Phlebotomy
&
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Donor Reactions
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Phlebotomy--- Content provided by FirstRanker.com ---
What is Phlebotomy
? Greek words phleba-, meaning "vein" and -tomy, meaning "to make an
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incision of"
? Done by a trained phlebotomist.
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Indications for blood sampling and bloodcol ection
? Laboratory tests for clinical management and health assessment.
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? Arterial blood gases for patients on mechanical ventilation, to monitorblood oxygenation;
? Neonatal and paediatric blood sampling
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? heel-prick (i.e. capillary sampling);? scalp veins in paediatrics
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? Capil ary sampling (i.e. finger or heel-pricks or, rarely, an ear lobe puncture) e.g
- testing of Hemoglobin levels before blood donation,
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- blood glucose monitoring, and- rapid tests for HIV, malaria and syphilis.
? Blood col ection
- Routine Blood Donation
- Therapeutic Phlebotomy
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Preliminary Steps
? Phlebotomist should introduce him/herself to the donor in a cheerful
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manner? Responsibility of the phlebotomist to make certain that all blood unit
numbers on the donor record, collection bags, and specimen tubes match
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and are applied properly
? Donor identification is the single most important process of the
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phlebotomy procedure--- Content provided by FirstRanker.com ---
Site of Phlebotomy
? Usually cubital fossa is chosen as the vein as it is palpable and required
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volume of blood can be easily drawn from this vein
? Examination of the area chosen for the Venipuncture
? Should have no local infections
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Site examination
? Check the site as professional donors/drug
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abusers will have multiple punctures? Collection is a sterile process so surgical
environment should be maintained
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? Both the phlebotomist and the donor should
follow the hand washing procedures
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Vein Selection? Often the best veins to use are not the ones seen most easily.
? Differences in the anatomy of arms among donors may cause problems in
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proper vein selection.? Vein location may differ from donor to donor.
? It is essential for the phlebotomist to know the general anatomy of the
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Differences b/w Artery and Vein
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Donor care
? Before, during and after donation
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? Donating blood should be a pleasant experience? The venue must be a safe place for the donor
? The venue must be comfortable - temperature, surroundings
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? Staff must be trained in interpersonal skills
Adverse reactions
? Facilities to deal with any reactions before, during or after donation
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Pre- Donation Checks of Equipment? All equipment and materials must be
? Correct
? Clean
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? Calibrated? Checked for performance
? Ready for use
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Equipments & Material Required in
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Donation Room
? Donor Couch
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? Blood Bags? Blood collection mixer
? Needle destroyer
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? Tube sealer
? Alcohol Swabs
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? Stripper? Spirit & iodine
? BP instruments
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Donor Identification
Correct identification of the donor
? At reception
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? Immediately before venipunctureCross- check the donor with available records
? Name, address, date of birth
Re-check the donor's identity
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Phlebotomy? To be performed by a trained person
? Usually cubital fossa is chosen as the vein is palpable and required
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volume of blood can be easily drawn from this vein? Examination of the area chosen for the venipuncture
? Should have no local infections
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Preparation of the area? BP cuff should be tied and pressure maintained at 40-60 mm Hg
? Tourniquet should be used carefully, as the pressure applied cannot be
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gauged.? No local anaesthetic drug need to be administered
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Donor Arm Cleaning
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Important to minimise risk of bacterial contamination during vene
puncture
? Follow the SOP for Methodology and selection of cleansing agent
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? Trained staff? Assessment of Compliance and effectiveness
Cleaning the area
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? Deflate the cuff and clean the area selected? Spirit /alcohol swab and iodine should be used to do this
? Savlon etc. is not recommended.
? Clean 4-5cms area in a concentric centrifugal pattern
? Do not touch the cleaned area after preparation.
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Procedure
? Apply tourniquet or blood pressure cuff at 60 mm Hg to upper arm.
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? Have donor open and close fist several times, holding gripper tightly? Remove needle protector
? Using thumb of free hand placed wel below prepared area...
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- pull skin taut.- inform donor that you are ready to perform venipuncture.
? Holding needle at a 30- to 45-degree angle, pierce skin with a quick thrust.
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? When bevel is completely under skin, lower angle of needle to 10-15? and advance into vein? Release clamp to let blood flow
? Instruct donor to relax hand and give gripper a slow, firm squeeze every 5-10
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seconds.
? Secure needle and tubing by placing tape
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? Loosen tourniquet or lower blood pressure cuff to 40-60 mm Hg.? Record necessary information on bag and donor records according to facility
policies and procedures
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? The procedure takes about 5-10minutes
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? Donor should not be left unattended? Bag should be periodically mixed so that uniform mixing of anticoagulant
with blood occurs
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? 1ml of blood=1.05gm
? 350ml=367gms+weight of the bag
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Monitoring Blood Col ection? Constant monitoring during donation
? Smooth Blood flow
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? Gentle mixing of blood
? Col ection time -5-10 min
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? Appropriate Volume col ected = ?10 % of desired volume? Sample col ection
-Identity checks
-Correct handling
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-LabelingAfter the procedure
? Deflate the cuff once the procedure is over
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? Clamp the tubing? Place the sterile swab and withdraw the needle
? Apply pressure and let the donor lie down for 5 minutes
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? Do not recap the needle
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? Stripping of tubings should be done to mix the blood in tubing withanticoagulated blood in the bag
? Collect Pilot samples for serology & grouping
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? Seal tube at least 5 segmentsPost Donation Care
? Donor should be constantly observed
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? Apply medicated adhesive when oozing stops? Check for any haematoma
? Check for any hypovolemic signs
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Post Donation Care (contd...)
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? Make them rest for 8-10 minutes before they go to refreshment area
? It is mandatory to provide light refreshments to the donors
? They should be observed for another 10 minutes while in refreshment
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area.? Make sure they are completely alright
Post-donation instructions
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Instructions to the donor after the donation
1.Drink more fluids than usual in the next 4 hours. Do not remain hungry.
2.Do not smoke for half an hour.
3.Do not take alcoholic drinks for atleast 6 hours.
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4.If there is bleeding from phlebotomy site, raise the arm and applypressure.
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5. If there is feeling of faintness or dizziness, donor should be in lie-down
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position or sit with head between knees. If symptoms persist, ask for help,
return to the bloodbank or consult a doctor.
6. Remove the bandage/band-aid after 5-6 hours
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ADVERSE DONOR REACTIONS
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Donor Reaction
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LocalizedSystemic
Reaction
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Reaction
1. Bruise or Hematoma
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1. Vasovagal Attack2. Phlebitis and Cellulitis
2. Tetany
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3. Nerve Injury
3. Air Embolism
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4. Puncture of artery5. Upper extremity Deep
Vein Thrombosis
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Bruise or Hematoma
? One of the most common
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complications? May be immediate of or Delayed
? Majority of cases restricted to small
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area in antecubital fossa--- Content provided by FirstRanker.com ---
Bruise or Hematoma
Management-
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Immediate Case-1. Deflate blood pressure cuff. Withdraw the needle from the vein if enlarging hematoma.
2. Place 3-4 gauze pieces over the hematoma apply digital pressure for 7-10 mins keeping donors arm
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above heart level.
3. Apply ice to the area for 5mins.
Delayed-
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1. Ice compression and analgesic if necessary
2. Keeping hand in rest. Avoid working by affected hand.
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3. Observation and informing donor regarding compartment syndrome & refer if necessaryOutcome-
General y resolve completely within 7-14 days and do not prevent
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donors from donating again
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Phlebitis and Cel ulitis
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? Incidence- 1 in 50000 to 1 in 100000? Mild phlebitis at the venepuncture site is common, self-limited and usually of little
consequence.
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? Presentation-
Mild discomfort, small swelling, pain, local linear or surrounding erythema
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? Complication-Despite a seemingly benign appearance, it may extend to local abscess formation or septic phlebitis
Phlebitis and Cel ulitis
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Management-
? Warm Compression
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? Oral Analgesic and antiinflammatory agents
? Administration of oral antibiotics
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Nerve Injury
? Incidence- Approx. 2/10,000 donations
? Cutaneous branches of the medial and ulnar nerves are injured
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occasionally by large bore phlebotomy needle.
? Direct nerve damage from the phlebotomy needle is not very common.
? Injuries are generally transient and rarely a source of donor distress.
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Nerve Injury
Presentation- Immediate severe shooting and radiating pain
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(earliest presentation), paraesthesias, sensory changes in forearm,wrist, hand. rarely loss of arm strength
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? Outcome- 70% of nerve injury usually disappear within a month, almost
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all resolve within one year.
Rare cases of complex regional pain syndrome (Reflex sympathetic dystrophy) has been
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reported.? Prevention- To reduce the risk of direct nerve injury need should be
inserted only once and no further manipulation or attempt ( single prick
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strategy)
Puncture of Artery
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? Incidence- 1/10,000 donations? More common among inexperienced phlebotomists than those with
experience.
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? Presence of bright red blood, rapid collection (within seconds), and apulsating needle suggest arterial puncture are indicators of arterial
puncture
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Puncture of Artery
Management-
Needle should be taken out early and local pressure should me applied for an extended period.
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Complications-
Hematomas, compartment syndrome, delayed nerve injury may happen
? Most donors recover quickly and completely.
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Fol ow up-Should be evaluated for pseudoaneurysm by ultrasound and doppler studies.
Upper Extremity Deep Vein Thrombosis
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? Very rare delayed type of complication? Symptoms-
? Pain in the upper limb
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? Swel ing of the arm
? Prominent palpable, cord like thickening of the
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thrombosed veinInvestigation- Ultrasonography doppler study should be used as an screening tool
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Upper Extremity Deep Vein Thrombosis
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Management- Thrombolysis is done by
unfractionated heparin.
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Anticoagulants is used like Dabigatran,Rivaroxaban, Apixaban, Wafarin in uncomplicated
cases.
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Systemic Reactions
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Vasovagal Reaction
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? Most common systemic reaction? Incidence- 250/10000 donations
? Predisposing factors-
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? First time donors
? Donors with low weight
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? H/o previous adverse reaction? Donor in Fasting state > 4hours
? Inadequate sleep last night
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Symptoms
? Chil s or cold extremities,
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? Feeling of warmth? Light- Headedness
? Nausea
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? Pal or
? Weakness
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? Hyperventilation? Declaration of nervousness ( Anxiety)
? Sweating
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Signs
? Hypotension
? Tachycardia or Bradycardia
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? Syncope? Seizure Activity ( Tonic- Clonic Convulsion)
? Twiching
? 3 types according to severity-
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1. Mild2. Moderate
3. Severe
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Mild vasovagal reaction
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Present with one or more
Nausea, dizziness, hyperventilation, vomiting, twitching and muscle spasm, sweating etc.
? Usual y brought about by the sight of blood or needle.
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Management-? Remove tourniquet and withdraw needle
? Raise Donor's leg above the level of head of Head
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? Loosen tight clothing and secure airway? Monitor vital signs
? Cold compress to the neck or forehead
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Moderate vasovagal reaction
? Mild vasovagal reaction + loss of consciousness
? May be associated with decreased pulse rate, may hyperventilate, may exhibit a
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fal in systolic pressure to 60mm Hg.
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Management
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? Check Vital signs frequently? Raise Donor's leg above the
level of head of Head
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? Administer 95% oxygen and
5% carbon-di-oxide
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Severe vasovagal reactionA donor experiencing convulsion defines a severe reaction. May be caused by-
1. Cerebral Ischemia,
2. Marked hyperventilation,
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3. EpilepsyMay be associated with vasovagal syncope, reduced blood flow to brain owing to
shock symptoms.
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? Management-? Prevention of further injury due to fal
? Ensure an adequate airway
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? Use anticonvulsant to manage Seizure
? Administer 95% oxygen and 5% carbon di oxide
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? Monitoring vitals? In case of Cardiac and respiratory difficulties perform CPR
Tetany
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? Occasionally observed in blood donors
? Incidence- 1/1000 donors
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? Predominantly seen in nervous subjects? Thought to be due to hyperventilation which causes excited donor to lose
excess of carbon dioxide.
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? Presents with twitching, muscular spasm, carpopedal spasm, laryngismus,
stridulus and positive Chvostek's sign.
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? Management-? Make the donor as comfortable as possible
? Rebreathing in a proper bag which brings prompt
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relief
? Inhaling 5% carbon dioxide from a cylinder
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? Ask the donor to breath slowly and shal owAir Embolism
?Rare incident now-a-days
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? When blood is taken into plastic bags that contain no air, no possibility ifair embolism
? When blood is taken into glass bottle air embolism may happen.
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?It may happen in some instruments of Apheresis.? Prime cause of air embolism in this circumstance is obstruction to the air
vent of the bottle.
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Al ergic Reaction? Donor may be hypersensitive to sterilizers special y ethylene oxide, ethly alcohol
etc.
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Symptoms and signs- Hives, difficulty in breathing, wheezing, hypotension or
hypertension, tachycardia or bradycardia, facial swel ing or flushing, burning eyes,
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angioedema etc. Even anaphylaxis may happen.Management-
Inj. Promethzine ( Any antihistaminic)
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Inj. Hydrocortisone if necessaryCitrate Induced Hypocalcemia
Citrate anticoagulants, used in apheresis donor collections, exerts effect by binding to calcium avoid
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clotting of blood.
Symptoms-
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1. Perioral or peripheral paresthesias or both,
2. Unusual taste,
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3. Transient nausea,4. Light-headedness,
5. Muscle Cramps
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6. Dysphagia
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Citrate Induced HypocalcemiaSigns-
1. Carpopedal Spasm,
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2. Tetany ( May be present if associated with hyperkalamia)
3. Change in pulse,
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4. Tremor,5. Chvostek's sign,
6. Seizure ( Grand mal, Petit mal)
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7. Laryngospasm
? Management-
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? Reducing citrate infusion rate? Administering calcium tablets for mild to moderate cases
? For severe cases termination of col ection and-
? Shifting the donor to Emergency Department
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? Vitals monitoring, ECG
? Electrolyte monitoring
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? Calcium gluconate injection if necessary (Inj Calcium Gluconate 10% IVover 10 to 15mins)
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Prevention of Donor
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Reaction
Post Donation Care
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? Pressure should be applied on the venepuncture site for sometime? Venepuncture dressing should be kept for 24 hours
? Strenuous exercise should be avoided for next 24hours
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? Plenty of fluids to be taken
? Heavy weights should not be lifted using the venepuncture arm
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? Prolonged standing should be avoided for rest of the day? Any il ness within 2 weeks to be reported at the Transfusion medicine department
? Avoid smoking and alcohol
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? Refrain from works special y pilots, drivers, police and surgeon
? If feeling faint or vertigo Donor should sit down and lower his head
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Some strategies can be taken-? Predonation Education- specialy among first time donors by
motivational audio-visual aids regarding need for blood in the community
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? Drive set up and environment- A wel planned, adequately staffed
and organized lay out of blood donation area or donation camp.
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? Staff supervision & phlebotomist skil - An experiencedphlebotomy staff and adequate supervision is important to reduce adverse incidents.
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? Distraction- Fear and
associated anxiety is an
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important factor associatedwith donor reaction.
Distraction techniques have
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shown to reduce the no of
donor reactions.
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? Water Ingestion-
? 350-500ml drinking water
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30minutes before whole blood
donation
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? The mechanism related toincreased gastric distension which
increases sympathetic tone and
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overal peripheral resistance, BP
and cerebral Blood flow.
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? Applied Muscle Tension (AMT)- AMTin combination with water hydration is
a fairly new concept in preventing
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presyncopal and syncopal reactions.
AMT involves Repetitive contraction
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of major muscle groups of the arms andlegs and there by promoting venous
return and cardiac output which affects
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cerebral blood flow.
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Salty Snacks-? The amount of salt we consume daily
affects the volume of our extracellular
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fluid.
? Increased dietary Sodium improves
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orthostatic tolerance in blood donors.?
The addition of salty snacks
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before and immediately after
donation is a low cost attractive
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approach to prevent donorreaction.
DONOR HAEMOVIGILANCE
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? Haemovigilance Programme of India has been formed jointly by National
Institute of Biologicals & Indian Pharmacopoeia Commission
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Collaboration on 10th December, 2012 and Donor Hemovigilance wasstarted on 14th June 2015.
? Every blood bank have to keep records of donor reaction in their own
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registry and in every month they have to register it in Blood Donor
Vigilance Programme Of India maintained by National Institute of
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References? WHO guidelines on drawing blood: best practices in phlebotomy
? Technical Manual- 18th Edition, AABB publication
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? Transfusion Medicine And Hemostasis, 2nd Edition, Beth H. Shaz, Christopher D. Hillyer, Elsivier
Publication
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? Rossi's Principles of transfusion Medicine- 5th Edition, Wiley Blackwell Publication? Mollison's Blood Transfusion in Clinical Practice- 12th Edition, Harvey G. Klein, David J.Anstee, Wiley
Blackwell Publication
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? Transfusion Medicine Technical Manual,Directorate General of Health Sciences
? Immunohematology and Transfusion Medicine, Mark T. Friedman, Kamille A. West, Springer Publication
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? Modern Blood Banking and Transfusion Practices- 6th Edition, Demise M. Harmening, F.A Davis Company