Bt complications

Nelia B. Perez RN, MSN

Complications, Nursing Complications, Nursing Interventions and Preventive Interventions and Preventive Measures of Blood Measures of Blood TransfusionTransfusion

InfiltrationThrombophlebitisCirculatory OverloadAir EmbolismCatheter embolism infectionTransfusion Reaction

InfiltrationInfiltration

– A substance (blood) that passes into the tissues and forms an accumulation of the blood to the skin

Manifestations:– Blanching of skin– Swelling, pain at site– Cool to touch– Decreased infusion rate

Nursing Interventions:– Discontinue IV– Restart in a new site– Apply warm compress to increase fluid

absorption

Preventive Measures:– Check the IV site before starting the transfusion– Monitor the site during the transfusion– Inspect the site thoroughly.– Make sure that a main line is set before starting

the transfusion.

ThrombophlebitisThrombophlebitis

– Inflammation of a vein with formation of a thrombus / clot

Manifestations:Manifestations:– Redness, heat & swelling at site– Possible pain– Red line along course of vein

Nursing Interventions:Nursing Interventions:– Discontinue IV– Restart in a new site– Apply warm compress to site

Preventive MeasuresPreventive Measures:– Check the site before transfusion– Monitor and inspect the site during and after

the transfusion– Inquire and tell the patient to notify you if any

sudden awkward feeling is felt– Check the integrity of the IV line and patency

Circulatory OverloadCirculatory Overload

– Too rapid infusion of the blood causing fluid volume overload to the patient

Manifestations:Manifestations:– Apprehension, shortness of breath– Coughing, frothy sputum, crackles– Engorged neck veins– Increased central venous pressure and

jugular vein pressure– Increased blood pressure and pulse

Nursing Interventions:Nursing Interventions:– Stop the infusion / Slow down IV rate– Inform the doctor at once.– Monitor CVP through a separate line– Maintain the I.V. infusion with normal saline solution– Administer oxygen.– Elevate the patient’s head.

Preventive Measures:Preventive Measures:– Always monitor the patient’s vital signs before, during

and after blood transfusion– Transfuse blood slowly.– Don’t transfuse more than 2 units of blood in 4 hours.– Have oxygen readily available at the bedside of the

patient.

Air EmbolismAir Embolism

– Obstruction of the circulation by air that has gained entrance to veins usually caused by empty IV lines and sets

– Blood given under air pressure following severe blood loss

Manifestations:Manifestations:– Dyspnea, cyanosis, hypotension, tachycardia– Loss of consciousness– Wheezing, chest pain

Nursing Interventions:Nursing Interventions:– Stop infusion immediately– Clamp tubing– Turn client to the left with his left down– Administer oxygen– Inform the doctor

Preventive Measures:Preventive Measures:– Have a clamp accessible at the bedside– Check the patient and site and line every now

and then– Monitor the time of the transfusion.

Catheter Embolism InfectionCatheter Embolism Infection

Clogging of the catheter set causing obstruction of a blood vessel by a clot or particle that leads to development of infection

Manifestations:Manifestations:– Fever, shills, flushing, tachycardia

Nursing Interventions:Nursing Interventions:– Stop the transfusion at once.– Replace the whole set.– Inform the doctor.– Open the main line

Preventive Measures:Preventive Measures:– Monitor patient’s vital signs.– Use a blood set with filter and check the patency of the whole

set before transfusion.– Assess patient for occurrence of signs and symptoms of fever.– Inspect the blood before the transfusion.– Change the blood tubing and filter every 4 hours.– Infuse each unit of blood over 2 to 4 hours; terminate the

infusion if the time period exceeds 4 hours.– Maintain sterile technique when administering blood

products.

Transfusion ReactionTransfusion Reaction

Includes Hemolytic, Allergic, Pyrogenic, Anaphylactic– Caused by ABO & Rh incompatibility, allergic

antigenManifestations:Manifestations:

– Fever, chills, headache, lumbar or sternal pain, palpitations, tachycardia, urticaria, laryngeal edema, bronchospasm,

– Flushing, heat along vein

Nursing Interventions:Nursing Interventions:– Stop the IV at once.– Continue main IV– Inform the doctor– Give medicines as prescribed– Send blood and urine specimen for work-up

Preventive Measures:Preventive Measures:– Have a thorough assessment of the patient before

hand. Take note of the occurrence of any allergies.– Monitor patient’s vital signs.– Always check the line, site, and set for the validity

and availability of the company…

Citrate IntoxicationCitrate Intoxication

– Large amounts of citrated blood in patients with decreased liver function.

Manifestations:Manifestations:– Neuromascular irritability– Bleeding due to decreased calcium– Cardiac arrhythmias– Hypotension– Muscle cramps– Nausea and vomiting– Seizures– Tingling in the fingers

Nursing Interventions:Nursing Interventions:– Monitor and treat hypocalcemia

– Encourage patient to eat foods rich in calcium

– Monitor how many blood bags already infused to the patient.

– Monitor calcium and citrate level if with multiple transfusions

Preventive Measures:Preventive Measures:– Remind the doctor about how many blood bags

already infused to the patient

– Avoid using citrated blood

– Monitor liver function

– Have calcium gluconate available in your unit.

WHAT TO DO IF TRANSFUSION WHAT TO DO IF TRANSFUSION REACTION OCCURS…REACTION OCCURS…

When they do occur, it is usually because of ABO incompatibility between patient and donor during transfusion of red cells.

Ensure that the intended recipient is getting the intended unit at the time of transfusion.

Acute Transfusion Reactions Acute Transfusion Reactions signs and symptoms will usually appear within the first 5-15 minutes after the transfusion is started, but can happen anytime during the transfusion.

Types of Acute Transfusion Reactions:Types of Acute Transfusion Reactions:– Acute hemolytic Transfusion Reaction

– Febrile nonhemolytic Transfusion Reaction

– Mild allergic (Urticarial)

– Anapylactic

– Transfusion Associated Circulatory Overload

– Transfusion – Related Acute Lung Injury

– Septic Transfusion Reaction

Symptoms you might see during an acute acute transfusion reactiontransfusion reaction include:

– Temperature increase of more than 1°C or 2°F – Bloody urine – Chills – Hypotension – Severe low back, flank, or chest pain – Low or absent urine output – Nausea and vomiting – Dyspnea, wheezing – Anxiety, "sense of impending doom" – Diaphoresis – Generalized bleeding, especially from punctures

and surgical wounds.

Should any of these symptoms occur, discontinue the unit immediately, hang normal saline (on a new tubing) to maintain vascular access, and call for assistance.

Closely monitor the patient’s vital signs and symptoms.

Notify the physician and obtain further orders to address the patient’s symptoms.

Recheck the patient’s identifying information against the transfusion record and blood bag.

All bags, tubings, filters, and paperwork should be retained and forwarded per hospital policy.

Importance of Giving Health Importance of Giving Health Education to Patients and FamilyEducation to Patients and Family

It can establish rapport to you and the patient and family.

Tension will be lessen on their part and anxiety will be alleviated.

To enlighten them the real concept of blood transfusion therapy.

It serves as a channel and communication between you and your patient.

The client’s major concern is likely to be the safety of the transfusion, specifically the risk of contracting AIDS.

Provide accurate information for the client, and begin efforts to ensure a safe and effective transfusion before the blood or component is collected.

Date and time the transfusion was started and completed

Name of the health care professional who verified the information of the patient and the blood

Catheter type and gaugeTotal amount of the transfusionPatient’s vital signs before and after the

transfusion

DOCUMENTING BLOOD DOCUMENTING BLOOD TRANSFUSIONSTRANSFUSIONS

Infusion device usedFlow rate and if blood warming was usedVital signs obtain prior to, during, and after

the transfusionName of the component, unit numberEvidence of possible transfusion reaction.

– Document interventions done and to whom you notified.

Patient’s outcome.

Date Time

12/12/08

2:00 pm

D = Patient reports nausea and chills

= Cyanosis of the lips noted at 1:50 pm, with PRBCs transfusing

A = Infusion stopped. Approximately 100 mL infused.

= Tubing changed of 1,000 mL of D5NSS infusing at KVO rate in right arm.

= Notified Dr. X.

= BP:170/90, Pulse Rate: 104, Respiratory Rate: 25, Temperature: 36.0°C.

= Blood sample taken from PRBCs. Urine specimen also sent out to lab for urinalysis.

= Gave patient diphenhydramine 50mg via IV as prescribed by the doctor.

= Two blankets placed on patient.

R = Patient reports he’s getting warmer and less nauseated.

= BP: 148/80; Pulse Rate: 80; Respiratory Rate: 20; Temperature: 36.8°C.

= Patient no longer complaining of nausea or chills.

---------------------------------------------------------------- Ram M. Mar, R.N.

TWELVE SIMPLE STEPS NECESSARY IN TWELVE SIMPLE STEPS NECESSARY IN CARING FOR A PATIENT RECEIVING BLOOD CARING FOR A PATIENT RECEIVING BLOOD TRANSFUSIONTRANSFUSION

STEP 1: OBTAIN PATIENT’S TRANSFUSION HISTORY

STEP 2: SELECT A LARGE GAUGE NEEDLE OR CATHETER

STEP 3: CONSIDER THE TUBING & FILTER’S PORE SIZE

STEP 4: FOLLOW PROTOCOL TO OBTAIN THE BLOOD PRODUCT ACCORDING TO HOSPITAL

POLICY

STEP 5: IDENTIFY THE BLOOD PRODUCT & THE PATIENT

STEP 6: OBTAIN BASELINE VITAL SIGNS & RECORD

STEP 7: USE 0.9% NORMAL SALINE FOR THE STARTER SOLUTION

STEP 8: START THE TRANSFUSION SLOWLY

STEP 9: MAINTAIN THE PRESCRIBED TRANSFUSION RATE

STEP 10: MONITOR PATIENT’S V/S & DOCUMENT

STEP 11: OBSERVE FOR ANY ADVERSE REACTION

STEP 12: COMPLETE THE NECESSARY PAPERWORK

Calculation of IV Flow RatesCalculation of IV Flow Rates

Calculation of cc/hr is essential in most IV therapy.

Volume

# of hrs

E.g. 1 L over 8 hrs = 125 cc/hr

50 cc over 20 minutes = 150 cc/hr

= cc/hr

Computations of flow and Computations of flow and drip ratesdrip rates

Calculation of gtt/min (Long Method)Calculation of gtt/min (Long Method)STEPS :

1. Need to know cc/hr to calculate2. Gtt factor = gtt / ml

gtt factors : macrodrip 10, 15, 20 gtts/ml microdrip 60 gtt/ml

EXAMPLE : LONG METHODDoctors Order : Run 1L D5W over 8 hours

Microdrip - 1000 ml ÷ 8 hours = 125 cc/hr

125 cc x 60 gtt/ml = 125 gtt/ml 60 min 1

10 gtt/ml set 125cc x 10 gtt/ml = 20 – 21 gtt/min 60 min 1

15 gtt/ml set 125cc x 15 gtt/ml = 31 gtt/min 60 min 1

20 gtt/ml set 125 cc x 20 gtt/ml = 41 – 42 gtt/min 60 min 1

SHORT METHOD

cc / hr ÷ 6for 10 gtt / min

cc / hr ÷ 4for 15 gtt / min

cc / hr ÷ 3for 20 gtt / min

cc / hr = gtt / min for microdrip set

10 Rights in Safe Drug Administration10 Rights in Safe Drug Administration• Right DRUG

• Right PATIENT

• Right DOSE

• Right ROUTE

• Right TIME

• Right DOCUMENTATION

• Right PATIENT’S HISTORY

• Right DRUG ALLERGIES

• Right DRUG-DRUG, DRUG-FOOD INTERACTION

• Right HEALTH EDUCATION