Department of Pathology
Division of Laboratory Medicine

Transfusion Manual
March 2014

 


ADMINISTRATION OF BLOOD PRODUCTS

THINGS TO CHECK AHEAD OF TRANSFUSION

  • Patient available in treatment area.
  • Hospital wristband affixed for inpatients, clinic card or patient verbally confirms two identifiers for outpatients.
  • (IP) Transfused Order documented in chart (for routine inpatient orders).
  • Vital signs acceptable (See Vital Signs).
  • IV is patent and of appropriate size and type (See Intravenous Equipment).
  • Compatible IV Solutions available (See Compatible IV Solutions).
  • Appropriate filters on hand (See Filters).
  • Pumps and pressure bags ready if needed (See Pumps and Pressure Bags).
  • Blood warmers ready if needed (See Blood Warmers).
  • Informed consent documented (See Informed Consent).
  • If requesting multiple units of red cells, clear with on-duty Transfusion Service technologist (Ext.48537) See Storage of Units Intended for Transfusion .

HOW TO REQUEST ROUTINE PRODUCT DELIVERY

  • Confirm products are ready in Epic or with transfusion service (Ext. 4-8537).
  • Release the Epic order to the blood bank when ready to transfuse.
  • If no 6 inch tube system available, call Hospital Material Transportation at 4-5619 and give patient name, medical record number, and product type clearly and slowly. Request that blood be picked up in Transfusion Service and delivered to your location.
  • If 6 inch tube system available, blood will be automatically sent to unit via the tube system upon release of the order.
  • Syringes and units already spiked cannot be tube transported.

RELEASE OF PRODUCT FROM TRANSFUSION SERVICE

  • Only Transfusion Service personnel may remove products from the Transfusion Service storage refrigerator, freezer, or rotator.
  • Individuals picking up product(s) must have the correct patient name, and medical record number, and state what products are requested.
  • Compare patient name and medical record number with Transfusion Service records and resolve discrepancies before issue.
  • Sign the Transfusion Service copy of the product requisition, and fill in the delivery location.
  • Double check requisition for clarity and accuracy, initial Transfusion Service copy of the product form, and time stamp with date and time issued.
  • Transfusion Service and hospital staff initialing these forms must have a copy of their initials on file in the Transfusion Service; otherwise, full signatures are required.

DISPENSING MULTIPLE BLOOD PRODUCTS FOR ONE PATIENT:

  • More than one unit may be issued for one patient when the clinical situation demands it.

RECEIPT OF BLOOD PRODUCTS IN PATIENT CARE AREA

  • Two approved staff members must check the consent and expiration date.
  • Immediately inspect unit for the following:
    • Leakage
    • Abnormal appearance
    • Return products to lab when segments appear much lighter in color than that of the bag, the red cell mass looks purple, a zone of hemolysis is observed just above the cell mass, the plasma or supernatant is murky, purple, brown, red, or grossly lipemic, or if particulate matter is present.
    • Expiration date/time.
  • Confirm that Unit number, Donor ABO and Rh type printed on tag matches information on blood bag.
  • Review crossmatch compatibility (use of uncrossmatched units requires written order from physician).
  • Recheck the physician's order to verify you have received the component ordered and any special processing that was ordered was completed (i.e. CMV negative, irradiated, autologous, directed donor, etc.).
  • Call blood bank (Ext. 494-8537) immediately if discrepancies identified for resolution recommendations.
  • Do not leave the blood unattended after it is checked.

CONFIRMING PATIENT & DONOR IDENTITY

BARCODED BLOOD ADMINISTRATION

  • One licensed individual can perform the following checks at the patient bedside.
  • Confirm that the tag belongs to the intended recipient by making sure the patient name and medical record number exactly match the information on the wristband or clinic card. Be particularly careful about minor spelling variations, different middle initials, etc.
  • When possible, confirm all identifications by asking the patient "What is your name and DOB?"
  • Log into Epic at patient bedside and navigate to the Patient List activity and scan patient barcode on hospital wristband.
  • Scan blood bag to verify active transfuse order, unit number, product description, and blood product match prepared product for this patient.
  • Document initiation of transfusion.
NON Barcoding Areas (OR, Clinics, HSD)

  • Two individuals must perform the identity check at the patient bedside.
  • For transfusions taking place outside of the operating suites, both individuals doing the identity check must be licensed.
  • For transfusions taking place within the operating suites, one individual must be licensed, and the other individual may be a certified anesthesia technologist or perfusionist who has been certified as proficient in performing identity checks on blood products.
  • Students should not participate in the identification process.
  • Always identify patients using two identifiers.
  • For inpatients, the hospital wristband must be used.
  • For outpatient transfusions, the patient's name and birthdate are confirmed with the patient and the transfusion tag is compared with the patient's clinic card.
  • When possible, confirm all identifications by asking the patient "What is your name?"
  • If patient is unable to respond, confirm patient identity via another method (other staff, family member, driver's license, etc. Document method of identification in medical record.)
  • Confirm that the transfusion tag belongs to the attached unit by confirming unit number, product description and blood type on the tag and the bag match exactly.
  • Confirm that the tag belongs to the intended recipient by making sure the patient name and medical record number exactly match the information on the wristband or clinic card. Be particularly careful about minor spelling variations, different middle initials, etc.
  • Report all discrepancies to transfusion services and resolve before initiating transfusion.

CHECKING VITAL SIGNS

  • Baseline BP, T, P, R (VS) should be recorded before starting infusion.
  • If baseline VS abnormal get MD approval before starting transfusion.
  • After starting transfusion, nurse will remain at bedside for 5 minutes.
  • Monitor the patient closely, retake and record complete VS at 15 minutes.
  • Nurse should periodically monitor the patient thereafter, taking appropriate action if any significant changes in the patient's clinical condition develop. Nurse need not remain at bedside during this time but should be available.
  • Patients should not leave patient care area or be transported during infusion without continuous observation.
  • Repeat and record VS at completion of infusion.

TRANSFUSION COMPLETION

  • Document volume infused in Epic.
  • Document completion of transfusion in Epic: in the blood administration flowsheet go to the rate row and enter zero for the rate. This will complete the transfusion.
  • If reaction suspected, stop tranfusion and follow transfusion reaction process.

COMPATIBLE IV SOLUTIONS

  • Use only compatible intravenous solutions with blood transfusion (Isotonic (0.9%) saline).
  • If incompatible solutions have been in an infusion line, flush thoroughly with isotonic saline before starting transfusion.
  • Add no medication to the blood before or during transfusion.  
  • IV Solutions for Use with Blood Products

    Acceptable for Use with Transfusion

    Comments

    0.9% saline

    Only solution approved for direct mixing with blood

    5% dextrose in 0.9% saline

    Approved for rinsing IV tubing

    5% dextrose in 0.45% saline

    Approved for rinsing IV tubing

    Unacceptable for Use with Transfusion

    Reason

    5% dextrose in water

    Clumping and hemolysis

    5% dextrose in 0.2% saline

    RBC agglutination at room temperature, hemolysis at 37°

    Lactated Ringer's solution

    Clotting due to CA++ content

STORAGE OF UNITS RECEIVED FOR TRANSFUSION

  • Units stored at room temperatures more than 30 minutes cannot be returned for credit and will be quarantined and destroyed if returned to transfusion service.
  • If delays are encountered (ie need to retart I.V., etc.), units can be held at the patient bedside, but the transfusion should be completed within 4 hours of issuance from the bloodbank.
  • Blood products can be kept at patient bedside when clinically indicated (i.e. massive transfusion, etc.).
    • Store RBCs, FFP units under wet ice in a validated container.
    • Place an insulating layer (chuck, paper towels, etc.) between the ice and the units.
    • If after prolonged storage, the ice in the container has completely melted, the units should not be transfused and must be quarantined and returned to the Transfusion Service.
    • Platelets, Cryoprecipitate adn Granuloyctes must be stored at room temperatures while awaiting infusion.
    • Blood cannot be stored in medication refrigerators.
    • Notify the Blood Bank staff and return products immediately if components are no longer needed for a patient, as the component may be suitable for transfusion to another patient.

TRANSFUSION OF ANTIBODY-POSITVE RED CELLS

Some units received from the Red Cross come from donors with red cell antibodies (antibody-positive units). Such units have an attached tag identifying the antibody. These units contain clinically insignificant amounts of antibodies because the majority of donor plasma is removed and diluted during component preparation and are safe to transfuse.

INFUSION RATES

  • In routine adult transfusions, the first 25-50 cc of a unit are given slowly (over 15-30 minutes) while the patient is carefully monitored. If the patient tolerates this "test dose", the rate may be increased so that the remainder of the unit is given over 1-2 hours.
  • Products can be infused as fast as the patient tolerates, but care must be taken to avoid circulatory overload in elderly.
  • Rates will vary with the patient's blood volume, homodynamic condition, and cardiac status.
  • Most products are given within 2 hours, although this time may be extended to 4 hours.
  • If a unit must be given over more than 4 hours, bacterial contamination becomes a concern and it is best to ask Transfusion Service to split component and infuse each half.

DISPOSING OF BLOOD PRODUCT BAGS

  • Discard blood product container and IV tubing according to hospital policy for waste disposal.
  • Do not dispose of bags or tubing if transfusion reaction suspected. See Adverse Reactions to Transfusion.

TRANSFUSION EQUIPMENT

NEEDLE SIZE

  • Needle size depends on the size and integrity of the vein.
  • Standard 18-gauge up to 23-gauge ultra thin needles and catheters are used for transfusion.
  • Needle size affects rate of flow but the smaller the gauge, the slower the flow rate.
  • Any size needle can be used to infuse blood as long as excess pressure is not needed to achieve desired flow rate (See Infusion Pumps and Pressure Bags).

TUBING & FILTERS

  • Red cell (RBC) transfusions: A standard blood Y administration set is satisfactory for all RBC transfusions.
  • Fresh frozen plasma (FFP) transfusions: A standard blood Y administration set is satisfactory for all FFP transfusions.
  • Platelet transfusion: Transfuse platelets through a standard blood solution administration set. After platelets are transfused, it is preferred (but optional) to rinse entrapped platelets from the filter by flowing 50-100 ml of 0.9% saline through it.
  • Granulocyte concentrate transfusions: Transfuse only through the standard (170 micron pore size) blood solution administration set. WBC depletion filters should not be used for granulocyte transfusions.
  • Cryoprecipitate transfusions: Cryoprecipitate must be filtered, and the most convenient filter for this purpose is a small (170 micron pore size) filter in the blood component infusion set.

CHANGING INFUSION SETS:

  • A single infusion set can be used to infuse multiple units.
  • Replace filter after 3-4 units or after 4 hours.
  • Change sooner if flow significantly impeded by filtered debris.  

MECHANICAL PUMPS

  • Mechanical pumps are used for rapid infusion during trauma and with very slow infusion rates required by neonatal and pediatric patients.
  • Use only pumps that have been properly maintained and that have been specifically approved for blood transfusion.
  • Operators must be trained and competent to operate device.
  • Some pumps use standard infusion sets; others require special software. Refer to the manufacturer's directions.

PRESSURE BAGS

  • Helpful when blood must be transfused rapidly (about 5 minutes per unit).
  • Should be inflated only until blood flow through the drip chamber is continuous, about 200 mm Hg. Pressures ³ 300 mmHg.
  • Excess pressure may cause the red cells to lyse or blood bag seams to split.
  • Excess pressure should not be applied to compensate for catheters that are too small.
  • Diluting red cells with saline or asking the Blood Bank to split a unit and giving only half at a time may help if the flow is too slow.

BLOOD WARMERS

  • Prevent cardiac arrhythmia associated with the rapid infusion of large volumes of cold blood.
  • Also recommend their use when transfusing patients with very strong cold agglutinins.
  • Blood must not be warmed above 42°C or above FDA approved manufacturer's recommendation.
  • Only temperature-controlled and monitored in-line devices are acceptable for use, and some require special software.
  • Warmer should be set up according to the manufacturer's directions and its temperature checked and recorded periodically with a calibrated thermometer during use.
  • Warmers beyond date for scheduled maintenance should not be used.