Infusion Therapy Packed Red Cells Using Microaggregate Blood Filter Set Administration

Infusion Therapy – Packed Red Cells Using Microaggregate Blood Filter Set Administration SECTION: 25.29 Strength of Evidence Level: 3 __RN__LPN/LVN__HHA

PURPOSE: 5. A caregiver able to assist the nurse administering To replace red blood cells (RBCs) lost due to anemia or the transfusion and capable of observing the patient to restore blood volume due to chronic occult blood loss. for adverse effects of transfusion must be present A microaggregate filter is used to filter out cellular debris during and after the transfusion. in addition to filtering out white blood cells that may 6. The physician must be readily available by phone cause febrile, nonhemolytic reactions. This procedure is and may be notified at the start and conclusion of a rarely done in the home healthcare setting. transfusion. 7. Patients may be pre-medicated with Lasix, Benadryl TYPES OF CELLS: and/or Tylenol prior to transfusion. a. Oral medications should be given 30 minutes 1. Packed cells, red cell mass, whole blood with the prior to transfusion. plasma removed - approximate volume 250 mL. b. IV medications should be given immediately 2. Leukocyte-poor RBCs are prepared by prior to transfusion. centrifugation or saline washing and contain few 8. Emergency medications or an anaphylaxis kit must white blood cells (WBCs), platelets and minimal be available. Most adverse reactions occur within plasma - approximate volume 200 mL. the first 15 minutes. 3. Frozen thawed, deglycerolized RBCs contain 9. Use at least 2 patient identifiers prior to minimal WBCs and no plasma - approximate administering medications. volume 180 mL. 10. Per Joint Commission recommendations, all tubes 4. AS-1 red cells is a new product to which ADSOL and catheters should be labeled to prevent the (AS-1), an additive that extends the shelf life of a possibility of tubing misconnections. Staff should unit to 49 days, is added to red cells after the emphasize to all patients the importance of plasma has been removed (can be used in place of contacting a clinical staff member for assistance whole blood or packed red cells) - approximate when there is an identified need to disconnect or volume 300 mL. reconnect devices. CONSIDERATIONS: PRECAUTIONS: 1. Packed red cell transfusions consisting of no more 1. If the patient has a temperature above 100.3 than 500 mL in 24 hours are to be given to patients degrees Fahrenheit orally, notify the physician with severe anemia and relatively normal blood before proceeding with procedure. volume. For these patients, transportation to the 2. Assure accessibility to venous access prior to hospital for a transfusion would be physically obtaining blood from the blood bank, if possible. exhausting. 3. The blood must be stored in an ice-packed cooler 2. Disease states in which home therapy may be with the temperature ranging between 1-10 degrees applicable include: Celcius during transportation from blood bank to a. Chronic gastro-intestinal bleeding. patient home. b. Anemia in the presence of chronic renal 4. A new blood filter is used with each unit of blood disease. infused. c. Anemia with bone marrow transplant. 5. Normal saline is the only IV solution that should be d. Anemia associated with malignancy. used with a blood transfusion and should both e. Sickle cell anemia. initiate and end the transfusion. f. Undiagnosed symptomatic anemia. 6. Blood should be infused within 4 hours after g. Angina when anemia is a factor. initiation of transfusion. After that time, the blood is h. Congestive heart failure when anemia is a considered contaminated. factor. 7. The patient should be observed throughout the i. Chemotherapy induced anemia. transfusion for a possible blood reaction, chills, 3. Patients with a history of adverse transfusion elevated temperature, restlessness, anxiety, reactions, cardiovascular impairment or no previous dyspnea, flushing, changes in pulse rate, chest history of transfusion should be referred to the pain, rash or itching. (See Infusion Therapy- Blood Medical Director for evaluation. Transfusion Reaction Management). 4. The physician's written order is to include: a. Type and amount of blood component. EQUIPMENT: b. Date of transfusion. c. Pre- and post-transfusion blood work. Gloves d. Duration of infusion. Alcohol applicator (wipe/swab/disk/ampule) e. Pre-medications. Transfusion record form f. Emergency medications/procedure to be used in case of a transfusion reaction. Packed cells Microaggregate blood sets, Y-type preferable (2) Infusion Therapy – Packed Red Cells Using Microaggregate Blood Filter Set Administration SECTION: 25.29 Strength of Evidence Level: 3 __RN__LPN/LVN__HHA

Leukocyte removal filter (optional) 15. Prepare normal saline bag and remove protective Standard IV tubing cap from solution spike. 16. Insert solution spike into normal saline container 250 mL bag of normal saline - 1 bag/unit to be infused and hang. Attach needle less adaptor to end of IV pole (optional) administration set (optional). Needle less adaptors 17. Invert drip chamber and open patient side clamp. Heparin solution (100 units/mL, or as prescribed) When drip chamber is 2/3 full, close patient side clamp and return drip chamber to normal position. Thermometer 18. Open patient clamp to fill patient tubing and expel Puncture-proof container air. DO NOT allow air to remain in patient tubing. Impervious trash bag Close patient clamp. 19. Clean injection port of central venous catheter, Cooler and ice peripheral IV line or subcutaneous catheter line with Equipment and emergency medications for transfusion alcohol applicator. Allow to air dry. DO NOT blot. reaction (See Infusion Therapy- Blood Transfusion Insert needle less adaptor on administration set into Reaction Management). injection port. 20. If not using needle less access system, clean PROCEDURE: injection port junction with alcohol applicator and 1. Contact physician by telephone and verify remove injection port. Attach administration set transfusion orders, availability of physician in case tubing to IV line. of emergency and document on home transfusion 21. Initiate flow with normal saline, regulating flow by record form. adjusting patient clamp. 2. Adhere to Standard Precautions. 22. To prime blood filter and transfuse blood, gently 3. Identify patient and explain the procedure and rotate cell mass. DO NOT shake. purpose to patient/caregiver including possible 23. Close all clamps (blood filter clamp is closed). adverse reactions. Ascertain whether patient has 24. Remove protective cap from blood filter spike. had a previous blood transfusion reaction. Grasp blood filter, insert spike into outlet port of 4. Verify patient's signature on consent for homecare blood bag using half twist pushing motion. treatment. Obtain patient's signature on informed [Note: Prime leukocyte removal filters per consent for packed red cell transfusion. manufacturer’s recommendations only. Prime 5. Verify blood product: regular blood filters per steps 25 and 26 below.] a. Check name and identification number of 25. Hold blood bag and filter upright, approximately 12 patient, identification method should be inches below level of normal saline container. implemented at time of type and cross-match 26. Fully open normal saline clamp and adjust blood for positive identification. filter clamp to allow solution to flow slowly in reverse b. ABO and RH of the recipient and compatibility direction through blood tubing and into filter until with donor. filter is filled with normal saline. Close normal saline c. Donor identification number. clamp. d. Expiration date on unit of packed red cells. 27. Hang blood bag. Fully open blood filter clamp. e. Color and appearance of unit of packed red 28. Regulate flow to patient with patient clamp. Flow cells. should be regulated to deliver 30 mL in 15 minutes. f. Name of person issuing the unit. 29. Document exact time blood infusion is started. g. Name of person to whom the unit was issued. Readjust flow 15 minutes after start. Average h. Date and time of issue. infusion time is 1 1/2 to 2 hours per unit, but must 6. Verify there is a competent caregiver in the home at be within 4 hours. the time of transfusion. 30. Monitor and record patient's vital signs after 15 7. Sign check off form. minutes, 30 minutes and then every 30 minutes. 8. Obtain baseline urine specimen (optional). 31. Assess patient throughout infusion for signs and 9. Assemble equipment on a clean surface close to the symptoms of blood transfusion reaction. patient. 32. If multiple units are to be given, flush the line with a 10. Place patient in a comfortable position, making sure minimum of 50 mL 0.9% NaCl between each unit. that site is accessible. DO NOT exceed saline flush of 150 mL 0.9% NaCl 11. Record baseline temperature, pulse, respirations for one unit. and blood pressure. 33. After transfusion is completed, flush tubing and filter 12. Auscultate and record assessment of lung fields for with normal saline. Note exact time blood baseline data. transfusion is completed. 13. Pre-medicate patient, if ordered. 34. Discontinue normal saline infusion - flush venous 14. Close blood filter clamp and patient side clamp and access with heparin solution (appropriate for type of then open solution clamp. venous access or remove peripheral IV. (According Infusion Therapy – Packed Red Cells Using Microaggregate Blood Filter Set Administration SECTION: 25.29 Strength of Evidence Level: 3 __RN__LPN/LVN__HHA

to Infusion Therapy Intravenous Therapy Administration.) 35. Discard soiled supplies in appropriate containers. 36. Remain with patient for 30 minutes after transfusion is completed to monitor and record patient's response. 37. Notify physician of completion of procedure and the patient's response. 38. Schedule follow-up visit per physician’s orders.

AFTER CARE: 1. Document in patient's record: a. Procedure and observations, including all vital signs. b. Medication administered, dosage, time, route and rate. c. Blood component infused, volume, expiration date, and ID numbers. d. Time infusion started and discontinued. e. Amount of normal saline used during transfusion. f. Heparin solution for flush, amount and strength. g. Type and appearance of venous access site. h. Patient's response to procedure, side effects and management. i. Instructions given to patient/caregiver. j. Communication with physician.