TITLE:
Blood Administration Guidelines
EFFECTIVE
DATE:
August 31, 2012
DATE
REVISED:
P&P #: 2.008
«DateRevised»
PAGE 1 of 7
DISTRIBUTION:
All Departments
PURPOSE:
TO
POLICY:
ALL NURSING STAFF WILL ADHERE TO ESTABLISHED POLICIES AND
PROCEDURES RELATING TO BLOOD PRODUCTS AND THE GUIDELINES OF CARE
FOR PATIENTS RECEIVING BLOOD COMPONENTS. ALL NURSES ARE REQUIRED
TO BE THOROUGHLY FAMILIAR WITH INFORMED CONSENT, INITIATION OF
INFUSION, MONITORING, TRANSFUSION REACTIONS, EMERGENCY RELEASE
OF UNCROSSMATCHED BLOOD, OBTAINING BLOOD FROM BLOOD BANK,
PATIENT REFUSAL AND RETURNING PRODUCTS TO BLOOD BANK.
PROCEDURE:
GUIDELINES OF CARE
PROVIDE A GUIDELINE FOR THE SAFE ADMINISTRATION OF BLOOD AND
BLOOD PRODUCTS.
1. Informed consent is to be obtained prior to administering blood
components for non-emergency transfusions.
2. Collect all necessary supplies and have IV accessible and ready for
use, prior to checking out products from Blood Bank. Only 0.9%
Normal Saline may be used with blood products.
3. Transfusion must be initiated within 30 minutes of the product leaving
Blood Bank. If there is a delay in starting the transfusion, the unit must
be returned to the Blood Bank and stored at the proper temperature
until ready for use. A unit of blood may not be transfused if it has been
out a room temperature for more than 30 minutes.
4. Prior to initiation of transfusion 2 (two) licensed nurses (1 must be an
RN) must verify unit and armband information against the transfusion
record. A) Patient blood bank armband must identify patient first and
last name, date of birth, medical record and admission number and
blood bank number. B) Unit information must include: patient name,
date of birth, medical record and admission number, patient’s
ABO/RH, unit number, expiration date, unit ABO/RH, type of product
and blood bank armband number.
Specific Blood Component Administration Guidelines:
TYPE OF
PRODUCT
SPECIAL CONSIDERATIONS
INFUSION
TIMELINE
Packed Cells
DO NOT use a blood pump if administering packed red cells unless
NSS is added to the bag of packed red cells.
2-4 hours
Platelets
Single donor platelets will be used. Check for pre-medication order for
antihistamine. Be sure to continue to agitate the platelets while they are
not in use and while they are being administered to prevent their
aggregation. Do not use micro aggregate filter.
30-60 min.
Plasma
Fresh frozen plasma cannot be re-frozen after thawing. If given for
clotting factors, infuse within 24 hours of thawing.
1-4 hours
Autologous
PRBCs
Observe for reactions like other components.
2-4 hours
Directed
Donor
Reactions may occur as with any PRBC other blood product
2-4 hours
DOCUMENTATION:
Nursing will complete the Blood Administration Flow Sheet (see attached) for each unit of blood
products administered. A copy must be returned to Blood Bank upon completion and original
placed on the patients chart.
Monitoring the Patient:

Pre-Transfusion: The patient’s temperature, pulse, respiration and blood pressure
must be determined and documented prior to initiating the blood transfusion so
that baseline data is available in the event of a transfusion reaction.

The patient will be monitored for the first 5-15 minutes of the transfusion to
observe the patient for signs and symptoms of a transfusion reaction. Patient’s
response during this period should be documented on the Blood Administration
Flowsheet.

During the transfusion: Vital signs (temperature, pulse, respiration and blood
pressure) will be taken 15 minutes after initiation of transfusion, 30 minutes after
initiation, then hourly until transfusion is complete.

The patient should not be routinely transported off the nursing unit while blood or
blood components are being administered. However, in the case of surgery,
special procedures, or radiation therapy, the patient may be transported while
blood is infusing with the following criteria being observed.

The patient will not be transported during the first 15 minutes of the blood or
blood product transfusion.

Exception: A possible life-threatening situation. If this occurs a nurse will
remain with the patient throughout the transport (i.e. to surgery).

The nurse on the unit will call and give report to a nurse or physician in the
receiving department who will assume responsibility for monitoring the
transfusions when the patient is in that department unless the sending nurse
remains with the patient.

The nurse will accompany the patient to the receiving department.

The nurse or physician from the receiving department will accompany the patient
back to the unit.

Patient’s response to and tolerance of the transfusion should be noted frequently.
POST TRANSFUSION:

Record vital signs at the end of the transfusion and observe patient closely until
one hour post-transfusion.

Discard blood syringe, tubing in Biohazard waste receptacle.

Obtain post-transfusion Hematocrit as ordered by physician. Report results to
physician.

Blood Bank Transfusion Record must be completed with all required elements to
include: 2 nurses signature, vital signs, transfusion reactions, transfusion start and
stop times.
TRANSFUSION REACTION:
AT THE FIRST SIGN OF AN ADVERSE TRANSFUSION REACTION:
A.
STOP TRANSFUSION IMMEDIATELY! (If Urticaria (hives)
or Rash only is noted, see Step #F.)
B.
Notify the Clinical Supervisor, Attending Physician and the blood
bank at once and describe symptoms. (Described below)
C.
Keep IV open with slow saline drip, but use a new administration
set to avoid infusing the blood remaining in the original set.
D.
Send the following to the Blood Bank STAT:
1.
Red top tube (no gel) AND one lavender tube drawn
atraumatically to avoid hemolysis.
2.
Complete a Blood Transfusion Reaction Report Form
Required. (Get Form from Lab)
3.
Remainder of the unit with attached IV set tied off and
needles removed. (Avoid contaminating the unit, as it may
need to be cultured.)
4.
Completed copy of the Blood Transfusion Reaction Report.
5.
First voided urine marked “Post Transfusion”.
E.
Check for agreement of all identifying names and numbers on
donor unit, transfusion record and patient armband.
F.
If the reaction symptoms are hives or skin rash ONLY with no
other complications, a Blood Transfusion Reaction Report need
not be filed. In this instance, Step D is not needed.
Notification of the physician and blood bank/lab must take place for the following types of
transfusion reactions:
TYPE
CAUSE
SIGNS AND SYMPTOMS
Hemolytic
Antibodies in the recipient's plasma react
with antigens in donor red blood cells. This
leads to donor cell agglutination and
capillary occlusion, blocking blood flow and
oxygen to vital organs. Eventually, the red
blood cells break down and release free
hemoglobin into plasma and urine. This
free hemoglobin may block the renal
tubules, resulting in renal failure.
Chills, Temperature 2 degrees
above baseline, backache,
restlessness, anxiety, nausea,
vomiting, chest pain,
tachycardia, dyspnea,
hypotension, cyanosis,
hemoglobinemia,
hemoglobinuria, oliguria, anuria,
jaundice, vascular collapse.
Allergic
Although its mechanism is unknown, it
probably results from the reaction of
allergens in donor blood with antibodies in
recipient blood.
Urticaria, pruritus, chills, nausea,
vomiting, headache, nasal
congestion, wheezing. In more
severe reactions:
bronchospasm, severe dyspnea,
laryngeal edema, circulatory
collapse.
Febrile
Recipient sensitivity to donor leukocytes or
platelets.
Temperature 2 degrees above
baseline, chills, flushing, back
pain, malaise, tachycardia,
headache, confusion, nausea
and vomiting
Bacterial
Circulatory
Overload
Air Emboli
Bacterial contamination of donor blood,
usually by gram-negative organisms.
Temperature 2 degrees above
baseline, chills, abdominal and
extremity pain, vomiting,
hypotension, bloody diarrhea.
Rate or volume of transfusion exceeds the
circulatory system's capacity.
Cough, chest pain, dyspnea,
distended neck veins,
tachycardia, cyanosis, frothy
sputum, pleural rales, and
hemoptysis.
Excessive air infused during transfusion,
Sudden shortness of breath;
sharp chest pain; anxiety;
coughing; decreased blood
pressure.
Citrate Toxicity
Hypersensitivity to product preservative
Cardiac arrhythmias;
nausea/vomiting; hypokalemia;
alkalosis; decreased blood
pressure.
EMERGENCY TRANSFUSION OF UNCROSSMATCHED BLOOD:
When an emergency situation arises and the physician determines that the patient’s life is in
jeopardy without an emergency transfusion, uncrossmatched blood may be given.
a. Nurse must fill out an Emergency Transfusion Request Form and it must be signed by
the physician within 24 hours.
b. Notify the Blood Bank that Emergency Release blood is needed, and who the patient
is.
c. Nurse must bring the patient’s sticker and obtain the number of specified emergency
release O-negative uncrossmatched units of PRBC.
d. Two licensed nurses shall verify blood identification labels and proceed with
transfusion.
e.
A blood Transfusion Record form shall be completed for each unit transfused. All
vitals and any reaction must be recorded.
OBTAINING BLOOD PRODUCTS FROM BLOOD BANK:
Blood will be signed out from the laboratory by one lab personnel and one RN. If blood is
needed after hours, the House Supervisor and one other licensed nurse may sign out blood from
the Blood Bank. If units are needed and not setup, lab must be notified to come in and complete
the orders.
1. IV line must be in place and ready for use prior to picking up units from the Blood
Bank.
2. Bring the patient’s sticker from the chart to the Blood Bank.
3. Verify name, visit number, patient’s ABO/RH, unit number, expiration date, unit
ABO/RH, type of product and BB armband number. Verify any other pertinent
information such as positive antibody screens and that the unit is negative for that
patient’s antibodies.
a. Information is to be read by Lab and verbal verification read back by RN. Any
discrepancy found needs to be corrected prior to disposition of blood.
4. Sign out units in Blood Bank log book. Issued by, issued to and date/time.
5. Blood must be transported to the floor in a biohazard bag and the transfusion started
within 30 minutes of checking out the unit. Only one unit of PRBC is to be released at
once, except in the case of an emergency.
REFUSAL OF BLOOD PRODUCTS:
It is the policy of HERITAGE PARK SURGICAL HOSPITAL to verify, by means of the “Refusal To
Permit Blood Transfusion” form, that the patient’s informed refusal has been obtained by the
treating physician after the patient has been informed of the possible risks and complications that
may occur as a result of the patient’s refusal to receive recommended transfusion of blood
products or components of blood.
1.
It is the exclusive duty and responsibility of the treating physician to provide
information and to obtain informed consent.
2.
In the event that the patient refuses to give consent for the proposed blood
transfusion, the physician has a duty to give the patient all the information that is
relevant to a meaningful decision sufficient for the patient to understand the
potential consequences of declining a blood transfusion.
3.
A valid consent can only be obtained under circumstances, which are free of any
suggestion of duress or coercion.
4.
It is the responsibility of the treating physician to document in the medical record
the initial refusal and the outcome (i.e., consent or continued refusal). The
documentation should specify that the physician gave the patient the relevant
information, including that pertaining to the potential consequences of declining a
blood transfusion.
5.
The Clinical Supervisor should be notified of the patient’s informed refusal.
6.
A notification form providing information on the patient’s informed refusal
should be completed and forwarded as appropriate.
End of Policy and Procedure
B LO OD ADM INIST RAT IO N GU ID EL IN ES
BLOOD
COMPONENTS
TYPE OF TUBING
VITAL SIGNS
USUAL LENGTH
INFUSION
NURSING
IMPLICATIONS
WHOLE BLOOD
Y-type blood
administration set.
Microaggregate
Filter if
administering to a
cardiothoracic
surgery patient
Prior to administration;
5 minute observation;
15 minutes; 30 minutes;
every one hour during
and upon completion.
3-4 hours
(maximum four
(4) hours.)
Watch for s/s transfusion
reaction. Change filter
every two units.
PACKED RED
BLOOD CELLS
Y-type blood
administration set
Prior to administration;
5 minute observation;
15 minutes; 30 minutes;
every one hour during
and upon completion.
2-3 hours
(maximum four
(4) hours.)
Watch for s/s transfusion
reaction.
FRESH FROZEN
PLASMA
Blood component
recipient set or can
be given through a
Y-type blood
administration set
Prior to administration;
5 minute observation;
15 minutes; 30 minutes;
every one hour during
and upon completion.
Depends on
patient's
condition.
Usually less than
one (1) hour
(maximum 4 hrs)
Watch for s/s of fluid
overload. ABO group
specific or compatible Rh
type is generally not
required since not
RBC's.
PLATELETS
Blood Component
Recipient set
Prior to administration;
5 minute observation;
15 minutes; 30 minutes;
every one hour during
and upon completion.
Less than one
hour
ALBUMIN
Tubing supplied with
product
Pre and post infusion
baseline and hourly
assessment until
transfusion is
completed.
Depends on
Patients
Condition.
Usually 1mL/min
for 25% Albumin
Comes from Pharmacy.
Watch for s/s of fluid
overload. Only one
person must identify
product and patient.
CRYOPRECIPITATE
Blood component
recipient set
Per blood administration
flowsheet
As quickly as
possible or as
ordered
Only someone
experienced in
venipuncture should
attempt IV on this
patient.
FACTOR VIII
Prefilled syringe or
IV tubing
Can be taken PRN
As quickly as
possible or as
ordered
It should be hung
promptly to ensure
stability and can be used
for 24 hour infusions.
DO NOT
REFRIGERATE.
FACTOR IX
Prefilled syringe or
IV tubing
Can be taken PRN
As quickly as
possible or as
ordered
MUST BE INFUSED
WITHIN 1-3 HOURS
FEIBA
Prefilled syringe or
IV tubing
Can be taken PRN
As quickly as
possible or as
ordered
MUST BE INFUSED
WITHIN 1-4 HOURS.
DO NOT
REFRIGERATE AFTER
RECONSTITUTION.
IBG
Prefilled syringe or
IV tubing or IM
Can be taken PRN or as
ordered
Initial dose of
0.5- 1 mg x 30
min. subsequent
doses at
125u/hr.
Should be infused at
room temperature.
Stability is maintained for
8 hours at room
temperature or 24 hours
refrigerated. DO NOT
SHAKE. DO NOT MIX
WITH OTHER IV
INFUSIONS.
****Only 0.9% Normal Saline may be used with any/all blood products.