Transfusions

Prior to Transfusion

Review the physician's transfusion order for:

  • Component type

  • Number of units

  • Special transfusion requirements

  • Rate of transfusion

Verify Informed Consent is in the medical record and signed by the:

  • Physician

  • Patient/authorized representative

  • Witness

  • In the absence of Informed Consent, proceed with transfusion only in urgent situations when the need to transfuse without consent is adequately documented in the medical record.

Prepare for Transfusion

  • Collect equipment & supplies:

    • Standard blood administration set with 150-260 micron filter - Infusion pump if appropriate

    • 250 ml bag of 0.9% Sodium Chloride

    • Alcohol wipe

    • Saline flush

  • Verify patient's vital signs are acceptable for transfusion.

  • Give premedication, if ordered.

  • Verify a patent IV line is available.

    • IV is a 14 to 22-gauge needle (Children can receive blood through a 22-gauge needle if necessary), refer to hospital policy for the specific size

  • Prime blood administration set tubing with 0.9% Sodium Chloride.

Blood Warmers

  • A blood warmer may be necessary for patients who are extremely cold or require rapid infusion. They can also be used in the OR/PACU.

  • Never use a microwave or hot water bath to heat blood.

  • Warming of blood should only be done using an FDA-cleared blood-warming device with an audible alarm system.

  • Always follow operating instructions when using a blood warmer.

Obtain the Blood

  • Prepare a Blood Component Dispense Record with patient information and the pretransfusion checklist.

  • Send to the Transfusion Service with an associate trained and authorized to pick up blood.

  • Together with the Transfusion Service associate, verify patient & blood component information. upon release, transport blood to the nursing unit immediately.

Notes:

  • Start the transfusion as soon as possible upon receipt.

  • Complete the transfusion within 4 hours of issue from Transfusion Service

  • Storage or removal from blood cooler.

    • Never place blood in a nursing unit refrigerator.

    • Return all unused blood to the Transfusion Service.

Bedside Verification

With a second licensed individual:

  • Confirm the written physician's order and completed transfusion consent is in the chart.

  • Verbally review the blood, attached label & Transfusion Record to:

    • Verify patient name & medical record number. Use the patient's hospital armband, and ask an alert patient to state their name and date of birth.

    • Verify the ABORh types of patient and blood.

    • Verify the blood identification number.

    • For BC, check the crossmatch interpretation & verify the crossmatch is not expired.

    • Verify the blood is not expired.

    • Verify any special transfusion requirements are met.

• If ANY information is missing or incorrect, immediately notify the Transfusion Service and return the blood.

Transfusion Certification Patient Education/Consent

  • Complete the Transfusion Certification area of the Transfusion Record to document a successful bedside verification.

  • Verbally review the signs & symptoms of transfusion reaction with the patient. For outpatients, also provide written instructions.

  • Complete the Patient Education/Consent area of the Transfusion Record.

Begin Transfusion

  • Document on the Transfusion Record:

    • The access line used for transfusion

    • If a blood warmer is being used

    • The transfusion start date/time and signature

    • The pre-transfusion vital signs

    • Start infusion at 1-2 mL/min for the first 15 minutes (except in cases of medical emergencies).

    • Use only 0.9% Sodium Chloride in the same IV set.

    • Never infuse blood & medications in the same IV line.

    • Remain with the patient for the first 15 minutes and observe for any signs & symptoms of an adverse reaction.

Monitor Transfusion

  • At the end of 15 minutes, record the date/time, a full set of vital signs, and a signature.

  • If no adverse reaction is noted, increase the flow rate as ordered.

  • At 60-minute intervals:

    • Record date/time, temperature, and signature

    • Assess patient for adverse signs & symptoms.

    • If adverse signs or symptoms are observed, record Pulse and BP

Transfusion Reaction

  • If the patient exhibits any signs or symptoms of a transfusion reaction

  • Document amount transfused

  • Stop the transfusion and, using a new IV set, keep the line open with 0.9 % sodium chloride IV infusion at 30 ml /hour

  • Record patient’s signs and symptoms -

    • Fever (1°C/2°F or higher from baseline 38°C/100.4°F or above )

    • Chills

    • Hives - itching

    • Chest pain

    • Back Pain

    • Hypoxemia

    • Shortness of breath

    • Change in BP

    • Change in pulse

    • Red or dark urine

  • Notify the physician immediately.

  • If adverse signs or symptoms are observed:

    • Stop the transfusion. Using a new IV set, keep the line open with 0.9% Sodium Chloride.

    • Record signs & symptoms.

    • Notify the physician immediately.

    • Check the patient's ID band, blood labels, and Transfusion Record.

    • If the physician suspects a transfusion reaction

    • Notify the Transfusion Service immediately.

    • Refer to the back of the Transfusion Record for additional instructions and information about acute transfusion reactions.

    • Send a copy of the Transfusion Record, administration set with attached blood and IV fluid, and a properly collected post-reaction blood sample to the Transfusion Service.

Post Transfusion

  • Flush all tubing with 0.9% Sodium Chloride.

  • Record transfusion stop date/time, a full set of vital signs, and a signature.

  • Record the amount transfused.

  • Remove all tubing & blood bag and discard them in biohazard trash

  • Verify all areas on the Transfusion Record are complete and place in the patient's chart.

References and Resources:

Cheryl