Infusion Therapy – Blood Transfusion Reaction ManagementSECTION: 25.03
Strength of Evidence Level: 3__RN__LPN/LVN__HHA
PURPOSE:
To provide prompt attention to any suspected transfusion reaction.
CONSIDERATIONS:
1.Transfusion therapy entails a number of calculated risks. Some of the potential complications cannot be prevented with absolute certainty.
2.Transfusion reactions may occur due to incompatibilities of red blood cells, leukocytes, platelets and plasma proteins.
3.Immediate reactions occur within 48 hours after the initiation of a transfusion. Most reactions occur within this time frame.
4.Delayed reactions occur two or more days after transfusion and usually are the result of alloimmunization or transmitted disease.
5.Yellowing of the skin can occur from 1-6 months after receiving blood.
6.All transfusion reactions must be reported to the physician and transfusion product supplier.
(See Infusion Therapy-Appendix B- Blood Transfusion Reaction Management.)
7.Per Joint Commission recommendations, all tubes and catheters should be labeled to prevent the possibility of tubing misconnections. Staff should emphasize to all patients the importance of contacting a clinical staff member for assistance when there is an identified need to disconnect or reconnect devices.
EQUIPMENT:
Gloves
Alcohol applicator (wipe/swab/disk/ampule)
Normal saline 500ml
Standard mini-drip or maxi-drip IV administration sets
Straight catheter set
Airway
Tourniquet
Vacutainer with needle
Lab studies supplies
Red top tube (chemistries)
Lavender top tube (CBC)
Blood culture tubes
Urine specimen container
Blood bank transfusion request
Patient's blood sample for type and cross-match and type and cross-match lab slips
Transfusion reaction form
Emergency medication
Tylenol
Lasix
Benadryl
Solu-Cortef
Epinephrine hydrochloride 1:1000
Puncture-proof container
Impervious trash bag
PROCEDURE:
1.Adhere to Standard Precautions.
2.Stop transfusion immediately and maintain IV at keep vein open (KVO) with normal saline. Consequences are in direct proportion to amount of incompatible blood administered. In minor reactions, blood transfusion may be resumed.
3.Notify physician at once.
4.Administer emergency medications, as ordered by physician.
5.Anticipate and be prepared for possible emergency backup, i.e., 911, CPR, hospital admission.
6.Support patient emotionally and physically.
7.Obtain vital signs, urine specimen and any lab specimens per physician orders.
8.Notify transfusion product supplier.
9.After patient is stabilized, transport to transfusion product supplier: remainder of unit of blood tubing, copies of the transfusion reaction form and copies of blood bank transfusion request.
10.Discard soiled supplies in appropriate containers.
AFTER CARE:
- Document in patient's record:
a.Date, time, procedure and observations, including all vital signs.
b.Type and appearance of venous access site.
c.Patient's response to procedure.
d.Instructions given to patient/caregiver.
- Copy of transfusion reaction form.
- Communication with physician.