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Зміст2. Duration of the class: 4 academic hour.
3.2. The student should be able
3.3. The student should master practical skills
5. Study questions
6. The literature
BUKOVINIAN STATE Medical university
DEPARTMENT OF PATIENTS CARE AND
HIGHER NURSE EDUCATION
on the methodical conference of department
of patients’ care and higher
“ ” ________ 200_ protocol N __
Chief of department, associate professor I.A. Plesh
FOR SELF-PREPARATION OF STUDENTS
TO PRACTICAL CLASS №7-8
nursing in surgery
for 3nd year students
of medical faculty №4,
specialty "nurse business''
Methodical instruction was prepared by:
Assistant Riabyi S.I.
Assoc. professor O.Y. Khomko
Chernivtsi - 2010
1. Topic: Blood transfusion
(the main rules of modern transfusiology. Infusion and transfusion in nurse’s work. Blood transfusion. The basic of isoserology. The ABO and Rhesus systems. The nurse’s task before Blood transfusion. Determination of blood group by standard serums and monoclonal antibodies. Concept of Rhesus factor. Determination of blood group by express method and method of antirhesus reagents. Determination of blood fitting to transfusion. Tests for blood compatibilities between donor and recipient).
3. Study aim:
3.1. The student should know:
·4. Advice for students:
Transfusion of blood
The idea of replacement of lost blood appeared in 14th- I5th century. But, as the anatomy-physiological bases of circulation were described by Harvey only in 1728, therefore transfusion of blood could not be carried out before this time.
In 1666, Richard Lower published the results of experiments on transfusion of blood to animals. These results were so convincing that Deni and Emerez in 16th repeated Lower's experiments on dogs and poured blood from lamb to a seriously ill patient. Despite the imperfect technique, the patient recovered.
In 1697 Merklin and in 1682 Attenmuller reported the results of the observation, according to which at mixing blood of two individuals agglutination sometimes occured. That specifies incompatibility of blood. Despite of obscurity of this phenomenon, in 1820, Biandel (England) successfully carried out transfusion of blood from man to man.
A large obstacle to blood transfusion was its fast coagulation. Therefore, in 1835 Bishoff offered to pour difibrinated blood. However, after transfusion of such blood there were a lot of complications, therefore the method was not widely used.
However, agglutination and coagulation of blood prevented the application of blood transfusion. These obstacles were eliminated after opening blood groups by K.Landsteiner and Y.Yansky (1901-1907). The first successful use of sodium citrate as an anticoagulant for stored blood was carried out by Hustin in Brussels in 1914 at St. Jean Hospital. Thus, the elements were in place for the development of blood bank, anticoagulation, cold storage, and the addition of sugar to prolong the life of the red cell.
Blood transfusion has become a common operation, but to prevent grave complications and produce good results it requires strict observance of certain rules. These include sterility in preparing the apparatus, precision in determining the blood groups, proper preservation of the sera and observance of other rules which at times seem «trifling». The blood of all people may be divided into four groups, according to its agglutination properties:
1) first group—0 ?? (I)
2) second group—A? (II)
3) third group—B? (III)
4) fourth group—AB (IV)
The agglutination reaction may be regarded as a combination of the agglutinins found in the serum (designated by the letters ? and ?) with the agglutinogens found in the erythrocytes (designated by the letters A and B).
Agglutination results when the agglutinin of the recipient's serum comes in contact with the corresponding agglutinogen of the donor's erythrocytes, for example, agglutinin a with agglutinogen A or agglutinin 0 with agglutinogen B.
For short, the groups are designated by figures and letters. Group 0 contains no agglutinogens. It is not agglutinated by the serum of the other groups. The blood of the people of this group may be transfused to anybody (i.e. universal donors), but it contains agglutinins a and p. Thus, the blood containing agglutinogens A (second group), B (third group) or AB (fourth group) may not be transfused to a person with blood of the First group; only the blood of the group O which contains no agglutinogens may be transfused to this person.
Group A contains the agglutinogen A on eyrthrocytes, while the serum contains agglutinin ? Consequently, only the blood which contains no agglutinogens (i.e. Group O) and the blood which contains agglutinogen A (i. e. Group A) may be transfused to the recipient of this group ; nor may the blood containing agglutinogen B (i.e. the blood of Groups B & AB) be transfused; the blood of Group A may not be transfused to a recipient of Group B because the Group B contains agglutinin which corresponds to agglutinogen A of the second group, and may be transfused to a recipient of Group AB, because the blood of this group has no agglutinins at all.
A person with Group B blood (III) may receive the blood of the Group O because it does not contain any agglutinogens at all; the blood of the second and fourth groups cannot be transfused to this person because it contains agglutinogen A of the erythrocytes, which corresponds to agglutinin of his serum. The blood of the third group may be transfused to a recipient of the third and fourth groups, because the blood of these groups does not contain corresponding agglutinins in the serum.
Lastly, the blood of the fourth group AB (IV) may be transfused only to a recipient of the same group because this blood contains agglutinogen of both types and does not contain any agglutinins of the serum; it follows that any of the other groups which contain any of the corresponding agglutinins (a, ( 3 or cd3) will agglutinate the blood of the fourth group. Contrariwise, the recipient of the fourth group may receive the blood of any group because the serum contains no agglutinins which could agglutinate the erythrocytes of any blood group.
Determining the blood group. The blood group must be determined in order completely to exclude any possibility of error. It is therefore very important to learn carefully the techniques of blood transfusion. The double reaction, i. e., determination of the blood group by standard sera (direct reaction) and determination of the serum group of the blood being examined by means of standard erythrocytes (reverse reaction), is the best method. More over not only one direct test is used, but it is desirable to perform it twice with two different series of sera.
Everything required for taking the blood must be prepared beforehand, namely Frank's needle, sterile cotton, alcohol or ether, pipettes, test-tubes, a stand for the test-tubes and a spirit lamp.
To determine the blood groups, the following things are prepared:
1. standard sera of groups 0 (I), A (II) and B (III);
2. slides or porcelain plate;
3. small glass or stand for serum ampules;
4. physiologic saline solution;
5. iodine tincture, alcohol, cotton, four pipettes, three glasses rods and three little glasses.
The conditions under which the blood groups are determined (good lighting and temperature of 15 - 25°C) are very important. The blood must not be examined at temperatures below 10°C and above 30°C because the results may prove wrong.
The documents showing the different blood groups must be very accurate. The necessary data bearing original numbers are recorded in a special journal. The first and last names of the person being examined, the results of the reactions and conclusion about the blood group are recorded. The latter is also recorded in the case history and other necessary documents.
The standard sera prepared in institutes of blood transfusion are kept locked in a dark dry place at a temperature not exceeding 20°C. The blood group, liter and period of time for which the given serum is valid are inscribed on the ampules.
The person working with standard sera must be sure of the specificity of the serum and its liter. In case of doubt the serum must be checked upon. One ml of serum is suffecient for 20 - 25 examinations.
A large drop of each standard serum of groups 0 (I), A (II) and B (III) is placed at definite points of the slide or clean white plate, the groups of serum being indicated in pencil. A separate pipette is taken for each serum; the pipettes are also marked and used only for taking the corresponding serum after which they are immediately placed in the glass bearing the mark of the corresponding group.
It is always better to place the drops of serum in a definite order (the drop of the third group on the right, of the second group in the middle and of the first group on the left), after which each drop of the serum is mixed with three drops of the patient's blood taken from the fleshy part of the finger.
The blood is drawn with Frank's needle from a finger wiped with cotton soaked in alcohol or ether. Sometimes the blood is taken from a helix or drawn with a syringe from a vein, or lastly with the aid of a tampon from the surgical wound.
Drops of the blood are placed with the aid of glass rods next to the drops of serum. Each drop of blood the size of a pin point is introduced into the drop of standard serum and is mixed with it. Separate rods for mixing each standard serum are used.
The reaction is watched for five minutes by the clock, the plate or slide being lightly shaken.
After three minutes a drop of physiologic saline solution is added to each drop of the mixture, the letter is mixed again and the final results are evaluated.
The reaction is studied against a white background. In the presence of agglutination red clumps resembling particles of brick dust are formed; the serum becomes transparent and colourless.
Absence of clumps and the presence of uniform turbidity of the mixture indicate absence of agglutination. If no agglutination occurs in any of the drops, it means that the patient's blood belongs lo the first group; if the blood agglutinates with the serum of the first and third groups and does not agglutinate with the serum of the second group, it is blood of the second group; if, on the contrary, it agglutinates with the blood of the first and second groups and does not agglutinate with the blood of the third group, it is blood of the third group; lastly, if it agglutinates with all three sera, it means that it belongs to the fourth group. The blood group of the donor is determined in the same manner.
The results may be recorded with the aid of a chart in which the presence of agglutination is marked by a plus sign (+) and absence of agglutination by a minus sign (—). The column on the right contains the conclusion about the blood group.
In doubtful cases the examination is repeated with another series of serum, a reverse reaction is performed or a more sensitive reaction in test-tubes is used.
It is necessary to have fresh, sufficiently active sera, and accurately to observe the technical rules for determining the groups, i.e., to place the drops of serum properly, marking the groups on the glass in a definite order, and use clean pipettes and glass rods for each individual serum.
Sometimes, there is pseudoagglutination. This is observed in cases in which the temperature is below 10°C, or condensation of the serum or drying of the drop takes place, and in cases of stale suspension of erythrocytes and insufficiently clean vessels (increased acidity of the medium). To make sure whether there is any pseudoagglutination, the drop of serum is dissolved with normal saline solution and, being slightly heated, is mixed again.
The appearance of agglutination may be prevented in the following cases: a rise in the temperature above 30°C, weak titre of the serum, excessive number of erythrocytes and insufficiently long observation. Special blood properties described in rare cases make it possible to distinguish subgroups among the A (If) and AB (IV) groups.
Rh (Rhesus) factor. The blood of 85% of the people contains an antigenic Rh factor, i e. they are Rh positive; 15 % of the people are Rh negative. The antibodies against this factor appear as a result of a Rh transfusions of Rh positive blood or during pregnancy in a Rh negative woman carrying a Rh positive foetus. The presence of such antibodies may be responsible for a severe reaction to the transfusion. It is therefore necessary to ascertain before the transfusion that were there repeated transfusions before and did they produce a reaction, and did the woman ever had premature labour or a stillbirth. If sensitivity to the Rh factor is suspected, special tests are made.
To conduct such a test 2-3 ml of the recipient's blood (without citrate) is taken into a test-tube. After coagulating the blood, seperate the clot from the walls of the test-tube with a glass rod and centrifuge it, the recipient's serum is obtained. Two drops of this serum and one drop of the donor's blood are mixed in a Petri dish and are placed in a waterbath (at a temperature of"42:450C) for 10 minutes.
The presence of agglutination indicates that this blood must not be transfused. A negative result does not exclude the possibility of sensitivity to the Rh factor and if the patient's history contains indications of his sensitivity, only Rh negative blood is transfused to this patient, this property of the blood being shown in the blood certificate.
Before the transfusion, Blood Compatibility Test is made by mixing a drop of the patient's serum with a drop of the blood to be transfused. In the absence of agglutination the blood is considered compatible (Fig. 1).
Fig. 1. The Blood CompatibilityTest (1. Compatible; 2. Not Compatible)
Before the transfusion it is necessary to perform a biological test, i.e. first to inject 10-15ml of the blood into the patient's vein and wait for five minutes. If there is no reaction, the injection of 10-15 ml of blood is repeated. In the absence of reaction (chills, small pain in the lumbar region of the back, vomiting, cold sweat and a drop in the pulse rate) the transfusion may be continued. Indications for blood trans-fusion:
1). The commonest, indication for blood transfusion is profuse haemorrhage, either external or internal.
2). It is indicated during certain major operations, where a good amount of blood loss is inevitable, e.g. radical mastectomy, abdominoperineal resection, etc.
3). In case of deep burns blood transfusion is indicated besides initial fluid and plasma administration, as there is considerable haemolysis and destruction of RBC.
4). Preoperatively, blood transfusion is required when the patient is already anaemic and there is no adequate time for Iron Replacement Therapy before operation. This is particularly needed before operations for malignant diseases.
5). In postoperative cases, blood transfusion is required when the patient has become considerably anaemic and debilitated, either due to excessive bleeding during operation, or as a result of infection or septicaemia.
6). In anaemic patients, particularly when the haemoglobin level is below 10 g/100 ml, blood transfusion is often indicated to treat anaemia. It must be remembered that in chronic anaemia, it is better to transfuse packed cells rather than whole blood to reduce more burden to the already burdened heart due to hypervolaemia.
7). In severe malnutrition and hypoproteinaemia, blood transfusion is indicated before any type of surgery.
8). In certain coagulation disorders like haemophilia, Christmas disease, thrombocytopenic purpura, etc. blood transfusions or blood fraction transfusions are required. In a few blood diseases, e.g. Hodgkin's disease, leukaemia, aplastic anaemia whole blood transfusion is required.
9). In treating cases of erythroblastosis foetal is due to Rh incompatability, exchange transfusion is often performed through umbilical vein of the newborn.
10). During chemotherapy for malignant diseases, blood transfusion is often indicated if the routine blood examination shows considerable diminution of RBC level.
Collection of blood for blood transfusion. Before collecting blood from an individual or donor, one has to make sure that the donor is not suffering from any disease, which may be transmitted into the blood. Particular attention is made that the donor is not suffering from hepatitis or AIDS (which is transmitted by HIV I and II viruses).
The donor lies down on a bed. A sphygmomanometer cuff is applied to the upper arm and is inflated to a pressure of 80 mm Hg. 0.5 ml local anaesthetic solution is injected subcutaneously in the antecubital fossa through which 15 gauge needle is introduced into the median cubital vein. The needle is connected to a plastic tube which is attached to a plastic bag, which forms a closed sterile unit. Blood from the donor is allowed to come out and run into the sterile bag, which already contains 75 ml of anticoagulant solution. During collection, blood is constantly mixed with the anticoagulant solution to prevent clotting. A specimen of blood is sent for grouping and cross-matching. About 410 ml of blood is taken in a single bag. Two types of anticoagulant solutions are usually used to mix with the donor blood.
The following stabilising solutions are most frequently used:
1. Citrate solution (0.5 sodium citrate, 0.85 NaCI and 100.0ml distilled water); 100.0ml of the solution being used for 100 ml of blood; may be stored for up to 12 days.
2. 5-6 % citrate solution (5.0 sodium citrate and 100.0 ml distilled water, 10.0 ml of the solution being used for 100 ml of blood ; may be stored for up to 14 days.
3. Glucose citrate solution (5.0 sodium citrate, 100.0 ml distilled water and 10.0 ml of 25% glucose); 10.0 ml of the citrate solution and 1.0 ml of the glucose solution are used for 100 ml of blood ; may be stored up to 25 days. Citrate solutions with an addition of 1.0 sodiumsulfathiazole/100.0 ml of the solution are also used.
4. Saccharose-glucose-citrate conserving solution : 7.0 acid sodium citrate, 80.0 saccharose, 12.0 glucose, 2.0 sodium sulfacyl, 0.012 rivanol and 1000.0 ml bidistilled water; permits storing of blood for up to 45 days.
With the above mentioned solution adenosine is added (CPDA-I) to increase the storage life of the blood.
Blood storage. All bloods that are collected from donors are stored in a blood bank in special refrigerator at controlled temperature of 4°C (ranging from 6°C to 2°C ). If blood is allowed to come in contact with higher temperature, there is danger of transmitting infection.
During storage of blood, the RBCs, which constitute the major component, lose their ability to release oxygen to the tissues of the recepient within 7 days. So when a patient requires massive transfusion, it is advisable to use at least I or 2 units of blood which are less than 7 days old.
WBCs are rapidly destroyed in the stored blood.
Platelets are also destroyed considerably at 4°C. But a few are still functionally useful after 24 hours. Clotting factors, e.g. factor V, VIII and platelets are also destroyed quickly.
Shelf life of stored blood in CPD solution is about 3 weeks. When blood is stored in CPDA-I solution, the storage life is increased to 5 weeks.
Types of blood transfusion. Five types of whole blood transfusion may be used:
1. The typical stored CPD blood from blood bank is most commonly used.
2. Warm blood — During cardiopulmonary operations, the blood may be warmed by passing the stored blood through a blood warming unit to reduce the risk of cardiac arrest which may be caused by transfusion of large volume of cold blood directly from the blood bank.
3. Filtered blood is sometimes used by filtering blood through a membrane with very small pores to filter off platelet aggregates and leucocytes in stored blood.
4. Autotransfusion is an old method of restoring the patient's blood volume by transfusing his or her own blood, who is excessively losing blood by injury such as ruptured spleen or ruptured liver or in ruptured ectopic gestation. The blood is collected from the peritoneal cavity and put into a sterile container. This blood is now filtrated through a few layers of sterile gauge into a container, which already contains anticoagulant CPD solution. This blood is now immediately transfused into the patient. This method is particularly used when stored blood is not available.
5. Exchange or replacement transfusion is indicated in new born infants suffering from erythroblastosis foetalis. The transfusion is given through the umbilical vein of the infant with a syringe with four way adaptor - first to the infant's body, second to the donor, third to the citrated saline and the other to the waste. Rh negative blood is exchanged with the infant's blood 5 to 10 ml at a time.
Such transfusion is also indicated in CO poisoning to remove carboxyhaemoglobin in exchange of fresh oxyhaemoglobin.
Besides whole blood, packed red cells are also transfused in certain conditions.
Packed red cells. This is specially transfused to patients with chronic anaemia, in elderly individuals, in children, and in those patients whose cardiac reserve is low and may suffer from cardiac failure if whole blood is transfused. If the whole blood is centrifuged at 2,000 to 2,500 g for 15 to 20 minutes or if the stored blood is allowed to stay idle so that the supernatant plasma is taken off and the blood sediment is used for packed cells.
Certain other fractions of blood, e.g. plasma, platelet rich plasma, etc. are also transfuied in various conditions.
Documentation. To avoid all errors, the para medical personnel must keep accurate records.
The donor's documents (permit for donating blood and passport) are examined in the operating room and a record is made in the conserved-blood journal. At the end of taking blood a complete record is made in the same journal in the presence of the donor; the record includes the date when the blood was taken, the ordinal number, the blood donor's name, amount of blood taken, stabiliser used, and name of physician, group, when the blood was filled in and when the blood was dispensed.
The same information is simultaneously recorded on the label which is pasted to the bottle/plastic bag containing the blood. Confusing labels or an incorrect record of the blood group may lead to grave complications. To avoid errors, donors of the same group are simultaneously admitted into the operating room or separate operating rooms are set apart for different blood groups. To prevent mistakes, the records in the journal and on the label are examined several times; the number in the journal must correspond to that on the label. Donors are allowed to leave only after the ascertaining the correctness of the documentation.
The labels have coloured identification strips: the 0 (I) group has a white strip, the A (II) group—a blue strip, the B (III) group— a red strip, and the AB (IV) group—a yellow strip.
The amount of the blood taken is marked on the certificate brought by the donor with reference to the number in the blood journal.
In the medical establishment where the blood transfusion is administered, the latter is recorded in the case-history including the record of the transfused blood, the patient's blood group, method, tests and the patient's reaction; all these informations are also recorded in the hospital blood transfusion journal.
6.1. Basic :
Methodical instruction was prepared by
Assistant Riabyi S.I.
A review is positive, associate professor Chomko O.J.
Materials of control of base level of preparation of students: tests.
Choose the correct answer/statement:
Real-life situations to be solved:
Answers to the Self-Assessment:
Hemotransfusional shock, II level.
Pyrogenous reaction, not serious level.
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|Higher nurse education||Higher nurse education|
|Higher nurse education||Higher nurse education|
|Higher nurse education||Higher nurse education|
|Higher nurse education||Higher nurse education|