Blood Transfusion

The transfer of blood or blood components from one person (the donor)
into the bloodstream of another person (the recipient). This may be done
as a lifesaving maneuver to replace blood cells or blood products lost
through bleeding. Transfusion of your own blood (autologous) is the
safest method but requires advance planning and not all patients are
eligible. Directed donor blood allows the patient to receive blood from
known donors. Volunteer donor blood is usually most readily available
and, when properly tested has a low incidence of adverse events. Blood
conserving techniques are an important aspect of limiting transfusion
requirements.
Blood Groups

BLOOD ANTIGEN ANTIBODY APPROXIAME

GROUP ON RBC IN PLASMA FREQUENCY
OF
OCCURRENC
E IN
POPULATION
A A ANTI-B 45%
B B ANTI-A 8%
AB AB NONE 3%
O NONE ANTI-A AND 44%
ANTI-B

Blood And Blood Components Commonly Used In

Infusion Therapy

BLOOD/BLOOD INDICATIONS AND

COMPONENTS CONSIDERATIONS
WHOLE BLOOD Volume replacement and oxygen-carrying
capacity; usually used only in significant
bleeding (.25% blood volume lost)

Packed red blood Increases RBC mass.

cells (PRBCs) Symptomatic anemia: platelets in the units
are not functional; WBCs in the unit may
 cause reaction and are not functional.

Platelets random Bleeding due to severe decrease in

platelets.
Prevent bleeding when platelets <5,000
10,000/mm
Survival decrease in the presence of fever,
chills, infection.
Repeated treatment decreased survival
Platelets single due to alloimmunization.
donor
Used for repeated treatment: decreases
alloimmunization risk by limiting exposure
Plasma (FFP) to multiple donors.

Bleeding in patients with coagulation

Granulocytes factor deficiencies, plasmapheresis.

Lymphocytes Severe neutropenia in selected patients;

(WBCs) controversial.
(apheresed)
Stimulate graft-versus-disease effect.
Cryoprecipitate

Von Willebrands disease

Hypofibrinoginemia
Antihemophilic Hemophilia A
factor (AHF)
Hemophilia A
Factor IX Hemophilia B (Christmas Disease)
concentrate
Hereditary VII, IX, X deficiency;
Factor IX complex Hemophilia A with factor VII inhibitors.

Hypoproteinemia; burns; volume

Albumin expansion by 5% to increase blood
volume; 25% decrease hematocrit.

Intravenous gamma Hypogammaglobulinemia (in CLL,

globulins (IgG) recurrent infections); ITP; primary
immunodeficiency states
Antithrombin III
Concentrate (AT AT III deficiency with or at risk for
III) thrombosis.

Standard Of Care Guidelines

When administering whole blood or blood components, unsure the
following:

Follow up on results of complete blood count and report to health

care provider so appropriate blood product can be ordered based on
patients condition.
Contact the blood bank with health care providers order and
ensure timely delivery of blood products.
Establish a patent I.V. line with compatible I.V. fluid.
Use appropriate administration setup, filter, warmer,, etc.
Obtain baseline vital signs.
Make sure proper blood product is given to the right patient.
Transfuse at prescribed rate during prescribed time, as tolerated by
patient.
Observe for acute reactions allergic, febrile, septic, hemolytic,
air embolism, and circulatory overload by assessing vital signs,
breath sounds, edema, flushing, urticaria, vomiting, headache, back
pain.
Notify patients health care provider or available house officer if
signs of reaction or other abnormality arise.
Be aware of delayed reactions and educate patient on risk and what
to look for: hemolytic, iron overload, graft-versus-host disease,
hepatitis, and other infectious diseases.
Nursing Management Before, During, And After
Blood Transfusion:

Pretransfusion Responsibilities:

Nursing actions during transfusion aim at prevention or early recognition

of adverse transfusion reactions. Preparation of the client for transfusion
is imperative, and institutional blood product administration procedures
must be carefully followed. Before administering any blood product,
review the agencys policies and procedures.

Legally, a physicians prescription is needed to administer blood or its

components. The prescription specifies the type of component, the
volume, and any special conditions the physician judges to be important.
Verify the prescription for accuracy and completeness. In many hospitals
a separate consent form must be obtained before a transfusion is
performed.

A blood specimen is obtained for crossmatching. The procedure and

responsibility of obtaining this specimen are specified by hospital policy.
The laboratory requires at least 45 minutes to complete the
crossmatching testing. In most hospitals a new crossmatching specimen
is required at least every 48 hours.

Blood components are viscous, requiring that a large needle (at least 20-
gauge) be used, whenever possible, for venous access, Both Y-tubing
and straight tubing sets are used for blood component infusion. A blood
filter to remove sediment from the stored blood products is included
with blood administration sets and must be used to transfuse most blood
products. In massive transfusion, a microaggregate filter may be used.

Use normal saline solution as solution to administer with blood products.

Ringers lactated and dextrose in water are not used for infusion with
blood products because they cause clotting or hemolysis of blood cells.
Never add drugs to bleed products.

Before the transfusion is started, it is essential to determine that the

blood component delivered is correct and that identification of the client
is correct. Check the physicians prescription simultaneously with
another registered nurse to determine the clients identity and whether
the hospital identification band name and number are identical to those
on the blood component tag. Checking the clients room number is not
an applicable form of identification. Examine the blood bag label, the
attached tag, and the requisition slip to ensure that the ABO and Rh
types are compatible. Check the expiration date and inspect the product
for discoloration, gas bubbles, or cloudiness, all indicators of bacterial
growth or hemolysis.
Transfusion Responsibilities

Before starting the transfusion, explain the procedure to the client. Take
the vital signs, including, temperature, immediately before starting the
transfusion. Begin the infusion slowly. Remain with the client for the
first 15 to 30 minutes. Any severe reaction usually occurs with infusion
of the first 50 ml of blood. Ask the client to report unusual sensation
such as chills, shortness of breath, hives, or itching. Assess vital signs 15
minutes after starting the transfusion to detect signs of a reaction. If
there are none, the infusion rate can be increased to transfuse 1 unit in
about 2 hours(depending on the clients cardiac status). Take vital signs
every hour throughout the transfusion or specified by agency policy.

Blood components without large amounts or RBCs can be infused more

quickly. The identification checks are the same as for RBC transfusions.
It may be necessary to infuse blood products at a slower rate for older
clients.

NURSING ACTIONS RATIONALES

Before infusion:

1. Assess laboratory values. Many institutions have specific

guidelines for blood product
transfusions.
2. Verify the medical
prescription. Legally, a physicians
prescription is required for
transfusion. The order should
state the type of product, dose,
and transfusion time.
3. Assess the clients vital
signs, urine output, skin Determine whether the client
color, and history of can tolerate infusion. Baseline
transfusion reaction. information may be needed to
help identify transfusion
reactions.
4. Obtain venous access. Use
a central catheter or 19- The large-bore needle allows
gauge needle if possible. cells to flow more easily without
occluding the lumen of the
5. Obtain blood products catheter.
from a blood bank.
Transfuse immediately. Once a blood product has been
released from the blood bank,
the products should be
6. With another registered transfused as soon as possible.
nurse, verify the clients
 name and number check Human error is the most
blood compatibility, and common cause of ABO
note expiration time. incompatibility reactions.

During Transfusion:

7. Administer the blood

product using the
appropriate filtered tubing.
Filters are needed to remove
aggregates and possible
8. If the blood product needs
contaminants.
to be diluted, use only
normal saline solution.
Hemolysis occurs if any I.V.
solution is used.
9. Remain with the client for
the first 15 to 30 minutes
of the infusion.
Hemolytic reactions occur more
often within the first 50 mL of
10. Infuse the blood
the infusion.
product at the prescribed
rate.
Fluid overload is potential
complication of rapid infusion.
11. Monitor vital signs.
 Vital sign changes often indicate
After Transfusion: transfusion reactions.

12. When the transfusion

is completed, discontinue
infusion and dispose of the Blood borne pathogens may be
bag and tubing properly. spread inadvertently through
improper disposal.
13. Document.

The client record should

indicate the type of product
infused, product number,
volume infused, time of
infusion, and any adverse
reactions.
Transfusion Reactions In Emergency
Medicine Treatment & Management
Emergency Department Care
All patients receiving blood products should be placed on continuous
cardiac monitoring and pulse oximetry.
Hemolytic transfusion reactions are treated as follows:
Stop transfusion as soon as a reaction is suspected
Replace the donor blood with normal saline
Examine the blood to determine if the patient was the intended
recipient and then send the unit back to the blood bank
Furosemide may be administered to increase renal blood flow
Low-dose dopamine may be considered to improve renal blood
flow
Make efforts to maintain urine output at 30-100 mL/h
Extravascular hemolytic reactions do not require any specific treatment.
However, if clinically ruling out intravascular hemolysis is difficult,
follow the same treatment.
Nonhemolytic transfusion reactions are treated as follows:
Aggressive treatment of simple febrile reactions is not necessary;
however, because the nonspecific symptoms are similar to those of
a hemolytic transfusion reaction, differentiating this entity from a
hemolytic reaction is necessary
 The transfusion should be terminated
Evaluate the patient for evidence of hemolysis
The patient's fever can be treated with acetaminophen
Anaphylactic reactions are treated as follows:
Stop the transfusion immediately
Support the airway and circulation as necessary
Administer epinephrine, diphenhydramine, and corticosteroids
Maintain intravascular volume
Minor allergic reactions are treated with antihistamines. Although the
necessity of stopping the transfusion is unclear, in more severe cases and
in uncertain cases, the transfusion should be stopped.
Transfusion-related acute lung injury is treated as follows [6, 7, 8] :
Monitor oxygen saturation
Provide supplemental oxygen to maintain oxygen saturation above
92%
Hypoxemia severe enough to require endotracheal intubation and
positive-pressure ventilation occurs in 70-75% of patients
No evidence supports the routine use of corticosteroids [9]
The blood bank should be notified
For graft versus host disease, no effective th erapies currently exist.
Emphasis needs to be placed on prevention.
Massive Transfusion
To decrease the risk of hypothermia in patients receiving massive
transfusion (commonly defined as 10 units of red blood cells [RBCs] in
24 h), administer the blood through a blood warmer. Do not place blood
in a microwave oven to warm, as this causes hemolysis. Treat
symptomatic hypocalcemia with calcium chloride or calcium gluconate.
Hemorrhage coupled with coagulopathy remains the leading cause of
preventable in-hospital deaths in trauma patients and in the emergency
setting, standard coagulation tests may be unavailable or unreliable.
Consequently, a strategy of transfusing platelets, fresh frozen plasma,
and RBCs in a fixed ratio of 1:1:1 has been widely adopted for use in
patients requiring massive transfusions.
A 1:1:1 protocol has been associated with improved survival in
retrospective studies in military and civilian settings, but those studies
suffered from methodologic limitations. In addition, that protocol may
lead to unnecessary exposure to blood components and an increased risk
of complications. However, two more recent studies, the randomized
Trauma Lab versus Formula Pilot Trial (TR-FL) and the Pragmatic
Randomized Optimum Platelet and Plasma Ratios (PROPPR) study,
largely support the use of this protocol.
In TR-FL, the fixed-ratio transfusion protocol proved feasible, but was
associated with increased plasma wastage. In PROPPR, early
administration of plasma, platelets, and RBCs in a 1:1:1 ratio compared
with a 1:1:2 ratio did not result in significant differences in mortality at
24 hours or at 30 days. However, more patients in the 1:1:1 group
achieved hemostasis and fewer experienced death from exsanguination
by 24 hours, with no other differences in safety between the two groups.

Medical Care
Continuous monitoring of vital signs during general anesthesia may
prevent acute circulatory (volume) overload, but it may not detect early
signs of other reactions (eg, acute hemolytic transfusion reactions).
The onset of red-colored urine in a transfused patient should raise the
question of a hemolytic transfusion reaction. When performing checks to
confirm that the correct blood was transfused to the correct patient,
centrifuge a urine sample to determine whether the red color represents
hematuria or hemoglobinuria (see image below).
Rapid test to distinguish hematuria from hemoglobinuria. The onset of
red urine during or shortly after a blood transfusion may represent
hemoglobinuria (indicating an acute hemolytic reaction) or hematuria
(indicating bleeding in the lower urinary tract). If freshly collected urine
from a patient with hematuria is centrifuged, red blood cells settle at the
bottom of the tube, leaving a clear yellow urine supernatant. If the red
color is due to hemoglobinuria, the urine sample remains clear red after
centrifugation.
In addition, the onset of abnormal bleeding/generalized oozing during
surgery in a transfused patient should raise the question of a hemolytic
transfusion reaction with disseminated intravsacular coagulation (DIC).
Acute hemolytic reactions (antibody mediated) are managed as follows:
Immediately discontinue the transfusion while maintaining venous
access for emergency management.
Anticipate hypotension, renal failure, and DIC.
 Prophylactic measures to reduce the risk of renal failure may
include low-dose dopamine (1-5 mcg/kg/min), vigorous hydration
with crystalloid solutions (3000 mL/m 2/24 h), and osmotic diuresis
with 20% mannitol (100 mL/m2/bolus, followed by 30 mL/m 2/h
for 12 h).
If DIC is documented and bleeding requires treatment, transfusions
of frozen plasma, pooled cryoprecipitates for fibrinogen, and/or
platelet concentrates may be indicated.
Acute hemolytic reactions (nonantibody mediated) are managed as

Follows:
The transfusion of serologically compatible, although damaged,
red blood cells (RBCs) usually does not require rigorous
management.
Diuresis induced by an infusion of 500 mL of 0.9% sodium
chloride per hour, or as tolerated by the patient, until the intense red
color of hemoglobinuria ceases is usually adequate treatment.
In febrile, nonhemolytic reactions, fever usually resolves in 15-30
minutes without specific treatment. If fever causes discomfort, oral
acetaminophen (325-500 mg) may be administered.
Avoid aspirin because of its prolonged adverse effect on platelet
function.
In allergic reactions, diphenhydramine is usually effective for relieving
pruritus that is associated with hives or a rash. The route (oral or
intravenous) and the dose (25-100 mg) depend on the severity of the
reaction and the weight of the patient.
In anaphylactic reactions, a subcutaneous injection of epinephrine (0.3-
0.5 mL of a 1:1000 aqueous solution) is standard treatment. If the patient
is sufficiently hypotensive to raise the question of the efficacy of the
subcutaneous route, epinephrine (0.5 mL of a 1:10,000 aqueous solution)
may be administered intravenously. Although no documented evidence
exists that intravenous corticosteroids are beneficial for the management
of acute anaphylactic transfusion reactions, theoretical considerations
cause most clinicians to include an infusion of hydrocortisone or
prednisolone if an immediate response to epinephrine does not occur.
Transfusion-related acute lung injury (TRALI) is managed as follows:
Immediately discontinue the transfusion while preserving venous
access.
Patients with mild episodes should respond to oxygen administered
by nasal catheter or mask. If shortness of breath persists after
oxygen administration, transfer the patient to an intensive care
setting where mechanical ventilation can be employed.
In the absence of signs of acute volume overload or cardiogenic
pulmonary edema, diuretics are not indicated.
 No evidence exists that corticosteroids or antihistamines are
beneficial.
Treat complications with specific supportive measures.

Circulatory (volume) overload is managed as follows:

Move the patient into a sitting position and administer oxygen to
facilitate breathing.
The most specific treatment is discontinuing the transfusion and
removing the excessive fluid.
If practical, the unit of blood component being transfused may be
lowered to reverse the flow and to decrease intravascular volume by
a controlled phlebotomy.
Less urgent situations may be managed by a parenteral or oral
diuretic (eg, furosemide).
If the patient has symptomatic anemia requiring additional
transfusions of RBCs, select concentrated (ie, CPDA-1-
anticoagulated) red cells (hematocrit = 80-85%). Avoid red cell
components diluted with saline additives (ie, AS-1).
Bacterial contamination (sepsis) is managed as
follows:
Immediately discontinue the transfusion, including all tubing,
filters, and administration sets, and save the transfusion materials
for cultures, while preserving venous access.
 After appropriate blood cultures have been obtained, initiate
treatment with intravenous broad-spectrum antibiotics. If a
microbiologic stain or a culture of the contents of the transfused
product identifies an organism, the initial broad-spectrum
antibacterial approach may be modified accordingly.
Consultations

The possibility of an acute transfusion reaction should trigger an

immediate consultation with the medical director of the hospital's blood
bank or a designee (eg, a clinical pathology resident, transfusion
medicine fellow). Depending on the findings, the blood bank consultant
may arrange for microbiologic stains and cultures of the residual
contents of the blood product container, clerical checks for patient and
product identification in the laboratory, repeat compatibility testing
using a freshly collected blood sample from the recipient, or other
pertinent diagnostic studies.

The diagnosis of an acute hemolytic transfusion reaction should trigger

consultation with a nephrologist to ensure optimal prophylactic
measures to prevent renal damage. [55]

A hematology consultation is appropriate if a hemolytic transfusion

reaction or bacterial contamination precipitates DIC.

A clinical diagnosis of bacterial contamination of a transfused blood

product should trigger an infectious diseases consultation.