Rh Factor

85 percent of the world population is having the antigen ‘D’ of the Rh blood group system. Those persons who possess this antigen is called ‘Rh positive’ and those do not inherit this antigen is called ‘Rh negative’. The name Rh factor comes from the Rhesus monkeys whose blood contains this antigen. This antigen was discovered in 1940 by Landsteiner and Wiener.

The Rh blood groups are of equal importance as the ABO groups because of their relations to haemolytic diseases of the newborn and their significance in blood transfusions. As in the case of ABO blood groups persons who are Rh positive do not have Anti ‘D’ (Anti Rh) antibodies in their serum. However, in contrast to the ABO blood type, persons who are Rh negative develop Anti Rh antibodies only after exposure to Rh positive blood, either by transfusions or by transplacental passage of red cells from a Rh positive foetus. If a person with Rh negative blood is accidentally transfused for the first time with Rh positive blood, he will not have transfusion reaction, because his blood does not have any Rh antibodies. But after this transfusion, his blood cells became sensitized to the Rh antigen and develop antibodies against the ‘D’ antigen. On receiving a second transfusion with Rh positive blood, some degree of reaction due to red cell destruction will occur.

A similar situation arises when a Rh negative mother is sensitized by red cells from Rh positive foetus. The maternal antibodies are capable of crossing the placenta  and destroying the foetal red cells. This usually occurs during a second or third pregnancy with Rh positive foetus. Severe fatal haemolytic anaemia and intrauterine death may occur. This problem has been largely prevented by prophylactic administration of Anti Rh serum (RhoGAM or Gamulin) to the susceptible Rh negative mother within 72 hours of developing a Rh positive baby or following a abortion.

 

Auto Transfusion


It is the collection, anticoagulation, filtration and reinfusion of blood from an active bleeding site. Because the reinfused blood is the clients own. The advantages of auto transfusion are:

The risk of technical errors of blood typing and cross matching eliminated.
Possible adverse effects associated with homologous blood transfusion can be avoided.
Dependence on homologous blood blanks can be reduced.
Reduce the incidence of exposure to blood-borne infections such as HIV, serum hepatitis and others.

A client for elective surgery may like to give one or two units of their own blood preoperatively, which can be stored and later used intra or post operatively.

 

GENERAL INSTRUCTIONS FOR GIVING BLOOD TRANSFUSIONS


Selection of the Donor

1. Donor shall be free of diseases of heart, kidneys, lungs, liver etc.

2. There should not be any history of cancer, jaundice, hepatitis, tuberculosis, allergies or any transmissible diseases. 

3. They have not donated blood within the previous 90 days. 

4. They should be physically healthy, and should be between 18 and 65 years of age with an average height and weight. 

5. Donors must have a normal temperature, pulse and blood pressure. 

6. They must not have been pregnant within the last 6 months. 

7. Their haemoglobin level must be above 12 grams per 100 ml. 

8. The donors are disqualified who have a history of recent dental surgery or major surgery, received blood or blood components, immunizations or vaccinations, use of narcotics etc. 

9. Before the blood transfusion, the ABO grouping and Rh typing with the recipient’s blood should be done and it should be compatible with the recipient’s blood. Death may occur by the transfusion of the blood from the ‘Universal donor’. 

10. Before the blood is transfused, the donor’s blood must be cross matched with the recipient’s blood. The donor’s red blood cells are mixed with the recipient’s serum (plasma) and the recipient’s red blood cells are mixed with the donor’s serum. There should be no agglutination or clumping. If any doubt exists, the test should be repeated. 

11. Explain the procedure to the donor and reassure him/her to win his confidence and co-operation. Explain the sequence of the procedure and tell him how he can co-operate in the procedure. Even though the blood collection is the responsibility of the laboratory technicians, the nurses help in the procedure by giving psychological support to the patient.  

12. Blood should not be collected empty stomach. The donor should not be dehydrated. Following the donation of blood, the donor should be given a sweetened drink and asked to take rest for one to two hours to prevent fainting attacks. 

13. Before the donor is allowed to leave the hospital, his pulse rate should be checked and he should be questioned as to have any giddiness. Any indication that he has not recovered completely from the weakening effect of loss of blood left in the patient, he should be kept under close observation. Check vital signs and color frequently. 

14. A second withdrawal of blood should not be made until the blood volume and its constituents have returned to normal, i.e., usually after 3 months.

 

GROUPING AND CROSS MATCHING

The individual from whom the blood is transferred is called the donor. The individual to whom the blood is transferred is known as the recipient. Indiscriminate transfusion may lead to serious conditions and even death. This consequence is due to the process of clumping or agglutination or breaking up (haemolysis) of red corpuscles. Agglutination is due to the interaction between substances in red blood corpuscles known as agglutinogens and those in the plasma are called agglutinins. Types of blood which get agglutinated in the transfusion is said to be incompatible.

 

ABO Grouping


Human blood is classified into 4 main groups (A, B, AB and O) based upon the type of antigens (agglutinogens) present in the erythrocytes, as well as the type of antibodies (agglutinins) present in the plasma. Two major agglutinogens which have been identified are the ‘antigen A’ and ‘antigen B’. Thus the persons with A type of blood have ‘A’ antigens in their red cells; and persons with B type of blood have ‘B’ antigens. Person with ‘AB’ blood have both A and B antigens while those with ‘O’ type of blood do not have either A or B antigens in their red cells.

Similarly, two major agglutinins have been identified. They are ‘anti A (alpha) agglutinins’ which agglutinates type A blood cells and ‘anti B (beta) agglutinins’ which agglutinates type B blood cells. The agglutinogen and the agglutinins of the same type will not be found in the same person. Otherwise the person’s own cells would have been attacked by the antibodies found in his plasma. Thus group A blood contains beta agglutinins and group B contains only alpha agglutinins. Group AB contains neither alpha or beta agglutinins and group O contains both alpha and beta agglutinins.

 

Donor and Recipient

Donor AB can donate blood to recipient AB with ‘o’ antibodies. No agglutination will take place since there is no agglutinin in the recipient’s blood. But he will not able to give blood to people with blood groups of A, B and O since their blood contains the agglutinins of b, a and ab in their plasma. Donor a can donate blood to recipient AB and A, since there is no alpha agglutinins in these groups.  Donor B can donate blood to recipients AB and B since there is no beta agglutinins in these groups. Donor O can donate blood to all four groups, since there are no antigens in the donor cells. Therefore group O is known as ‘Universal donor’. Similarly, we find recipient AB can receive blood from all groups, since there is no agglutinins in the recipient’s plasma. Therefore group AB is known as ‘Universal recipient’. Blood ‘O’ group can be given to all 4 groups, but it can receive blood only from O. similarly, AB can receive blood from all groups, but it can donate blood only to AB.


 

blood transfusion, purpose, grouping, cross matching, preparation and complications

COMPLICATIONS OF BLOOD TRANSFUSIONS

 A transfusion reaction is a systemic response by the body to blood incompatible with that of the recipient. It is cause by R.B.C. incompatibility, or allergic sensitivity to the leucocytes, platelets or plasma protein components of the transfused blood or to the potassium or citrate preservative in the blood


General Adverse reactions include:

1. Acute Haemolytic Transfusion Reaction 

Nursing Actions: 

a. Observe the patient closely for the first ten minutes of transfusion. Since these reactions occur very rapidly, the rate of flow should be minimal.


b. Discontinue the blood immediately when reactions is assessed


c. Inform the physician and implement treatment as prescribed by the physician


d. Inform the laboratory to do grouping and cross matching of the blood. The donor blood is sent back to the laboratory and a specimen of the recipient’s blood is retested to confirm the diagnosis.


e. Maintain intravenous infusion with 5 percent glucose or saline using a new I.V. set. Large quantities of fluid are given to promote diuresis and to counteract shock.


f. Monitor vital signs every 15 minutes to assess shock and collapse.


g. Record the fluid intake and output to assess the degree of kidney functions.

Indwelling catheter is put into to monitor the urinary output.
h. Oxygen inhalation is given to relieve dyspnoea


i. Allay patient’s anxiety  with reassurance.

 

Medical Treatment may include the following:


a. Large quantities of fluid to promote diuresis, to prevent shock and collapse and to prevent haemoglobin from precipitating.


b. Mannitol, an osmotic diuretic to counteract oliguria and to increase the flow of tubular fluids and to prevent haemoglobin plugs, in the kidneys.


c. Heparinization to prevent intravascular coagulation


d. Oxygen and epinephrine to treat dyspnoea and wheezing


e. Sedation to treat restlessness and apprehension


f. Blood transfusion with properly matched blood to control shock


h. Haemodialysis for complete renal failure

 

2. Delayed Hemolytic Transfusion Reaction
 

3. Pyrogenic Reaction
 

4. Allergic Reaction
 

5. Anaphylactic Reaction
 

6. Transmission of Infectious Diseases 

Besides the above said complications there is certain risk associated with blood transfusion.

1. Circulatory Overload 

Precautions:

a. Administer the blood very slowly to prevent overloading the heart and pulmonary oedema

b. Check the patient’s pulse every 15 minutes for tachycardia – an indication that the heart is over working as a pump 

c. Examine the patient’s neck veins for fullness – an indication of circulatory overload 

d. If possible, assess the venous pressure. Elevation of central venous pressure over 10cm of H2O indicates a circulatory overload 

e. Observe the patient for symptoms of respiratory distress and listen for the sound of rales 

f. Give a minimum quantity of blood at a time. If necessary, the blood transfusion may be repeated after an interval 

g. Stop the transfusion at once and inform the doctor if the patient develop tachycardia, symptoms of circulatory overload, pulmonary oedema, raised venous pressure etc.

 

2. Hyperkalemia


3. Hypocalcemia 

4. Infiltration and haematoma at the site of the needle 

5. Thrombophlebitis 

6. Pulmonary embolism
 

Transfusion reactions are life threatening but with prompt nursing interventions, the physiological stability can be maintained. The following measures should be undertaken, in case of suspected reaction.

 

a. Stop the infusion immediately 

b. Notify the physician 

c. Connect the I.V. line with 0.9 % Normal Saline 

d. Be with the client, observing the signs and symptoms and monitoring the vital signs till they are steady

e. Get ready the emergency drugs such as vasopressors, antihistamine, steroids and fluids. 

f. Prepare for cardio-pulmonary resuscitation 

g. Obtain a urine specimen and send to the laboratory 

h. Save the blood container and tubing for return to the blood bank 

i. Document the reaction, and the measures carried out.

AUTHOR: ANILKUMAR BELKOTI 

BLOOD TRANSFUSION – PURPOSE, GROUPING AND CROSS MATCHING, PREPARATION AND COMPLICATIONS.

COLLECTION, STORAGE AND TRANSPORTATION OF BLOOD

1. Collection of blood from the donor is done in the laboratory by the laboratory technicians. The donor’s blood is collected into a sterile container containing anticoagulant solution. The anticoagulant used is ACD solution (Acid citrate dextrose) or citrate phosphate dextrose.


2. All the articles used for the collection of blood should be sterile. They should be pyrogen free.


3. Each donor until must be labeled in clear, readable letters, bearing the following information’s to be verified at the time of administration:

a. Name of the donor
b. Donor number
c. ABO grouping
d. Rh typing
e. Date of drawing blood
f. Date of expiry
g. Results of tests for hepatitis and syphilis etc.

 
4. The donor blood, immediately after it is withdrawn, should be place in the refrigerator. Usually it is stored at a temperature of 1 to 6 degree celcius.


5. Stored blood shall be inspected daily and before use for evidence of haemolysis or bacterial contamination.


6. The transportation of the blood in the hospital should be done within 30 minutes after it is taken from the place of storage. If blood is kept at the room temperature, the temperature of the blood will rise above 10 degree celcius in 30 minutes. If the blood is not used, it should be returned to the refrigerator within half an hour.


When blood is transported to distant place, use percooled insulated bags to keep the temperature of the blood below 10 degree celcius.


7. Freezing and heating of the blood will destroy the blood cells.

 

REGARDING ADMINISTRATION OF BLOOD TO THE RECIPIENT

1. When sending the recipient’s blood sample for grouping and cross matching, it must be carefully labeled at the bedside of the recipient with the following identifications – recipient’s name, hospital number, bed number, ward number etc. fresh samples, taken within 4 hours should be used for typing and cross matching. 

2. A request form should accompany the specimen and it should contain the following data:
 

a. The recipient’s name
b. Hospital number
c. Bed number
d. Ward number
e. Name of the physician
f. Exact amount of blood component requested
g. Diagnosis of the patient
h. Any blood transfusions given earlier, if so, the group used and type of the blood administered, any reactions observed etc.


3. It is essential that the physician writes all orders for typing, cross matching and administration of whole blood and blood products.


4. When blood or blood products have to be administered, it is recommended that two registered nurse or a physician and a registered nurse should independently verify all identifying information’s on the report of the cross match, unit table and the patient identifications. Any error in the identification, results in the major adverse reactions. Should there be any discrepany, the unit should be returned to the blood bank with the remarks.


5. Whole blood and the blood products should be administered through a appropriate, sterile, pyrogen free transfusion set containing a filter which will remove clots and larger aggregates of leucocytes and platelets.

6. Care to be taken to prevent introduction of air into the apparatus. 

7. It is recommended to use 18 gauge needle for infusion, to prevent damage to the red cells and to provide an adequate rate of flow.

8. No medication – antibiotics, vitamins, calcium etc. should be added to the unit of blood or administered through the same intravenous system as they may cause damage to the red cells. 

9. If I.V. infusions are to be given immediately before, during or after the blood transfusions, always use physiologic saline to prevent haemolysis of the blood in the tubing. Dextrose should be avoided. If another I.V. fluid is to be given, rinse the infusion set with normal saline before starting the solution. 

10. Prior to administration of blood, the patient’s vital signs should be recorded correctly on the nurse’s record to provide a baseline for further observation. 

11. Adjust the rate of flow to 5 to 10 ml per minute during the first 30 minutes of transfusion, to detect any complications as early as possible. The subsequent flow rate depends upon the condition of the patient and the need for rapid infusion. Give the blood at a slower rate if the patient is elderly, suffering from heart and lung disease, anaemia, debilitating diseases etc. 

12. Whole blood and packed cells are administered cold. No attempt is made to heat the blood. However, blood may be allowed to stand at the room temperature for 30 to 45 minutes before it is administered to the patient. 

13. Once the patient is exposed to the atmosphere (the unit is opened), it should be discarded. 

14. The procedure involved in the administration of the blood is the same as that of administration of I.V. infusions. Watch the patient carefully for the onset of any complications. Any reactions developed in the patient should be reported to the charge nurse and the physician immediately. Early detection of complications and the steps taken to counteract them, save the life of the patient. 

15. The following observations are made throughout the procedure: 

a. Rate of flow
b. Signs of circulatory overload
c. Urinary output (maintain intake and output chart over 24 hours)
d. The needle site for signs of infiltration, haematoma, and dislodgement of needle etc
f. Blood level in the container. Never allow the blood bottle to be completely empty to prevent the entry of air
g. Reaction to the blood transfusion
h. Patency of the infusion set 

16. Keep the patient warm and comfortable with blankets if necessary. 

17. Record on the nurse’s record with date and time: 

a. The amount of blood administered
b. The group and the type of blood administerd
c. The rate of flow
d. Any reaction observed
e. Any medications administered e.g. antihistamine


18. Offer bedpan before starting the procedure and as necessary. 

19. When leaving the ward, the charge nurse should report the following to the relieving nurse.


a. The name and the bed number of the patient receiving the blood transfusions
b. The time at which the drip has started

c. Type of blood that is given 
d. Amount of blood that is administered and the quantity to be given more
e. Any specific precautions to be followed
f. The specified rate of flow
g. Any reactions observed
h. Any medications administered
i. General condition of the patient

BLOOD TRANSFUSION

It is the transfusion of whole blood or its components such as blood cells and plasma from one person (donor) to another person (recipient). This involves two procedures – the collection of blood from the donor and the administration of blood to the recipient.

 

Purpose:


1. To restore the blood volume when there is sudden loss of blood due to haemorrhage (haemoptysis, haematemesis, antepartum and postpartum haemorrhages, operations etc.), trauma or burns.


2. To raise the haemoglobin level in cases of severe anaemia which are not corrected by the administration of vitamins and iron therapy.


3. To treat deficiencies of plasma proteins, clotting factors and haemophilic globulin etc.


4. To provide antibodies (immunotransfusions) to those persons who are sick and having lowed immunity by giving blood or plasma taken from persons who has just recovered from the same disease.


5. To replace the blood with haemolytic agents with fresh blood (exchange blood transfusions) as in case of erythroblastosis foetalis, haemolytic anemia etc.


6. To improve the leucocyte count of blood as in agranulocytosis.


7. To combat infection in patients with leucopenia.