BLOOD AND BLOOD

TRANSFUSIONS
Blood Composition
Administering Transfusions
Blood Transfusion Reactions
 Blood Composition
Blood contains two basic components
 Cellular elements -The cellular or formed elements
makes up about 45% of the blood volume. They include:
Erythrocytes, or RBCs
Leukocytes, or WBCs
Thrombocytes (platelets)

 Plasma -Plasma, the liquid component of blood, makes up

about 55% of blood volume. The two most significant
components of plasma are:
Water (serum)
Protein (albumin, globulin, and fibrinogen)
 Other elements in plasma
include:
 Lipids
 Electrolytes
 Vitamins
 Carbohydrates
 Nonprotein nitrogen compounds
 Bilirubin
 Gases
 Blood products
Current technology allows freshly donated
blood to be separated into its component
parts:
 RBCs
 Plasma
 Platelets
 Leukocytes
 Plasma proteins, such as immune globulin,
albumin, and clotting factors
 Whole blood

centrifugation

PRBCs Platelet-rich plasma

High speed
centifugation

1 unit FFP
RD platelet Thawing &
centrifugating

cryoprecipitate
 Compatibility

 Recipient blood is choosy about donor blood.

Any incompatibility can cause a serious
adverse reaction. The most severe is a
hemolytic reaction, which destroys RBCs and
may become life-threatening. Before a
transfusion, testing helps to detect
incompatibilities between recipient and donor
blood.
Typing and crossmatching establish the compatibility of
donor and recipient blood. This precaution minimizes the
risk of a hemolytic reaction. The most important test
includes:

 ABO blood typing

 Rh typing
 Crossmatching
 Direct antiglobulin test
 Antibody screening test
 Screening for such disease as hepatitis B and C, HIV,
human T-cell lymphotrophic virus type I and type II,
syphilis and for certain patients, cytomegalovirus.
 ABO blood type

The four blood types in the ABO system are:

A- 30%
B-15%
AB-4%
O-51%
Antigen is the substance that can stimulate the
formation of an antibody.
An antigen may induce the formation of a
corresponding antibody if given to a person who
doesn’t normally carry the antigen
Antibody is an immunoglobulin molecule
synthesized in response to a specific antigen
ABO system includes two naturally occurring
antibodies : anti-A and anti-B. one, both or none of
these may be found in the plasma.
The interaction of corresponding antigens and
antibodies of the ABO system can cause
agglutination (clumping together)
Blood transfusions can introduce other antigens
and antibodies into the body. Most are harmless,
but any could cause a transfusion reaction.
 Antigens and Antibodies: A
stimulating Discussion
Blood type Antigen Antibody

A A Anti B

B B Anti A

AB A,B,AB none

O none Anti A & B

 O, you’re everybody’s type!!

 Because group O blood lacks both A and B

antigens, it can be transfused in limited
amounts in an emergency to any patient –
regardless of the recipient’s blood type – with
little risk of adverse reaction.
 That’s why people with O blood are called
universal donors
 Any donor will do!!

 A person with a AB blood type has neither

anti-A nor anti-B antibodies.
 This person may receive A,B, AB, or O
blood, making him a universal recipient.
 Rh blood group

Another major blood antigen system, the

Rhesus (Rh) system, has two groups
Rh positive
Rh negative
Rh system consists of different inherited
antigens – D, C, E, c, or e. these
antigens are highly immunogenic – they
have a high capacity for initiating the
body’s immune response.
 HLA blood group
 Human Leukocyte antigens are essential to
immunity. HLA is a part of the
histocompatibility system. this system
controls compatibility between transplant or
transfusion recipients and donors.
 The HLA system:
Is responsible for graft success or rejection
May be involved with host defense against
cancer
May be involved when WBCs or platelets fail
to multiply after being transfused
If this happens, the HLA system could trigger
a fatal immune reaction in the patient
 Blood Feud!!
 When mismatching occurs, antigens and anti bodies
of the ABO system do battle. Antibodies attach to the
surfaces of the recipient’s RBCs causing the cells to
clump together
 The clumped cells can plug small blood vessels.
This antibody-antigen reaction activates the body’s
complement system, a group of enzymatic proteins
that cause RBC destruction (hemolysis)
 RBC hemolysis releases free hemoglobin into the
bloodstream, which can damage renal tubules and
lead to kidney failure.
Hemolysis
 Purpose of transfusion
therapy
Restore and maintain blood volume
Improve the oxygen carrying capacity of
blood
Replace deficient blood components
and improve coagulation
 Transfusing Blood Products
Two ways to administer blood and blood products are:
 Peripheral IV line:
 Not the best idea if large volumes must be
transfused quickly
 It is recommended that a 20G or larger peripheral
IV catheter be used for rapid transfusions in acute
situations.
 Peripheral veins are commonly used in nonacute
transfusion situations. the small diameter of the
vein and peripheral resistance can slow the
transfusion
 CV line
Large volumes of blood products can be delivered
quickly through the CV line because of the large
size of the blood vessels and their decreased
resistance to infusion.
 Transfusion Risks
 Because of careful screening and testing, the supply
of blood is safer today than it has ever been, even so,
a patient who receives a transfusion is still at risk for
life-threatening complications, such as hemolytic
reaction, exposure to infectious diseases, such as
HIV and hepatitis
 Therefore, the doctor, the nurse, and the patient
(when able) must weigh the benefits of a transfusion.
 Many facilities have special consent forms for
transfusions
Who can give and can’t give
blood???
 Donors must be screened to
reduce the risk associated with
transfusions
Eligible donors must be:
 At least 17 years old
 Weigh at least 110lb (50kg)
 Be free from skin diseases
 Not have donated in the last 56days
 Have a hemoglobin level of at least 12.5g/dl
(women) to 13.5 g/dl (men)
 Ineligible donors include:
 Those who have HIV or AIDS
 Who are male and have had sex with other men since
1977
 Who have had sex with prostitutes in the last 12 months
 Who have taken illegal drugs IV
 Who have had sex with anyone in the above categories
 Who have had hepatitis
 With certain types of cancer (other than minor skin
cancer)
 With hemophilia
 Who have received clotting factor concentrations
 Who have spent a total of 3 months in the united kingdom
since January 1, 1980
 Who have been treated for syphilis or gonorrhea ion the
past 12 months
 Who have been tattooed within the past 12 months
 Your primary responsibility!!
 Whatever the source of blood or blood products, your primary
responsibility is to prevent a potentially fatal hemolytic reaction
by making sure the patient receives the correct product.
 Upon transfusion, always follow the same basic procedure
Begin by:
 Check – to make sure an informed consent was signed, then
double check the patient’s name, medical record number, ABO
and Rh status (and other compatibility factors), and blood bank
identification number against the label on the blood bag, also
check the expiration date on the bag
 Verify – ask another nurse or doctor to verify all information,
according to facility policy, make sure that the doctor who
checked the blood product have signed the blood confirmation
slip, If even a slight discrepancy exists, don’t administer the
blood. Instead, immediately notify the blood bank and return the
blood product.
 Inspect – the blood to detect abnormalities, then confirm the
patient’s identity by checking the name, room number, and bed
number on his/her wrist band and if possible the patient himself.
 Blood Components
Component Therapuetic implications
effects
Whole Blood 1 unit Given in
500 ml increases hct massive blood
to 3-4% and loss
increases hgb
to 1g/dl
Packed RBC Same with WB Infuse 3-
250-350ml 4ml/kg/H
Transfuse in
1-2h
Platelets in Increases 10ml/min.
200-400ml in platelets to Don’t
4-6 pooled 50,000/cumm refrigerate
units
FFP 200- Increases Transfuse
250ml/kg clotting factor by ASAP
2%
Cryo Increases
10-15ml fibrinogen to 60-
70mg/dl
 Whole Blood
Complete (pure) blood
Indications
 To restore blood volume in hemorrhaging, trauma, or
burn patients
Nursing considerations
 Use straight line or Y-type IV set, can infuse rapidly in
emergencies, but adjust the rate to the patient’s
condition and the transfusion order, and don’t infuse
over more than 4 hours
 Whole blood is seldom used other than emergency
situations because its components can be extracted
and administered separately
 Whole blood is commonly used in emergency
treatment
 Packed Red Blood Cells (RBCs)
Same RBC mass as whole blood with 80% of the
plasma removed

Indications
 To restore or maintain oxygen carrying capacity
 To correct anemia and surgical blood loss
 To increase RBC mass
Nursing considerations
 Cross typing: Same with whole blood
 Set used is same with whole blood, can infuse
rapidly in emergencies, adjust rate to patient’s
condition and order, don’t infuse over more than
4 hours
 RBCs have the same oxygen carrying capacity
as whole blood, minimizing the hazard of volume
overload
• Using packed RBCs avoids potassium and
ammonia buildup that sometimes occurs in the
plasma of stored blood
• Packed RBCs shouldn’t be used for
anemic conditions correctable by
nutrition or drug therapy
 Leukocyte-poor RBCs
Same as packed RBCs except 70% of the leukocytes are
removed
Indications
 To restore or maintain the oxygen carrying capacity
 To correct anemia and surgical blood loss
 To increase RBC blood mass
 To prevent febrile reactions to leukocyte antibodies
 To treat immunosupressed patients
 To restore RBCs to patients who have had two or
more nonhemolytic febrile reactions
Nursing considerations

 Same as with whole blood

 Use straight-line or Y-type IV set. May require a
microagetate filter for hard-spun, leukocyte-poor
RBCs. Infuse over 1 ½ to 4 hours
 Cells expire 24 hours after washing
 RBCs have the same oxygen carrying capacity as
whole blood, minimizing the hazard of volume
overload
 Leukocyte-poor RBCs shouldn’t be used for anemic
conditions correctable by nutrition or drug therapy
 White blood cells (WBCs,
leukocytes)Whole blood with all the RBCs
and 80% of the plasma removed
Indications
 To treat a patient with life-threatening
granulocytopenia (granulocyte count usually less
than 500/µl) who isn’t responding to antibiotics
(especially if he has positive blood cultures or
persistent fever greater than 38.3˚C
 Nursing considerations
 Cross-typing: same as with whole blood
 WBcs are preferably human leukocyte antigen
compatible but not necessary unless patient is HLA
sensitized from previous transfusions
 Use straight-line set with standard in-line blood filter.
Dosage is 1 unit daily for 4 to 6 days or until infection
clears
 WBC infusion may induce fever and chills. To prevent
this reaction, premedicate the patient with
antihistamine, acetaminophen, steroids, or
meperidine hydrochloride. Administer antipyretic if
fever occurs but don’t discontinue the infusion. Flow
rate may be reduced for the patient’s comfort
 Because reactions are common, administer slowly
over 2 to 4 hours. Check the patient’s vital signs and
assess him every 15 minutes throughout the
transfusion
 Give the transfusion in conjunction with the antibiotics
to treat infection
 Platelets
Platelets sediment
From RBCs or plasma
Volume: 35 to 50ml/unit of platelets = 7x100,000,000
platelets
Indications
 To treat thrombocytopenia caused by
decreased platelet production, increased
platelet destruction, or massive transfusion
stored blood
 To treat acute leukemia and marrow aplasia
 To restore platelet count in a preoperative
patient with a count of 100,000/µl or less
Nursing considerations

 Cross typing: ABO compatibility isn’t necessary but is

preferable with repeated platelet transfusions. Rh type
match is preferred
 Use blood component drip administration set; infuse
100ml over 15 minutes. Administer at 150 to 22 ml/hour,
or as rapidly as the patient can tolerate; don’t exceed 4
hours. Don’t use a microaggregate filter
 Platelet transfusions aren’t usually indicated for conditions
of accelerated platelet destruction, such as idiopathic
thrombocytopenic purpura or drug induced
thrombocytopenia
 Patients with a history of platelet reaction require
premedication with antipyretics and antihistamines. A
leukocyte removal filter may be necessary
A platelet count may be ordered 1 hour after platelet
transfusion to determine platelet transfusion increments
 Plasma and Plasma
fractions
Plasma and plasma fractions are
anticoagulated clear portion of blood that
has been run through a centrifuge. They
make up about 55% of blood and are used
in transfusion therapy to:
 Correct blood deficiencies such as low
platelet count
 Control bleeding tendencies that result from
clotting factor deficiencies
 Increase the patient’s circulating blood
volume
 Fresh frozen plasma (FFP)
Uncoagulated plasma separated from red blood cells (RBCs). FFp
is rich in coagulation factors V, VIII and IX.

Indications
 To expand volume
 To treat postsurgical hemorrhage or shock
 To correct an undetermined coagulation
factor deficiency
 To replace a specific factor when that factor
alone isn’t available
 To correct factor deficiencies resulting from
hepatic disease
Nursing Considerations
 Cross-typing: ABO compatibility isn’t
necessary but is preferable with repeated
platelet transfusions. Rh type match is
preferred. Use a straight-line set and
administer as rapidly as tolerated. Large
volume transfusions of FFP may require
correction for hypocalcemia. Citric acid in FFP
binds calcium.
Albumin 5% (buffered saline)
Albumin 25%
(salt-poor)
Human albumin is a small plasma protein separated from plasma.
Volume: 5% = (50mg/ml) in 50 ml, 250-ml, 500-ml, and 1,000-ml vials

Indications
 to replace volume in treatment of shock from
burns, trauma, surgery, or infections
 to replace volume and prevent marked
hemoconcentration
 to treat hypoprotinemia ( with or without
edema)
Nursing Considerations
 cross-typing isn’t necessary
 use a straight line set, rate and volume
dependonthe patient’s condition and response
 reactions to albumin (fever, chills, nausea) are
rare
 albumin is commonly given as volume expander
until crossmatching for whole blood is complete
 albumin shouldn’t be mixed with protein
hydrolysates and alcohol solutions
 albumin is contraindicated as an expander in
severe anemia; administer cautiously in patients
with cardiac and pulmonary disease because of
the risk of heart failure from circulatory overload
Factor VIII (antihemophilic factor)
Cold insoluble portion of plasma recovered from FFP

Indications
 To treat a patient with hemophilia A
 To control bleeding associated with factor
VIII deficiency
 To replace fibrinogen or factor VIII
Nursing Considerations

 Cross-typing: ABO compatibility isn’t necessary

but is preferable
 Use the manufacturer supplied administration
set, administer with filter. Standard dose
recommended for treatment of acute bleeding
episodes in hemophilia is 15 to 20units/kg.
 Half-life of factor VIII (8to 10 hours) necessitates
repeat transfusions at these intervals to maintain
normal levels
 Administer IV as rapidly as tolerated, but don’t
exceed 6ml/minute: monitor pulse rate while
infusing
Factors II, VII, IX, X complex (prothrombin
complex)
Lyophilized commercially prepared solution drawn from pooled
plasma

Indications

To treat congenital factor V deficiency and other

bleeding disorders resulting from an acquired
deficiency of factors II, VII, IX, and X
Nursing Considerations

 Cross-typing: No ABO or RH matching is

necessary
 Use a straight-line set; dosage is based o
desired level and the patient’s body weight
 Risk of hepatitis is high
 Coagulation assays are performed before
administration and suitable intervals during
treatment
 Administration is contraindicated when the
patient has intravascular coagulation and isn’t
undergoing heparin therapy
 Specialized Transfusion
Methods
 Specialized methods for administering blood
include:
 Autotransfusion, the process of collecting,
filtering, and reinfusing the patient’s own blood.
 Hemapheresis, the process of collecting and
removing specific blood components and then
returning the remaining components to the donor
 Seeking skilled Nurses

 Hemapheresis and autotransfusion must be

performed by skilled personnel.

 Only nurses who are familiar with the

procedures should monitor and evaluate a
patient’s condition throughout the
transfusion.
 Patients with special needs

 Pediatric and elderly patients require special

care during transfusion therapy.
 transfusing blood into a neonate requires
specialized skills because the neonate’s
physiologic requirement differs vastly from
those of an older infant, child, adolescent,
or adult.
 Pediatric patients
Half-unit for half-pints
 Blood units for pediatric patients are prepared in half-
unit packs, and a 24G catheter is used to administer
the blood.
Rating children differently
 The rate of the infusion also differs. Usually, a child
receives 5% to 10% of the total transfusion in the first
15 minutes of therapy. To maintain the correct flow
rate, be sure to use an electronic infusion device.
 A Child’s normal circulating blood volume determines
the amount of blood transfused. The average blood
volume for children and infants older than 1 month is
75ml/kg. the proportion of blood volume to body
weight decreases with age.
Good communication!!
 Whenever you transfuse blood in an infant or child, explain the
procedure, its purpose, and the possible complications to the
parents or legal guardian. If appropriate, also include the child
in the explanation. Ask the parents for the child’s transfusion
history, and obtain their consent.
 Closely monitor the child, particularly during the 1st
15minutes, to detect any early signs of a reaction. Use a blood
warmer, if indicated, to prevent hypothermia and cardiac
arrhythmias, specially if you’re administering blood through a
central line.

A child’s problem with grown-up indications

 In massive hemorrhage and shock, the indications for blood
component transfusion in children similar to those for adults,
although accurate assessment is difficult. Draw blood from a
central vein to get more accurate hemoglobin and hematocrit
measurements, or use blood pressure readings to assess blood
volume.
 Elderly patients

 An elderly patient with preexisting heart

disease may be unable to tolerate rapid
transfusion of an entire unit of blood
without exhibiting shortness of breath or
other signs of heart failure. The patient may
be better able to tolerate half-unit blood
transfusions.
Transfusion Reactions
 Most common reactions are not Life-
threatening.
 Some reactions can be reduced by
modified(filtered, washed, or irradiated)
blood components.
 Results from 2 mechanisms
Immune-mediated- due to preformed
antibodies
Nonimmune mediated-chemical properties
of the blood stored.
 Immune mediated

 Acute hemolytic transfusion reactions

-hypotension, tachypnea, tachycardia, fever,
chills, hemoglobinemia
- monitoring of V/S
-Stop transfusion immediately
-posttransfusion blood sample should be
sent to blood bank for analysis
 Allergic reactions
- stop transfusion
- administer antihistamines orally or IM
-cellular components should be washed for
extremely sensitized patient.
Anaphylactic Reaction
-diff. breathing, coughing, nausea and
vomiting,hpotension, bronchospasm,
LOC,respiratory arrest and shock.
-stop transfusion
-epinephrine, glucocorticoids
 • Acute lung injury
• Dyspnea, fever, wheezing, chills,
bronchospasm, crackles, non-productive
cough, pulmonary infiltrates,
hypo/hypertension
– Care:
• MV
• O2 & Fluids
• Steroids, Epinephrine, diuretics
 Nonimmunologic Reactions
 Fluid overload
- monitoring rate and volume of transfusion
Hypothermia
-refrigerated or frozen blood components
Eletrolyte Toxicity
-Storage can increase K content
-hypocalcemia-due to citrate chelates the
calcium
 Iron Overload
-200-250mg of Iron
- Erythropoietin
Infection Complications
-Viral infection Hepa C, B, HIV,CMV
-Bacterial Contamination
Yersinia, Pseudomonas, Escherichia
-patient develops fever and chills and can
progress to septic shock and DIC
-stop transfusion
-reverse any signs of shock
- give broadspectrum antibiotics
-blood should be sent for culture and sensi
 Alternatives to transfusion

 Erythropoeitin – stimulates erythrocyte

productionin patients with anemia of
chronic renal failure and other condition