Authors

  1. Hudgins, Kerstin MSN, RN, CCRN, CEN
  2. Carter, Esther BSN, RN, CMSN

Abstract

The conservation of blood products and the use of alternatives to blood transfusion are the best practice. Patients treated with blood conservation techniques will have a reduced risk of blood-borne diseases and a reduced risk of human error that can occur during blood processing. The bedside nurse plays a vital role in educating the patient and the caregiver regarding risks, benefits, and alternatives. A combination of techniques explored focuses on minimizing blood loss, building the patient's own blood supply, or both. Medications, herbs, and supplements can increase bleeding and place the patient at risk for a transfusion. Evidence from a variety of sources indicates that postoperative patients who receive a blood transfusion will have a harder time with wound healing and overall recovery. Allogeneic blood transfusions can induce clinically significant immunosuppression, as well as other effects in recipients, to include a re-occurrence of cancer. For the Jehovah's Witnesses patient, receiving blood transfusions against their conscience is equal to rape. Therefore, appropriate management entails an understanding of ethical and legal issues involved. Providing meticulous medical care, such as essential interventions and techniques to reduce blood loss, can minimize the risk of subsequent need for blood transfusions and decrease the financial burden to the health care system and its consumers.

 

Article Content

BLOOD TRANSFUSIONS can be lifesaving or life-threatening. Blood conservation measures can increase survival rates, decrease length of stay, improve wound healing, decrease infection rates, reduce risk of immunosuppression, and reduce transfusion reactions and complications. Patients treated with blood conservation techniques will have a reduced risk of blood-borne diseases and a reduced risk of human error that can occur during blood processing. Blood conservation is a combination of techniques that focus on minimizing blood loss, building the patient's own blood supply, or both. The risk of mortality increases with each unit transfused to the patient.1 Alternatives to blood can include erythropoiesis-stimulating agents, various iron supplements, Folic acid, and vitamin C and B12. Patients who have their hemoglobin optimized prior to surgery using these medications have a reduced risk of needing a transfusion.

 

BLOOD TRANSFUSION RISKS

Numerous medications, herbs, and supplements can increase bleeding and place the patient at risk for a transfusion. Some of these include fish oil, aspirin, garlic, green tea, ginger, flaxseed, onion, parsley, chamomile, clove, and turmeric.2 Kcentra is now available for the emergent reversal of Coumadin (warfarin). Vitamin K should also be considered to enhance coagulation.

 

Transfusion-associated circulatory overload

A transfusion-associated circulatory overload (TACO) is the most common reaction reported with transfusions. It is the primary reason why furosemide is given prior to or between units of blood. It is highly underreported and underdiagnosed.3 Transfusion-associated circulatory overloads are associated with increased length of stay and increased morbidity. The nurse can be alert to signs of a TACO by monitoring for symptoms of fluid retention: oxygen saturation, increased edema, blood pressure, heart rate, auscultation of the patient's lungs, and intake and output. Special attention should be given to the appropriateness and rate of the transfusion, diuretic cover, and the fluid balance.3

 

Transfusion-related acute lung injury

A hemolytic reaction can be determined by a clerical and serological workup in the blood bank. Although both TACO and transfusion related lung injury (TRALI) present with similar conditions (pulmonary edema, hypoxemia, and infiltrates on chest X-ray film), a TRALI is an immune reaction most commonly occurring because of antibodies in donor plasma from parous female or transfused blood donors, which react with transfused patient's leukocytes.3 The pathologist will determine if it is a true reaction once reported to transfusion services.

 

Transfusion-related immunomodulation

Autologous blood is considered a liquid tissue transplant and sometimes produces the same scenario as organ transplants. Postoperative patients who receive a blood transfusion will have a harder time with wound healing and overall recovery. Evidence from a variety of sources indicates that allogeneic blood transfusions can induce clinically significant immunosuppression, as well as other effects in recipients, to include a reoccurrence of cancer. This clinical syndrome is generally referred to as transfusion-associated immunomodulation or TRIM.4 The body prefers to fight one battle at a time. When a patient has undergone surgery, has wounds and indwelling catheters, and received a blood transfusion, he is likely to fight the blood transfusion, leaving the wounds and indwelling catheter site to fight for themselves, therefore increasing the risk for infection, thus possibly provoking a TRIM.

 

BLOOD CONSERVATION BENEFITS

The first 2 units of blood a patient receives in a calendar year are not covered by most insurances no Medicare. One unit of blood ranges in price from 500 dollars to 1000 dollars. Hospitals can have a more efficient use of their blood supply and decreased financial burden by implementing a blood conservation program. Blood conservation is evidence-based and improves patient outcomes.1

 

BLOOD TRANSFUSION ALTERNATIVES

Epoetin alfa

Epoetin alfa (Epogen) is an erythropoietin stimulating agent (ESA). Erythropoietin is a naturally occurring hormone in the kidney. Epoetin alfa prompts the bone marrow to increase red cell production. The reticulocyte count (immature red blood cell production) will start increasing soon after administration. It is extremely important to administer ESAs with iron, as ESAs alone will make the patient iron-deficient. Most Jehovah's Witnesses (JW) patients accept epoetin alfa, but it has a small fragment of albumin in its composition and is therefore considered a conscience drug by this population. The alternative to epoetin alfa is Aranesp (darbepoetin alfa), an erythropoiesis-stimulating protein that is produced in Chinese hamster ovary (CHO) cells by recombinant DNA technology.5 It does not contain the albumin and is generally accepted by the JW population.

 

Iron preparation

As mentioned above, iron must be given with ESAs unless the patient has iron overload. Iron must also be given with Vitamin C as this is its catalyst. Nondiabetic patients can drink orange juice to increase absorption of iron supplements. Venofer (iron sucrose) provides first-line intravenous (IV) iron therapy for the treatment of iron deficiency anemia in adult and pediatric patients 2 years and older with chronic kidney disease (CKD).6

 

Vitamin B12 and folate

Vitamin B12 also called cobalamin, and folate, also called folic acid are imperative ingredients for increasing a patient's own blood supply. Both nutrients play important roles in creating red blood cells and making DNA and RNA to help build cells.7 It is safer for a patient to maintain their own blood levels, rather than exposing them to autologous blood when anemic.

 

Acute normovolemic hemodilution

Acute normovolemic hemodilution (ANH) is a perioperative procedure that is used primarily by anesthesiologists, which can be a great benefit to the patient. ANH involves a controlled removal of whole blood immediately prior to the operation. After the patient is put to sleep, whole blood is drained off via gravity. The blood loss is replaced with crystalloid IV fluids such as Ringer's lactate or normal saline, thus maintaining the patient's intravascular volume. The operative procedure is conducted with a normal blood volume, but with a reduced red cell mass. At the end of surgery, the stored autologous blood is restored to the patient.8

 

OTHER METHODS

Other methods and techniques can also limit transfusions such as reduction of phlebotomy, utilizing an in-line blood-sampling device when frequent blood draws are indicated to decrease waste, application of a cell saver system when possible, limiting IV fluids during surgery, the use of tranexamic acid, desmopressin acetate, and aminocaproic acid.1 All measures should be taken to stop the bleeding first.

 

Cell saver system

Cell salvage may be indicated in numerous types of invasive procedures and offers a safe, resource-saving, and relatively inexpensive method to avoid allogeneic red cell transfusion. If the anticipated blood loss is 20% or more of the patient's estimated blood volume; cross-match-compatible blood is unobtainable; the patient is unwilling to accept allogeneic blood but will give consent to receive blood from intraoperative blood salvage, as in the case of Jehovah's witnesses, utilizing a cell saving device should be considered. Application may be individualized depending on the patient's starting blood cell count, gender, age, and body weight that can all influence the risk of requiring blood products.9

 

Tranexamic acid

Tranexamic acid is a synthetic derivative of the amino acid lysine that exerts its antifibrinolytic effect through the reversible blockade of lysine binding sites on plasminogen molecules. Intravenously administered tranexamic acid caused statistically significant reductions in transfusion requirements in some studies.10

 

Desmopressin acetate

DDAVP (desmopressin acetate), a synthetic analogue of the natural pituitary hormone 8-arginine vasopressin (ADH), an antidiuretic hormone affecting renal water conservation.11 The clinical indications for desmopressin expand beyond hemophilia and von Willebrand disease (vWD). The compound is efficacious even in bleeding disorders not involving a deficiency or dysfunction of factor VIII or vWF (Factor), including congenital and acquired defects of platelet function and such frequent abnormalities of hemostasis as those associated with chronic kidney and liver diseases. Desmopressin is used prophylactically in patients undergoing surgical operations characterized by large blood loss and transfusion requirements.12

 

Aminocaproic acid

Amicar (aminocaproic acid) is a synthetic antifibrinolytic. It is designed for the treatment of hemorrhage caused by hyperfibrinolysis and for surgical bleeding prophylaxis or the reduction of surgical bleeding associated with cardiopulmonary bypass as monotherapy or in combination with desmopressin (DDAVP).13

 

JEHOVAH'S WITNESSES PATIENTS

Most nurses at some point in their career have stressed over a JW patient refusing blood, even though their life is at stake. For the JW patient receiving blood transfusions against their conscience is equal to rape. The nurse should honor the patient's beliefs and encourage the provider to do the same, thus considering alternatives and prescribing medications that will stimulate red cell production. The authors have personally encountered patients with a hemoglobin of 2 to increase to a hemoglobin of 10 with medications alone in the absence of acute hemorrhage. Most hospitals have a JW liaison that can be consulted if the patient has questions about what treatment is allowed. Conscience drugs such as epoetin alfa and albumin must be agreed to by the patient based on their principles. Because of the rapid growth in the membership of this group worldwide, physicians attending hospitals should be prepared to manage such patients. Therefore, appropriate management entails an understanding of ethical and legal issues involved, providing meticulous medical care, such as essential interventions and techniques to reduce blood loss and, hence, reduce the risk of subsequent need for blood transfusion.14 Cell saver and dialysis are also conscience-based procedures, and most JW patients approve of these procedures. Clinicians may find the hospital liaison and further information by going to JW.org and connecting to the medical information for clinicians.

 

CONCLUSION

The bedside nurse plays a vital role in educating the patient and caregiver regarding risks, benefits, and alternatives. The conservation of blood products and the use of alternatives to blood transfusion is best practice. Allowing the patient's own body to enhance red cell production leads to better patient outcomes and decreased length of stay. Optimizing a patient preoperatively can reduce a patient's need for blood intra- and postoperatively, thus sparing blood bank reserves and avoiding the potential for reaction and complications. With the increasing costs of health care, limiting transfusions decreases the financial burden to the health care system and its consumers.15Blood Conservation is the cutting edge of medical technology, clearly demonstrating advantages for the patient, nurse, and hospital.

 

REFERENCES

 

1. Khan JH, Green EA, Chang J, et al Blood and blood product conservation: results of strategies to improve clinical outcomes in open heart surgery patients at a tertiary hospital. J Extra Corporeal Technol. 2017;49(4):273-282. https://www.ncbi.nlm.nih.gov/pubmed/29302118[Context Link]

 

2. Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks of herbal, homeopathic, and dietary supplements: a hidden nightmare for plastic surgeons?. Aesthet Surg J. 2012;2(3):332-346. https://doi.org/10.1177/1090820X12438913[Context Link]

 

3. Agnihotri N, Agnihotri A. Transfusion associated circulatory overload. Indian J Crit Care Med. 2014;18(6):396-398. http://doi.org/10.4103/0972-5229.133938American[Context Link]

 

4. Blajchman MA. Transfusion immunomodulation or TRIM: what does it mean clinically? Hematology. 2005;10(1):208-214. https://www.ncbi.nlm.nih.gov/pubmed/16188675[Context Link]

 

5. Rx List. Aranesp(R). 2017. https://www.rxlist.com/aranesp-drug.htm#medguide[Context Link]

 

6. American Regent, Inc. Venofer(R). 2015. http://www.venofer.com/Index[Context Link]

 

7. Freeborn D, Haldeman-Englert C. Vitamin B-12 and Folate. Health Encyclopedia. Rochester, NY: University of Rochester Medical Center; 2018. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&conte[Context Link]

 

8. Murray D. Acute normovolemic hemodilution. Eur Spine J. 2004;13(suppl 1):S72-S75. http://doi.org/10.1007/s00586-004-0755-8[Context Link]

 

9. Esper SA, Waters JH. Intra-operative cell salvage: a fresh look at the indications and contraindications. Blood Transfus. 2011;9(2):139-147. doi:10.2450/2011.0081-10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096856/[Context Link]

 

10. Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs. 1999;57(6):1005-1032. https://www.ncbi.nlm.nih.gov/pubmed/10400410[Context Link]

 

11. Rx List. DDAVP(R). 2017. https://www.rxlist.com/ddavp-drug.htm[Context Link]

 

12. Mannucci PM. Desmopressin (DDAVP) in the treatment of bleeding disorders: the first 20 years. Blood. 1997;90:251-252. http://www.bloodjournal.org/content/90/7/2515?sso-checked=true[Context Link]

 

13. Prescriber's Digital Reference. Aminocaproic acid-drug summary. 2018. http://www.pdr.net/drug-summary/Amicar-aminocaproic-acid-1954#0[Context Link]

 

14. Chand NK, Subramanya HB, Rao GV. Management of patients who refuse blood transfusion. Indian J Anaesth. 2014;58(5):658-664. http://doi.org/10.4103/0019-5049.144680[Context Link]

 

15. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine: blood transfusion. N Engl J Med. 1999;340:438-447. doi:10.1056/NEJM199902113400606 [Context Link]

 

blood conservation; blood hemodilution; blood salvage; blood substitutes; blood transfusion; Jehovah's witnesses