Transfusion of Blood and Blood Products

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), the American Association of Blood Banks (AABB), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 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. It restores intravascular volume and improves blood oxygen carrying capacity (after several hours).

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. It helps restore blood volume while preventing fluid overload, improves blood oxygen carrying capacity, and reduces risk of metabolic complications. 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. For patients receiving multiple blood products, packed RBCs may be further manipulated to remove WBCs by washing or freezing the product in the blood bank or by the use of a small-pore (20 – 40 ?m) filter during administration.

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. It restores clotting factors, except platelets, and expands plasma volume.

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. Platelets should not be refrigerated.

Patients may become alloimmunized to human leukocyte antigens (HLA) through exposure to multiple platelet products. Aphresis 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.

Dosage is generally 1 unit of platelets for each 10 kg; however, patients who are actively bleeding or undergoing surgical procedures may require more.

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 helps control bleeding due to blood loss or blood clotting disorders related to liver disease and failure, disseminated intravascular coagulation (DIC), over anticoagulation with warfarin, all congenital or acquired clotting factor deficiencies, and dilutional coagulopathy resulting from massive blood replacement. 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.

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.

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. Indications include treatment of life-threatening bacterial or fungal infection unresponsive to other therapy in patients with severe neutropenia. The dosage is usually 1 unit daily for approximately 5 to 10 days, discontinuing if not therapeutic response. Transfuse 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. The process for WBC transfusion is the same as red cell transfusion. Premedication with antihistamines, acetaminophen, steroids, or meperidine may be required to prevent adverse reaction. 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.

To reduce the risk of specific transfusion-related complications, blood products may receive further processing or treatment:

Leukocytes are removed from blood products through filtration, washing and freezing to reduce the risk of febrile, nonhemolytic transfusion reactions and alloimmunization to HLA antigens. The function and proliferation of donor lymphocytes are inhibited by irradiation, to decrease the risk of post-transfusion graft-versus-host disease (GVHD) in immunocompromised patients.

Filtration: A blood product may be filtered for leukocytes before release from the blood bank. More commonly, it is released with the appropriate filter that must be attached to the standard infusion set at the bedside per manufacturer’s or blood bank instructions.

Standard filters of 170 ?m effectively remove gross fibrin clots. Microaggregate filters of 40 ?m remove microscopic aggregates of fibrin, platelets, and leukocytes that accumulate in RBC products during storage. Filter use is recommended during rapid, massive transfusion 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 are available for use with platelet products that remove 80% to 95% of leukocytes and retain 80% of the platelets.

Washing RBCs or platelets washed with a normal saline solution removes 80% to 95% of the WBCs and virtually all of the plasma to reduce the incidence of febrile, nonhemolytic transfusion reactions. Washing requires an additional hour of processing time and the shelf life of the product is reduced to 24 hours after this additional manipulation.

Freezing: RBCs frozen within 7 days of blood collection remain viable for 7 to 10 years. Removal of the hypertonic freezing preservative (glycerol) before transfusion eliminates all of the plasma and 99% of WBCs. Thawing and deglycerolization of RBCs requires an additional 90 minutes of preparation time and reduces shelf life to 24 hours after this additional manipulation. Freezing is also effective method of storing rare blood types and Autologous RBCs.

Irradiation:  Exposure of blood products to measure amounts of gamma irradiation inhibits lymphocyte function and proliferation without damaging RBCs, platelets, or granulocytes. This eliminates the ability of transfused lymphocytes to engraft in the immunocompromised transfusion recipient and the accompanying risk of post transfusion GVHD.

1.      Hemorrhage: hemoglobin of <10gm

2.      Hematologic diseases: aplastic anemia, leukemia, or chemotherapy resulting in platelets < 10,000 mm

3.      Clotting factor deficiencies

4.      Hypoproteinemia, hypoalbuminemia

5.      Chronic anemia: hemoglobin < 6 gm

6.      Thrombocytopenia, bone marrow aplasia

Blood Compatibility

The surface membrane of the RBC is characterized by the presence or absence of glycoproteins known as antigens. More than 400 different antigens have been identified on the RBC membrane. The clinical significant antigens number less than a dozen, and of these, only two antigenic systems, ABO and Rh, require routine prospective matching before the transfusion.

ABO Antigens

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. Antibody directed against the missing antigen(s) is produced by the age of 3 months in neonates.

Antibodies (immunoglobulins) are proteins produced by B-lymphocytes and consisting of two light and two heavy chains, forming a Y-shape. Antibodies generally have a high degree of specificity interacting only with the antigen that stimulated their production. The five classes of immunoglobulins are determined by differences in their heavy chains: IgG, IgA, IgM, IgD and IgE.

The interaction of antibodies and antigens triggers an immune response, the humoral immune response. The extent of the humoral response elicited by anti-A and anti-B interaction with A and B antigens depends on the quantity of antibody and antigen.

Antibodies against the A and B antigens are large IgM molecules. When they interact with and coat the A and B antigens on the RBC surface, the antibody/cell complexes clump together (agglutinate).

Antibody/cell complexes also active the complement cascade, resulting in the release of numerous active substances and RBC lysis. The large antibody/cell complexes also become trapped in capillaries, where they may cause thrombotic complications to vital organs, and in the reticuloendothelial system, where they are removed from circulation by the spleen.

Other Red Blood Cell Antigens

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.

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

Possible Risks of Receiving a Blood Transfusion

1. Hemolytic Reaction

o       Cause:  The person giving the blood and the person receiving the blood do not having matching blood.

o       Effect:  Fever, chills, blood in urine, kidneys shutting down Death occurs in approximately 1 out of 100,000 transfusions.

2. Febrile Reaction

o       Cause:  The body reacting to the blood given to the patient

o       Effect:  Fever, chills that stop after the transfusion is stopped  There is no lasting effect

3. Allergic Reaction

o       Cause:  The body reacting to the blood being given to the patient

o       Effect:  Itching, hives, and sometimes breathing problems. These are treated with medication and the transfusion is stopped.  There is no lasting effect.

4. Hepatitis

o       Cause:  A virus that is carried in the blood of the person donating the blood that is given to the person getting the blood

o       Effect:  Only a few people will have the symptoms of Hepatitis.  A few people with Hepatitis can go on to have liver disease including Cirrhosis of the liver.

o       Risk:   Hepatitis A – very rare

o       Hepatitis B – 1: 63,000 to 1: 200,000 transfusions

o       Hepatitis C – 1: 250,000 to 1: 500,000 transfusions

5. AIDS

o       Cause:  A virus that is carried in the blood of the person donating the blood that is given to the person getting the blood that is now called HIV  Due to present testing done on all the blood given, the possibility of blood having the AIDS virus has been almost eliminated.

o       Effect:  HIV infection and AIDS

o       Risk:   1: 913,000 transfusions

6. CMV (Cytomegalovirus)

o       Cause:  A virus that is carried in the blood of the person donating the blood that is given to the person getting the blood.  This is only a risk to people with low resistance to disease and newborn infants.

o       Effect:  This virus may infect lungs, kidneys and nerve tissues in those patients with low resistance.

o       Risk:   1: 7,500 transfusions

7. HTLV-1

o       Cause:  A virus that is carried in the blood of the person donating the blood that is given to the person getting the blood.  It is believed that it is a very low rate of being given – similar to the rate for HIV.

o       Effect:  1 to 3% of those infected may go on to have a rare form of Leukemia or nerve problem.

o       Risk:   1: 641,000 transfusions in susceptible patients

Transfusion Reactions

The majority of blood transfusions cause no adverse reaction; however, even with the assurance of pretransfusion testing, 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 and capillary occlusion, 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 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.

On a rare occasion, a reaction will not occur until a week or more afterwards. 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.

Interventions

If you suspect a transfusion reaction:

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, anuria.

7.      Collect a urine specimen

a.      If the first post transfusion urine, mark on the specimen “possible blood transfusion”.  The lab tests this specimen for presence of hemoglobin, which indicates a hemolytic reaction.

8.      Obtain an order for BUN, Creatinine, and bilirubin because they 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 order

a.      SQ Epinephrine to counteract allergic response

b.      Mannitol (osmotic diuretic) to decrease risk of kidney damage

c.      Bicarbonate IV to alkalize urine and help prevent and decrease 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.

Blood Transfusion Options

Autologous Transfusion

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.

Homologous Transfusion

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 donor and recipient.

Directed Transfusion

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.

Alternatives to Blood Transfusion

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.

Administering a Blood Transfusion

Equipment:

1.      Blood administration set - primed

2.      Normal Saline

3.      Informed consent

4.      Venipuncture equipment

5.      Blood filter – primed

Essential Steps:

1)     Ensure informed consent has been obtained prior to getting the blood from the lab and before the transfusion except in extreme emergencies.

2)     Explain the procedure to patient and provide patient education. 

3)     Start and IV using 18 gauge catheter

a)     Avoid using anything smaller than a 20 gauge except in the neonatal population

b)     Attach normal saline to the needle hub and start infusion at 10cc/hr

4)     Get a complete set of vital signs before blood infusion is begun. 

a)     A temperature of greater than 100 ° should be called to the physician before proceeding with the transfusion

5)     Obtain blood/blood product from the blood bank

a)     Check expiration date

b)     Observe for abnormal color, red cell clumping, gas bubbles, and extraneous material. 

c)      Return abnormal/ outdated blood to the blood bank

6)     Verify all information and document with another healthcare professional

a)     Compare name and number on patient’s ID bracelet with that on blood bag label

b)     Check blood bag ID number and ABO and Rh compatibility

7)     Begin transfusion within 30 minutes of obtaining product from the blood bank

8)     Begin transfusion slowly, approximately 20ggts/minute in first 15-30 minutes

a)     observe for signs and symptoms of transfusion reaction

b)     Take a complete set of vital signs after 15 minutes into transfusion

c)      If no signs of transfusion reaction, increase rate to ordered rate

d)     Take a complete set of vital signs 30 minutes into transfusion.

9)     Complete the transfusion within 4 hours

a)     Take a complete set of vital signs

b)     Flush main line with Normal Saline to clear tubing and IV catheter

c)      Discontinue blood bag and dispose according to hospital policy

Documentation:

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

Transfusion Tips

Ø      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 initiation of infusion. If the 30 minutes is exceeded, return the unit to the blood bank.

Ø      Use only Normal Saline solution.  Dextrose solutions cause red blood cells to clump, swell, and hemolyze.  Lactated Ringers contain calcium that counteracts anticoagulants in the blood bag.

Ø      Use appropriate in-line filters. Replace the filters and administration set after each unit.

Ø      Transfusions must be infused within 4 hours.

Ø      Provide psychological support, explain all procedures, and reassure the patient and his/her family.

References

Goldberg, K., “Nurse Review: A Clinical Update System”.  Springhouse    

          Corporation, Pennsylvania, 1988.

Hamilton, H., “Procedures, Nurses Reference Library”.  Springhouse

           Corporation, Pennsylvania, 2003.

Nettina, Sandra M., “The Lippincott Manual of Nursing Practice” 7th Ed. Lippincott, Philadelphia, Pennsylvania, 2001.

Springhouse Review for Medical-Surgical Nursing Certification – An Indispensable Study Guide for the A.N.A. Exam 3rd Ed. Springhouse, Lippincott Williams & Wilkins, Pennsylvania, 2002.