusion is the same as red cell transfusion. Premedication with antihistamines, acetaminophen, steroids, or meperidine may be required to prevent an adverse reaction.
WBCs must be infused within 24 hours of collection; because WBCs have a short survival time and therapeutic benefit is directly related to dose and viability. |
Do not administer amphotericin B immediately before or after WBC transfusion because pulmonary insufficiency has been reported with concurrent administration. Many institutions recommend a 4-hour gap to avoid this risk. |
Plasma consists of platelets suspended in plasma. Products vary according to the number of units (each unit is a minimum of 5.5 X 1010 platelets), and the volume of plasma is 50 – 400 mL.
Plasma (Fresh or Fresh Frozen) consists of water (91%), plasma proteins including essential clotting factors (7%), and carbohydrate (2%). Each unit is the volume removed from a unit of whole blood (200-250 mL. Plasma restores clotting factors, except platelets, and expands plasma volume. Storage in liquid state results in the loss of labile clotting factors V and VIII so that only plasma that has been fresh frozen can be used to treat factor V and VIII deficiencies. The dosage depends on clinical situation and assessment of prothrombin time (PT), partial thromboplastin time (PTT), or a specific factor assays.
Platelets may be obtained by centrifuging multiple units of whole blood and expressing off the platelet-rich plasma (multiple-donor platelets) or from a single volunteer platelet donor using automated cell separation techniques (aphaeresis). The use of single donor products decreases the number of donor exposures, thus decreasing the risk of alloimmunization and transfusion-transmitted disease. Platelet transfusions are usually a 6 unit IV bolus infused over 20 to 30 minutes. Dosage is generally 1 unit of platelets for each 10 kg; however, patients who are actively bleeding or undergoing surgical procedures may require more.
| Platelets must not be refrigerated. |
Patients may become alloimmunized to human leukocyte antigens (HLA) through exposure to multiple platelet products. Apheresis products form HLA-matched platelet donors may be necessary. However, HLA-matched transfusions are often difficult to obtain due to the tremendous number of possible HLA combinations in the population.
Cryoprecipitate consists of certain clotting factors suspended in 10 to 20 mL plasma. Each unit contains approximately 80 to 120 units of factor VII (antihemophilic and von Willebrand factors), 250 mg fibrinogen, and 20% to 30% of the factor XIII present in a unit of whole blood. Indications include correction of deficiencies of factor VIII (i.e., hemophilia A and von Willebrand’s disease), factor XIII, and fibrinogen (i.e., DIC). The adult dosage is generally 10 units, which may be repeated every 8 to 12 hours until the deficiency is corrected or until hemostasis is achieved.
| Blood Component | Indications |
| Whole blood |
|
| Packed RBCs |
|
| Leukocyte poor RBCs (70% of leukocytes removed) |
|
| WBCs (leukocytes) |
|
| Platelets |
|
| FFP (fresh frozen plasma) |
|
| Albumin 5% (buffered saline) or Albumin 25% (salt-poor) |
|
| Factor VIII concentrate |
|
| Cryoprecipitate |
|
Autologous transfusion is the transfusion of the patient’s own blood. Autologous transfusion eliminates the risks of alloimmunization, immune-mediated transfusion reactions, and transmission of disease, making it the safest transfusion choice.
Before elective procedures, the patient may donate blood to be set aside for later transfusion. Autologous RBCs can also be salvaged during some surgical procedures or after trauma-induced hemorrhage by use of automated cell-saver devices or manual suction equipment. Autologous blood products must be clearly labeled and identified.
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 donated blood, post-donation instructions, and education regarding risk for human immunodeficiency virus (HIV) infection and signs and symptoms. Donors are screened against eligibility criteria designed to protect both donors.
In directed transfusion, blood products are donated by an individual for transfusion to a specified recipient. This option may be used in certain circumstances (e.g., a parent providing sole transfusion support for a child), but in general there is no evidence that directed donation reduces transfusion risks.
Erythropoietin or iron can be taken to avoid transfusion in some cases; but, it takes days to months to replace blood cells. Antifibrinolytics drugs can decrease the amount of bleeding during surgery but cannot replace lost platelets or clotting factors.
Because recipient blood reacts to donor blood, a type and crossmatch must be done to establish compatibility. Any incompatibility can cause a potentially life-threatening emergency .
The surface membrane of the RBC is characterized by the presence or absence of glycoproteins known as antigens. The major antigens in the ABO system are inherited. Blood transfusions can introduce other antigens and antibodies into the body. Most are harmless, but any transfusion could cause a reaction. Only two antigenic systems, ABO and Rh, require routine cross-matching before the transfusion.
Solutions other than 0.9% saline and ALL medications are incompatible with blood products, which will result in agglutination or hemolysis. |
The ABO blood group system is clinically the most 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 exposure to antigen is unique to the ABO system. An antibody directed against the missing antigen(s) is produced by the age of 3 months in neonates.1
| Blood Group | Antigen on RBC | Antibody in Plasma | Approximate Frequency of Occurrence in Population |
|---|---|---|---|
| A | A | Anti-B | 45% |
| B | B | Anti-A | 8% |
| AB | A and B | None | 3% |
| O | None | Anti-A and Anti-B | 44% |
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 antibody and antigen.
When mismatching occurs, antibodies against the A and B antigens attach to the surfaces of the recipients RBCs, leading to a hemolytic reaction.
The universal donor is type O negative, and the universal recipient is AB positive.
Non-ABO RBC antigen-antibody reactions usually do not produce powerful immediate hemolytic reactions, but several do 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 in the absence of specific exposure, but there is a high incidence of antibody development (alloimmunization) after exposure to D. Two common methods of sensitization to these RBC antigens are by 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 the use of Rh-negative blood products. In the case of Rh-negative mother and Rh-positive fetuses, exposure to D can be treated using Rh immunoglobulins, which will prevent anti-D formation.
xposures 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.
Most blood transfusions cause no adverse reaction; however, even with the assurance of pretransfusion crossmatching, blood transfusions may produce some adverse effects.
Hemolytic transfusion reaction results because antibodies in the recipient’s plasma react with antigens in donor RBCs. This 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. This free hemoglobin may block the renal tubules resulting in renal failure.
Although the mechanism of an allergic transfusion reaction is unknown, it probably results from the reaction of allergens in donor blood with antibodies in the recipient blood. Febrile transfusion reaction occurs because the recipient has a sensitivity to the donor leukocytes or platelets. Bacterial transfusion reaction is a contamination of donor blood, usually by gram-negative organisms. Circulatory overload occurs because the rate or volume of the transfusion exceeds the circulatory systems capacity.1
| TYPE | SIGNS & SYMPTOMS |
|---|---|
| Hemolytic | Chills, fever, backache, headache, restlessness, anxiety, nausea, vomiting, chest pain, tachycardia, dyspnea, hypotension, cyanosis, hemoglobinemia, hemoglobinuria, oliguria, anuria, jaundice, vascular collapse |
| Allergic | Urticaria, pruritis, chills, nausea, vomiting, headache, nasal congestion, wheezing, in more severe reactions: bronchospasm, severe dyspnea, laryngeal edema, circulatory collapse |
| Febrile | Fever, chills, flushing, back pain, malaise, tachycardia, headache, confusion, nausea, vomiting |
| Bacterial | Fever, chills, abdominal and extremity pain, vomiting, hypotension, bloody diarrhea |
| Circulatory overload | Cough, chest pain, dyspnea, distended neck veins, tachycardia, cyanosis, frothy sputum, pleural rales, hemoptysis |
Severe transfusion reactions usually occur within 15 minutes of beginning the transfusion. On a rare occasion, a reaction will not occur until a week or more afterward. If the patient should experience unexplained tiredness, fever, darker than normal urine color, or yellowing of the whites of the eyes within 3 months of the transfusion, the patient should consult a physician.
If you suspect a transfusion reaction1:
If a transfusion reaction is anticipated, prophylactic treatment with antihistamines and/or antipyretics may be given preceding blood administration.
Routine laboratory testing is performed to assess the compatibility of a particular blood product with the recipient before release of the blood product from the blood bank. These tests include:
Routine laboratory testing is performed to identify antigens or antibodies in donor blood that may indicate prior exposure to specific blood-borne diseases. Such testing supplements other principles of donation 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:
