Posted in Fundamentals

Transfusing blood products is a high-risk procedure that requires careful attention to detail and excellent patient assessment skills. For this reason, any time you administer blood products you will be doing it with another RN to ensure all the safety checks have been conducted. Whether you’re a nurse wanting to boost your confidence in this area, or a student preparing for a blood transfusion check-off, this lesson is a great review of the key things you need to know.

For a review of the different types of blood products, click here.

You can also listen to episode 253 to maximize your review of blood transfusion basics and the different types of blood products. Tune in wherever you listen to podcasts, or straight from the website here.

Step 1: Prepare the Patient

The infusion of any blood products is started within thirty minutes of acquiring it from the blood bank, so it’s important to do a few preparatory tasks in advance. Note that if you obtain a blood product from the blood bank and are unable to start the infusion within thirty minutes, it must be returned to the blood bank as it cannot be stored in a non-blood bank refrigerator.

  • Ensure informed consent has been obtained. If it’s an emergency situation and no one is available to provide consent, the physician will document this in the medical record and the transfusion will proceed. With informed consent, the physician explains the risks, benefits and alternatives. The patient is given the opportunity to ask questions and, of course, has the right to refuse treatment. 
  • Explain the procedure to the patient if any items were not discussed during informed consent. Ensure the patient understands why they need the transfusion, how it will be performed, how long it will take, the type of blood product they will receive and how you will monitor for adverse reactions. Make sure the patient knows which symptoms to report such as itching or difficulty breathing.
  • Confirm the type and screen has been completed. This is a lab test that confirms the patient’s blood type and screens for any known antigens. If a type and screen has been conducted, the patient will be wearing a “blood band.” This screening must have taken place within three days of the transfusion, so always ensure your type and screen is current.
  • Confirm your patient has a patent IV no smaller than 22G, though an 18 to 20G is preferred as it provides optimal flow rates while being well tolerated. For rapid transfusion,  larger gauge needles (14G and 16G) will be used.
  • Administer any PO pre-medications 30 minutes prior to the transfusion and administer IV medications just prior to the transfusion. Common pre-medications are acetaminophen and diphenhydramine. 
  • Perform a baseline assessment of the patient that includes assessing skin color, lung sounds and for the presence of a rash. Ask the patient if they currently have any chills, itching, rash, muscle aches, or difficulty breathing. These are symptoms of a transfusion reaction but could also be related to other issues. You need to be able to determine if the signs and symptoms started before or after the blood transfusion.

Step 2: Gather and Prepare Your Equipment

Before obtaining blood products from the blood bank, ensure you have all the necessary equipment and that it is ready for the transfusion. This includes:

  • Choose the appropriate IV tubing. Blood tubing is a specific type of IV tubing of which there are two types. One type allows you to flow by gravity with an option to squeeze a bulb to infuse the blood more quickly. The other type is for use with an IV infusion pump. Blood tubing has two spikes that Y-site together above the filter. One spike is for the blood product, and one spike is for the flush solution (0.9% sodium chloride).
  • Blood tubing contains a built-in filter that eliminates clots and other debris before the blood product enters the patient.
  • Most facilities have a limit of using IV tubing for two transfusions only, and only when conducted back-to-back. When in doubt, always obtain new IV tubing.
  • Prime the tubing with 0.9% sodium chloride. 
  • If you are using an IV pump, set up the IV pump in advance.
  • Other general equipment used for any IV access includes gloves, saline flushes and alcohol pads.

Step 3: Prepare To Administer the Blood Product

Before administering blood products, inspect the bag to ensure it is suitable for transfusion. Look for any tears or leaking from the bag, discoloration, clumps or gas bubbles. If you notice anything unusual about the product, do not infuse the unit and contact the blood bank immediately.

The following steps are conducted in coordination with another RN, with each person verifying each step independently. Note that this process may vary slightly from facility to facility, so always check your facility policy. 

Please take care to go through each step carefully as the risk for blood transfusion reactions increase when the RN does not follow facility procedures or when inexperienced personnel administer transfusions. Two step verification mitigates some of this risk.

  • Verify the patient’s identity by checking their medical ID bracelet and asking them their name and birthdate if they are able to participate.
  • Verify the provider’s order which should indicate the type and amount of blood product to be infused. Some orders may specify a time such as prior to an invasive procedure, but most will be to infuse asap or STAT, depending on the patient’s condition.
  • Confirm that informed consent has been signed and that the consent form is in the medical record.
  • Verify the blood product identification number – it will be on the unit of blood and on a tag attached to the bag.
  • Verify the patient’s blood type when applicable, including Rh factor.
  • Verify the blood type of the blood product when applicable, including Rh factor.
  • Verify the expiration date on the blood product.
  • Verify the transfusion ID number against the patient’s blood transfusion wristband to confirm the numbers match (this is often simply called the “blood band”). This is a unique number for that patient’s most recent type and screen and will be changed when a new type and screen is drawn. 
  • Many facilities will require scanning of different components of the blood product and the patient’s wristband.

ABO COMPATIBILITY

If you are using a blood warmer, insert the tubing into the blood warmer device. These are used to prevent hypothermia from large or rapid transfusions of cold blood and are often utilized in trauma units and emergency departments. Note that the warmer must not heat the blood above 40-degrees C to avoid hemolysis. 

Step 4: Begin the Transfusion

Just prior to starting the infusion, take your patient’s baseline vital signs. Perform hand hygiene, put on your gloves, scrub the hub of the patient’s IV, and connect the blood tubing.

Initiate the blood transfusion at a slow rate for the first fifteen minutes, which is generally somewhere between 50 ml/hr and 120 ml/hr, depending on the patient’s condition and your facility protocol. STAY WITH THE PATIENT FOR THE FIRST 15 MINUTES to observe for any signs of a transfusion reaction. At the 15 minute mark, take another set of vital signs. 

Once you are confident the patient is tolerating the blood transfusion without any adverse effects, your facility protocol will likely include increasing the flow rate of the blood product. Note that the amount of time you have to complete the transfusion will be limited, so take that into account, along with the patient’s condition, when adjusting your flow rate. 

During the transfusion, ensure the patient knows when to alert you to any unexpected effects and check in on the patient periodically (at least every 30 minutes). Monitor the patient for signs of circulatory overload, especially for rapid transfusions. Signs of overload include dyspnea, increased work of breathing, coarse lung sounds and tachycardia. 

Once the transfusion is complete, flush the IV with normal saline and take another set of vital signs to compare against the patient’s baseline measurements. Be aware that reactions can occur after the transfusion is complete. Acute reactions can occur within the 24 hours following the transfusion, while delayed reactions can occur up to four weeks later.

When a Reaction Occurs

While transfusion reactions are rare, they can and do occur. While many are mild, some are life threatening and require swift recognition and treatment. 

Signs of a reaction include:

  • Fever – A temperature of 38-degrees C or higher, or an increase by 1 or more degrees C from baseline
  • Chills
  • Skin – Flushed skin, rash, itching, hives
  • Respiratory – Wheezing, dyspnea
  • Cardiac – Tachycardia, hypotension
  • Neurological – Feeling of unease, anxiety, dizziness
  • Abdominal – Nausea, abdominal pain
  • Pain – Pain at IV site, chest, flanks or back
  • Genitourinary – Dark or blood-tinged urine (hemoglobinuria)

In general, the most common signs and symptoms are fever, chills, itching and hives. Other signs such as respiratory distress, hemoglobinuria, hypotension and very high fever can indicate a much more severe reaction has occurred.

If an acute transfusion reaction occurs, stop the transfusion immediately, then notify the provider and the blood bank. In some cases of mild reactions, the MD may prescribe diphenhydramine and/or acetaminophen and instruct you to resume the infusion. If this is the case, the infusion should be infused slowly with very close observation of the patient.

In severe reactions, disconnect the blood tubing from the patient and return the blood product to the blood bank. DO NOT flush the IV line and immediately acquire alternate IV access.

The basics of acute blood transfusion reactions

Febrile non-hemolytic: This is the most common type of reaction and is typically indicated by a 1-degree rise in temperature from baseline. The patient is likely to receive acetaminophen and, when the MD deems the reaction is not severe, the transfusion will be continued.

Allergic: This is due to an allergy to a protein in the donor blood and can range from a mild reaction to anaphylaxis (which is rare). In most cases it is mild and does not require disruption of the transfusion as it will typically respond well to diphenhydramine.

Acute hemolytic: This is a serious reaction that unfortunately can result from ABO incompatibility due to a clerical error. The patient can show signs of extreme distress including hypotension and shock, hemoglobinuria, nausea/vomiting, pain, chills and fever.

Delayed hemolytic: This is essentially the same type of reaction as described above only it occurs after the transfusion.

Septic: A reaction related to contaminated blood products, primarily platelets because they are stored at room temperature. The patient will show signs of severe infection including high fever, chills, hypotension and tachycardia. The patient can also have nausea/vomiting, dyspnea and cardiovascular collapse. Septic transactions typically occur during or soon after the transfusion is completed.

Transfusion-related acute lung injury (TRALI): This is a common cause of death related to a transfusion reaction and results in acute respiratory distress syndrome. An immune response between donor antibodies and antigens in the recipient causes the release of mediators that result in pulmonary edema. The patient will show signs of respiratory distress during the transfusion or within hours of the transfusion.

Transfusion-associated circulatory overload (TACO): This is a consequence of fluid volume overload, the patient will have shortness of breath, coarse lung sounds and possibly edema.

Step 5: After the Transfusion

Once the transfusion is complete, continue to monitor the patient for signs of reaction. Acute reactions can occur up to 24 hours after the transfusion, while delayed reactions can occur within hours up to four weeks later. 

You’ll also assess the patient for signs of improvement. This could be noted by: 

  • Monitoring labs
  • Improved blood pressure
  • Decreased bleeding
  • Improved skin signs
  • Improved LOC, etc…

I hope this review of blood product transfusion has you feeling more confident with this very important skill. It’s something you will do routinely in the acute care setting, especially if you work in a trauma unit, an ICU or oncology (though, of course, transfusions can occur in any setting!).

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