This chapter focuses on the principles of safe blood transfusion practice. The aim of this chapter is to develop and support the knowledge of health-care professionals involved in prescribing or administering blood components (red blood cells, platelets, plasma) and plasma protein products (PPP). Several standards and guidelines define the minimum criteria required to maintain safety and enhance transfusion practices. These include the Canadian Standard Association’s Blood and Blood Components,1 the Canadian Society for Transfusion Medicine (CSTM) Standards for Hospital Transfusion Services,2 Health Canada’s Guidance Document: Blood Regulations,3 the AABB Standards for Blood Banks and Transfusion Services4 and the College of American Pathologists (CAP) Transfusion Medicine Accreditation Checklist.5 Each healthcare facility’s policies and procedures must include mechanisms to ensure ongoing training and competency assessment of the theoretical and practical knowledge of all staff involved in the transfusion process. Show
Pre-transfusion considerationsPatient blood managementPatient blood management (PBM) is an evidence-based interdisciplinary approach that aims to improve patient outcomes by avoiding or reducing unnecessary transfusion during the course of a patient’s treatment.6 This may be accomplished pre-operatively by optimizing hemoglobin levels using iron and erythropoietin, as well as assessing the potential for correction of coagulation abnormalities.7 For non-surgical patients, alternatives to avoid or limit transfusion should also be considered whenever possible. Decision to transfuseThe prescribing of a blood component or PPP is a clinical decision made by a health-care provider (i.e., physician or other health-care professional authorized to order transfusion) based on evidence-based practice guidelines and often made in consultation with a physician with transfusion medicine expertise. Although pre-transfusion diagnostic test results may suggest transfusion is warranted, a clinical assessment of symptoms and consideration of outcome measures should be included in the decision to transfuse. Informed consentInformed consent for transfusion is a standard safety requirement.8 In the Commission of Inquiry on the Blood System in Canada, the Honourable Commissioner Justice Horace Krever emphasized the importance of informed consent for the administration of blood components and PPP.9 His recommendations included:
The health-care facility is responsible for developing the policy and procedures for obtaining informed consent prior to the transfusion of blood components or PPP. These must include the following:8
Discussion between the health-care provider and the patient should take place well in advance of the surgical or therapeutic intervention, if possible, to allow time for the patient to consider their options. The health-care provider must document the discussion of risks, benefits, and alternatives with the patient, in accordance with facility-specific policies. Informed refusalPatients have the right to refuse transfusion or treatments involving the use of blood components and PPPs. In addition to the discussion with the health-care provider of the risks, benefits and alternatives to the use of blood components or PPPs, the patient’s decision to refuse should follow an informed discussion of the risks of refusal. Refusal should be clearly documented on the patient's medical record in accordance with facility-specific policies. Patients may choose to refuse treatment involving the use of blood components and PPPs for personal or religious reasons. Jehovah’s Witnesses often refuse transfusion, though use of recombinant human erythropoietin and some PPPs may be acceptable to some individuals.10 Each member of the faith decides individually what is personally acceptable and the refusal documentation should clearly reflect the details of the patient’s decision. Additional information is available from the Jehovah’s Witness Hospital Information Services (Canada) 24-hour emergency line at 1-800-265-0327 or online at JW.org.10 Transfusion ordersThe health-care provider documents the orders for administration of a blood component or PPP and documents the clinical indication. The provider’s orders should include:2
Pre-transfusion testingPre-transfusion testing is completed to ensure compatibility between the patient and a blood component for transfusion. Patient misidentification and incorrect sample labeling contribute to the administration of ABO-incompatible blood and the potential for hemolytic transfusion reactions.11 Misidentification can occur at several points during the transfusion process, including during patient specimen collection and testing, blood product request, issue and administration. It is imperative that positive patient identification is maintained through the entire process. Pre-transfusion blood samples are labelled at the time of draw at the patient’s bedside, using at least two unique identifiers. Positive patient identification must occur at this time, using the patient’s armband to confirm the patient’s name and unique identifying number. Whenever possible, the accuracy of the patient’s armband should be confirmed by asking the patient to spell their name and state date of birth. To prevent ABO-incompatible transfusion errors, health-care facility policy may require ABO blood group confirmation for first-time transfusion patients or use of positive patient identification technology to confirm donor unit and patient identifiers at the bedside.1 For more on pre-transfusion testing, including patient identification and sample labelling, see Chapter 8 of this Guide. Pre-transfusion sample testing and identification of compatible red cells is typically straightforward but can be a complicated and time-consuming process when antibodies are present. If red blood cells are required urgently before pre-transfusion testing is complete, the transfusion service should be notified immediately. In emergency situations, red cell units could be issued prior to completion of testing based on health-care facility policies and procedures and/or transfusion medicine and attending physician consultation. IV accessBlood components and PPP may be administered through a variety of central venous access devices (CVAD) or peripheral intravenous catheters. Considerations for selection of appropriate IV access include:
Administration setsAdministration set requirements vary for blood components and PPPs. These requirements are outlined in facility-specific policy, which should be developed in consultation with the transfusion service. Sets for blood componentsThe administration of blood components requires the use of a standard blood filter, which may range in pore size from 170 to 260 microns. The filter, which must be completely covered with the blood component, is intended to remove clots, cellular debris and coagulated protein. A leukocyte reduction filter is no longer required during transfusion, as all blood components issued in Canada have undergone leukocyte reduction by filtration during preparation (see the Canadian Blood Services Circular of Information16 and Chapter 2 of this Guide for more information).17 Blood components must be transfused within 4 hours of issue. If the transfusion is interrupted for any reason, administration must be discontinued after 4 hours even if the transfusion is not complete. Facilities should follow the manufacturer’s recommendations and local policy for changing the blood administration sets. If there is a delay between units in a multiple unit transfusion, the administration set should be changed to minimize the likelihood of bacterial growth. Sets for PPPsThe administration of PPPs requires varied supplies, differing by product type and brand. PPPs for intravenous administration may require use of a standard, vented or filtered set or may be administered by direct intravenous push. Other PPPs are administered by intramuscular or subcutaneous route. Facilities should refer to the product monograph and local policy to determine what, if any, filtration is required during reconstitution or administration. Infusion devicesAll equipment used in the transfusion process must be approved by Health Canada and the manufacturer and be maintained in accordance with the manufacturer’s specifications for continued safety. Health-care facilities must have an approved process for ongoing inspection and validation for all infusion devices. Infusion devices have been known to cause mechanical hemolysis;18 therefore, prior to implementing the use of an infusion device, confirmation that it has been approved for use in transfusing blood components should be obtained from the manufacturer. See Chapter 10 of this Guide for more information about the causes of mechanical hemolysis. Infusion devices may be used to transfuse blood components (e.g., infusion pumps, rapid infusers, blood warmers and pressure devices). The use of infusion devices must always adhere to the health-care facility policy. Pressure infusion devicesA pressure infusion device may be used for rapid administration of blood components. The pressure applied to the blood component should not exceed 300 mm Hg as this may result in hemolysis or bag breakage. Blood warmer devicesA blood warmer device may be used to prevent hypothermia during rapid administration of cold blood components, such as in the operating room or trauma setting.12,19 A blood warmer device may be used in routine transfusion for a patient with cold agglutinin disease; however there is limited evidence for the efficacy of this strategy and warming the patient is more likely to be feasible and just as likely to be beneficial.20 Blood warmer devices should have a temperature alarm system if the temperature exceeds 42°C. When a blood warmer is used, the temperature upon initiation and the unique identifier of the device (e.g., serial number) should be documented. Baseline Patient AssessmentPre-transfusion patient assessment and a measurement of baseline vital signs must be documented within 30 minutes prior to transfusion. Identify any potential risks of a transfusion reaction or any pre-existing symptoms that could later to be mistaken for a transfusion reaction (e.g., pre-existing rash). If the patient is able to participate, education should be provided so the patient understands the importance of immediately reporting any new onset symptoms during or after transfusion. Any pre-medications required should be prepared and administered as ordered (e.g., 30 minutes prior to initiation, immediately prior to initiation). Transportation and storageBlood components and PPP must be stored in monitored blood storage and transported in a validated system. Storage and transport systems are validated and monitored by the transfusion service.8 A blood component or PPP should only be obtained from storage when all preparation for administration is complete. Prior to obtaining a blood component or PPP, confirm that a transfusion order exists and informed consent is documented. Follow health-care facility procedures when obtaining a blood component or PPP from the transfusion service or satellite blood refrigerator. It is imperative that positive patient identification is confirmed again at this time and the right product is obtained for the right patient. If the retrieved blood component or PPP is no longer required, it should be returned immediately to the transfusion service to maintain safe storage conditions and prevent waste. Local policies may dictate the timing and/or temperature requirements for returning blood components or PPPs to the transfusion service. TransfusionPre-transfusion safety checkThe pre-transfusion safety check includes checking the blood component or PPP and verifying positive patient identification on the product to the patient. All identifying information linking the patient to the blood component or PPP must be matched. Verification of patient and product identification shall be completed in the presence of the patient using the patient’s identification band. There are several key points in the pre-transfusion safety check:
Always follow facility-specific policies for confirming patient identification and the blood component or PPP. Table 1: ABO compatibility Blood group of recipientAntigen(s) present on recipient red blood cellsAntibody present in recipient bloodCompatible red blood cells from groupsCompatible plasma from groupsMay receive platelets from groupsAAAnti-BA, OA, ABA, AB, B, OBBAnti-AB, OB, ABB, AB, A, OABA, BNoneAB, O, A, BABAB, A, B, OONoneAnti-A, Anti-BOA, B, AB, OO, AB, A, B
Table 2: Rh compatibility of red blood cells Rh of recipientMay receive from groupsRh positiveRh positive or Rh negativeRh negativeRh negative* * Refer to facility-specific policies and procedures for the use of Rh-positive red blood cells for emergency-release (i.e., uncrossmatched) situations in Rh-negative recipients, as Rh-positive red blood cells may be transfused for women over 45 years old and for male patients. Depending on the blood component or PPP to be administered, there will be additional considerations. See Table 3 for a summary of administration requirements.14 As mentioned previously, misidentification can occur at several points during the transfusion process and it is imperative that positive patient identification is maintained through the entire process. The safety check immediately prior to administration of a blood component or PPP is the last opportunity to prevent an identification error from reaching the patient. Initiating the transfusionThe following list summarizes the general steps included in preparing for and initiating a blood transfusion. 1. Review provider’s order to transfuse.
Table 3: Initiating requirements summary Blood componentIndicationCompatibilityAdministrationRed blood cells
* In an emergency or massive hemorrhage setting, some transfusion services may have specific policies that allow use of group A plasma to recipients with unknown blood group.
Patient monitoringSerious and life-threatening reactions can occur unpredictably and progress rapidly; therefore, patients must be closely monitored. Follow the facility-specific policy for patient monitoring during transfusion and post-transfusion. Remain with, or be in a position to closely observe, the patient for the first 5 to 15 minutes following the start of each unit. Observe the patient for signs and symptoms of reaction (hives, itchiness, feeling feverish or chills, difficulty breathing, pain, or any other significant change following the start of transfusion); instruct the patient or care provider to notify the nurse immediately if symptoms are observed. Reassess the patient and repeat vital signs after 15 minutes and increase flow rate if no reaction is observed.12 Patient monitoring and vital sign recording should be based on the patient’s clinical condition and performed according to facility-specific policies for the duration of the transfusion. If a transfusion reaction is suspected, immediately stop the transfusion and maintain vascular access with normal saline. Follow facility-specific procedure or physician’s orders for management of the suspected transfusion reaction. See Chapter 10 of this Guide for additional information. Post-administrationAt the end of the transfusion, the administration set may be flushed:
The empty blood component or PPP container and any administration supplies should be safely discarded as per facility-specific policy. Document the transfusion event according to facility-specific policy and procedures. Documentation includes date, start and finish times, blood component or PPP transfused, unit or lot number, names or persons starting and monitoring the transfusion, vital signs, volume transfused, and all interventions related to the transfusion. In addition, inpatients receiving blood components or PPP should receive notification of the transfusion as per facility-specific mechanisms.8 For outpatients, review post-transfusion care with the patient or caregiver. Provide the patient with written information outlining the signs and symptoms of transfusion reactions, what to do in case of a transfusion reaction, and contact information for reporting a transfusion reaction. Continue to monitor the patient post-transfusion for signs and symptoms of a transfusion reaction. Generally, changes in the patient’s status or vital signs occurring within six hours of the transfusion should be considered a potential adverse outcome of the transfusion and should be reported to the transfusion service. Report any suspected transfusion reaction to the transfusion service. Continuous infusion of coagulation factorsCoagulation factor replacement by continuous infusion is used in many centres across the country for the management or prevention of serious bleeding in patients with coagulation disorders. As this procedure falls outside recommendations in the product monograph, each institution is required to develop its own policies and procedures to direct and guide this practice. Continuing professional development creditsFellows and health-care professionals who participate in the Canadian Royal College's Maintenance of Certification (MOC) program can claim the reading of the Clinical Guide to Transfusion as a continuing professional development (CPD) activity under Section 2: Self-learning credit. The reading of one chapter is equivalent to two credits. Medical laboratory technologists who participate in the Canadian Society for Medical Laboratory Science’s Professional Enhancement Program (PEP) can claim the reading of the Clinical Guide to Transfusion as a non-verified activity. AcknowledgementsThe author acknowledges Leonor De Biasio, RN, BScN, CPNC, and Tihiro Rymer, BScN, MLT, as authors of a previous version of this chapter and Allahna Elahie, BSc (Hons), MLT, and Sarah Oxley, RN, BScN, for their review of the current version. Suggested citationO'Reilly C. Blood administration. In: Clarke G, Chargé S, editors. Clinical Guide to Transfusion [Internet]. Ottawa: Canadian Blood Services, 2019 [cited YYYY MM DD]. Chapter 9. Available from: https://professionaleducation.blood.ca If you have questions about the Clinical Guide to Transfusion or suggestions for improvement, please contact us through the Feedback form. What nursing actions must you perform before starting the blood transfusion?Nursing Interventions. Verify doctor's order. ... . Check for cross matching and typing. ... . Obtain and record baseline vital signs.. Practice strict asepsis.. At least 2 licensed nurse check the label of the blood transfusion. ... . Warm blood at room temperature before transfusion to prevent chills.. Identify client properly.. What are the procedures prior to blood transfusion?Your blood will be tested before a transfusion to determine whether your blood type is A, B, AB or O and whether your blood is Rh positive or Rh negative. The donated blood used for your transfusion must be compatible with your blood type.
What should you assess first before a blood transfusion?Patients should be under regular visual observation and, for every unit transfused, minimum monitoring should include:. Pre-transfusion pulse (P), blood pressure (BP), temperature (T) and respiratory rate (RR).. P, BP and T 15 minutes after start of transfusion – if significant change, check RR as well.. |