Infusion Therapy

The rules of transfusion: Best practices for blood product administration

Blood transfusions are a life-sustaining and life-saving treatment—but they aren’t without risk. Conditions that warrant blood transfusions range from acute trauma to intraoperative blood loss to compromised blood-cell production secondary to disease or treatment. If you’re a nurse on the front line of patient care, you must be adept at administering blood products safely and managing adverse reactions with speed and confidence.

Why reactions occur
Blood transfusion reactions typically occur when the recipient’s immune system launches a response against blood cells or other components of the transfused product. These reactions may occur within the first few minutes of transfusion (classified as an acute reaction) or may develop hours to days later (delayed reaction). If red blood cells are destroyed, the reaction may be classified further as hemolytic; all other types of reactions are broadly classified as nonhemolytic.
Some reactions result from infectious, chemical, or physical forces or from human error during blood-product preparation or administration. (For details on types of reactions, signs and symptoms, appropriate interventions, and prevention methods, see A closer look at transfusion reactions in pdf format by clicking on the download now button.)

Before starting the transfusion
Safe practice starts with accurate collection of pretransfusion blood samples for typing and crossmatching. Some facilities may require a second authorized staff member to witness and sign the form as the phlebo­tomist obtains the specimen. Also take these other key actions before you begin the transfusion:
•    Verify that an order for the transfusion exists.
•    Conduct a thorough physical assessment of the patient (including vital signs) to help identify later changes. Document your findings.
•    Confirm that the patient has given informed consent.
•    Teach the patient about the procedure’s associated risks and benefits, what to expect during the transfusion, signs and symptoms of a reaction, and when and how to call for assistance.
•    Check for an appropriate and patent vascular access.
•    Make sure necessary equipment is at hand for administering the blood product and managing a reaction, such as an additional free I.V. line for normal saline solution, oxygen, suction, and a hypersensitivity kit.
•    Be sure you’re familiar with the specific product to be transfused, the appropriate administration rate, and required patient monitoring. Be aware that the type of blood product and patient’s condition usually dictate the infusion rate. For example, blood must be infused faster in a trauma victim who’s rapidly losing blood than in a 75-year-old patient with heart failure, who may not be able to tolerate rapid infusion.
•    Know what personnel will be available in the event of a reaction, and how to contact them. Resources should include the on-call physician and a blood bank representative.
•    Before hanging the blood product, thoroughly double-check the patient’s identification and verify the actual product. Check the unit to be transfused against patient identifiers, per facility policy.
•    Infuse the blood product with normal saline solution only, using filtered tubing.

Premedication
To help prevent immunologic transfusion reactions, the physician may order such medications as acetaminophen and diphenhydramine before the transfusion begins to prevent fever and histamine release. Febrile nonhemolytic transfusion reactions seem to be linked to blood components, such as platelets or fresh frozen plasma, as opposed to packed red blood cells; thus, premedication may be indicated for patients who will receive these products. Such reactions may be mediated by donor leukocytes in the plasma, causing allosensitization to human leukocyte antigens. Cytokine generation and accumulation during blood component storage may play a contributing role.

Leukocyte-reduced and irradiated blood products
Use of blood products that have been leukocyte-reduced, irradiated, or both has been shown to reduce complications stemming from an immunologic response. In organ transplant candidates, these products reduce the risk of graft rejection.

Administering the transfusion
Make sure you know the window of time during which the product must be transfused—starting from when the product arrives from the blood bank to when the infusion must be completed. (See Quick guide to blood products in pdf format by clicking on the download now button.) Failing to adhere to these time guidelines increases the risk of such complications as bacterial contamination.


Detecting and managing transfusion reactions
During the transfusion, stay alert for signs and symptoms of a reaction, such as fever or chills, flank pain, vital sign changes, nausea, headache, urticaria, dyspnea, and broncho­spasm. Optimal management of reactions begins with a standardized protocol for monitoring and documenting vital signs. As dictated by facility policy, obtain the patient’s vital signs before, during, and after the transfusion.
If you suspect a transfusion reaction, take these immediate actions:
•    Stop the transfusion.
•    Keep the I.V. line open with normal saline solution.
•    Notify the physician and blood bank.
•    Intervene for signs and symptoms as appropriate.
•    Monitor the patient’s vital signs.
Also return the blood product to the blood bank and collect laboratory samples according to facility policy. If and when clinically necessary, resume the transfusion after obtaining a physician order. Carefully document transfusion-related events according to facility policy; be sure to include the patient’s vital signs, other assessment findings, and nursing interventions.
Most fatal transfusion reactions result from human error. The most important step in preventing such error is to know and follow your facility’s policies and procedures for administering blood products. Be aware, though, that prevention isn’t always possible—which means you must be able to anticipate potential reactions and be prepared to manage them effectively. To promote good patient outcomes, you must be knowledgeable about the best practices described in this article.

Selected references
Silvergleid A. Immunologic blood transfusion reactions. UpToDate. October 17, 2008. www.uptodate.com/patients/content/topic.do?topicKey=~EE8E1UGcUSyKQT. Accessed December 22, 2008.
Visit www. AmericanNurseToday.com/journal for a complete list of selected references.

Sabrina Bielefeldt and Justine DeWitt are Oncology Certified Nurses at Georgetown University Hospital in Washington, D.C. Ms. Bielefeldt is the Clinical Manager and Ms. DeWitt is a Clinical Nurse IV on the Inpatient Hematology Oncology unit. Ms. DeWitt also serves as Co-Chair of the hospital’s Nursing Practice Council.

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