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Blood Administration made Bloody Easy Module 2 – Indications and Compatibility Content derived from Bloody Easy Blood Administration handbook & Bloody Easy for Nurses eLearning modules Prepared by Ana Lima Transfusion Safety Nurse Sunnybrook Health Sciences Centre October 2010 Learning Objectives Understand the major uses, appropriate storage and expiration times for blood products and plasma derivatives. Describe tubing requirements and typical infusion times for administering blood products and plasma derivatives. Understand the ABO and Rh blood groups and how they impact on compatibility of blood products. Indicate which blood groups are appropriate in urgent situations when the patient’s group is unknown. NOTE: Always consult your hospital policy for information specific to your facility as practice may vary. 2 Blood Donation In Canada (excluding Québec) blood is collected by Canadian Blood Services (CBS) from volunteer donors. The donor undergoes a health screening which includes vital signs, hemoglobin check and a questionnaire. The collected blood is tested for blood group and transmissible diseases. 3 Blood Products/Components About 450mL of whole blood is collected into an anticoagulant preservative solution and the majority of donor white blood cells (WBC) are removed by a leukoreduction filter. Each donation can be separated into up to 4 products or components; Red blood cells Plasma and Cryosupernatant Plasma Platelets Cryoprecipitate Some blood products are collected using a cell separator machine by a method called apheresis. Usually the donor donates 1 type of blood product while the rest of their blood is returned to them. 4 Red Blood Cells Major Uses Bleeding or anemic non-bleeding patients with signs and symptoms of impaired tissue oxygen delivery. Tachycardia Shortness of breath Dizziness 5 Storage & Expiration 2-6° C in approved fridge only Up to 42 days Administration Blood tubing required Initiate transfusion slowly for first 15 minutes unless massive blood loss Transfuse over no more than 4 hours Typically over 1 ½ - 2 hours with slower rates for patients at risk for circulatory overload Plasma Major Uses Liver disease coagulopathy Massive transfusion Plasma exchange for TTP/HUS* when cryosupernatant plasma not available 6 Storage & Expiration Frozen 1 year Once thawed - stored at 1-6° C expires after 24 hours or 5 days (product specific as per CBS recommendation) * TTP/HUS = Thrombotic Thrombocytopenic Purpura/Hemolytic Uremic Syndrome Administration Blood tubing required Initiate transfusion slowly for first 15 minutes unless massive blood loss Transfuse over no more than 4 hours Typically over 30 minutes - 2 hours Platelets Major Uses Control or prevent bleeding in patients with: Low platelet counts Congenital platelet dysfunction Platelets not functioning due to the effects of medications (ASA, Clopidogrel - Plavix®) Platelet dysfunction following cardiopulmonary 7 bypass Storage & Expiration 20-240 C on an agitator to prevent clumping 5 days Administration Blood tubing required New blood tubing recommended Initiate transfusion slowly for first 15 minutes unless massive blood loss Transfuse over no more than 4 hours Typically over 60 minutes Cryoprecipitate Major Uses To replace: Fibrinogen: In patients actively bleeding who have a low fibrinogen level Coagulation Factors: Only when more specific factor concentrates are not 8 available Storage & Expiration Frozen 1 year Once thawed expires after 4 hours stored at 20-240 C Administration Blood tubing required Transfuse as rapidly as tolerated The ABO & Rh Blood Group Systems and Compatibility 9 ABO Blood Group The ABO blood group is determined by the presence or absence of the A and B antigens on the surface of the red blood cells (RBC). By 4 months of age a person will naturally acquire antibodies against the antigens that are not present on their red blood cells. These antibodies are found in the plasma. 10 ABO Antigen Antibody Group on RBC in plasma Percentage of population A A Anti-B antibody 42% B B Anti-A antibody 9% AB A and B neither 3% O neither 46% Anti-A and Anti-B antibodies ABO Antibodies and Compatibility A patient’s antibodies will destroy transfused red blood cells if they are incompatible. Donor antibodies found in plasma and platelet products can destroy a patient’s red blood cells if they are incompatible. The resulting potentially fatal reaction is called an Acute Hemolytic Transfusion Reaction 11 Rh(D) Blood Group The Rh(D) blood group is determined by the presence or absence of the D antigen on the surface of the RBC. Anti-D antibodies can be produced by an Rh negative person after they are exposed to Rh positive RBCs (or platelets). This can occur with transfusion or during pregnancy if the fetus is Rh positive. It is important to prevent the development of Anti-D antibodies in females who may in future become pregnant as the Anti-D antibodies can seriously harm an Rh positive fetus. 12 Rh(D) Group Rh(D) Percentage Antigen of population Rh Positive Present Rh Absent Negative 85% 15% Patient Blood Group Compatible Donor Blood Group Plasma/ Cryosupernatant Plasma Cryoprecipitate Red Blood Cells Platelets O Positive O Pos O Neg Rh Pos or Neg O preferred Any Group Any Group O Negative O Neg Rh Neg O preferred Any Group Any Group A Positive A Pos, A Neg O Pos, O Neg Rh Pos or Neg A preferred A, AB Any Group A Negative A Neg O Neg Rh Neg A preferred A, AB Any Group B Positive B Pos, B Neg O Pos, O Neg Rh Pos or Neg B preferred B, AB Any Group B Negative B Neg O Neg Rh Neg B preferred B, AB Any Group AB Positive Any Group Pos/Neg Rh Pos or Neg AB preferred AB Any Group 13 Negative AB Any Group Neg Rh Neg AB preferred AB Any Group Compatibility and Urgent Transfusions As well as the ABO and Rh groups, a pre-transfusion sample also screens for other more uncommon antibodies that can be acquired with blood exposure or pregnancy. Some antibodies can cause acute or delayed hemolysis. In urgent situations, where the blood group and screen testing have not been completed, the patient may need to receive a transfusion from a universal donor group. 14 Patient Red Blood Cell Transfusion Plasma Transfusion * Females less than 45 years of age O Negative AB All others O Positive or O Negative AB * Rh of Plasma (and cryoprecipitate) is not relevant for compatibility Plasma Derivatives Some donor plasma is sent to fractionation plants that extract and purify certain proteins to make plasma derivatives including; Albumin Intravenous Immune Globulin (IVIG) Rh Immune Globulin (RhIg) Other Immune Globulins Coagulation factors The most commonly infused plasma derivatives are reviewed in the next slides 15 Albumin 5% and 25% Major Uses Ascites patients undergoing large volume paracentesis greater than 5 litres (25% albumin) Spontaneous Bacterial Peritonitis (25% albumin) Hepatorenal syndrome (25% albumin) Plasma exchange procedures (5% albumin) 16 Storage & Expiration Administration Standard vented IV set – no blood tubing or filtering required. Bottles must be vented – Expires as indicated on most standard IV sets packaging have a vent that can be opened otherwise a vented set is required Begin infusion slowly then as tolerated Room temperature < 30° C Intravenous Immune Globulin (IVIG) Major Uses Storage & Expiration Replacement of immunoglobulins Storage variable by brand Control of some infections and autoimmune diseases Expires as indicated on packaging Administration Standard vented IV set – no blood tubing or filtering required Bottles must be vented – most standard IV sets have a vent that can be opened otherwise a vented set is required Compatible with D5W. Some brands are not compatible with normal saline. Infusion pump required Begin infusion slowly and increase as tolerated For maximum rate – check package insert/hospital policy as brand specific Frequent Vital Sign monitoring 17 required Rh Immune Globulin (RhIg) Major Uses Storage & Expiration Used for Rh-negative patients: 2-8° C Following exposure or possible exposure to Rh-positive blood To prevent sensitization to the Rh(D) antigen during pregnancy Expires as indicated on packaging Treatment of nonsplenectomized Rh-positive patients with Immune Thrombocytopenic Purpura (ITP) 18 Administration Administered usually IM but may be given IV Administered IV through a standard IV set May be given slow push usually by Physician Monitoring for hemolysis required Prothrombin Complex Concentrate (PCC) octaplex® Major Uses Reversal of warfarin (Coumadin®) or Vitamin K deficiency in bleeding patients and those requiring emergency surgery 19 Storage & Expiration 2-25° C Expires as indicated on packaging Use immediately once reconstituted Administration Full dosage may be pooled into an empty minibag Standard IV set – no blood tubing or filtering required Usually infused over 15 - 30 minutes May also be given slow push usually by Physician Dosage based on patient weight and INR value – usually 2 - 4 vials for adults Effect is immediate and lasts 6 - 12 hours For complete reversal, Vitamin K 10 mg. IV must also be given Assessment Quiz 20 1. Where can Red Blood Cells be stored? a. b. c. d. e. Ward fridge Medication fridge if only for a short time Blood Transfusion Laboratory fridge All of the above None of the above Answer: 21 2. A 17 year old female is admitted to Emergency after being hit by a car. She requires an immediate Red Blood Cell transfusion for active bleeding before her blood group can be determined. Which blood group is appropriate for this patient? a. b. c. d. e. Group AB positive Group O negative Group O positive Group AB negative Any blood group is appropriate in this urgent situation Answer: 22 3. The physician has ordered 3 units of plasma. The patient’s blood group is B negative. You are checking the first unit of plasma which is blood group B. What is the next step? a. Wait for the other 2 units of plasma to be ready and then start the transfusion b. After completing the bedside check begin the transfusion c. Contact the physician immediately d. Contact the Blood Transfusion Laboratory immediately to request B negative plasma Answer: 23 4. Which blood product is used to control significant bleeding in a patient who has been taking daily ASA? a. b. c. d. e. Albumin Cryoprecipitate Red blood cells Plasma Platelets Answer: 24 5. Which of the following must be transfused through a blood tubing? a. b. c. d. e. f. Platelets Intravenous Immune Globulin Albumin Rh Immune Globulin All of the above None of the above Answer: 25 6. For a red blood cell transfusion which blood groups are likely compatible for a patient whose blood group is A positive? a. b. c. d. A pos, A neg, O pos and O neg only A pos and A neg only A pos and AB pos only Apos, B pos, AB pos and O pos Answer: 26 7. An individual whose blood group is B negative has the following antigens and antibodies: a. B antigen on their red blood cells and anti-O antibodies b. A antigen on their red blood cells and anti-B antibodies c. B and D antigens on their red blood cells and antiD antibodies d. B antigen on their red blood cells and anti-A antibodies Answer: 27 8. Which of the following plasma derivatives would be appropriate for a patient actively bleeding who is on daily warfarin (Coumadin®)? a. b. c. d. e. Albumin Intravenous Immune Globulin Tetanus Immune Globulin Rh Immune Globulin Prothrombin Complex Concentrate (Octaplex®) Answer: 28 9. How should red blood cells be transfused? a. b. c. d. e. Using a standard IV set primed with D5W Using a vented IV set primed with D5W Over 5 to 6 hours Typically over 1 ½ to 2 hours Diluted with 200mL of Saline to decrease viscosity Answer: 29 10. Which of the following is True? a. In Canada blood is collected from volunteer donors by Canadian Blood Services b. The universal plasma for urgent transfusion is group B c. Plasma and cryoprecipitate do not need to be transfused through a blood tubing d. Platelets are not associated with any transfusion reactions Answer: 30 Assessment Quiz Answers 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 31 c b b e a a d e d a NAME: Blood Administration Made Bloody Easy Module 2 – Indications and Compatibility Date:_________ End of Module 2 Module 1 – Transfusing the Patient Module 2 – Indications and Compatibility Module 3 – Transfusion Reactions 33