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					MONITORING AND

   MAINTAINING

                   BLOOD

                         AND

BLOOD PRODUCT

 TRANSFUSIONS

 MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Credits:

We would like to thank the following people and companies for their assistance in providing technical
information for this course:

       Bonnie England - Canadian Red Cross-Blood Services
       Du-Pont Pharmaceuticals
       Baxter Health Care Corporation




                      MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
MONITORING AND MAINTAINING BLOOD AND BLOOD PRODUCT TRANSFUSIONS


COURSE DELIVERY METHOD

This course is for 12(2) certification. Its method of delivery will be as follows:
        Course material will be provided through web based courseware or by handout of course
           material which will be self paced study
        1 - 2 hour review inservice by Medical Director or his designate
        Written Examination
        Practical Examination



EVALUATION

The skill of monitoring and maintaining blood and blood product transfusions will be evaluated
according to the following format:
       1. Written Examination with minimum of 80%
       2. Practical Examination

The written examination will be compiled by the Medical Director. This exam will contain questions
based on lecture material and inservice handouts provided to participants of the course.

The practical examination process will be approved by the Medical Director and conducted by his
designate.


METHODS USED TO MAINTAIN COMPETENCY

Competency will be maintained for those who have received endorsement in the following manner:
     1. Through discussions held about the skill during regular Medical Director or inservice
        meetings
     2. Through bi-annual course material review


PERFORMANCE AUDITING

Performance will be audited by way of random analysis of cases where the skill has been used. The
Medical Director or his designate will evaluate the EMT-P's proficiency according to their standards of
acceptance. Further auditing will be conducted by PCR review of the case in which the skill was used.




                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
INTRODUCTION

This course for Monitoring and Maintaining Blood and Blood Product Transfusions is an approved
course that upon successful completion, will assist the EMT-Paramedic to achieve 12(2) endorsement
with Mountainview Regional Emergency Services, as described under the Health Disciplines Act of
Alberta.

This course is intended to familiarize the EMT-P with the procedure for monitoring and maintaining a
transfusion of blood or a blood product, while being observant for any reactions that may occur. Blood
products discussed in this module will include only those most commonly used and it is up to the
practitioner to familiarize himself with any individual product they may be transporting. Further it is
the responsibility of the practitioner to remain current with accepted standards of care.




                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Blood and its Role in the Human Body

Blood is a liquid form of connective tissue that has many roles, making it one of the most important
fluids in the body. Sometimes referred to as the “River of Life”, and its functions are transportation,
regulation and protection.

          Transportation                          Regulation                             Protection
     Carries oxygen from the             aids in the regulation of pH          Protects against disease
      lungs to body tissues.               through buffers and amino              through phagocytic white
     Carries CO2 from the body            acids                                  blood cells and antibodies.
      tissues to the lungs                essential in
     Moves nutrients from the             thermoregulation by                   Protects against blood loss
      stomach and digestive                allowing heat loss through             through clotting.
      organs to the cells.                 the skin (through
     Carries waste products               vasodilation) and heat                The process by which
      from body tissues to the             retention through                      blood is made is called
      kidney's, lungs and sweat            vasoconstriction                       Haemopoiesis.
      glands                               (restricting heat loss
     transports hormones from             through the skin)
      the endocrine glands to             regulates water content of
      target organs                        cells principally through
     transports enzymes to                dissolved sodium ions
      various cells




Characteristics of Blood



  Viscosity is 4.5 - 5.5
                                                                                          Hemoglobin is
        (Water is 1)
                                                                                         33.6 – 33.9 g/dl




   Blood is slightly
  heavier than water


                                                                                              Blood makes up about
                                                                                               8 % of body weight

  pH of blood is
COMPONENTS OF                                Salt concentration is
   7.35 to 7.45                                 0.85 to 0.9 %
                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
BLOOD

Blood is made up of 2 components, formed elements and plasma and each component is made up of
other specialized molecules. Following is a brief review of these 2 major components, the composition
of each and their individual functions.

PLASMA

Plasma is the straw colored fluid in which the formed elements are suspended. When blood has been
drawn and is allowed to settle, formed elements settle to the bottom and the plasma stays on top. When
centrifugal forces are applied to blood the plasma and formed elements are more thoroughly separated.
The following are some characteristics of plasma:

      plasma is mostly water (approx 92%)
      7-9% of plasma solutes are proteins (also known as plasma proteins)
      plasma proteins include:
           - albumin (produced by the liver)
           - globulins (antibody proteins)
           - fibrinogen (takes part in the blood clotting process along with platelets

      plasma transports substances that are needed by cells and substances that have been removed
       from the cells. Some of the substances transported to cells by plasma include:
           - ions such as sodium, chloride, calcium, etc
           - glucose and other sugars
           - amino acids
           - hormones
           - cholesterol and other fats
           - urea and other waste products
           - enzymes




                   Hematocrit                                         Complete Blood Count (CBC)
                             Hematocrit - is the                                             The complete blood
                             fraction of blood                                               count is the calculation
                             that is composed of                                             of the cellular content
                             red blood cells.                                                (formed elements) of
                                                                                             blood.
                             Normal hematocrit
                             (hct):
                              Male = 40.7 -
                                  50.3%
                              Female: 36.1 -
                                  44.3%




                      MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
FORMED ELEMENTS

Formed elements or the tissue part of the blood include erythrocytes, leukocytes and thrombocytes.
Below are relevant features of the formed elements:


                    Erythrocytes, also called red blood cells (RBC’s), are mature red blood cells that are
                    biconcave discs with a center that is depressed inward. This shape and structure allow for
                    maximal gas exchange, which occurs through diffusion. The following are important
                    features of erythrocytes:

                        are flexible, allowing them to temporarily change shape
    Erythrocytes




                         easily so they can get through capillaries.
                        upon maturation, erythrocytes remain functional for up to
                         120 days
                        several million hemoglobin molecules are present in each
                         erythrocyte
                        about 33 percent of the erythrocyte is hemoglobin
                        hemoglobin transports carbon dioxide and oxygen via
                         hemoglobin



                   Leukocytes, also called white blood cells (WBC’s), are less abundant than red blood cells
                   by a ratio of 1:700 and are responsible for
                   protecting the body against infection from
    Leukocytes




                   malicious bacteria and virus. Leukocytes function
                   within the immune system as well as by
                   phagocytosis, each of which are dependant on the
                   other. There are numerous types of leukocytes each
                   of which have their own life cycle and can range
                   from between 10 days and 15 years.


                   Thrombocytes, also known as platelets, are formed in the bone
    Thrombocytes




                   marrow, and have a life span of 7 – 10 days. Their primary role is in
                   the control of bleeding. Platelets are activated when bleeding occurs
                   and through a chemical reaction, are caused to clump together causing
                   a platelet plug at the site of bleeding. This reaction also causes other
                   clotting mechanisms to become engaged.


.




                                MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Blood Types and Crossmatching Relating to Transfusions

                                                                      Can Give              Can Receive
         Blood Group – Antigens and Antibodies
                                                                      Blood To              Blood From
               Blood group A
     If you belong to the blood group A,
     you have A antigens on the                                           AB                AB, A, B, 0
     surface of your red blood cells and
     B antibodies in your blood plasma.
               Blood group B
     If you belong to the blood group B,
     you have B antigens on the                                      A and AB                A and 0
     surface of your red blood cells and
     A antibodies in your blood plasma.
               Blood group AB
     If you belong to the blood group
     AB, you have both A and B
     antigens on the surface of your red                             B and AB                B and 0
     blood cells and no A or B
     antibodies at all in your blood
     plasma.
                Blood group O
     If you belong to the blood group O,
     you have neither A or B antigens
     on the surface of your red blood                               AB, A, B, 0                 0
     cells but you have both A and B
     antibodies in your blood plasma.




                     MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
The Rh Factor
There is also an Rh factor on the red blood cell's surface which is considered an antigen. When it is
present, it is considered to be Rh+ and Rh- when it isn’t present. A person with Rh- blood does not
have Rh antibodies naturally in the blood plasma (as one can have A or B antibodies, for instance). But
a person with Rh- blood can develop Rh antibodies in the blood plasma if he or she receives blood from
a person with Rh+ blood, whose Rh antigens can trigger the production of Rh antibodies. A person with
Rh+ blood can receive blood from a person with Rh- blood without any problems.

Because of these patterns, a person with type O blood is said to be a universal donor. A person with
type AB blood is said to be a universal receiver. In general, however, it is still best to mix blood of
matching types and Rh factors.


CROSSMATCH TESTS

A cross match consists of testing the patient's serum against a sample of red cells from the actual unit
that is going to be used for transfusion. There are two types of cross matches:

      The Immediate Spin Crossmatch is accomplished by mixing the patient's serum with a sample
       of RBC from the unit selected for transfusion and observing for immediate agglutination and/or
       hemolysis (as will be caused by ABO antibodies). The immediate spin cross match takes about
       5 minutes to complete.
      A full crossmatch is done by incubating the patient's serum with the cells to be transfused for 15
       minutes, then observing for agglutination and performing an antiglobulin test. The full cross
       match test takes about 30 minutes to perform.




                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Transfusion Products

There are several types of products available for transfusion, most of which are derived from whole
blood but some are synthetically produced. In this section only the following commonly used products
will be reviewed:

               Products from Whole Blood                     Synthetic Transfusion Products
       There are several components that make up        Synthetic colloid like products are also
       blood and then several sub-components that       available and are used to replace or augment
       make up these components. Almost all             transfusions of blood or blood products.
       individual constituents can now be separated     Several are in use including:
       and stored for individual use.
                                                                Pentastarch
               Red Blood Cells                                 Dextran
               Plasma                                          Hypertonic Saline
               Platelets                                       Hemasol
               Fresh Frozen Plasma
               Coagulation Factors
               washed RBC's
               Albumin
               Immune Globulins



A person who has donated blood usually gives up about 450 ml of blood (whole blood) which is then
taken to a processing site where individual components are separated. Once separated, they are
packaged and stored using different types of containers and temperatures. This leads to optimum shelf
life of each product.

The main purpose of these synthetic products are for volume expansion and to keep fluid from leaking
out of the vascular space.




                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
PACKED CELLS (RBC'S)

Packed cells are derived from whole blood by separating the formed elements from the plasma using
either gravity or centrifugal methods. The plasma is removed and the remaining
formed elements are repackaged for later use. Through this process, some of the
WBC's and platelets may have been removed. A unit of packed cells has a
volume of 240 - 340 ml. Use of RBC's instead of whole blood offers a reduced
risk of circulatory overload, reduced incidence of transfusion reactions related to
plasma components and reduced quantity of anticoagulants and electrolytes.


                  Indications
            Anemia unresponsive to                                      Dose
             medication                                        dependent on the clinical
            Acute (significant) blood                          situation and/or the
             loss                                               hemoglobin
                                                               (each unit of red cells
                                                                should raise the
                                                                hemoglobin concentration
                                                                by 10 - 15 g/l in the
                                                                average adult)




                         Administration
                                                                          Contraindications
                   transfusion should not
                    exceed 3.25 - 4 hours                               hypovolemia without
                   use tubing with inline                               significant red cell mass
                    blood filter only                                    defecit
                   see also general                                    anemia which can be
                    administration principles                            corrected with
                                                                         medications




                    SIDE EFFECTS AND HAZARDS

                         See transfusion complications




                        MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
ALBUMIN 25%

Albumin is one of the major plasma proteins in the blood, responsible for viscosity of blood and aids in
the regulating blood volume by preventing diffusion of water and electrolytes out of
the blood (into the interstitial fluid).

Albumin 25% is an hyperoncotic colloid. It has an oncotic equivalent of 5 times
the volume of normal human plasma. When administered, albumin 25% is
equivalent to giving 5 times the amount of normal human plasma.

                  Indications
         blood volume expansion in
          hypovolemic shock                                         Dose
                                                        based on the clinical situation
         maintenance of colloid osmotic
          pressure in extensive burns or                 and the Physicians orders
          acute liver failure
         fluid replacement during
          therapeutic plasma exchange
         renal failure




                  Contraindications                                        Administration
             known hypersensitivity                                 use only the supplied
             in patients whom a rapid                                administration tubing
              increase in circulating volume                         document time each new bottle
              would be harmful                                        was started
                                                                     see also general administration
                                                                      principles




                                SIDE EFFECTS AND HAZARDS
                         allergic reaction (rare)              dilutional anemia
                         hypotensive reaction                  circulatory overload
                           (rare)
                         pyrogenic reactions
                           (rare)
                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
PLASMA (and Fresh Frozen Plasma)

When whole blood has been separated and formed elements removed, the remaining component is
plasma. This plasma is then anticoagulated, repackaged and frozen for
later use.

Plasma and Fresh Frozen Plasma are virtually the same product. All
plasma proteins are available as well as all clotting factors. The
difference is the amount of Factor V and Factor VIII (clotting factors) in
each. Fresh Frozen Plasma is frozen within 8 hours of collection.
Plasma is processed in 8 - 72 hours following original collection and frozen. Factor V and Factor VIII
deteriorate quickly (past 8 hours) and so concentrations are reduced in Plasma. Levels remain within
normal ranges in Fresh Frozen Plasma.

               Indications                                                   Dose
      Replacement of multiple                                    As ordered by the physician
       clotting factors
      Temporary volume expansion
       (during or after very rapid
       infusion of RBC's)
      Disseminating Intravascular
               .
       Coagulation




           Contraindications                                             Administration
      no specific contraindications
       but is not recommended to be                                use inline blood filter set only
       used alone for the correction of                            see also general administration
       hypovolemia (if at all)                                      procedures




                                  SIDE EFFECTS AND HAZARDS
              may cause circulatory overload
              infectious diseases can be transmitted
              allergic reactions may occur
                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
PENTASTARCH (PENTASPAN)

Pentastarch is an artificial colloid derived from a waxy starch composed almost entirely of a pectin type
material. This is a product with a molecular weight that is suitable for use as a plasma volume
expander. Pentastarch is amber to pale yellow and clear. Infusion of pentastarch results in expansion
of plasma volume in excess of the volume infused and persists for 18 - 24 hours. Pentastarch can be
expected to improve hemodynamic status for 12-18 hours.

                    Indications                                            Contraindications
                                                                    known hypersensitivity to
         when plasma volume expansion is
          desired in the management of shock                         hydroxyethyl starches
                                                                    bleeding disorders
          due to hemorrhage, surgery, sepsis
                                                                    congestive heart failure where fluid
          burns or other trauma.
                                                                     overload is a potential problem.
                                                                    renal disease with oliguria or anuria
                                                                     unrelated to hypovolemia




                               Dosage
                 Acute Hemorrhage = 20 ml/kg/hr
                 do not exceed 2000 ml/day or 28
                  ml/kg
                 standard intravenous infusion tubing
                  may be used for this product




                                      Warnings and Precautions
   pentastarch may precipitate circulatory overload. Monitor patient carefully and frequently
   large volumes may alter coagulation mechanisms
   hypersensitivity has been seen and responds well to antihistamines
   administration of large amounts may decrease hemoglobin concentration and dilute plasma proteins
    excessively.
   caution in pregnancy and in nursing mothers - benefits must outweigh risks
   pediatric use has not been studied.
   be especially attentive to patients with impaired renal clearance (this is how pentastarch is
    eliminated)



                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
PENTASTARCH (cont.)

                                          Adverse Effects

        Coagulation disorders          Nausea                              Increased heart rate
        Fever                          Parasthesia                         Chest pain
        Edema                          Dizziness
        Weakness                       Diarrhea
        Temporary weight gain          Fatigue

         Ld50* (female) = 19.8 g/kg              Ld50* (male) = 18.1 g/kg




                   MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Other Products Used for Transfusion

Platelets
The major indication for platelet transfusion is the treatment or prevention of bleeding in profoundly
thrombocytopenic patients with bone marrow failure due to malignancy and/or suppressive therapy.
Platelets are also infused when there is platelet dysfunction.


Coagulation Factors
Coagulation factors should be administered according to the sending hospitals guidelines and the
physicians orders. Some coagulation factors you may see include:

      Cryoprecipitate – a fibrinogen replacement used in patients with von Willebrand’s Disease or in
       hemophilia when Factor VIII is not available
      Factor VIII Concentrate – used primarily in patients with hemophilia


Washed RBC’s
Washed Red Blood Cells are packed RBC’s that have most of the used in situations where a patient has
previously experienced non-hemolytic febrile reactions or have had severe allergic reactions to blood
products.

Gamma (Immune) Globulins
Gamma globulins are specialized proteins (antibodies) made by the body's immune system. They are
obtained from the pooled plasma of healthy blood donors. When administered, they provide passive
immunity or alter the immune response by increasing the individual's antibody titer and antigen-
antibody reaction potential. These products are generally given IM but some are given intravenously.
When monitoring the transfusion of these products, adjust the flow rate according to the physicians
orders


Dextran
Dextran is a sugar containing solution (not a blood product) that is very hypertonic which promotes
movement of fluid into the vascular compartment thus increasing the intravascular volume. Infusion
rates should be maintained according to physicians orders.




                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Transffusiing Bllood iin Pediiattriic Pattiientts
Trans us ng B ood n Ped a r c Pa en s
The procedure of transfusing blood and blood products in the pediatric population should be essentially
the same as in the adult population. While it is uncommon to see a pediatric patient receiving blood
products in the prehospital setting, you should maintain the infusion (generally) as you would an adult
while considering the following:

Blood Preparation/Administration
There are smaller packs of blood products available for neonates and smaller children. Ensure that you
obtain a copy of the procedure the staff are using when administering these products. In some cases
blood will be administered via syringe pump.

Hypothermia
Warming of blood products is usually not done and not necessary in most cases. When large amounts
of blood products are administered there is a chance that your patient may become hypothermic
(especially small children). While managing these kids, ensure that you maintain their temperature
using warmed blankets and keeping the ambient temperature at a suitable level.

Circulatory Overload
A standard dose for pediatric blood transfusions would be 10 to 20 ml/kg for 15 to 30 minutes,
depending on patient status. Volume overload is a constant concern in pediatrics and there is a much
smaller margin for error in estimating blood volumes for pediatric transfusions. A maximum volume
for transfusion should be established prior to transfusion and continual monitoring of circulatory status
should be maintained.

Cross-matching
Neonates and infants under four months of age rarely form antibodies in response to foreign red cell
antigens. For this reason, cross-matching may be omitted when providing blood for this group.
However, due to their relatively small blood capacity, coagulation occurrences may be more severe and
life-threatening should incompatibility occur.

Reactions
Due to less advanced compensatory mechanisms, smaller total surface areas, and smaller total blood
capacities, reactions during transfusions for pediatric patients may be more severe. Careful monitoring,
quick action and the availability of pediatric resuscitative equipment must be ensured.

Intraosseous Transfusion
Blood and blood products can be delivered via the intraosseous route safely and without any hemolysis
of red blood cells. The transfusion product can also be pressure infused using standard pressure
infusion devices without significant hemolysis.




                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
COMPLICATIONS OF TRANSFUSION

Transfusion reactions are adverse effects that occur directly from the administration of blood and/or
blood products. The can be immune response reactions or can occur as a result of contaminated blood.

Despite all precautions that are taken in the process of administering blood or blood products, there is
always a possibility that the patient may develop a transfusion reaction of some sort. Transfusion
reactions occur in about 3% of patients receiving blood or blood products and the severity of the
reaction varies greatly. It is rare that a patient dies from a transfusion reaction. Half of all acute
hemolytic reaction deaths occur as a result of administrative errors, particularly in the lab. It is
estimated that there is one death in about 500,000 as a result of mismatching of the patient and the unit
of blood.

While transporting patients with blood or blood producti s it is essential that you be attentive to signs or
symptoms that may be indicative of such reactions. If you believe that your patient is experiencing a
transfusion reaction, you should proceed in the following manner:

        Stop the transfusion immediately to limit the amount of blood infused.
        Keep the intravenous line open with infusion of 0.9% normal saline.
        Reassess your patient, ensure adequate ABC’s
        Manage any signs/symptoms supportively.
        Inform receiving hospital of your concerns.
        Do not discard used bags. They may be required for further testing.


         Anaphylaxis                   Treat according to the Anaphylaxis Protocol and patient condition

         Febrile Reaction                  Administer acetaminophen PO (if available)

See also, Appendix A for more on managing transfusion reactiions




                             MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
    Type                 Signs and Symptoms                                          Causes


                                                                  Immediate intravascular hemolysis is
                                                                  most often due to ABO incompatibility
                Fever, chills, chest pain, hypotension,
                                                                  and this is due to clerical or
                nausea, dyspnea, flushing, tachycardia,
                                                                  administrative error
 Hemolytic      anxiety, generalized bleeding, DIC, back
                pain, oliguria, anuria, pain at infusion
                                                                  Delayed intravascular or extravascular
                site, hemoglobinuria, shock, rigors
                                                                  hemolysis due to antibodies unrelated
                                                                  to the ABO system


                Fever (>2OC rise in temperature without           Leukoagglutinins
   Febrile      other explanation) chills, rigors,                Platelet antibodies, pyrogens bacterial
                headache, nausea, vomiting                        contamination


                                                                  Patient allergy to soluble product in
  Allergic      Local erythema, hives, itching
                                                                  donor plasma

                Coughing, bronchospasms, abdominal
                                                                  Anti-IgA antibodies in IgA deficient
Anaphylaxis     cramps, vomiting, diarrhea, hypotension,
                                                                  patients
                loss of consciousness

Circulatory     Coughing, cyanosis, dyspnea, tightness            Hypervolemia due to excess volume or
 Overload       in chest, headache                                speed of infusion

     Non-
Cardiogenic
  pulmonary
    edema                                                         WBC aggregates due to donor leuko-
                      Pulmonary edema, dyspnea
   (TRALI:                                                        agglutinins vs. recipient WBC’s
 transfusion
related acute
 lung injury)




                    MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Preparing the Infusion

The principles of preparing the blood administration set is similar to that of a standard IV tubing keeping
the following in mind:

      Reserve the port that is more inline with the tubing
       for the blood and the other for the saline.
      When filling the drip chamber, ensure that it is filled
       past the filter. This will ensure that the filter does not
       become clogged with debris prematurely.
      Attach only normal saline to the blood tubing:
           o Ringers Lactate and other calcium containing
               substances promote clotting
           o Dextrose containing solutions cause the red
               blood cells to hemolyze.
           o 5% Albumin, plasma protein fraction or compatible plasma may be given through the
               same line as the blood product
      The normal saline attached to the blood tubing cannot have any medication added to it.


Blood tubing will need to be changed in any of the following situations:

      2 consecutive units have been given (especially with RBC’s, albumin or
       fresh frozen plasma)
      4 hours has elapsed for the infusion
      A single infusion of certain products (such as Immune globulins,
       cryoprecipitate, or platelets) has been completed
      The filter has become occluded with clots
      The infusion does not run in spite of troubleshooting efforts




                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
GENERAL ADMINISTRATION PRINCIPLES


1. Temperature, Pulse and Respirations should be taken every 15 mins.

2. Blood out of the fridge and not kept chilled for more than 20 mins. should not be used.

3. If the clinical situation allows, each unit of blood or blood product should be infused at the rate of 5
   ml/min for the first 15 minutes to observe for any immediate reactions.

4. Maximum infusion time should be 3.25 hours. This prevents bacteria from growing as the blood
   becomes warm.

5. The administration set should be changed after every 2 units of blood (ideally) or at least every 4
   hours.

6. If you attach a new bag, take one sticker from it and attach it to your paperwork or to the paper
   work that accompanies the patient from the hospital.

7. Intravenous catheter size should be at least 19g. Smaller catheters can be used but the rate of
   infusion will be substantially slower and if pressure infused, the RBC’s may be destroyed.

8. Increase flow rate of blood cells by adding a small amount of normal saline through one limb of the
   Y connection at the same time the blood is running.

9. If medications will be required, start another intravenous for this purpose.

10. Warming of blood is usually not necessary but if it is done, use approved warmers only. DO NOT
    MICROWAVE BLOOD - hemolysis may occur.

11. If the transfusion is complete and there are no other IV sites, you must change the IV tubing as soon
    as you can.

12. When pressure infusing blood, don’t use a blood pressure cuff. Uneven pressures are put against
    the bag and leaks may develop. Standard pressure infusion devices can be used.

13. The most common problem associated with transfusions (especially with RBC’s) is that the
    infusion runs too slowly or stops. Follow the procedures below to troubleshoot the problem:

          Elevate blood container.
          Check patency of needle
          Check that the needle is sufficiently large.
          Examine filter for excess debris.
          Examine blood bag for presence of clot.
          Add normal saline 50 to 100 cc to the blood bag.


                       MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
CONCLUSION

The skill of monitoring and maintaining blood and blood product transfusions is not a difficult one.
One must be aware of the reason for the product being transfused, any side effects/hazards and the rate
at which the transfusion should be administered. Most importantly, the EMT-P should be aware of and
alert to the possibility of transfusion reactions. Identification and treatment of a transfusion reaction is
of utmost importance when transporting a patient with blood/blood product transfusions.




                        MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Appendix A

The following flowchart illustrates the management of specific transfusion reactions. Ensure that you follow
your local protocols.




                           MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
Appendix B
BLOOD AND BLOOD PRODUCT TRANSFUSION - COMPLICATION STATISTICS

Here are some interesting statistics provided by the Bureau of Biologics regarding complications of Transfusion:

In Canada, there are 1,000,000 units of whole blood collected annually, and from these:
            800,000 of whole blood and RBC's are processed
            500,000 units of platelets are produced and 350,000 are used
            67,000 units of cryoprecipitate are produced and 57,000 are used
            92,000 units of Fresh Frozen Plasma are produced and 82,000 are used

It is felt that throughout the world, there is under reporting of deaths related directly to blood transfusions (yes,
even in Canada). Therefore the following statistics do not accurately reflect the actual number of complications.

Generally speaking, the following statistics are relevant for complications arising from transfusions in Canada
(consider the above numbers). These statistics were averaged from three years of data.
   There are 5 deaths per year that may be related to blood transfusions and of these 5 deaths;
       . 3 (60%) are probably related to the transfusion of a blood product
       . Some of these deaths are not "clear cut" as to the cause being related to the transfusion
       . Of these deaths, "most" are from Acute Hemolytic Transfusion Reaction.
          It was pointed out that Acute Hemolytic Transfusion Reaction is a result of
       HUMAN ERROR !!!!
       . Approximately 20% are a result of bacterial contamination

The following numbers have been collected from the USA from 1995 and concerns the estimated risk of various
complications following transfusion of blood products:
Hemolytic reactions (and most are minor) = 1/6000
Fatal reaction                           = 1/600,000
HIV Transmission                         = 1/420,000
Bacterial                               = 1/2500
Anaphylaxis                              = 1/500,000

It was emphasized that deaths from HIV (attributed to transfusion infection) were not considered in the
estimation of transfusion related deaths.


Thanks to Dr. Farid Hindieh of the Bureau of Biologics
for his kind assistance in compiling the above statistics




                            MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
REFERENCES

  1. Canadian Red Cross Society. Clinical Guide to Transfusions (3ed), 1993

  2. Canadian Red Cross Society. Circular of Information. February 1994

  3. Williams, W.J., Buetler E., Erslev A.J. Lichtman M.H.           Hematology (3ed), 1983, McGraw Hill Book
     Company.

  4. Tortora G.J., Grabowski S.R. Principles of Anatomy and Physiology (8th ed) 1996, Harper Collins
     Publishers Inc.

  5. Goodnough L. T., Brecher M. E., Kanter M. H., AuBuchon J. P. , Medical Progress: Transfusion
     Medicine - Blood Transfusions N Engl J Med 1999; 340:438-447, Feb 11, 1999.

  6. de la Roche MR, Gauthier L. Rapid transfusion of packed red blood cells: effects of dilution, pressure,
     and catheter size. Ann Emerg Med. 1993 Oct;22(10):1551-5.

  7. David Thompson Health Region – Standard of Practice Guidelines for Blood Product Administration
     (2004/03/04)

  8. Blood Transfusion Manual – London Health Sciences Center 1999




                         MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
NOTES




        MVRES Monitoring and Maintaining Blood and Blood Product Transfusion
AB0 blood grouping system

According to the AB0 blood typing system there are four different kinds of blood types: A, B, AB or 0 (null).




Rh factor blood grouping system




                           MVRES Monitoring and Maintaining Blood and Blood Product Transfusion