BLOOD TRANSFUSIONS
Blood Transfusions / Blood Components

A copy of the GBMC policy for “Blood Transfusions / Blood Components” is included in this section. You are responsible for knowing this entire policy and following it 100% of the time when involved with the administration of blood products. Should your patient have an adverse reaction to the administration of a blood product, you will need to follow the procedure for transfusion reaction contained within this policy.

NOTE: Platelets and autologous units must be picked up from the blood bank. They cannot be sent to the nursing units via the pneumatic tube system.

GBMC

CLINICAL POLICY AND PROCEDURE

BLOOD TRANSFUSIONS/BLOOD COMPONENTS

Approval:

Signature on file:

VP of Nursing, CNE

I. PURPOSE

To establish guidelines for the administration of blood and blood products.

II. DEFINITION OF TERMS

A. Type and Screen: Determine ABO and Rh factor (refers to Type). Perform antibody screen and if positive, antibody identification will be performed for patients who may require blood in near future. Required preparation for transfusions of certain blood products. Indicated for the preoperative patient who may require intraoperative transfusion.

B. Type and Crossmatch: Determine ABO, Rh, antibody screen and crossmatch. Required preparation for transfusion of red blood cell products.

III. POLICY

A.A physician’s order is necessary for a blood transfusion.

B.A physician must obtain informed consent for the initial transfusion and any additional units that are needed for a change in the patient’s condition or for reasons other than the initial reason for transfusion.

C.Only one unit of blood is issued by the Blood Bank at one time. Exception: GOR, ICU, ER, DR when patient condition indicates, red cell and thawed plasma products are issued in an insulated blood product shipping box on ice. Platelet products must remain at controlled temperature (20-24°C controlled room temperature) with agitation.

D.If blood or components cannot be infused in four hours due to patient condition, the product should be divided in the Blood Bank and stored appropriately in the Blood Bank until needed.

E.No medication or other solutions (except 0.9% normal saline) may be added to any unit of blood, or simultaneously infused in the same I.V. line.

F.Under no circumstances should blood be put in any refrigerator outside the Blood Bank.

G.Blood drawn for a Type and Screen will be held for 72 hours. Any time during this 72-hour period, blood drawn for the type and screen may be used to crossmatch blood for patient use.

H.Crossmatched blood will be held for 48 hours in the Blood Bank.

I.If multiple red cell transfusions are to be given over a period of days, a fresh Typenex labeled specimen for crossmatching must be drawn every seventy-two (72) hours (exception: NICU patient). If only plasma or platelets (non-red cell products) are being transfused, then a new patient sample is not necessary on the same admission.

J.When fresh frozen plasma is ordered, the Blood Bank must be notified one half hour before it is to be given so it can be thawed.

K.The unit of blood must begin transfusing within twenty-five (25) minutes of pickup from the Blood Bank or be returned to the Blood Bank for proper storage.

L.Blood and blood products must be hung by a registered nurse, LPN, or physician.

M.Transfusion reaction, regardless of severity, must be reported promptly by the nurse or physician on a Transfusion Reaction Form (800-7).When platelets, irradiated red cells or other special products are ordered, arrangements must be made by the Blood Bank with the American Red Cross. Blood Bank will indicate approximate amount of time needed to provide product.

N.The Y-type blood transfusion tubing may be used with 2 units of blood. The Y-set must not be used for maintenance IV solutions or antibiotics.

O.The empty blood transfusion bag is discarded in biohazard trash.

P.If the product was not totally transfused, then document the reason on the Unit Transfusion Record.

Q.In addition, if more than 50cc of untransfused product remain, then hand carry untransfused product to Blood Bank for proper accountability and disposition (FDA requirement).

R.Entered/opened blood bags cannot be returned through the pneumatic tube. Chart the original copy of the completed Transfusion Record Form and return the copy to the Blood Bank.

IV. EQUIPMENT

  1. Request for Issue of Blood (Form 800-72)
  2. 18 or 20 gauge IV catheter. 24 gauge IV catheter – NICU only.
  3. Unit of blood or blood product
  4. Y-Type blood administration set or appropriate administration set for blood component
  5. 0.9 % normal saline
  6. Transfusion Record - sent with blood component from the Blood Bank
  7. Gloves
  8. Circular of Information for the Useof Human Blood and Blood Components, most current copy should be available on each Clinical Unit (additional copies available from Blood Bank).

V. PROCEDURE

A. Ordering/Obtaining Blood or Blood Component

1. To type and crossmatch a patient for blood transfusion, refer to Procedure "Blood Recipient Identification System (Blood Bracelet): Use of".

2. If the patient has been typed and screened within the last 72 hours, and later a transfusion is ordered, call the Blood Bank and ask for the blood to be crossmatched.

3.Check the computer to see if blood/blood component is available for the patient.

4.Complete the "Request for Issue of Blood" form (#800-72). For red cell products, the Typenex unique transfusion number must be written at the bedside from the patient’s bracelet onto the Request Form.

5.Send the request form to the Blood Bank (Station 93) via the pneumatic tube. (Products which cannot be sent through the pneumatic tube are autologous, directed donors, platelet products, cryoprecipitate, special antigen negative products that are not replaceable). If requested product is not received in the pneumatic tube, call the Blood Bank.

6. Prior to the issue of requested product, the Blood Bank will monitor the appropriate use of blood and blood components by confirming established hospital transfusion criteria are met (red cells/hct <30%, platelets/count less than 20,000 with or without bleeding or 50,000 in cases of major surgery, plasma/PT >18secs or PTT >45secs, Cryo/factor deficiency). If criteria are not met, then technologist will call nurse to obtain patient clinical information and ordering physician, and refer the case to the pathologist for clinical review.

B. Blood/Blood Component Administration

1.The physician will explain the procedure and associated risks to the patient and obtain consent (Documented on Form 601-C50 Question #3).

2. The RN will provide the patient information regarding blood transfusion.

3. Obtain IV access with 18g, 20g, or 24g (NICU only) angio cath prior to obtaining the blood unit.

4.Using Y-type blood administration set, close all clamps.

5.Attach 0.9% normal saline solution to one side of the Y-set and prime the tubing. Normal saline is the only compatible solution to use with the blood or blood component. Crystalloid solutions and medications may cause agglutination and/or hemolysis of the blood or blood components.

6.Obtain baseline vital signs and temperature, and record on Blood Vital Signs Intervention in Meditech PCS (part of the Blood Admin Order Set) or, for units still documenting on paper, the Transfusion Record. (Take baseline vitals prior to spiking blood product with transfusion filter set).

7.At the bedside, two licensed nurses (one must be an RN) must check the data (patient first name and last name, medical record number and for all red cell products, the Typenex number) on the patient’s Typenex and identification bracelets with the label on the unit of blood and the unit Transfusion Records to ensure correct identification of the patient and Other information to be confirmed to ensure the correct administration of the appropriate blood product, blood product label, blood types, product unit number, product expiration date and any special product requirements i.e., CMV negative, Irradiated, Leukodepleted and for all red cell products, the crossmatch results. Both persons identifying the unit of blood must be documented on the Blood Administration Verification Intervention in Meditech PCS, or, for units still documenting on paper, sign the Transfusion Record.

8. Don gloves and attach blood unit to other side of the Y-tubing.

9. Attach blood tubing to IV line. Begin the rate of flow at (5 ml./minute or less for the first 15 minutes) of the transfusion and observe the patient during this time. This flow rate allows patient to receive a sufficient amount of blood while nurse is remaining at the patient’s side. Symptoms of a severe transfusion reaction are usually manifested during the first 15 minutes of blood transfusion. For inpatient units, document the start time of the infusion and initial rate of the infusion on the Blood Product Infusion Intervention in Meditech PCS.

10.Decrease the rate of flow to (100cc/hour as per order by physician unless contraindicated by patient’s condition. In pediatric and geriatric patients, the rate of flow may need to be decreased and split units ordered. (For platelet products flow rate may remain at 5ml/minute and for plasma products increase flow rate to 10 ml/minute). For inpatient units, and rate changes during the transfusion should be documented on the Infusion Changes Intervention in Meditech PCS.

11.Instruct the patient to report any chilling, shortness of breath, or unusual symptoms immediately to the nurse.

12.Vital signs and temperature must be assessed 15 minutes x2, after initiation, and then hourly. For inpatient units, this information is to be documented on the Blood Vital Signs Intervention in Meditech PCS.

13.The licensed nurse should stay with the patient during the first 15 minutes to monitor for symptoms of possible transfusion reaction.

14. Use a standard blood administration set for up to two units.

15.Flush the Y-type blood administration set or appropriate administration set with 0.9% normal saline after the unit of blood has infused.

16. For inpatient units, document the date and time the transfusion is terminated, the amount given and whether a reaction occurred on the Blood Product Completion Intervention in Meditech PCS. For all units still documenting on paper, record the vital signs, date and time the transfusion is terminated, the amount given and whether a reaction occurred on the Transfusion Record.

17. The empty transfusion container is discarded in biohazard trash.

18. If the product is spiked with filter and/or transfusion started, but IV access is lost; or, for some other reason the transfusion cannot be started or continued, then notify Blood Bank and immediately hand carry product with filter to Blood Bank for appropriate storage. Once IV access is re-established, and then Blood Bank will determine if blood product can be transfused.

19. Verify that Blood Administration documentation is complete. Place the original Transfusion Record on the patient’s medical chart. For inpatient units, nurses should write “See EMR” on the Transfusion Record, as this information has been entered into Meditech PCS. Return the copy to Blood Bank.

20.Document in the Notes section of Meditech PCS (or in the Progress Notes section of the chart for units still documenting on paper) how the patient responded to the blood/blood component transfusion, and patient’s status following the transfusion.

21.Documentation of amount of blood infused:
- Inpatient Units: Blood Product Completion Intervention in Meditech
PCS
- ER: In Meditech EDM
- OR/NICU: On Paper (ICU nurses can put OR’s blood product infused
documentation into the I&O in PCS for I&O accuracy)
- Any other non-PCS areas: On Paper

C. Transfusion Reaction:

  1. If a reaction is suspected, stop the blood immediately and initiate normal saline infusion.
  2. Notify the physician and Blood Bank immediately. If only a mild allergic reaction, hives only, and transfusion of product urgent, then physician may prescribe anti-histamine and then continue transfusion with close observation.
  3. Recheck identification of patient, Typenex bracelet, crossmatch tag, and unit number.
  4. If Suspected Transfusion Reaction Workup is indicated, then remove original Typenex bracelet from patient’s arm and return to Blood Bank.
  5. Return remaining blood with transfusion set in a plastic bag to Blood Bank. (Must be hand carried. Never return opened products through the pneumatic tube).
  6. Draw a new type and crossmatch Typenex sample, (special Blood Bank plastic pink top vacutainer tube).
  7. Collect first urine voided by the patient and send to lab marked "Transfusion Reaction Specimen".
  8. Complete a Transfusion ReactionReport Form according to directions on the form and send form, untransfused product, the new Typenex sample and Blood Bank copy of the Transfusion Record, along with the old Typenex bracelet to the Blood Bank immediately.
  9. Complete a Blood Bank request form and mark the Transfusion Reaction Work-up.

10. Document in Notes section of Meditech PCS (or in the Progress Notes section of the chart for units still documenting on paper) that a transfusion reaction occurred and patient’s status after the reaction.

VI. BIBLIOGRAPHY

Glover, G, Powell, F. 1996 (Blood Transfusion). Nursing Standard, Vol. 10 Number 21.
Laborich, T. 1997 (Transfusion Therapy, Nursing Implications). Clinical Journal ofOncology Nursing, Vol.1, Number 3, Pages 61-72.
Fitzpatrick, L. & Fitzpatrick T. 1997 (Blood Transfusions). Nursing 97, August Pages 34-41.

Circular of Information for the Use of Human Blood and Blood Components, prepared jointly by the American Association of Blood Banks (AABB), America’s Blood Centers (ABC), and the American Red Cross (ARC), and is recognized as acceptable by the Food and Drug Administration (FDA), July 2002.

APPROVED: PNC 9/99 PCC 9/99

REVIEWED/REVISED:9/73, 1/82, 10/83, 2/84, 7/84, 1/85, 4/88, 8/92, 11/93, 3/95, 4/99, 6/03, 10/03, 1/04, 12/04, 5/05

bloodtransfusion_0505

ADDENDUM:

  1. Transfusion Reactions
  2. Acute hemolytic –

Symptoms: chills, fever, pain in the chest or lower back, flushing of the face, hematuria, tachycardia, tachypnea, hypotension, dyspnea, bleeding, acute renal failure, shock, severe respiratory or cardiac collapse.

Cause: ABO incompatible red cells, red dell antibodies in patient’s plasma attached to antigens on transfused red cells causing red cell destruction.

  1. Febrile, non-hemolytic –

Symptoms: Fever (rise of 1 C or 2 degrees F), chills, headache, flushing, anxiety, rigors, and muscle pain.

Cause: Release of interleukins from lyzed white cells in the blood product.

  1. Mild allergic –

Symptoms: flushing, itching, urticaria (hives).

Cause: Sensitivity to foreign plasma proteins or blood product preservative.

  1. Anaphylactic –

Symptoms: anxiety, urticaria, wheezing, laryngeal edema, progressing to cyanosis, shock, and possible cardiac arrest.

Cause: Severe sensitivity to foreign plasma proteins or blood product preservatives, especially patient who developed anti-IgA antibody to IgA plasma protein.

  1. Transfusion Complications:
  2. Circulatory overload –

Symptoms: dyspnea, pulmonary congestion (rales), headache, hypertension, tachycardia, distended neck veins.

Cause: Fluid administered faster than circulation can accommodate.

  1. Sepsis –

Symptoms: Rapid onset of chills, high fever, vomiting, diarrhea, and marked hypotension and shock.

Cause: Contaminated blood products.

  1. Transfusion-related acute lung injury, commonly called TRALI. Clinical signs and symptoms of 1 to 2 degree/s C rise in temperature, usually accompanied by chills or rigors, shortness of breath associated with oxygen destruction hypotension, and tachycardia. Reaction symptoms are noted between one to six hours after completion of transfusion. Chest x-ray shows interstitial and alveolar infiltrates which are diffuse and bilateral (ARDs-like). TRALI cases are associated with presence of HLA antibodies or anti-neutrophil antibodies in plasma of the blood donor.
  2. Delayed transfusion reaction – Delayed hemolysis from destruction of transfused
    red cells by alloantibodies not detected during pre-transfusion compatibility
    testing.
  3. Transmission of infectious disease – hepatitis, HIV, CMV (Cytomegalovirus), HTLV-I/II (Human T-cell lymphotropic virus, Malaria, Babesiosis, West Nile Virus, Creutzfeldt Jakob Disease (CJD), and other potential infectious agents.
  4. Iron overload (patients receiving >100 units for chronic anemia)
  5. Graft-versus-host disease

Attachment – Transfusion Reaction Report