1. Clinical Module
Blood Transfusion
Facts

2. PowerPoint
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3. Introduction
Welcome to the learning module on Blood Transfusion. This module provides a reminder of safety and risk management factors during blood transfusion therapy. Knowledge of signs and symptoms of suspected transfusion reaction is key to providing the safest transfusion possible.

4. Description of the Course
This course is designed to refresh the nurse’s knowledge of transfusion facts. The module includes procedure review and a post-test.
This module is recommend for RNs and LVNs performing blood or blood component transfusions.
An annual review of blood and blood component information is required.
This module was prepared by:
Carol Bradford, BSN, RN, Staff Educator

5. Learning Objectives
By the end of the module the learner will be able to:
Describe various transfusion reactions.
Identify signs and symptoms of a suspected transfusion reaction.
Discuss proper documentation during a Blood or Blood Component Transfusion.

6. Procedure Review

7. Guidelines for Request, Acquisition and Transfusion of Blood or Blood Components Transfusion Reaction Response (SOP)
Review the ‘Standard of Practice’ (SOP) Procedure found on the hospital Intranet under “Clinical Procedures”
Review Hospital Policy #20-10,002 ‘Guidelines for Blood Products Utilization, Emergency Release of Blood and Transfusion Reactions’ under “Hospital Policies”
The following slides include key parts of the Blood Transfusion procedure.

8. Prescribed Action: Request and Acquisition
Verify Informed Consent has been obtained prior to initiating infusion and verify all pre-transfusion education has been completed. For an emergency situation, See Emergency Release of Blood or Blood Component Before Completion of Compatibility Testing form. Physician signature required on form. A copy of the completed form will be supplied to the Emergency Department by the lab for the Emergency Department’s patient record.
Initiate lab request via computer.
Obtain blood or blood component from lab at appropriate time, utilizing the Blood Products Physician Order (PHYORD 134) or the Emergency Release of Blood or Blood Component Before Completion of Compatibility Testing form. An initial copy of the blood consent needs to be taken to lab for the first unit of blood or blood product. Appropriately trained staff (RNs, LVNs, and trained OR/ER techs) may obtain blood from the blood bank.
Lab will select the unit of blood or component which corresponds to the chart copy of the physician order (PHYORD 134) from the blood bank refrigerator.

9. Prescribed Action: Request and Acquisition cont.
Verify with the blood bank scientist the patient’s name, medical record number, blood group, RH type and unit number agree with the information on the Blue Crossmatch form attached to the unit of blood or component. Verify the blue crossmatch form contains a unique blood bank armband #. Any discrepancies MUST BE RESOLVED before the blood or component may be issued.
The Scientist will examine the unit for abnormal color or appearance (purple color, zone of hemolysis above red cell mass, visible clots, murky plasma, purple, brown, or red plasma). Direct any questions regarding the unit’s color or appearance to the Blood Bank Scientist.
Place unit in biohazard bag for transport.
Complete the checkout process via computer with the blood bank scientist. Computer checkout includes: unit #, type & RH, component, expiration date, patient name, patient number, patient medical record number, physician’s name, department, check-out date and time, and blood appearance.

10. Initiation of Transfusion
Start IV with normal saline( if not in progress) using a #18 gauge venipuncture device if possible.
Prime tubing with normal saline only.
Obtain baseline vital signs.
At the patient’s bedside, two licensed staff shall verify doctor’s order to transfuse and check patient’s name, birth date, blood type, RH factor, donor number and patient medical record number. Both will sign, along with date and time, on the blue crossmatch form at the bedside after checking against patient’s armband and blood bank armband. The yellow blood bank armband must be present and the number must match the number on the unit copy of the requisition slip, other wise the unit cannot be transfused.
Premedicate if known allergy per Dr. Order.
Connect blood or blood component to IV using appropriate tubing & filter.

11. Initiation of Transfusion cont.
Start transfusion slowly at a rate of 120 ml/hr or less for the first 15 minutes, then increase the rate if no signs and symptoms of transfusion reaction occur. Note: the transfusion should be completed in 4 hours (including time unit removed from blood bank refrigerator). In an emergency situation, the flow rate will be dependent on patient condition, an increase in the standard flow rate above the recommended 120 ml/hr for the first 15 minutes requires a physician order. Patients who receive blood or plasma at rates faster than 100 ml/minute for 30 minutes are at increased risk for cardiac arrest unless the blood is warmed. Blood also must be warmed if more than 6 units are infused. There must be a physician order to warm blood.
Repeat vital signs approximately every 5 minutes for first 15 minutes and observe the patient closely for signs & symptoms of reaction. The vital signs should be repeated approximately every 30 minutes until infusion completed. Post infusion vital signs should be taken approximately one hour past completion of the final unit of the transfusion.

12. Initiation of Transfusion cont.
Observe patient frequently for signs of reaction [chills, fever (increase of 1 degree Celsius or 1.8 degrees Fahrenheit), flushing, pain, rash, itching, hives, CXP, hypotension, back pain, sudden SOB, cyanosis, HA, tachycardia, diarrhea, nausea, vomiting] or signs of pulmonary congestion throughout the transfusion.
After blood has infused, clear tubing with Normal Saline.
Under normal circumstance, tubing and filter must be used for no more than 4 hours.
Discard disposable items.
Place empty blood container with attached tubing in a Red biohazardous bag for disposal on the nursing unit. Return the WHITE crossmatch slip to lab.
All patients being discharged within 6 hours of transfusion will be given a copy of “Discharge Instructions for Transfusion” at discharge.

13. Transfusion of Components
Transfusion of Plasma-
Follow previous guidelines for Request and Acquisition.
Plasma units must be checked for fibrin clots by the lab scientist before infusing.
Use standard blood infusion tubing and filter used for red cells to infuse plasma.
Follow previous guidelines for Initiation of Transfusion (steps Start infusion slowly at a rate of 120 ml/hr or less for the first 15 minutes, then increase the rate if no signs /symptoms of transfusion reaction. Patients who receive blood or plasma at rates faster than 100 ml/minute for 30 minutes are at increased risk for cardiac arrest unless the blood is warmed. Blood also must be warmed if more than 6 units are infused. There must be a physician order to warm blood.)
Frequently more than one unit of plasma is ordered for transfusion at a time. Each unit can be spiked with the same infusion set as long as all units are infused within 4 hours. Change filter if infusion rate slows.

14. Transfusion of Components cont.
Transfusion of Cryoprecipitate-
Follow previous guidelines for Request and Acquisition.
Cryoprecipitate units must be checked for fibrin clots by the lab scientist before infusing
Use standard blood infusion tubing and filter used for red cells to infuse Cryoprecipitate.
Follow previous guidelines for Initiation of Transfusion steps 1-14.
Frequently more than one unit of cryoprecipitate is ordered for transfusion at a time. Each unit can be spiked with the same infusion set as long as all units are infused within 4 hours. Change filter if infusion rate slows.
The volume of cryoprecipitate in each unit is ml. Therefore, if four units are ordered, they should be given as quickly as possible in succession, not to exceed 120 ml/hr for the first 15 minutes. This will require dedicated nursing attention until all units are infused.

15. Transfusion of Components cont.
Transfusion of Platelet, Pheresis
Follow previous guidelines for Request , and Acquisition.
Platelet units must be checked for fibrin clots by the lab scientist before infusing.
Use standard blood infusion tubing and filter used for red cells to infuse platelets. Platelets are associated with a higher incidence of bacterial contamination than any other component. Platelets are stored at room temperature, providing a conductive environment for growth of microorganisms.
Follow previous guidelines for Initiation of Transfusion steps 1-14.
Frequently more than one unit of platelets is ordered for transfusion at a time. Each unit can be spiked with the same infusion set already in place as long as all units are infused within 4 hours. Change filter if infusion rate slows.

16. Suspected Transfusion Reaction
Key Signs/Symptoms:
Chills, flushing
Fever-temperature increase >1.8 °F or 1°C
Dyspnea, sudden SOB, cyanosis HA
Chest pain (CXP)
Back or flank pain
N/V, diarrhea
Rash, itching, hives
Hypotension
Tachycardia
Shock

17. Suspected Transfusion Reaction
Key Points:
Stop transfusion; document date/time on Transfusion Form
Keep IV open with 0.9% NaCl (Normal Saline)
Verify correct unit was given to correct patient.
Notify attending physician and the Blood Bank (lab).
Note: transfusions can only be resumed with Mild Allergic Reaction showing improvement with antihistamines.
After transfusion is terminated (except for mild allergic): Send urine sample with blood unit and administration set to the Laboratory.
Lab will draw post-transfusion blood specimens.

18. Reaction Types Mild Allergic: S/S -Pruritus, urticaria
Administer antihistamines as ordered, resume transfusion if improved within 30 minutes (the only time we can resume).
Moderate Allergic:
S/S -Hives, dyspnea, abdominal pain, hypotension, nausea, anaphylaxis
Administer antihistamines, epinephrine, vasopressors, corticosteroids as ordered.
Febrile:
S/S -Fever, chills, rigor, anxiety, mild SOB
Administer antipyretics as ordered.
(See Management of Acute Transfusion Reactions)
Acute Hemolytic:
S/S Anxiety, CXP, flank pain, SOB, chills, fever, shock, bleeding, hemoglobinuria
Treat shock as ordered with vasopressors, IV fluids, corticosteroids; maintain airway, monitor renal status.

19. The Management of Acute Transfusion Reactions information is from the American Association Of Blood Banks (AABB).

20. Documentation
Crossmatch Tag (Two licensed signatures verifying bedside check)
Blood Products Physician Orders -PHYORD 134 [Use of transfusion orders (PHYORD 134) is mandatory for unit pick-up]
Emergency Release of Blood or Blood Component Before Completion of Compatibility Testing (use in an emergency for unit pick-up and for consent)
Patient Consent (when not an emergency, each patient will sign one consent for blood or blood component transfusion, take copy with you when picking up the first unit)
Blood or Blood Component Transfusion Record (Fill out form completely, all information is important)
Electronic Documentation (make reference to the Transfusion Record in the electronic record)
Report of Suspected Transfusion Reaction (complete top section when reaction occurs)

21. Patient Consent Patient Consent for Blood or Blood Product Transfusion
Provide patient a copy of “Risks and Benefits of Blood Transfusion”
Take this signed form with you to pick up the first blood product.

22. Blood Transfusion Record
Complete all items on form.
Start transfusion at 120 ml/hr. or less for the first 15 minutes.
V/S every 5 minutes for the first 15 minutes, then every 30 minutes until complete and one hour post transfusion.
For emergencies, if two units are started at the same time (separate IV sites) may document both on the same form, be sure to print both unit numbers in the “Print the Blood Unit #” space.
NOTE: even with computer documentation we are utilizing this form until further notice (3/10/17).

23. Physician Order PHYORD 134
Take a copy of the physician order with you to pick-up unit of blood (or blood component).
(the next two slides contain details of the order set)

24. Physician’s Orders PHYORD 134 (1/2)
BLOOD PRODUCTS PHYSICIAN ORDERS
PRBC: [check indications that apply] Platelets: [check indications that apply]
 HCT <21%  Plt count <10,000/mm3 non-bleeding pt
 HGB 7.0Gm/dl  Plt. Count <50,000/mm3 with an actively bleeding
HGB8.0Gm/dl with coronary artery disease and patient or a patient in OR
unstable angina / myocardial infarction /
cardiogenic shock
 Active Bleeding
 Surgery  Massive Bleed
 Autologous Transfusion  Plt. dysfunction not responding to tx
 Other: ________________Automatic Chart  Other: _________________Automatic Chart Review Review
Plasma Frozen within 24 hours: [check indications that apply] Cryoprecipitate: [check indications that apply]
  Active Bleeding and PT/PTT >1.5 the mean of  Bleeding patient with: Hypofibrinogenemia
the reference range (<150mg/dl)
 Surgery and PT/PTT>1.5 the mean of  Hemophilia A
the reference range
 Immediate reversal of Warfarin Tx  Von Willebrand’s Disease
 Massive blood transfusion > 10 units
 Other: _______________Automatic Chart Review  Other: _______________Automatic Chart Review

25. Physician’s Orders PHYORD 134 (2/2)
Yes No
  Transfusion Information, Risks, Benefits and Alternatives Given To Patient by Physician
(if no, contact physician)
ORDERS:
 Have Patient Sign Consent for Blood Transfusion
 Type/cross match ______________ units PRBC
 Type/screen ___________________ units PRBC
 Transfuse _____________________ units PRBC
 Transfuse _____________________ units Plasma Frozen within 24 hours
 Transfuse ____________________ Platelet Pheresis
 CBC or HCT/HGB 30 min after 2nd unit or _____________________
 Furosemide (Lasix) ___________ mg  PO  IV  X 1 dose  every______ hr X_____ doses
 prior to ________ Unit(s)  between ________ Units  after _________ Unit(s)
TRANSFUSION REACTION:
 Stop transfusion, notify physician, notify the Blood Bank, complete transfusion reaction form

26. Yellow Blood Bank Armband
The yellow blood bank armband must be present and the numbers must match the number on the unit copy of the requisition slip, otherwise the unit cannot be transfused.

27. Transfusion Top Tips Key Points:
Must have a physician’s order for rapid blood infusion.
Must have a physician’s order to warm blood.
Blood is to be given <120 ml/hr for the first 15 minutes.
Use blood filters with all blood components.
Must have a consent in the chart to transfuse, if an emergency use the Emergency Release of Blood Component Before Completion of Compatibility Testing (attached to hospital policy #20-10,002 and Clinical Procedure “Guidelines for Request, Acquisition and Transfusion of Blood or Blood Components Transfusion Reaction Response”).

28. Transfusion Top Tips Key Points continued:
Must have Blood Products Physician Orders (PHYORD 134) with you to pick-up unit.
After two licensed staff check the unit at the bedside, they both sign the blue crossmatch form.
It is unacceptable to store blood in the refrigerator on the unit for even a short time.
Only transfuse blood or blood components with Normal Saline (0.9% NaCl)
One indication to administer PRBCs is when HCT is <21% or HGB is <7.0 gm/dl.

29. Transfusion Process Overview
Receive order to transfuse blood/blood product (utilize paper physician order set PHYORD 134)
Patient signs the consent for Blood Transfusion or in an emergency utilize the ‘Emergency Release of Blood Component Before Completion of Compatibility Testing’
Take a copy of the consent and paper physician order with you when picking up the blood product from the lab scientist (after the first unit of blood is transfused, only need the physician order to pick up more units).
Check the unit with another licensed nurse at the patient’s beside.
Start transfusion within 30 minutes of obtaining the unit from the blood <120ml/hr. Blood filter should be used no more than 4 hours.
Monitor the patient closely (baseline V/S, every 5min. for the first 15min. every 30min. until complete, then 1 hour post transfusion).
Stop the unit and notify the physician immediately if any S/S of transfusion reaction, complete reaction documentation.

30. Thank you for Reviewing Blood Transfusion Facts
You may now return to take the test. Good Luck!