BLOOD TRANSFUSION

 INTRODUCTION
Blood transfusion is a common medical procedure that involves transferring blood or blood components from a donor to a
recipient. It is a life-saving intervention used to replace lost blood, improve oxygen-carrying capacity, correct coagulation disorders, or
provide specific blood components like platelets or plasma. Nurses play a crucial role in ensuring the safe and effective administration of
blood transfusions, adhering to strict protocols to prevent adverse reactions and promote positive patient outcomes. This procedure
outlines the essential steps and responsibilities involved in blood transfusion.

 DEFINITION
Blood transfusion is the intravenous administration of whole blood or its components (e.g., packed red blood cells, platelets, fresh
frozen plasma, cryoprecipitate) into a patient's circulatory system.

 PURPOSES
The primary purposes of blood transfusion include:
 Restoring blood volume: In cases of significant blood loss due to trauma, surgery, or hemorrhage.
 Improving oxygen-carrying capacity: By increasing the number of red blood cells in patients with severe anemia or chronic blood
disorders.
 Correcting coagulation deficiencies: By providing clotting factors found in fresh frozen plasma or cryoprecipitate to patients with
bleeding disorders.
 Replacing platelets: In patients with thrombocytopenia (low platelet count) to prevent or treat bleeding.
 Providing specific blood components: For various medical conditions, such as immunoglobulin deficiencies or specific protein
deficiencies.
 INDICATIONS
Indications for blood transfusion include:
 Acute blood loss (e.g., trauma, surgery, gastrointestinal bleeding)
 Symptomatic anemia (e.g., fatigue, shortness of breath, dizziness)
 Chronic anemia unresponsive to other treatments
 Thrombocytopenia or platelet dysfunction with active bleeding or high risk of bleeding
 Coagulopathies (e.g., hemophilia, disseminated intravascular coagulation)
 Sickle cell crisis
 Thalassemia
 Bone marrow failure
 Exchange transfusion for neonatal hyperbilirubinemia

 CONTRAINDICATIONS
There are no absolute contraindications to blood transfusion when it is a life-saving measure. However, relative contraindications and
considerations include:
 Mild, asymptomatic anemia (usually managed with iron supplements or other therapies)
 Fluid overload or congestive heart failure (requires careful monitoring and slower infusion rates)
 Religious objections (e.g., Jehovah's Witnesses) – respectful alternative treatments should be explored.
 Risk of allergic reactions (premedication may be considered)

 EQUIPMENT
The following equipment is required for a blood transfusion:
 Prescribed blood product (checked and verified)
 Blood administration set with an in-line filter (Y-type or straight)
 IV access (appropriate gauge peripheral IV catheter, central line, or port)
 Normal saline (0.9% NaCl) solution for priming and flushing
 IV pole
 Gloves (non-sterile)
 Alcohol swabs or antiseptic solution
 Tourniquet
 Tape or transparent dressing
 Scissors
 Sharps container
 Blood transfusion record/chart
 Vital signs monitoring equipment (sphygmomanometer, thermometer, pulse oximeter, stethoscope)
 Emergency equipment readily available (e.g., epinephrine, antihistamines, corticosteroids, resuscitation cart)
 BEFORE CARE (Pre-transfusion)
1. Verify Physician's Order: Confirm the order for blood transfusion, including the type of blood component, volume, and transfusion
rate.
2. Obtain Informed Consent: Ensure the patient or their legal guardian has received adequate information about the procedure, potential
risks, benefits, and alternatives, and has signed the consent form.
3. Assess Patient History:
 o Previous transfusion reactions and their nature.
o Allergies (medications, latex, food).
o Current medications.
o Cardiac and renal status (to assess for fluid overload risk).
o Baseline vital signs.
4. Baseline Assessment:
o Vital Signs: Obtain a complete set of baseline vital signs (temperature, pulse, respiration, blood pressure, oxygen saturation).
Document these thoroughly.
o Physical Assessment: Assess skin for rashes, itching, or hives; assess respiratory status for shortness of breath or wheezing;
assess for signs of fluid overload (e.g., crackles in lungs, peripheral edema).
5. Establish IV Access:
o Insert a peripheral IV catheter of appropriate gauge (usually 18-20 gauge for adults to allow for adequate flow rate without
causing hemolysis of red blood cells). For rapid transfusions, a larger gauge (14-16 gauge) may be necessary.
o Ensure patency by flushing with normal saline.
o If a central line or port is used, confirm its patency and suitability for blood transfusion.
6. Blood Product Retrieval and Verification:
o Only obtain blood product from the blood bank when ready to transfuse. Blood products should not be out of controlled
temperature storage for more than 30 minutes before transfusion begins.
o Two-Person Verification (at the bedside): With another qualified healthcare professional, meticulously verify the following
information against the patient's identification band and the blood bank tag/slip:
 Patient's full name
  Patient's unique identification number (e.g., medical record number)
 Blood component type (e.g., Packed Red Blood Cells, Fresh Frozen Plasma)
 Donor unit number
 ABO and Rh type of both donor and recipient
 Expiration date and time of the blood product
 Presence of any abnormal discoloration, clots, or gas bubbles in the blood bag. Do not transfuse if abnormalities are noted.
o Never transfuse blood that has not been properly verified.
7. Prime Blood Administration Set:
o Close all clamps on the blood administration set.
o Spike the normal saline bag with one port of the Y-set (if applicable).
o Open the roller clamp on the normal saline line and prime the tubing, ensuring no air bubbles.
o Close the normal saline roller clamp.
o Keep the other port of the Y-set (for blood) clamped until ready to spike the blood bag.
8. Patient Education: Reiterate the purpose of the transfusion, what to expect, and instruct the patient to report any unusual symptoms
immediately (e.g., chills, itching, shortness of breath, back pain, headache).

 STEPS OF CARE IN DETAILS (During Transfusion)

1. Perform Hand Hygiene and Don Gloves.
2. Connect Blood Product:
o Spike the blood bag with the remaining port of the Y-set (or the single spike if using a straight set).
o Hang the blood bag on the IV pole.
3. Connect to Patient:
o Connect the primed blood administration set to the patient's IV access site.
4. Initiate Transfusion Slowly (First 15 Minutes):
o Open the roller clamp on the blood administration set to allow the blood to infuse slowly, typically at 2 mL/minute or
approximately 10-20 drops per minute. This allows for early detection of an acute transfusion reaction.
o Remain at the bedside for the first 15 minutes of the transfusion. This is the critical period for most severe acute transfusion
reactions.
5. Frequent Monitoring During the First 15 Minutes:
o Vital Signs: Retake vital signs (temperature, pulse, respiration, blood pressure, oxygen saturation) at 5 minutes and 15 minutes
after initiation. Compare to baseline.
o Patient Assessment: Observe for any signs of transfusion reaction:
 Mild: Rash, itching, hives.
 Moderate: Chills, fever (>1∘C increase from baseline), flushing, headache, anxiety.
 Severe: Dyspnea, wheezing, chest pain, back pain, flank pain, hypotension, tachycardia, oliguria/anuria, feeling of
impending doom.
6. Adjust Infusion Rate (After 15 Minutes):
o If no signs of reaction are observed after the initial 15 minutes and vital signs are stable, adjust the infusion rate to the prescribed
rate or a rate appropriate for the patient's condition and the blood product (e.g., PRBCs typically infuse over 2-4 hours; FFP and
platelets are infused rapidly, often over 30-60 minutes).
o Do not exceed 4 hours for a unit of red blood cells to reduce the risk of bacterial proliferation.
7. Ongoing Monitoring:
 o Vital Signs: Continue to monitor vital signs every 15-30 minutes for the first hour, then every hour, and at the completion of the
transfusion, or more frequently as indicated by patient condition or facility policy.
o Patient Assessment: Continuously assess the patient for signs of transfusion reaction or fluid overload throughout the
transfusion.
8. Documentation: Document all vital signs, patient assessments, start and end times of transfusion, volume transfused, and any reactions
or interventions.
9. Fluid Management: Avoid infusing other solutions or medications into the same IV line as blood, except normal saline, which can be
used to flush the line before and after transfusion. Dextrose solutions can cause hemolysis of red blood cells.
10. Completion of Transfusion:
o Once the blood product has infused, clamp the roller clamp.
o Flush the IV line with normal saline to clear any remaining blood from the tubing.
o Disconnect the blood administration set and dispose of it in a biohazard waste container.
o Re-assess vital signs and document the end time of the transfusion.

 AFTER CARE (Post-transfusion)

1. Post-transfusion Vital Signs: Obtain a complete set of vital signs (temperature, pulse, respiration, blood pressure, oxygen saturation)
immediately after the transfusion is complete and document them.
2. Patient Assessment: Assess the patient for any delayed transfusion reactions (e.g., fever, rash, jaundice) or signs of fluid overload.
3. Disposal of Equipment: Dispose of the blood bag and administration set according to facility policy (biohazard waste).
4. Documentation: Complete all necessary documentation, including:
o Start and end times of the transfusion.
o Total volume infused.
 o Patient's response to the transfusion.
o Any reactions observed and interventions taken.
o Vital signs throughout the procedure.
o Name of the nurse administering the transfusion and the nurse who assisted with verification.
5. Laboratory Studies: Anticipate post-transfusion laboratory orders (e.g., complete blood count, hemoglobin, hematocrit) as ordered by
the physician to assess the effectiveness of the transfusion.
6. Patient Education: Reinforce instructions to the patient to report any delayed symptoms they might experience after discharge (e.g.,
fever, chills, rash, dark urine).

 COMPLICATIONS
Transfusion reactions can range from mild to life-threatening. Prompt recognition and intervention are crucial.
Immediate Transfusion Reactions (occur within 24 hours of transfusion):
 Acute Hemolytic Reaction (AHTR): Most serious. Caused by ABO incompatibility. Symptoms: fever, chills, back pain, chest pain,
hypotension, tachycardia, dyspnea, dark urine, feeling of impending doom. STOP TRANSFUSION IMMEDIATELY.
 Febrile Non-Hemolytic Transfusion Reaction (FNHTR): Most common. Caused by antibodies to donor leukocytes. Symptoms: fever
(rise of >1∘C), chills, headache, flushing. Usually managed with antipyretics and slowing the transfusion rate.
 Allergic Reaction (Mild to Severe): Caused by sensitivity to donor plasma proteins. Symptoms:
o Mild: Urticaria (hives), pruritus (itching), flushing. Treat with antihistamines; transfusion may continue slowly if symptoms
resolve.
o Severe (Anaphylactic): Dyspnea, wheezing, hypotension, angioedema, shock. STOP TRANSFUSION IMMEDIATELY. Treat
with epinephrine, antihistamines, corticosteroids.
  Transfusion-Associated Circulatory Overload (TACO): Caused by too rapid infusion or too much volume, especially in patients with
compromised cardiac or renal function. Symptoms: dyspnea, orthopnea, crackles in lungs, peripheral edema, hypertension, JVD. Slow
transfusion rate, elevate head of bed, administer diuretics as ordered.
 Transfusion-Related Acute Lung Injury (TRALI): Life-threatening, acute lung injury. Symptoms: sudden onset of dyspnea,
hypoxemia, bilateral pulmonary edema without cardiac overload, fever, hypotension. STOP TRANSFUSION IMMEDIATELY.
Respiratory support (oxygen, mechanical ventilation) is often required.
 Bacterial Contamination/Sepsis: Rare but serious. Symptoms: rapid onset of high fever, chills, hypotension, shock. STOP
TRANSFUSION IMMEDIATELY. Send remaining blood bag and patient blood cultures to lab. Administer broad-spectrum antibiotics
and supportive care.
Delayed Transfusion Reactions (occur more than 24 hours after transfusion):
 Delayed Hemolytic Reaction: Caused by antibodies to minor blood group antigens. Symptoms: fever, unexplained drop in hemoglobin,
mild jaundice.
 Transfusion-Associated Graft-versus-Host Disease (TA-GVHD): Rare, usually fatal. Donor lymphocytes engraft in
immunocompromised recipient. Symptoms: fever, rash, diarrhea, liver dysfunction, pancytopenia. Prevented by irradiating blood
products for at-risk patients.
 Post-transfusion Purpura: Severe thrombocytopenia due to antibody formation.
 Iron Overload (Hemosiderosis): In patients receiving chronic transfusions (e.g., thalassemia).
 Infectious Disease Transmission: (e.g., HIV, Hepatitis B/C, West Nile Virus, Zika) – extremely rare due to stringent donor screening
and testing.

NURSES RESPONSIBILITY
The nurse has significant responsibilities throughout the blood transfusion process to ensure patient safety and optimal outcomes:
 Pre-transfusion:
o Verifying physician's order and obtaining informed consent.
 o Assessing patient's history and baseline vital signs.
o Establishing and maintaining patent IV access.
o Educating the patient about the procedure and potential reactions.
o Performing the critical two-person verification of the blood product at the bedside.
o Ensuring the blood product is retrieved and initiated within the appropriate timeframe.
 During Transfusion:
o Initiating transfusion slowly and remaining at the bedside for the first 15 minutes.
o Monitoring vital signs and continuously assessing the patient for signs of transfusion reactions.
o Promptly recognizing and intervening if a transfusion reaction occurs (stopping the transfusion, notifying physician, maintaining
IV access, administering emergency medications as ordered).
o Adjusting the infusion rate as per physician order and patient tolerance.
o Maintaining sterility and proper tubing management.
o Accurately documenting all aspects of the transfusion.
 Post-transfusion:
o Obtaining and documenting post-transfusion vital signs.
o Assessing for delayed reactions.
o Properly disposing of equipment.
o Completing all necessary documentation.
o Communicating significant findings or concerns to the physician.
o Patient education regarding post-transfusion symptoms.
 BIBLIOGRAPHY

 Brunner & Suddhart’s Textbook of Medical Surgical Nursing, vol 2, 12th ed, 2010: pp 2161 – 2163
 Colmer ; Moroney’s Surgery for Nurses, 16th ed, 1981 : pp 98 – 106
 Howard, Steinmann, Sheehy’s emergency nursing principles & practice, 6th ed, 2003 pp
 Thygerson, Gulli & Krohmer, First Aid, 5th ed, 2006 : pp 23 – 27
 wikipedia[Link]
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