1. Bedside Labs: Blood Transfusions
What, When, and How?

2. Nursing Role in Transfusion
Virtually all blood products at Parkview Health facilities are transfused by nurses.
More than 15,000 units are transfused per year system-wide!

3. Nursing Role in Transfusion
Patient, sample, & blood product identification process failures are responsible for the majority of mistransfusion events.
Our processes must ensure the correct patient, the correct sample, & correct blood product, every time!
Clearly nurses play a huge role
in transfusion safety!

4. Nursing Role in Transfusion
As a patient advocate in transfusion, consider the following questions to maximize effectiveness & safety of transfusions:
Why is the blood or component being given?
What is in the product?
How is it handled and stored?
Is it ABO- and Rh- compatible?
How should it be administered?
What adverse reactions may develop?
Have physician’s orders been issued?
Has patient consent been obtained?

5. Types of Blood Products
Red Blood Cells (RBCs)
Used to restore oxygen-carrying capacity
Crossmatch is required for routine transfusion
One unit should raise the hemoglobin level 1 to 1.5 g/dL
Must be stored in a monitored refrigerator.
Indicated for symptomatic anemia due to chronic or acute blood loss

6. Types of Blood Products
Fresh Frozen Plasma (FFP)
Indicated to replace clotting factors lost due to severe bleeding or disease, reverse effects of warfarin & bring aPTT /PT within hemostatic range
ABO/Rh is required (or a previous blood type on file), but a crossmatch is NOT required
Expires 5 days after thawing & must be stored refrigerated
Cannot be refrozen

7. Types of Blood Products
Platelets (apheresis platelets, single donor platelets, platelet pool or random platelets)
Indicated for treatment of bleeding due to critically decreased circulating platelet counts or functionally abnormal platelets
Platelets are necessary to form blood clots to stop bleeding
ABO/Rh is required (or a previous blood type on file), but a crossmatch is NOT required
One unit should raise the platelet count 30,000 to 50,000
Must be stored at room temperature, ˚C.
Because apheresis platelets are obtained from a single donor (reducing the number of donors that the patient is exposed to) they are the most commonly used platelet product

8. Types of Blood Products
Cryoprecipitate (CRYO)
Used to replace clotting factors for which there is no specific factor concentrate, and fibrinogen
ABO/Rh is required (or a previous type on file), but a crossmatch is NOT required
Expires 4 hours after thawing and must be stored at ROOM TEMPERATURE
Cannot be refrozen
Indicated for severe bleeding or immediately prior to an invasive procedure in patients with significantly low fibrinogen

9. Transfusion Safety Infectious Diseases
Blood transfusion is a “living tissue transplant”
Even though all donors are tested for infectious diseases, no blood product can be guaranteed to be disease-free
Transfusion-transmitted diseases include:
HIV
Hepatitis B and Hepatitis C
Other viruses, bacteria, and parasites

10. Transfusion Safety Bacterial Contamination:
Can cause serious or fatal septic reactions
Platelets are more likely to cause septic transfusion reactions
Bacterial growth is accelerated in products stored at room temperature
Sources most often are donor skin or blood
Less likely sources are disposables or environmental
Remember, blood products are collected aseptically but are not necessarily sterile!

11. Transfusion Safety Mistransfusions
Administration of incorrect or incompatible blood component
Currently, most significant risk associated with blood transfusion
Can be fatal
The most common cause is error during bedside clerical check
Much greater rate of fatalities than that of infectious disease transmission
Occurs in approximately 1 in 16,000 transfusions

12. Transfusion Safety Mistransfusions - Examples
Transfusing ABO-incompatible RBCs
Transfusing to an unintended recipient
Transfusing the wrong type of product, for example, FFP instead of platelets

13. Transfusion Safety Other Noninfectious complications of transfusion:
Immune responses
TRALI, febrile non-hemolytic reactions
Formation of antibodies to donor red cells
Iron overload with chronic transfusion
Circulatory overload
Allergic reactions

14. Agencies that Regulate Blood Product Administration
FDA - Food & Drug Administration
CAP - College of American Pathologists
AABB - American Association of Blood Banks
TJC – The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations)

15. Regulatory Oversight We are governed by many regulatory agencies
These agencies work together to maintain the safety of blood supply
Hospitals are REQUIRED to monitor blood transfusion practices & adverse outcomes
Our Transfusion Medicine Committee develops evidence-based transfusion practice guidelines to promote efficient use of blood supply

16. Orders/Ordering Required elements of a transfusion order:
Physician order, written on chart
Blood product to be transfused
Number of products to be transfused
Ideally should include administration rate (or use standard infusion rate)
For example: “transfuse 2 units of packed red blood cells over 2 ½ hours each”
Not valid orders: “Give 2 units now” or “Give FFP”

17. Orders/Ordering: Important Points
Correct patient!
Correct product type & quantity
Packed cells may be added on to a current type & screen
Specify “to give” or “to hold” when entering order
Surgery may call orders to Blood Bank.
The order requires patient name, MRN, physician name, caller name, blood product, & number of units

18. Orders/Ordering: Important Points
Are there any special instructions?
Irradiated - prevention of Graft vs. Host complications in immunocompromised patient.
CMV negative - prevention of CMV transmission to immunocompromised patient.
Autologous - ordered ONLY when the patient has donated blood for themselves (AUTO=self)

19. Orders/Ordering: Important Points
Special instructions (continued)
Directed - patient has had specific donor donate for him
Split unit - usually ordered when a unit is to be given slowly (>4 hours from time issued to end of transfusion)
Leukoreduced - this instruction does not need to be added to any order because our blood supplier universally leukoreduces our blood products by filtration

20. What is a CMV negative and irradiated blood product?
CMV negative refers to the donor testing and means the donor does not possess antibodies to Cytomegalovirus, which generally means that they have not had this virus and cannot transmit it to the transfusion recipient.
Irradiated means that the donor unit has received a specific “dose” of radiation that will disrupt the WBCs present in the donor unit, but does not damage platelets or red blood cells.

21. CMV negative and irradiated packed cell units
CMV negative and irradiated packed cell units. Look for the green “ANTI-CMV NEGATIVE” sticker, and the white RAD-SURE sticker indicating that the unit has been irradiated. The RAD-SURE sticker may be anywhere on the donor unit face.

22. CMV negative and irradiated platelet unit.

23. Why would my patient require CMV negative products?
Cytomegalovirus is transmitted by transfused WBCs in the donor blood, and in an immunocompromised patient may lead to a severe infection with multiple organ involvement. Immunocompromised patients include newborns, patients with stem cell or bone marrow transplants, and patients with leukemia or lymphoma. Specifying CMV negative products for these patients decreases the risk of transfusion associated virus transmission.

24. Why would my patient require irradiated blood products?
Immunocompromised patients are also at higher risk for transfusion-associated graft-versus-host disease or TA-GVHD. TA-GVHD occurs when WBCs from the donor unit migrate to the patient’s bone marrow, engraft there and begin producing antibodies that recognize the “host” (recipient) as foreign. Symptoms include macropapular rash, erythroderma, vomiting, profuse diarrhea, pancytopenia and liver dysfunction. Death is usually due to infection and hemorrhage and the mortality rate is >90%. The disease is virtually untreatable. The effect of irradiation on a blood product is to neutralize the donor WBCs present, thereby avoiding TA-GVHD.

25. Specimen Collection Specimen requirements:
2 full tubes: one pink top and one red top (NO SERUM SEPARATOR TUBES)
Pink top tube may be used for automated testing in Blood Bank
A lavender tube may be substituted for the pink tube
Type & screen specimens expire on third day after collection at 23:59

26. Specimen Collection Labeling requirements: Full name of patient
Medical record number
Date & time of collection
Employee ID number (initials are NOT acceptable for nurse collected samples & will be refused)

27. Specimen Collection A specimen will be rejected if:
ANY required labeling is missing
Specimen is grossly hemolyzed
IV contamination is suspected
Volume is insufficient
Testing reveals an ABO discrepancy
HEMOLYSIS

28. Preparing for Transfusion
Educate the patient and/or family about reason for transfusion, including the risks & benefits of procedure
Ensure consent is signed before initiation of transfusion
Review history of transfusions including:
Previous transfusion reactions
Any problems reported by the patient
Notify lab if any problems to previous transfusions

29. Preparing for Transfusion
Pretransfusion medications, if any - administer per prescribing physician’s order
Obtain pretransfusion vital signs within 30 minutes of the beginning of transfusion

30. Assess patency and size of IV line –
Needle Size A large-gauge needle is preferred.
Adults:
18- to 20-gauge needles are recommended for a good rate of flow, without undue discomfort for the patient.
Chronically transfused or pediatric patients:
When adequate venous access is difficult to maintain, the largest possible needle should be used.
Red Blood Cells (RBCs) can be safely administered through 23- to 25-gauge needles; however, the flow rate will be slower.
Non-Red-Cell-Containing Blood Components
Examples: Platelets, Fresh Frozen Plasma (FFP), and Cryoprecipitated AHF.
Can be rapidly administered through small-gauge needles.

31. Blood Administration Set and Filters
All blood components should be infused through administration sets designed specifically for this use. The set usually contains a 170-micron filter designed to trap fibrin clots and other debris that accumulate during blood storage.
Most standard filters have a four-unit maximum capacity. (Check the manufacturer’s instructions.)
If the first unit requires ≥4 hours for infusion, the filter should not be reused.
Blood collected in surgery by cell saver process, and wound drainage collections, should be infused with a 40-micron filter.

32. Blood Administration Set and Filters
Tubing is available in two basic configurations:
Straight:
Usually has a medication injection site a few inches from the hub.
If an adverse reaction develops, a “keep-vein-open” saline drip initiated at this site will maintain IV patency but avoid exposure to the 30 to 50 mL of blood remaining in the tubing and filter.
Y-type:
Simplifies the process of adding normal saline to red cells (if necessary).
Provides ready access to a saline flush if the blood component remaining in the tubing at the end of the transfusion.

33. Preparing for Transfusion
Blood Dispensing Form-Send completed blood dispensing form to the lab only after all pre-transfusion preparations are completed
Essentially a list of indications for transfusion at Parkview Health as established by our Transfusion and Medical Executive Committees
Used to determine if transfusion is appropriate
It is important to complete it correctly, including:
Name & medical record number of patient
Name & signature of the nurse requesting blood product

34. Preparing for Transfusion
Blood Dispensing Form (continued)
Must indicate reason for transfusion
If nurse cannot determine from patient assessment or from physician’s notes, call for clarification
“Per doctor’s order” or “low hemoglobin” are NOT acceptable indications

35. Transfusing
A bedside clerical check must be performed by one RN & one licensed professional/paramedic
Full name & MRN on patient armband MUST match name & MRN on compatibility label of blood product AND transfusion administration record
Unit number & ABO/Rh on blood product face label must match unit number ABO/Rh on compatibility label AND transfusion administration record

36. Transfusing Bedside Clerical Check (continued)
Unit ABO/Rh must be compatible with patient ABO/Rh
Reverse side of transfusion administration record includes a compatibility chart for red cell & non-red cell products
Unit must not be expired
Expiration date (and time, if applicable) is located on unit face label & compatibility label
Take the chart or a copy of the order to the bedside to be sure that special instructions, such as irradiation, have been met.

37. Special Instructions or Attributes
Check the patient’s written order to be sure that any special attributes, such as CMV negative and irradiation, have been met.

38. Transfusing Face label Back of unit Unit number Expiration date
Product type
Unit ABO and Rh
Compatibility label

39. Transfusing Compatibility Label
PATIENT INFORMATION
DONOR INFORMATION

40. Transfusing Visual inspection of unit
For non-red cell products: check for clots or leaking
For packed cells: check for clots, leaking, purple red cell mass, or murky, purple, brown or bright red plasma above cell mass
If any of above are found upon inspection, call blood bank immediately.
Do not hang the unit!

41. Transfusing
Return unit to the blood bank if unable to transfuse product for any reason
A unit which is not spiked may be returned to the blood bank up to 30 minutes after time of issue
If unit has been spiked or was issued >30 minutes ago, it is still acceptable to transfuse as long as transfusion is complete within 4 hours of original issue time
Notify blood bank that a unit is being returned & reason for returning it

42. Transfusing Initiation of transfusion
Except for normal saline, no medications or solutions should be added or transfused concurrently with blood products
All blood products must be transfused using tubing specific for blood product administration that includes a filter to remove clots & aggregates.
An RN must remain at the beside with patient for first 15 minutes of transfusion. Before leaving the patient unattended, instruct him or her to report anything “unusual” immediately.
For non-emergent transfusions infusion should start slowly during first 15 minutes, at approximately 2 ml per minute

43. Suggested adult infusion rate
Transfusing
If there is no sign of a reaction after first 15 minutes, flow can be increased to rate prescribed by physician or according to chart below:
Component
Suggested adult infusion rate
Red Blood Cells
mL/hour
FFP
mL/hour or gravity flow
Platelets
Cryoprecipitate
As rapidly as tolerated
Flow rate should be adjusted according to the volume that patient’s circulatory system can tolerate

44. Transfusing
Nurse to check vital signs & assess patient 15 minutes after initiation of transfusion
A licensed professional/paramedic must then perform assessment of patient every 30 minutes until completion of transfusion
Vital signs must be checked at completion of transfusion & an assessment performed one hour post-transfusion
Outpatients may choose to leave prior to one hour assessment
Provide post-transfusion instructions to the patient and/or family

45. After Transfusion Signatures of professionals identifying blood
Transfusion Administration Record should thoroughly document transfusion, including:
Signatures of professionals identifying blood
Starting transfusionist
Ending transfusionist
Professionals performing vital signs/assessments
Date/ time transfusion started & completed
All product inspections, pre-transfusion preparations, bedside clerical checks, vital signs, & assessments
Any patient care notes, e.g., “patient experiencing chills”, “increased blood pressure - patient was ambulatory”, or “patient had headache prior to transfusion”

46. After Transfusion
Return yellow copy of completed transfusion administration record to blood bank within 24 hours.
White copy must be placed in chart

47. Congratulations. You have Completed the Course.
 Back
Congratulations. You have Completed the Course.
We hope this Computer Based Learning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented.
Go to the Net Learning Tutorial entitled Bedside Labs: Transfusion Reaction to complete the written test and receive credit on your educational transcript.
This education is required yearly for all coworkers who perform blood transfusions.