A 60 yr old female presented to the emergency room with vomiting and abdominal pain. After several tests she was diagnosed as having a perforated gastric ulcer. You are the nurse in the emergency room and have just received an order from the doctor to transfuse the patient with 2 units of PRBC's. Patient's Hgb is 7 g/dL. Her vitals are as follows: BP 120/62, P 66, R 16, T 97.6. Use at least 2 sources for your answers. Remember to include your references

1)     Discuss at least three reasons the doctor may have chosen to infuse PRBC's rather than another blood product.

2)     What are items that you will educate the patient on before starting the transfusion?

3)     Before starting the transfusion, what are checks that will need to be made between 2 nurses?  Detail these checks and explain why these checks are important to prevent adverse effects.

4)     After 10 minutes your patient complains of SOB, runny nose, and you notice she is beginning to develop a rash on her arm.  Her vitals are: BP 116/58, P 80, R 22, T 98.0.  What is your preliminary diagnosis?  What are your first 3 steps to assure patient safety?

5)     Explain why patients who have multiple transfusions can get hypocalcemia.  

1)Discuss at least three reasons the doctor may have chosen to infuse PRBC's rather than another blood product.

• Packed red blood cells are typically given in situations where the patient has either lost a large amount of blood or has anemia that is causing notable symptoms. Red blood cells are essential to good health and can be lost due to trauma (gunshot wound, car accident), internal bleeding, or health problems such as significant anemia. Red blood cells carry oxygen from the lungs to the tissues of the body. To determine if a blood transfusion should be given, a blood test called a complete blood count (CBC) is done.(citation) www.verywellhealth.com
• 1. The patient's hemoglobin level is 7gd/L but the normal hemoglobin for female is between 12.1 to 15.1 g/dL or 121 to 151 g/L. The doctor prescribed transfusion of PRBC to prevent Anemia.
• If a disease or condition affects the body's production of red blood cells, the hemoglobin levels may drop. Fewer red blood cells and lower hemoglobin levels may cause the person to develop anemia.(citation) my.clevelandclinic.org
• 2. The whole blood is not typically transfused unless the patient needs a massive amount of blood to counteract tremendous blood loss. Instead, packed red blood cells, which is whole blood minus the plasma portion, is typically given.(citation) www.verywellhealth.com
• The patient is a 60 year old elderly and at risk for fluid overload. If given with whole blood, the patient can experience circulatory overload.
• Transfusion-associated circulatory overload (TACO) is a common transfusion reaction in which pulmonary edema develops primarily due to volume excess or circulatory overload. (Citation) uptodate.com
• 3. The patient is in an emergency situation where blood transfusion should be immediate.
• The use of Packed Red Blood Cells (PRBC) provides more effective volume expansion and increased oxygen carrying capacity and is therefore routinely used during hospital resuscitation of the major trauma patient, with major trauma centres storing PRBC for immediate administration. (Citation) sjtrem.biomedcentral.com

2)What are items that you will educate the patient on before starting the transfusion?

• Blood administration sets. Blood components must be transfused using an administration set approved for this purpose. The set must incorporate a filter (170 to 200 µm) which removes large clots and aggregates and ensures an effective transfusion flow rate. 
• Change blood administration set when the transfusion is completed, or every 12 hours if continuing to transfuse or with new IV fluids or in accordance with the manufacturer's instructions.
• Infusion devices and blood warmers. Blood components may rapidly infused or warmed just prior to or during transfusion if clinically indicated. Only approved blood devices should be used.
• All equipment used to administer blood components including volumetric infusion and external pressure or rapid infusion devices, syringe drivers and blood warmers must be operated according to the manufacturer's instructions and be designated safe and appropriate for blood transfusion.
• Compatible fluids. The blood administration set may be primed with the blood component or 0.9% sodium chloride.
• Do not add medication to the pack, blood administration set or IV line, or infuse solutions other than 0.9% sodium chloride through the same tubing along with blood components.
• Electrolyte solutions containing calcium, such as Haemaccel®, Hartmann's solution, lactated Ringer's solution must never be added to, or administered through, the same IV line as blood components containing citrated anticoagulant.(citation) www.transfusion.com.au

3)Before starting the transfusion, what are checks that will need to be made between 2 nurses? Detail these checks and explain why these checks are important to prevent adverse effects.

• Some blood transfusion reactions and blood transfusion errors occur as the result of inaccurate client identification and by using the two person verification technique that involves two nurses checking the blood, the order and the client's identity using at least two unique identifiers.
• The two nurses will check the blood against the order
• Check the client's identity
• Check the client's blood type against the type of blood that will be infused
• Check the expiration of the blood or blood component
• Check the client's number against the blood product number.
• The nurses will also visually inspect the blood for any unusual color, precipitate, clumping and any other unusual signs.
• The order for the blood or blood component must be a complete order that specifies exactly what will be administered. The client will also give consent for the transfusion.
• The gauge of the intravenous catheter should be 18 gauge and the blood should be administered with normal saline using a Y infusion set that is specifically used for the administration of blood and blood products.
• If a blood filter is used, the filter must be inspected to insure that it is suitable for the specific blood product that the client will be getting.
• Blood should not remain in the client care area for more than 30 minutes so it is important that the nurse is prepared to begin the transfusion shortly after the blood is delivered to the patient care area.
• The nurse must take baseline vital signs just prior to the infusion of blood or a blood product and then the nurse should remain with and monitor the client for at least 15 minutes after the transfusion begins at a slow rate since most serious blood reactions and complications occur shortly after the transfusion begins. All blood and blood products must be administered completely in less than 4 hours. (Citation) registerednursing.org

4)After 10 minutes your patient complains of SOB, runny nose, and you notice she is beginning to develop a rash on her arm. Her vitals are: BP 116/58, P 80, R 22, T 98.0. What is your preliminary diagnosis? 

• Based on the vital signs and assessment given, the patient is likely experiencing transfusion reaction.
• The most common signs and symptoms include fever, chills, urticaria (hives), and itching. Some symptoms resolve with little or no treatment. However, respiratory distress, high fever, hypotension (low blood pressure), and red urine (hemoglobinuria) can indicate a more serious reaction. (Citation)ncbi.nlm.nih.gov

What are your first 3 steps to assure patient safety?

• Stop the transfusion immediately, and notify the physician.
• Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion.
• Send the blood bag and tubing to the blood bank for repeat typing and culture.
• The nurse should also draw another blood sample for plasma hemoglobin, culture, and retyping. And collect a urine sample as soon as possible for hemoglobin determination. (Citation) nurseslabs.com

5)Explain why patients who have multiple transfusions can get hypocalcemia.  

• The potential for hypocalcemia among patients receiving large amounts of donated blood products over a short time period is due to the presence of the anticoagulant citrate in the bag that donated blood is collected to. 
• Each unit of packed red cells for transfusion contains approximately 3 gm citrate. This amount of citrate is normally rapidly (within 5 minutes) cleared from blood by the liver. 
• However, among the very sick patients who require multiple units of donated blood products, this process of liver elimination is compromised. Additionally, of course, the citrate dose is very high. 
• These two factors determine that citrate accumulates in blood of those receiving massive transfusion where it chelates (binds to) circulating ionized calcium, thereby reducing plasma iCa concentration. (Citation) acutecaretesting.org
• Symptomatic hypocalcemia during transfusion of citrated blood or plasma is rare, because healthy patients rapidly metabolize citrate in the liver and kidney. However, a clinically important fall in serum ionized calcium concentration can occur if citrate metabolism is impaired due to hepatic or renal failure or if large quantities of citrate are given rapidly, for example, during plasma exchange or massive blood transfusion.(citation)medscape.com