Transfusion therapy refers to the process of administering whole blood or blood components to a patient through an intravenous (IV) needle or catheter placed in a patient's vein. Blood and blood products may be autologous (comprised of the patient's own blood), homologous (blood donated from another person), or synthetic (blood products developed in a laboratory). Some of the types of blood products available for transfusion include: whole blood, plasma, platelets, packed red blood cells (RBCs), leukocyte-poor RBCs, white blood cells (WBCs), clotting factors (II, VII, VIII, IX and X complex), anti-inhibitor coagulant complex, human antithrombin III, and human Rh (D) immune globulin.
The most common purpose for administering a transfusion is to replace lost blood volume. Transfusions are also given to increase the blood's ability to carry oxygen to the tissue, to improve immunity, or to correct blood-clotting problems. Some specific purposes of transfusions include:
- Replacement of blood volume lost due to trauma or surgery.
- Correction of anemia caused by chronic conditions.
- Treatment of immune suppression.
- Treatment of thrombocytopenia.
- Replacement of missing clotting factors.
- Correction of coagulation deficiencies.
- Treatment of hemophilia or other congenital clotting deficiencies.
- Treatment of chronic hypoproteinemia.
- Suppression of active antibody response in Rh negative patients exposed to Rh positive blood.
Donor blood must be compatible to the recipient of the transfusion. Compatibility blood testing (type and cross match) must be performed before administering homologous blood to avoid serious transfusion reactions. This blood test assures that the donor blood matches and is compatible with the recipient blood (including the blood type and the Rh factor). In an emergency when there is no time for matching blood, type O, Rh-negative blood (universal donor) is used until compatibility testing can be performed.
To minimize the chance of giving a patient the wrong product and causing a severe transfusion reaction, blood and blood products are labeled with patient name, number, type, and Rh factor by the blood bank. The clinician should check and record the blood bag name, number, type, and Rh factor against the patient's identification armband and the lab slip numbers twice with another nurse before administering blood products. The nurse should recheck the physician's order and the expiration date on the blood product before giving the blood product.
Patients must understand and sign an informed consent form before receiving a blood transfusion. Blood is never given without the patient's consent. When a patient is unable to give consent, the closest family member should sign the form. The consent assures that the patient or family member is aware of the risks involved in blood transfusions including the potential for an allergic reaction, transfusion reaction, and/or the possibility of contracting an infection from the transfusion.
Special equipment is used for blood transfusions to assure proper flow of the blood product and to filter out impurities or small clots. Use appropriate blood tubing, filter tubing, and/or needle filters as directed in the policy of the medical setting. The tubing may vary according to the blood product being administered. Blood and blood products require a separate IV line, separate IV lumen in a multi-lumen central line, or an IV line that has been thoroughly flushed with normal saline. Blood and blood products are not compatible with IV solutions other than normal saline. Drugs should not be administered through the IV line while blood or blood products are running. Drugs may be given in some medical settings through a separate lumen of a multi-lumen central IV line if the lumen is flushed with normal saline before and after drug administration.
Blood should be given to the patient within 30 minutes of receiving it from the blood bank. If there is a delay because of IV line issues or other patient needs, the blood should be returned to the blood bank until the staff is ready to administer the blood. This decreases the chance of bacteria growing in the blood bag and helps prevent confusion and errors. Never transfuse blood for longer than four hours to minimize risks of infection.
Nurses monitor patients receiving blood or blood products closely by checking their vital signs every 15 minutes during the first hour of the transfusion and hourly thereafter or as dictated by the policy of the medical setting. Transfusion reactions most often occur within the first 15 minutes of the blood administration. If signs such as high fever, rapid pulse, wheezing, shortness of breath, flushed face, chest pain, flank pain, hematuria or restlessness occur, the nurse should stop the
Antipyretic—A medication used to reduce fever.
Autologous transfusion—The collection, filtration and re-administration of a person's own blood. The blood for an autologous transfusion is collected, filtered, and stored for a patient prior to surgery or may sometimes be salvaged after a traumatic injury or during major surgery.
Clotting factors—Plasma proteins normally found in the blood that work with platelets to help blood clot.
Coagulation—The process of thickening or clotting of the blood.
Hematuria—The appearance of blood or blood cells in the urine.
Hemolytic reaction—A serious transfusion reaction that occurs when donor blood type or Rh factors are not compatible with the recipient's blood. Red blood cell destruction within the body causes symptoms such as shaking, chills, fever, chest pain, difficulty breathing, flank pain, and abnormal bleeding. Hemolytic reactions can lead to major organ failure, shock, and death.
Homologous transfusion—The intravenous delivery of blood or blood products donated by one person (donor) to another person (recipient).
Hypocalcemia—A deficiency of calcium in the blood which can cause symptoms of muscle tingling or cramps, nausea, vomiting, lowered blood pressure, and seizures.
Hypoproteinemia—A deficiency of protein in the blood.
Hypothermia—An abnormally low body temperature, usually below 92°F (33.3°C).
Non-hemolytic febrile reaction—An antigen antibody reaction that occurs in 1% of all transfusions. Symptoms include a temperature elevation, chills, palpitations, back pain, chest pain, or headache.
Plasma—The liquid portion of the blood.
Platelets—Small disc-shaped substances found in the blood that assist in blood clotting.
Red blood cells—Cells found in the blood that contain hemoglobin, transport oxygen to body tissue, and are responsible for the red coloring of the blood.
Thrombocytopenia—A persistent deficiency of blood platelets that leads to problems with blood clotting.
transfusion, change the IV tubing, and run in normal saline slowly. The nurse should keep the line open in the event that drug therapy is needed to reverse the reaction. He or she should elevate the head of the bed, administer oxygen if needed, monitor the patient's vital signs, and contact the physician immediately. The reaction should be documented and the blood bag and tubing returned to the blood bank for testing. There is usually a transfusion reaction protocol in the medical setting for collecting post-reaction blood or urine specimens. If the patient develops itching and a rash during a transfusion, the nurse should slow the flow rate down and contact the physician before stopping the blood. The physician may elect to administer antihistamines and continue the blood transfusion. If the patient develops a low-grade fever during transfusion, the nurse should slow the flow rate and contact the physician before stopping the blood. The physician may elect to administer an antipyretic and continue the transfusion.
Fluid overload can occur (especially in children or the elderly) as a result of a transfusion running too rapidly. The nurse should run blood in slowly (generally over two hours) and monitor the patient closely for restlessness, rapid pulse, or respiratory distress. The flow rate should be adjusted according to the physician's order or the policy of the medical setting. Flow rates may vary according to the product. For instance, the rate for whole blood may be different than the rate for packed cells.
The blood or blood product is checked by two nurses, two times to be sure the label on the bag matches the patient and the lab slip. The patient should state his name, and the armband should be checked to avoid errors. The nurse should check the expiration date on the unit, to make sure to not give blood products past their expiration dates. He or she should gently rotate the bag in the hands to mix the blood or blood components and then connect the blood or blood product to the IV line in place of the normal saline. If a Y-tubing is in use, the saline line is shut off and the blood product line is opened. Blood products are usually started slowly at 5-10 ml per minute for the first 15 minutes. The line and the patient should be checked frequently during the first 15 minutes of the transfusion to assure that the line is intact, the rate is correct, and the patient is not displaying signs of a reaction. After 15 minutes, vital signs should be obtained and compared to pre-transfusion vital signs to detect any changes. The blood flow rate can then be increased to the correct flow rate for the product being delivered. The patient's vital signs, affect, IV site, and transfusion flow rate should be checked and recorded every 15 minutes for the first hour of the transfusion and then hourly until the completion of the transfusion or according to the medical setting policy.
A blood specimen is drawn from the patient, so that the blood bank can type, match, and prepare the appropriate blood product. In most settings an armband is placed on the patient's wrist at the time of the blood draw with a number and name that will later match the blood product label. A physician or nurse will explain the procedure to the patient and obtain a signed informed consent for the transfusion. A physician or nurse will insert either a peripheral or central IV line and connect it to a normal saline drip with appropriate blood tubing and filters in place. If the patient has a peripherally inserted central catheter (PICC), it is better to start another peripheral IV to deliver blood because a PICC line has such a long narrow tubing that blood flows slowly through it and has a tendency to clog the line. Blood will flow most easily through a large bore (#18 or #19) needle or catheter. A blood pump, pressure bag, or blood warmer should be obtained if necessary. Blood warmers are most often used in the surgical or neonatal setting. Most IV pumps will pump blood without damaging the cells, but the medical center's policy should be checked for using blood pumps. The nurse should take and record a set of base-line vital signs, including the patient's blood pressure, temperature, pulse, and respirations prior to transfusion. The patient should be placed in a comfortable position in bed during a transfusion to enhance relaxation and decrease resistance to the blood flow.
When the transfusion is complete, the IV line is flushed with normal saline and discontinued or changed to other IV solutions with new IV tubing for ongoing IV therapy. The patient should be observed for 30 minutes after a transfusion for delayed reactions. A final set of vital signs is taken and recorded 30 minutes after the transfusion is finished. Blood slips are returned to the lab. Fresh IV tubing should be used for subsequent units of blood or blood products. Gloves should be worn when handling used blood supplies. Blood bags, tubing, and catheters are placed in a contaminated trash bag that can be sealed and discarded. Needles are placed (without recapping) in a puncture-proof contaminated needle box.
Complications of transfusion therapy are not frequent but can include:
- allergic reactions
- hemolytic reactions
- non-hemolytic febrile reactions
- circulatory overload
- microbial contamination
- disease transmission (AIDS, hepatitis C or bacterial infection)
The results of transfusion therapy are usually rapid and positive. Blood volume is expanded, missing factors are replaced, clotting problems are corrected, or immunity is improved. In some cases, a patient may need multiple transfusions to reach desired effect. Most transfusions are safe; however, mild febrile and allergic reactions occur in about 1-2% of all transfusions. Severe or fatal transfusion reactions are rare. Autologous transfusions are the safest type of transfusion and pose the least risk for infection or reaction. Autologous blood, however, is not always available when needed.
Health care team roles
Transfusion therapy is usually performed by a registered nurse in a controlled medical setting because of the need for ongoing assessment and the potential for transfusion reaction. Transfusions are occasionally administered in the home by a registered nurse who has access to appropriate equipment, emergency medical back-up, and immediate contact with a physician.
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Mary Elizabeth Martelli, R.N., B.S.