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Red Blood Cell Administration Facilitator: Barbara Bischoff Policy • Physicians: Administer and discontinue blood products by order • RN’s and LPN’s: Administer and discontinue blood products by physician’s order • LPN’s: Second witness must be an RN or physician Purpose • RBCs contain hemoglobin • RBCs serve as primary agent for oxygen transport to cells • RBC components increase : Mass of circulating red cells Oxygen carrying capacity Contraindications RBC containing components should not be used: Solely for volume expansion To increase oncotic pressure of circulating blood To treat anemias treatable with hematinic medications such as: Iron Vitamin B12 Folic acid Erythropoietin Ordering • Written consent must be obtained prior to ordering • Nurses use order entry for request • Complete: Consent for Infusion of Blood, Blood Product(s), Derivatives and/or Tissue • Computer downtime use: Instructions for Completing Blood/Blood Product Orders Transfusion Checklist Consent Form Equipment • Unit Issue and Transfusion Record form • IV Tray (#18 Cathlon preferred) • Blood Secondary set with 170 micron filter • IV Pole • Infusion Pump • Extension Set • Vital Sign Machine • Normal Saline • Transfusion Checklist • Unit of packed cells Requisition for Pick Up • LPN or RN may pick up blood from Blood Bank • Blood Product Pickup slip: Contains patient information Indicates red blood cells are ready Issuing of Red Blood Cell Product • “Issue Unit” in Meditech • Generates Transfusion Record form • Preprinted: • Issue time • Date • Messenger’s initials • Blood Bank technologist’s initials Signature Signatures Fill out completely Lab Check • Completed by both Blood Bank technologist and LPN/RN. • Preprinted: Issue time Date Messenger’s initials Technologist's initials • Both persons sign on the appropriate signature line • Secure form to unit bag • Place both in a sealed biohazard Zip-lock bag for transport Lab Check (Cont) • Check: Patient’s ID number Red blood cell unit ID number ABO compatibility • Documents to be checked: Written request for pick-up Unit Issue and Transfusion Record Form Label on packed red blood cell bag Warning • All comparisons must match exactly • Do not initiate transfusions with discrepancy • Contact Blood Band immediately Packed Red Blood Cell Unit Verification • At bedside: • Compare patient armband • Form attached to unit of cells. • Verify: • Patient: Name, ID number, Blood type • Donor Unit: Number, Blood Type, Expiration Date • Patient must state their name • Both identifiers sign the Unit Issue and Transfusion Record Form • Most transfusion reactions result from identification error. Precautions • Verify with the attending physician: • Interruption of existing IV solution • Starting a new line • Consider total fluid volume • Never add medication to unit of blood • Use new Blood Secondary Set with every unit • Patient must always receive ABO compatible blood. Storage and Handling • Maximum room temperature time prior to infusing: • 30 minutes • Blood Bank will dispose as Regulated Medical Waste • May be returned to Blood Bank Refrigerator for: • Delay before use • Temporary discontinue • Never place in Nursing Unit refrigerator • Not adequate for safe storage Procedure • Prior to obtaining blood product • Administer pre-medications • Check order verification • Obtain baseline vital signs: • Temperature • Pulse • Respirations • Blood Pressure • Chart vital signs Procedure (Cont) • Set up blood secondary set following instructions • Don gloves and personal protective equipment. • Connect blood Secondary set with a 170 micron filter to red blood cell blood unit • Rotate pack gently to mix cells and small amount of plasma. • Close clamp and suspend red blood cell unit from IV pole. Procedure (Cont) • Compress plastic chamber filling filter and drip chambers • Make sure filter is submerged with blood • Blood dripping on filter can damage RBC’s • Open clamp to expel all air from tubing Transfusion Time • Recommendation: < 2 hours • Never > 4 hours • Delay of completion increases: • Deterioration of labile components • Possibility of inadvertent bacterial contamination • Transfusion time dependent on size of IV cathlon • Infusion time increased with smaller cathlon Flow Rate • Adjust flow to 20-30 drops per minute for first 10-15 minutes • If no immediate adverse symptoms occur: • Flow rate may be adjusted to 40-45 drops per minute • Closely follow transfusion to verify the desired rate continues • Adjust as necessary Gravity Pump 4 hours =20 drops/min =90 ml/hr 3 hours =40 drops/min =120 ml/hr 2 hours =60 drops/min =175 ml/hr 35 minutes =200 drops/min =700 ml/hr Management of Flow • Causes of slow flow: • Obstruction of the filter or needle • Excessive viscosity of the component • Steps to investigate and correct the problem include: • Elevating the blood container to increase hydrostatic pressure. • Checking the patency of the needle. • Examining the filter for excessive debris. • Consult with an attending physician Observation • Observe patient closely during the transfusion: • Continuously for the first 15 minutes • Recheck after second 15 minutes • Continue to assess patient every half hour • Monitor and document vital signs. • Observe for signs and symptoms of a transfusion reaction. Monitor • Monitor the patient for signs of possible transfusion reaction: • Flushing of face • Tachypnea • Wheezing • Tachycardia • Sudden chills and fever • Distended neck veins • Oppressive feeling in chest • Sharp pain in lumbar area • Decrease in blood pressure Flushing • Flush only with Normal Saline • Dextrose and calcium ions (L R) can hemolyze, clot • Do not interrupt Blood Transfusion for any medication Action for Reaction • If any signs of reaction occur Stop the Transfusion • Add 50 ml normal saline piggyback to keep vein open • Notify: • Attending physician • Nursing supervisor • Blood Bank. • Follow instructions: “Suspected Transfusion Reaction Form” Suspected Transfusion Reaction Documentation • Record: • Date and start time • Vital signs throughout transfusion • Date and time discontinued • Amount given and any reaction • Signature • Use Unit Issue and Transfusion Record form • Second nurse verifies no omissions on the form Completion • Place white copy of Unit Issue and Transfusion Record on the patient’s chart • Return to the Lab: • Yellow copy • Empty blood container • Tubing in a clear plastic biohazard bag. • Never place sharps in bag. • Separate yellow copy from empty unit using the outside pocket. Delayed Reactions • Ambulatory Care Patients • Discharged patient’s who received blood/blood products • Notify doctor of: • Rash • Fever • Chills • Difficulty Breathing • Leg or Chest pain Thank you for your attention ! Any questions or comments? References • Swartz, C.F. (2012). Red blood cell administration. Amsterdam, NY. St Mary’s Hospital.