BLOOD TRANSFUSIONS
Blood Transfusions / Blood Components
A copy of the GBMC policy for “Blood Transfusions / Blood Components” is included
in this section. You are responsible for knowing this entire policy and following it
100% of the time when involved with the administration of blood products. Should
your patient have an adverse reaction to the administration of a blood product, you
will need to follow the procedure for transfusion reaction contained within this
policy.
NOTE: Platelets and autologous units must be picked up from the blood bank. They
cannot be sent to the nursing units via the pneumatic tube system.
GBMC
CLINICAL POLICY AND PROCEDURE
BLOOD TRANSFUSIONS/BLOOD COMPONENTS
Approval:
Signature on file:
VP of Nursing, CNE
I.
PURPOSE
To establish guidelines for the administration of blood and blood products.
II.
DEFINITION OF TERMS
A. Type and Screen: Determine ABO and Rh factor (refers to Type). Perform antibody
screen and if positive, antibody identification will be performed for patients who may
require blood in near future. Required preparation for transfusions of certain blood
products. Indicated for the preoperative patient who may require intraoperative
transfusion.
B. Type and Crossmatch: Determine ABO, Rh, antibody screen and crossmatch.
Required preparation for transfusion of red blood cell products.
III.
POLICY
A. A physician’s order is necessary for a blood transfusion.
B. A physician must obtain informed consent for the initial transfusion and any
additional units that are needed for a change in the patient’s condition or for
reasons other than the initial reason for transfusion.
C. Only one unit of blood is issued by the Blood Bank at one time. Exception:
GOR, ICU, ER, DR when patient condition indicates, red cell and thawed
plasma products are issued in an insulated blood product shipping box on ice.
Platelet products must remain at controlled temperature (20-24°C controlled
room temperature) with agitation.
D. If blood or components cannot be infused in four hours due to patient condition,
the product should be divided in the Blood Bank and stored appropriately in the
Blood Bank until needed.
E. No medication or other solutions (except 0.9% normal saline) may be added to
any unit of blood, or simultaneously infused in the same I.V. line.
F. Under no circumstances should blood be put in any refrigerator outside the
Blood Bank.
G. Blood drawn for a Type and Screen will be held for 72 hours. Any time during
this 72-hour period, blood drawn for the type and screen may be used to
crossmatch blood for patient use.
H. Crossmatched blood will be held for 48 hours in the Blood Bank.
I. If multiple red cell transfusions are to be given over a period of days, a fresh
Typenex labeled specimen for crossmatching must be drawn every seventy-two
(72) hours (exception: NICU patient). If only plasma or platelets (non-red cell
products) are being transfused, then a new patient sample is not necessary on
the same admission.
J. When fresh frozen plasma is ordered, the Blood Bank must be notified one half
hour before it is to be given so it can be thawed.
K. The unit of blood must begin transfusing within twenty-five (25) minutes of
pickup from the Blood Bank or be returned to the Blood Bank for proper
storage.
L. Blood and blood products must be hung by a registered nurse, LPN, or
physician.
M. Transfusion reaction, regardless of severity, must be reported promptly by the
nurse or physician on a Transfusion Reaction Form (800-7).When platelets,
irradiated red cells or other special products are ordered, arrangements must be
made by the Blood Bank with the American Red Cross. Blood Bank will
indicate approximate amount of time needed to provide product.
N. The Y-type blood transfusion tubing may be used with 2 units of blood. The Yset must not be used for maintenance IV solutions or antibiotics.
O. The empty blood transfusion bag is discarded in biohazard trash.
P. If the product was not totally transfused, then document the reason on the Unit
Transfusion Record.
Q. In addition, if more than 50cc of untransfused product remain, then hand carry
untransfused product to Blood Bank for proper accountability and disposition
(FDA requirement).
R. Entered/opened blood bags cannot be returned through the pneumatic tube.
Chart the original copy of the completed Transfusion Record Form and return
the copy to the Blood Bank.
IV.
EQUIPMENT
A. Request for Issue of Blood (Form 800-72)
B. 18 or 20 gauge IV catheter. 24 gauge IV catheter – NICU only.
C. Unit of blood or blood product
D. Y-Type blood administration set or appropriate administration set for blood
component
E. 0.9 % normal saline
F. Transfusion Record - sent with blood component from the Blood Bank
G. Gloves
H. Circular of Information for the Use of Human Blood and Blood Components, most
current copy should be available on each Clinical Unit (additional copies available
from Blood Bank).
V.
PROCEDURE
A. Ordering/Obtaining Blood or Blood Component
1. To type and crossmatch a patient for blood transfusion, refer to Procedure
"Blood Recipient Identification System (Blood Bracelet): Use of".
2. If the patient has been typed and screened within the last 72 hours, and later a
transfusion is ordered, call the Blood Bank and ask for the blood to be
crossmatched.
3. Check the computer to see if blood/blood component is available for the
patient.
4. Complete the "Request for Issue of Blood" form (#800-72). For red cell
products, the Typenex unique transfusion number must be written at the bedside
from the patient’s bracelet onto the Request Form.
5. Send the request form to the Blood Bank (Station 93) via the pneumatic tube.
(Products which cannot be sent through the pneumatic tube are autologous,
directed donors, platelet products, cryoprecipitate, special antigen negative
products that are not replaceable). If requested product is not received in the
pneumatic tube, call the Blood Bank.
6. Prior to the issue of requested product, the Blood Bank will monitor the
appropriate use of blood and blood components by confirming established
hospital transfusion criteria are met (red cells/hct <30%, platelets/count less than
20,000 with or without bleeding or 50,000 in cases of major surgery, plasma/PT
>18secs or PTT >45secs, Cryo/factor deficiency). If criteria are not met, then
technologist will call nurse to obtain patient clinical information and ordering
physician, and refer the case to the pathologist for clinical review.
B. Blood/Blood Component Administration
1. The physician will explain the procedure and associated risks to the patient and
obtain consent (Documented on Form 601-C50 Question #3).
2. The RN will provide the patient information regarding blood transfusion.
3. Obtain IV access with 18g, 20g, or 24g (NICU only) angio cath prior to
obtaining the blood unit.
4. Using Y-type blood administration set, close all clamps.
5. Attach 0.9% normal saline solution to one side of the Y-set and prime the
tubing. Normal saline is the only compatible solution to use with the blood or
blood component. Crystalloid solutions and medications may cause agglutination
and/or hemolysis of the blood or blood components.
6. Obtain baseline vital signs and temperature, and record on Blood Vital Signs
Intervention in Meditech PCS (part of the Blood Admin Order Set) or, for units
still documenting on paper, the Transfusion Record. (Take baseline vitals prior to
spiking blood product with transfusion filter set).
7. At the bedside, two licensed nurses (one must be an RN) must check the data
(patient first name and last name, medical record number and for all red cell
products, the Typenex number) on the patient’s Typenex and identification
bracelets with the label on the unit of blood and the unit Transfusion Records to
ensure correct identification of the patient and Other information to be confirmed
to ensure the correct administration of the appropriate blood product, blood
product label, blood types, product unit number, product expiration date and any
special product requirements i.e., CMV negative, Irradiated, Leukodepleted and
for all red cell products, the crossmatch results. Both persons identifying the unit
of blood must be documented on the Blood Administration Verification
Intervention in Meditech PCS, or, for units still documenting on paper, sign the
Transfusion Record.
8. Don gloves and attach blood unit to other side of the Y-tubing.
9. Attach blood tubing to IV line. Begin the rate of flow at (5 ml./minute or less
for the first 15 minutes) of the transfusion and observe the patient during this
time. This flow rate allows patient to receive a sufficient amount of blood while
nurse is remaining at the patient’s side. Symptoms of a severe transfusion reaction
are usually manifested during the first 15 minutes of blood transfusion. For
inpatient units, document the start time of the infusion and initial rate of the
infusion on the Blood Product Infusion Intervention in Meditech PCS.
10. Decrease the rate of flow to (100cc/hour as per order by physician unless
contraindicated by patient’s condition. In pediatric and geriatric patients, the rate
of flow may need to be decreased and split units ordered. (For platelet products
flow rate may remain at 5ml/minute and for plasma products increase flow rate to
10 ml/minute). For inpatient units, and rate changes during the transfusion should
be documented on the Infusion Changes Intervention in Meditech PCS.
11. Instruct the patient to report any chilling, shortness of breath, or unusual
symptoms immediately to the nurse.
12. Vital signs and temperature must be assessed 15 minutes x2, after initiation,
and then hourly. For inpatient units, this information is to be documented on the
Blood Vital Signs Intervention in Meditech PCS.
13. The licensed nurse should stay with the patient during the first 15 minutes to
monitor for symptoms of possible transfusion reaction.
14. Use a standard blood administration set for up to two units.
15. Flush the Y-type blood administration set or appropriate administration set
with 0.9% normal saline after the unit of blood has infused.
16. For inpatient units, document the date and time the transfusion is terminated,
the amount given and whether a reaction occurred on the Blood Product
Completion Intervention in Meditech PCS. For all units still documenting on
paper, record the vital signs, date and time the transfusion is terminated, the
amount given and whether a reaction occurred on the Transfusion Record.
17. The empty transfusion container is discarded in biohazard trash.
18. If the product is spiked with filter and/or transfusion started, but IV access is
lost; or, for some other reason the transfusion cannot be started or continued, then
notify Blood Bank and immediately hand carry product with filter to Blood Bank
for appropriate storage. Once IV access is re-established, and then Blood Bank
will determine if blood product can be transfused.
19. Verify that Blood Administration documentation is complete. Place the
original Transfusion Record on the patient’s medical chart. For inpatient units,
nurses should write “See EMR” on the Transfusion Record, as this information
has been entered into Meditech PCS. Return the copy to Blood Bank.
20. Document in the Notes section of Meditech PCS (or in the Progress Notes
section of the chart for units still documenting on paper) how the patient
responded to the blood/blood component transfusion, and patient’s status
following the transfusion.
21. Documentation of amount of blood infused:
- Inpatient Units: Blood Product Completion Intervention in Meditech
PCS
- ER: In Meditech EDM
- OR/NICU: On Paper (ICU nurses can put OR’s blood product infused
documentation into the I&O in PCS for I&O accuracy)
- Any other non-PCS areas: On Paper
C. Transfusion Reaction:
1. If a reaction is suspected, stop the blood immediately and initiate normal
saline infusion.
2. Notify the physician and Blood Bank immediately. If only a mild allergic
reaction, hives only, and transfusion of product urgent, then physician may
prescribe anti-histamine and then continue transfusion with close observation.
3. Recheck identification of patient, Typenex bracelet, crossmatch tag, and unit
number.
4. If Suspected Transfusion Reaction Workup is indicated, then remove original
Typenex bracelet from patient’s arm and return to Blood Bank.
5. Return remaining blood with transfusion set in a plastic bag to Blood Bank.
(Must be hand carried. Never return opened products through the pneumatic
tube).
6. Draw a new type and crossmatch Typenex sample, (special Blood Bank
plastic pink top vacutainer tube).
7. Collect first urine voided by the patient and send to lab marked "Transfusion
Reaction Specimen".
8. Complete a Transfusion Reaction Report Form according to directions on the
form and send form, untransfused product, the new Typenex sample and
Blood Bank copy of the Transfusion Record, along with the old Typenex
bracelet to the Blood Bank immediately.
9. Complete a Blood Bank request form and mark the Transfusion Reaction
Work-up.
10. Document in Notes section of Meditech PCS (or in the Progress Notes section
of the chart for units still documenting on paper) that a transfusion reaction
occurred and patient’s status after the reaction.
VI.
BIBLIOGRAPHY
Glover, G, Powell, F. 1996 (Blood Transfusion). Nursing Standard, Vol. 10 Number 21.
Laborich, T. 1997 (Transfusion Therapy, Nursing Implications). Clinical Journal of Oncology
Nursing, Vol.1, Number 3, Pages 61-72.
Fitzpatrick, L. & Fitzpatrick T. 1997 (Blood Transfusions). Nursing 97, August Pages 34-41.
Circular of Information for the Use of Human Blood and Blood Components, prepared jointly by
the American Association of Blood Banks (AABB), America’s Blood Centers (ABC), and the
American Red Cross (ARC), and is recognized as acceptable by the Food and Drug
Administration (FDA), July 2002.
APPROVED: PNC 9/99
PCC 9/99
REVIEWED/REVISED: 9/73, 1/82, 10/83, 2/84, 7/84, 1/85, 4/88, 8/92, 11/93, 3/95, 4/99, 6/03,
10/03, 1/04, 12/04, 5/05
bloodtransfusion_0505
ADDENDUM:
A. Transfusion Reactions
1. Acute hemolytic –
Symptoms: chills, fever, pain in the chest or lower back, flushing of the face,
hematuria, tachycardia, tachypnea, hypotension, dyspnea, bleeding, acute renal
failure, shock, severe respiratory or cardiac collapse.
Cause: ABO incompatible red cells, red dell antibodies in patient’s plasma
attached to antigens on transfused red cells causing red cell destruction.
2. Febrile, non-hemolytic –
Symptoms: Fever (rise of 1 C or 2 degrees F), chills, headache, flushing, anxiety,
rigors, and muscle pain.
Cause: Release of interleukins from lyzed white cells in the blood product.
3. Mild allergic –
Symptoms: flushing, itching, urticaria (hives).
Cause: Sensitivity to foreign plasma proteins or blood product preservative.
4. Anaphylactic –
Symptoms: anxiety, urticaria, wheezing, laryngeal edema, progressing to
cyanosis, shock, and possible cardiac arrest.
Cause: Severe sensitivity to foreign plasma proteins or blood product
preservatives, especially patient who developed anti-IgA antibody to IgA plasma
protein.
B. Transfusion Complications:
1. Circulatory overload –
Symptoms: dyspnea, pulmonary congestion (rales), headache, hypertension,
tachycardia, distended neck veins.
Cause: Fluid administered faster than circulation can accommodate.
2. Sepsis –
Symptoms: Rapid onset of chills, high fever, vomiting, diarrhea, and marked
hypotension and shock.
Cause: Contaminated blood products.
3. Transfusion-related acute lung injury, commonly called TRALI. Clinical signs
and symptoms of 1 to 2 degree/s C rise in temperature, usually accompanied by
chills or rigors, shortness of breath associated with oxygen destruction
hypotension, and tachycardia. Reaction symptoms are noted between one to six
hours after completion of transfusion. Chest x-ray shows interstitial and alveolar
infiltrates which are diffuse and bilateral (ARDs-like). TRALI cases are
associated with presence of HLA antibodies or anti-neutrophil antibodies in
plasma of the blood donor.
4. Delayed transfusion reaction – Delayed hemolysis from destruction of transfused
red cells by alloantibodies not detected during pre-transfusion compatibility
testing.
5. Transmission of infectious disease – hepatitis, HIV, CMV (Cytomegalovirus),
HTLV-I/II (Human T-cell lymphotropic virus, Malaria, Babesiosis, West Nile
Virus, Creutzfeldt Jakob Disease (CJD), and other potential infectious agents.
6. Iron overload (patients receiving >100 units for chronic anemia)
7. Graft-versus-host disease
Attachment – Transfusion Reaction Report