TRANSFUSION BASICS:

Nursing Responsibilities

Blood is a Controlled Substance:

Like medications, blood is regulated by the Food and Drug Administration (FDA) and the
New Jersey Department of Health & Senior Service (NJDOH&SS)

Pre-transfusion Responsibility:

1) Check that a valid informed consent for blood products is in the chart.
2) Consent is valid for the entire current admission or for 30 days for outpatients.
3) Transfusion orders - Three Steps:
a. Compatibility testing: Type and Screen (valid for three days, except
newborns valid for first 120 days of life)
b. Pre-medication orders (if any)
c. Transfusion order (must include: type and number of blood product (s),
transfusion indicator, date and time of administration, donor source,
administration rate, any special needs)
Note: Special Needs are: irradiated, leukoreduced, CMV negative, sickle
negative, washed and number of aliquots (for pediatric patients).
Sources are: autologous or allogeneic (bank or directed).

Responsibilities of the Person Drawing Blood Samples:

1) Take the label from Cerner printer to the patient.
a) If you do not have a Cerner Label, call the Laboratory Phlebotomy Service to
print out the label in your Patient Care Location/Unit.
b) You must have the label to ensure proper identification prior to blood draw.
2) Request the patient if he/she is conscious and rational to state his/her name.
3) Ensure that the patients ID band and the labeled sample exactly match.
a) Before drawing the blood sample, compare the patient information on the Cerner
label item by item with the information on the patients identification (ID)
armband (full name, date of birth and medical record number)
b) Discrepancies in information on either the ID armband or the Cerner label must
be corrected before a blood sample is drawn.
4) Draw patients blood, apply CERNER label to tube NEVER WRITE ON THE
TUBE- Only on the label.
5) Label the blood sample at the patients bedside. Every blood sample label:
a) Must have the initials or the signature of the person drawing the blood sample.
b) Must have the date and time the blood sample was drawn.
6) Before leaving the patients bedside, the person drawing the blood sample must verify
and compare the patients full name, MRN and DOB on the ID armband with the
information on the labeled blood sample.

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Second Confirmatory Sample Draw for ABO CONFIRMATION:
1) After entering the patients type and screen order in the computer, Transfusion
Services will check their database for any historical record of patients ABO/Rh.
2) If no record exists, Transfusion Services activates a second confirmatory order.
3) Transfusion Services will send a request to the Laboratory Phlebotomy Service to
draw the second confirmatory draw.
4) The second confirmatory draw may be drawn by the CCT or RN if needed
immediately or when a central line is available.
a) Call Laboratory Phlebotomy if the nurse or CCT will draw the confirmatory
sample.
b) Phlebotomy will re route the label to the Patient Care Location/Unit.

Rejection of MISLABELED Blood Samples:

Transfusion Service will reject a blood sample if these key procedural
elements are NOT followed:
1) Sample label must include the Patients Name:
a) First, last name and middle initial (if applicable) must be spelled correctly
and be legible.
b) For patients with long names, the patients name on the blood sample label
MUST match the patients name on the ID armband.
2) Sample label must also include:
a) Date and time blood sample was drawn
b) Initials or signature of the person drawing the blood sample
3) The blood sample must NOT be double labeled.
4) The blood sample label must be firmly attached to the sample tube.
5) The Medical Record Number must contain all 7 numbers.

Down Time Procedures:

If there is a downtime with the computer system, the specimen must have a legible
addressograph label with the signature of the person (NO INITIALS) drawing the
blood sample and the date and time of the blood draw. It must be accompanied with the
Downtime Order Requisition Form.

Preparing for Transfusion:

1) For FFP, notify Transfusion Service at least 45 minutes before transfusion to allow
for thawing.
2) Do not schedule a blood product transfusion if the patient has other tests scheduled.
3) Do not start a transfusion in a febrile patient (especially platelets).
4) NEVER transport a patient with infusing blood products without an accompanying
RN present.
5) If you suspect that a transfusion will exceed 4 hours, request Transfusion Services to
split the unit (included in Special Instruction in the Order by LIP). Once the
product is hung, it cannot be split or altered.
6) All blood products must be transfused and completed within 4 hours after issuance
by Transfusion Services.

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Before Starting Blood Product Transfusion Process:
1) Verify patients identification by checking the patients ID armband.
2) Start an IV with the largest but appropriate gauge: for adults 18 gauge is preferable,
20 gauge is acceptable. If your patient has a PICC/TLC/PORT, check and make sure
that they are functioning well.
3) To avoid delays, check that the IV is functional before picking the unit from
Transfusion Services.
4) If you cannot hang the blood product right away, promptly return the unit to
Transfusion Services.
5) Blood must be hung within 30 minutes of the blood product LEAVING Transfusion
Services. NEVER:
Lay it on the counter
Store it in your medication refrigerator
Put it in your pocket until you have time
Hang the unit after 30 minutes upon receipt from Transfusion
Services

Transfusion Record Forms

1) Each blood product will have a Transfusion Record Form attached to it.
a) This form has two parts:
i. Copy A is the Chart copy and must be placed in the patients chart.
ii. Copy B is the Transfusion Services copy: Promptly return to Transfusion
Service upon completion of the transfusion
b) Please Note: Copies A & B are NCR (no carbon required) and must contain
exactly the same information.

Blood Product Administration Practice Essential Guidelines:

1) Two person verification by One RN and another RN/LPN/LIP (transfusionists) must
be done at bedside using the patients ID armband, Transfusion Record Form and
donor unit (blood product bag). They must verbally verify the following:
a. Patients name, MRN and Date of birth
b. Donor unit number
c. Type of blood product,
d. Donor and recipient blood group (ABO/Rh type)
e. Crossmatch interpretation (compatible, incompatible, requested for
emergency or not required)
f. Unit expiration date and time on the donor unit and transfusion record
Note: All the labels attached on the front of the donor unit must be checked
for accuracy including donor unit label, blood bank compatibility label and
any additional labels applied to the donor unit for antigen type tests and
expiration date.
2) All information must exactly match. If any discrepancies exist, return the product
to Transfusion Services immediately.

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3) The Transfusion Record form must be signed by the two (2) transfusionists before
any transfusion can be started.
4) Once the blood product two person verification is completed, the unit must be hung
immediately.

Examples of Labels:
Safe Alternate Blood Type: Applied when patient blood type and donor unit blood types
are different, but safe for blood product administration.

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Transfusion Record:

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FFT Expiration Date Label: This label shows the expiration date of the Thawed Fresh
Frozen Plasma. This label also displays the unit number of the blood product.

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Blood Bank Compatibility Label: This label is applied to each blood product issued
from the Transfusion Services. This label must stay attached to the blood product and
contains the same information as that on the Transfusion Tag. (Shown on the bottom of
the donor unit on the attached picture).
Antigen Type Label: This label is applied to red cell unit when additional antigen type
test/s is/are performed on the unit (shown on top of the unit on the attached picture)

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Starting the Transfusion:
1) Blood tubing with the proper standard filter (170 to 260 micron) must be used.
2) Never use a single filter set for more than 4 hours because of the risk of bacterial
growth.
3) A Y-type Blood Set filter is used for every unit of blood. If flow rate slows after
more than a unit is transfused, change the filter set.
4) Rarely, non-leukoreduced blood or platelets are issued by Transfusion Service. If
this occurs; Transfusion Services will issue one unit per leukocyte reduction filter
with the blood product to decrease the risk of transfusion complications.
5) Never use a leukoreduction filter for granulocyte transfusions.

Pall Leukoreduction Filter

Measurement of baseline vital signs:

1) Immediately before initiating transfusion, obtain the patients vital signs:
a. temperature
b. pulse
c. respiration
d. blood pressure
2) These provide baseline values for comparison with any changes that may occur
during transfusion.
3) Vital sign measurements should be repeated after 15 minutes and at 30 minute
intervals until transfusion is completed and they should be recorded in the
Transfusion Record.
4) All corrections to any errors or any changes on the Transfusion Record form should
be properly corrected by:

a. Clearly drawing ONE LINE across the erroneous item.

b. Documenting reason for change.
c. Entering correct information.
d. Affixing the date of correction.
e. Affixing initials of the person making any changes.

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Transfusion of Blood Products in the NICU

1) All infants must be placed on NPO two (2) hours prior to transfusion, during
transfusion and two (2) hours post transfusion.
2) All blood will be infused via a 24G peripheral IV.
3) Each Order shall include the following:
a) Volume by ml/KG or total volume required
b) Transfusion time
c) Name, Date of birth, and Medical Record Number
d) Indication
e) Donor source: allogeneic, banked or directed (autologous NA)
f) Special Needs: irradiated, leukoreduced, CMV negative, sickle
negative, washed and number of aliquots
4) Complete the Blood/Blood Component Pick-Up Slip and send with PCT/CCT for
pick up.
5) All blood and blood components are issued in a labeled aliquot bag with or
without an attached labeled syringe and the Transfusion Record.
6) Two person verification by One RN and another RN/LPN/LIP (transfusionists)
must be done at bedside using the infants ID armband, Transfusion Record Form
and donor unit.
7) Prime tubing and set up syringe pump.
8) Complete vital signs and documentation per policy.
9) Remember to complete Transfusion log book, place the Part A copy in chart
and return the transfusion Part B copy to Transfusion Service.

Transfusion Record Required Documentation:

Documentation must be 100% complete before returning each tag to Transfusion Services:
1. Two authorized signatures of the transfusionists
2. Date of transfusion
3. Start time and End time of transfusion
4. Volume infused
5. Signature of person who completed the transfusion.
6. Pre-transfusion vital signs
7. Vital signs 15 minutes after starting, then at 30 minute intervals.
8. Post transfusion vital signs

Verification of Completion of Transfusion Record:

1) Verification for "completeness" and "correction of all transfusion information in the
Transfusion Record Form must be done during the:
a) First review upon completion of transfusion, by the RN administering the
product.
b) Second review by a second RN to ensure completion.

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2) This will facilitate the completion of all required information before the
Transfusion Records are sent back to Transfusion Services.
3) The Part B Transfusion Record copy must be hand delivered or tubed to Transfusion
Services as soon as possible.

Transfusion Reactions
Categories and Management of Transfusion Reactions:

Hemolytic Transfusion Reaction (HTR)

a. Result from RBC incompatibility.

b. Most severe when ABO incompatible red cells react with patients
isohemagglutinins (preformed antibodies) resulting in acute destruction of
transfused red cells.
c. Fever is the most common sign of an acute HTR.
d. Clerical evidence of incorrect recipient is presumptive evidence of HTR- a
change in color of the post transfusion specimen sample is consistent with
hemolysis.
e. Further tests (DAT, LDH, haptoglobin, bilirubin, etc) to detect hemolysis.
f. Treatment is empirical and anticipatory and is aimed at preventing renal
failure and DIC.
g. STOP TRANSFUSION and maintain hemodynamic stability.
i. Give normal saline infusion to maintain urinary output greater than
100ml/hour and systolic blood pressure greater than 100mmHg.
ii. Give Lasix IV if urine output diminishes.
iii. Consider IV dopamine if blood pressure diminishes.
iv. If there are no contraindications give a bolus of heparin followed
by continuous heparin drip - draw blue top tube prior to bolus for
base-line coagulation parameters.

Shock

a. Usually presents with hypotension.

b. Rule out HTR, anaphylaxis or bacterial contamination.
c. May present with or without fever.
d. Shock with fever indicates bacterial contamination:
i.Basic treatment is volume and antibiotics.
ii.Draw blood culture on patient
iii.Transfusion services will culture the blood product unit. This will
include a gram stain. Any 3 degree F rise in temperature will require
cultures of both component/unit and patient.
e. Shock without fever may indicate anaphylaxis; most likely secondary
to IgA deficiency:

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 i. Basic treatment is volume and epinephrine.
ii. If IgA deficiency is confirmed by Transfusion Services, transfuse:
1. IgA negative FFP and Cryoprecipitate
2. IgA negative or washed blood (RBC) and platelets.

Urticarial Reaction

a. An allergic reaction between recipient antibody to donor plasma

proteins
b. Stop the transfusion.
c. Give antihistamine.
d. Rule out HTR or anaphylaxis if with hypotension.
e. If transfusing RBC, do HTR workup. Submit a properly labeled
lavender top tube.
f. For other blood products (platelets, FFP or Cryoprecipitate) only a
clerical check is needed without a hemolytic workup.
g. Obtain an order to resume the transfusion (if applicable).
h. Consider prophylactic anti-histamine for subsequent transfusion.

Febrile Reaction

a. May be from leukoagglutinins in the recipients blood or from

cytokine (i.e., IL-1, IL-6 or IL-8) accumulation during storage.
b. Stop the transfusion.
c. Ensure that HTR, bacterial contamination and TRALI are ruled out.
d. Bacterial contamination must be ruled out for 3 F rise in temperature
need to draw blood cultures of the patient.

TRALI (Transfusion associated acute lung injury)

a. From WBC antibodies in donor (rarely from recipient) reacting with

transfused donor leukocytes.
b. Presents with hypoxemia, respiratory distress, hypotension, fever and
bilateral pulmonary edema on CXR.
c. Stop the transfusion.
d. Respiratory support mechanical ventilation.
e. Rule out cardiogenic pulmonary edema (TACO).

TACO (Transfusion associated circulatory overload)

a. Patient presents dyspnea, orthopnea, cough, tachycardia, and headache.
b. Increase in BP and widened pulse pressure is characteristic.
c. Stop the transfusion.
d. Place patient in sitting position, give O2 and diuretics.
e. Rule out TRALI.

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 f. Transfusion Services will issue split units to be transfused very slowly.

Transfusion Associated Sepsis

a. Due to bacterial contamination of blood components usually from the

donor during collection, disposables and the environment during
processing, storage and administration.
b. Patient presents with fever, chill/rigors and hypotension.
c. Fatal reactions may be from endotoxin associated with gram negative
bacteria.
d. Stop the transfusion
e. Rule out HTR
h. Cultures on both component and patient needed. Grams Stain is done as
part of each culture.

NURSING PROCEDURE FOR MANAGEMENT OF

SUSPECTED TRANSFUSION REACTION

1) Stop the transfusion immediately. Do not take the unit down, check and record
vital signs and time of reaction. Complete the Transfusion Record and check all
appropriate boxes.
2) Keep the line open by normal saline drip through a new IV administration set. If a
stopcock is in place, discard blood in tubing through side port, maintaining sterility of
blood tubing. Then proceed with slow normal saline drip.
3) Confirm the Identity of the Recipient by Comparing the Transfusion Record
the Blood Product Unit and the Patient ID Armband.
4) Follow Instructions for Nursing Procedure for Management of Suspected
Transfusion Reaction located at the back of the Transfusion Record Form.
5) Notify the appropriate physician: house staff (if covered), house physician or
Advanced Practice Nurse (APN). The Licensed Independent Practitioner (LIP)
is expected to evaluate the patient at bedside.
6) Call Transfusion Services (extension 2060 or 2061) regarding the suspected
transfusion reaction and give the name of the LIP contacted or that none is available.
7) The Transfusion Services will contact the Transfusion Medicine Physician or his/her
designee, who will then contact the bedside LIP or arrange for the patient to be seen.
8) Provide the bedside LIP with the Transfusion Record.
9) The bedside LIP will complete this transfusion record and sign the verification of
examination and determine the severity of the reaction.
10) The Transfusion Medicine Physician and the bedside LIP should then immediately
confer to determine clinical status and any laboratory procedures necessary.

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11) An order must be obtained if decided by the bedside LIP and the Transfusion
Medicine Physician to restart the transfusion.
12) The LIP will order a Transfusion Reaction Work up Order.
13) Enter the applicable transfusion reaction order in SCM:
a. Transfusion Reaction Work up: Non-RBC
b. Transfusion Reaction Work up: RBC
i. Collect a post transfusion blood sample in a properly labeled
lavender top tube.
14) As soon as possible the reaction section of this record should be completed and
signed by the LIP and returned to Transfusion Service with the blood product and
attached administration set.
15) Return the transfusion record, blood product with attached administration
set and lavender top tube (if applicable) to Transfusion Services

Please Note: Do not restart blood/blood component until the consultation is

Complete and an Order to restart the transfusion is received.

Categories of Transfusion Reactions:

1) Hemolytic
a. Acute Hemolytic
b. Delayed Hemolytic
2) Febrile, nonhemolytic
3) Allergic
4) Anaphylactic
5) Transfusion related acute lung injury (TRALI)
6) Transfusion associated circulatory overload (TACO)
7) Transfusion associated bacterial contamination

Signs and Symptoms of Transfusion Reactions:

1) Signs or symptoms of transfusion reactions range from mild fever and discomfort to
dramatic clinical changes, such as shock and hemorrhage.
2) Watch for any of the following symptoms:
a) Fever is any increase in temperature of 2 degrees Fahrenheit or 1 degree
Celsius. If the 2 degree F rise in temperature results in a 100.4F
temperature this is a suspected acute transfusion reaction and managed
accordingly.
b) Tachycardia (rapid pulse)
c) Significant drop in blood pressure
d) Back pain
e) Pain at the infusion site (without extravasation)
f) Chest pain.
g) Urticaria/hives/Rash
h) Anaphylaxis (severe allergic reaction)

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i) Anxiety
j) Chills
k) Agitation
l) Dyspnea
m) Flushing
n) Nausea
o) Headache
p) Hematuria

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