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Back to Basics Where Quality Runs through the Veins of Patient Care Edna Matheson, BN RN Blood Matters Nov. 18th, 2016 • There is no involvement with industry to disclose for this presentation. Note! • This presentation highlights key aspects of safe transfusion practices for transfusionists. – RN; LPN; NP; anaesthetist; anesthesia tech/assistant; midwife; RRT (ECLS specialist) Selected CSA Standards • Canadian Standards Association develops standards for transfusion medicine services in Canada • Standard CAN/Z902-15, A National Standard of Canada, Blood and Blood Components – Applies to all aspects of transfusion medicine including collection, processing, storage and use of blood components and blood products Nursing Scopes of Practice • Entry level competency for RNs – experience in this procedure may or may not have occurred during their clinical practicum • Non-mandatory entry level competency for LPNs is organization specific – To patients with established plans of care with predictable outcomes – Outcomes of component or product must be predictable Within LPN Scope of Practice Examples of patients that would fall within the LPN SOP for blood component/product administration include: • a hemodynamically stable patient with anemia that requires RBC’s • administration of WinRho • subsequent doses of albumin to a patient whose outcome from the first dose is progressing as anticipated Competency Requirements • Transfusionists must meet the knowledge and competency requirements of their organization • Competency assessment includes but is not limited to – assessment of knowledge – operating procedures and theory – direct observation of performance – monitoring of recording and reporting. Knowledge Requirements • Blood Transfusion Modules on the provincial eLearning.nshealth.ca website: – Transfusion 1 Blood Basics – Transfusion 2 Administration – Transfusion 3 Adverse Reactions – Transfusion 4 Therapy Exam • Read policy; transfusion safety checklists; patient guide brochure Blood and Blood Components • Blood: referred to as whole blood and is made up of the following components: – Red cells, platelets and plasma – On average, an adult has about 5 liters of blood circulating throughout their system Blood and Blood Components • Blood components: the separated parts of whole blood – Red cells transport oxygen and carry nutrients to the cells and carry away carbon dioxide – Platelets participate in clot formation – Plasma helps with clotting, is used to make other products Manufactured Products (Plasma Derivatives) • Products that are derived from plasma manufacturing processes include: – IVIG (Gamunex, IVIGnex) – Albumin – Rh Immunoglobulin (Win Rho) – Hepatitis B & CMV Immune Globulin – Octaplex®/Beriplex® Orders for Blood Components/Products • Written order to include: – Type of component or product – Specific product requirements (e.g. irradiated) – Number of units and/or volume – If warmer or pressure device is to be used (massive bleeds) Processing Blood Bank Orders • Determine if a blood sample is required • Pre-transfusion blood sample collected to: – determine patient’s ABO and Rh type – identify antibodies the patient may have – crossmatch compatible units when components are ordered • Blood sample expires 96 hours after collection, unless pre-admission clinic patient Entering Orders in computer • What does the lingo mean? – Group and Rh – Type and Screen – BBH – Add on test for product Collecting blood sample • Witnessing and verifying blood bank specimen collection at the bedside – Misidentification can lead to acute hemolytic transfusion reactions – Error in sample labeling is the number one preventable error in transfusion errors • It is imperative the bedside identification and labeling of the sample is performed precisely Patient Identification • Ensure patient wearing correct armband (current account number) • Take blood sample labels to the patients bedside. • Check the patients armband EVEN when the patient is familiar to you • Verify the labels match the patient’s ID and checked by witness • Label tubes after collection but BEFORE leaving the bedside • Document that you drew the blood sample Pre-transfusion testing • Compatibility testing on a blood component is to ensure it will not produce a harmful reaction with the recipients blood Compatibility Table Donor ABO Group Recipient ABO Group RBCs Plasma Platelets UNKNOWN O AB AB O O O, A, B, AB O, A, B, AB A A, O A, AB A, AB B B, O B, AB B, AB AB AB, A, B, O AB AB Blood/Fluid Warmer • Blood warmers/pressure devices are recommended during massive bleeds – Not to exceed 42°C – Pressure devices (rapid infusers should not exceed 300mmHg). • Knowledge gap related to use of blood warmers – guidelines and quick reference instructions available on pump Unmatched blood • Unmatched blood (e.g. Trauma cases where patient may be unidentified) – O Negative Red Cell(s) and AB plasma will be ordered and issued. – A pre-transfusion specimen should be drawn prior to transfusion, if possible. – Physician must sign Emergency Release of Unmatched Blood provided by Blood Bank (required for red cells) Consent • Written consent must be obtained by authorized prescriber and signed by patient or substitute decision maker • Single consent sufficient to cover ongoing transfusion requirements related to that treatment • Refusals must be documented in writing Pre-Administration • Patient education – Pamphlet – Document teaching • Ensure patient wearing correct armband • Review order for transfusion and if there is a pre-med • Specific product requirements (irradiated) Pre-Administration • Pre-medicate only if ordered by physician • Perform a baseline physical assessment prior to obtaining component or product: – Vitals signs within 1 hr of starting transfusion – Lung assessment – Identify conditions that may increase risk of transfusion-related adverse reactions – Presence of appropriate and patent vascular access – Current lab values Vascular Access • Ensure IV site is patent – Short peripheral IV catheter can be 20 – 22 gauge for adults based on vein size and patient preference. (INS 2016) – For rapid administration, use 14 – 18 gauge • Central Venous Access Devices (CVADs) – Multiple lumens allow for concurrent administration of medications/solutions – Infusion may be slower in smaller gauge PICCs – Risk for hypothermia is increased with CVAD Prepare Blood Infusion Set • Prime set with 0.9% Normal Saline • Close all clamps • Do not suspend container directly over infuser • Open clamp • Repeatedly squeeze drip chamber until fluid level is slightly above top of filter • Tap chamber to eliminate air Pre-Administration Verification • Verify in presence of patient by transfusionist and another LPN, RN, PCP, NP, Midwife – Order for transfusion – Double identifiers on patient’s ID band against blood tag or report match – ABO group, Rh type and serial number on tag or report matches or is compatible with label • Product will not expire during transfusion • For home care setting, RN, Midwife and responsible adult This is the donation number (i.e. unit number). It is used for any double checks and documentation. ABO and Rh Group Collection date and time Component description, e.g. red blood cells. If the product has been irradiated, it will be indicated here Product Volume Expiration date and time Special testing (i.e. CMV or specific antibodies) Stop in Your Tracks • If any of the above criteria are not met, do not start the transfusion, notify Blood Transfusion Services (BTS) • Do not start the transfusion until the discrepancy is satisfactorily resolved Pre-Administration • Visually inspect component for clots, clumps and discoloration (cloudy, floaties) • Gently agitate blood component to mix thoroughly • Do NOT use if container is not intact or if the appearance is not normal – return to BTS Time of Issue • Blood tags or Issue/Transfuse Record have the time of issue a blood component or product is removed from a monitored blood refrigerator – If greater than 30 minute delay from time of issue to start of transfusion expected, return product to Blood Bank (monitored fridge). – If the blood component or products is not used, time must be stamped again on return to the blood refrigerator Pull port protector apart with both hands • Insert spike using ¼ turns until septum is pierced. • Do NOT over-spike • Remove spike by twisting using ¼ turns as you pull. • Pulling spike downward will tighten the port on the spike • Once spike is loosened from port – pull straight down Four hours? • Red Blood Cells must be completely transfused within 4 hours from the time it is issued from the monitored blood refrigerator (i.e. from the LAB) • Blood sets are to be changed every 4 hours • Any remaining RBCs after 4 hours from the time of issue from the fridge must be discontinued and discarded Caution on Blood Set Package Administration • Sign or print Meditech ID and start time on blood tag – Keep tag attached during transfusion Infusion rates • Monitor infusion rates (slower rates may be necessary for elderly, cardiovascular compromise or at risk for fluid overload) – Red cells are started at 2 mL/minute (120 mL/hr) for first 15 minutes • Subtract the 30 mLs from total volume and infuse the remaining volume over 1.5 to 2 hours Monitoring • Monitor patient for signs of reaction throughout transfusion – Stay with patient first 5 minutes from the first time the blood enters the vein (Most transfusionists stay with patients during the first 15 minutes) – Check for reaction q5min x 2; q1h; 1 hr post (exception would be 15 mins after routine maternal WinRho) Vital signs and reaction checks • LPNs may be assigned/participate in care by performing VS/reaction checks. • Increase frequency of monitoring for patients with a greater risk for circulatory overload, history of previous reactions or who are unstable. • Repeat initial monitoring for each new bag / lot number • If the transfusion is less than sixty (60) minutes, do vital signs prior and just after transfusion. Administration • Never add medications to blood components • Accurate documentation (refer to your organization’s health record documents / PCS) Post-administration without Reaction • Disconnect blood set and store for 4 hours • Continue to monitor for febrile or pulmonary reactions • Complete blood tag, remove and send to BTS within 24 hours • If no reaction, discard container and administration set in stiff sided Biohazard container with lid • Review post-transfusion bloodwork Patient Notification • Notification Letter – Given to patients once during LOS or course of treatment (e.g. series of IVIG) • Do not need product specifics (available in patient record if ever needed) • Document notification given and place copy on health record – Prompt added to discharge checklist Transfusion Reactions • Serious Sign or Symptom – Disconnect transfusion (i.e. do not just clamp blood and open saline) • Maintain IV line with appropriate solution (usually normal saline) • Notify physician • Check VS q15 mins until stable (SpO2) • Repeat clerical check (pt ID and ABO/Rh) Minor Reaction • If minor reaction with onset more than 15 minutes into transfusion, can resume cautiously ONLY as directed by physician • Stay with patient for 5 minutes initially, then assess q5 min x 2, and hourly thereafter (change to staying for 15 mins) • Assess vital signs after 15 minutes • Immediately stop transfusion if serious signs and symptoms develop Reaction investigations and follow up • Notify Blood Bank of ALL reactions – Remove transfusion tag and add comment re reaction – Place container and administration set in ziploc bag and return to Blood Bank • Meditech - Enter TRX for Lab tests • Lab to determine which tests to perform per Appendix B – Table on Investigations • Complete a SIMS report Questions?