Blood Administration and Transfusion Reactions

This course has been awarded two

(2.0) contact hours.

Copyright © 2018 by RN.com.

All Rights Reserved. Reproduction and distribution
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First Published: March 25, 2005

Revised: April 12, 2018
Expires: April 30, 2021

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Acknowledgements
RN.com acknowledges the valuable contributions of…

…Suzan R. Miller-Hoover DNP RN CCNS CCRN-K

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disclosure policy that requires course faculty to declare any real or apparent commercial affiliation
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Purpose
The purpose of this course is to provide the learner with information about blood products, blood
product administration, and risks of transfusion.

Objectives
After successful completion of this course, you will be able to:
1. Identify the rationale for the selection of specific blood transfusion products including whole blood,
packed red blood cells, and platelets.
2. Describe pre-administration nursing priorities to assure safe administration of blood products.
3. Identify potential pre-administration medications and rationale for use.
4. Identify six critical pieces of information that must be co-assessed by two licensed personnel prior
to blood administration.
5. Describe the essential steps with the administration of blood products including tubing, filter,
priming solution, and rate of administration.
6. Identify signs and symptoms of suspected acute and late transfusion reactions.
7. Describe immediate nursing action required for the patient with a suspected hemolytic transfusion
reaction.

Introduction
Blood transfusions, when used correctly, can improve health and save lives. The United States (U.S.)
has one of the most comprehensive and safest blood supplies in the world.

Appropriate use of blood and blood products can be directly related to a well-organized blood
management system, and the ongoing education and training of staff involved in the transfusion
process.

Nursing care for patients requiring blood component transfusion is centered on blood component
knowledge, thorough pre-assessment skills, and through the application of accurate infusion
parameters. Awareness of the signs and symptoms of early and late transfusion reactions is key.

This course reviews essential nursing considerations for all stages of blood administration including
the pre-assessment, equipment needed, blood product administration information, and review of
potential post-transfusion reactions.

Blood Facts
Annually in the United States:
• Every two seconds someone needs blood
• A single car accident victim can require 100 blood transfusions
• Nearly 21 million blood components are transfused
o The average transfusion is 3 units
o 36,000 transfusions are required every DAY
o 7,000 units of platelets are needed every DAY
o 10,000 units of plasma are needed every DAY
• There are 6.8 million blood donors
o 36% of the population is eligible to donate blood
 Less than 10% of the eligible donate
• 13.6 million units of whole blood and red blood cells are collected
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The History of Blood Transfusions
Blood transfusions were first recorded in 1492 when Pope Innocent VIII, in Rome, had a stroke and
lapsed into a coma. The Pope’s physician advised a blood transfusion as a therapeutic measure for
the Pope's illness. Sadly, and not surprisingly, the Pope did not benefit and died later that year (The
History of Blood Transfusion Medicine, 2005).

• 1901, Austrian physician by the name of Karl Landsteiner documented the first three human
blood groups
• Early 1900’s: Development of sodium citrate and citrate-glucose, long-term anticoagulants,
that allowed preservation of blood.
• 1950: The plastic infusion bag replaced glass storage bottles
• 1960-1970: More precise standards were developed for blood administration
• 1985: Screening all donated blood for HIV began
o In the years since, improved processes for testing and refining blood products has
helped to ensure the safety of the blood supply
(The History of Blood Transfusion Medicine, 2005 & The History of Blood Banking, 2013)

The History of Blood Banking

The first United States federal license permitting the processing and manufacture of whole blood was
issued in 1946. Blood banking was experiencing rapid growth due to the return of physicians from
World War II who had experienced the effectiveness of transfusion therapy.

The American Association of Blood Banks (AABB) was formed in 1947. Now known as AABB, this
international organization defines the highest standards of medical, technical and administrative
performance activities related to transfusion and cellular therapies. The AABB standards of practice
serves as the guiding foundation for the Joint Commission (TJC) and Centers for Medicare and
Medicaid Services (CMS) guidelines for the transfusion of blood components. Each hospital blood
bank should have a copy of the most recent edition of the AABB standards and these standards
should be used when developing and revising blood transfusion policies (AABB, 2012 & 2018).

Did You Know?

AABB standards are revised and published every April of the even numbered years. This year’s
revision is number 31 (AABB, 2012 & 2018).

Sources of Blood Products

There are three basic sources of blood products. These include autologous blood, donor specific and
banked blood. Patients that experience a considerable blood loss during a surgical procedure may be
a candidate for auto transfusion as well.
• Autologous Blood
o One of the safest and most effective ways to treat blood loss is to give patients their
own blood through the process of preoperative donation.
o Replacement of lost blood with previously donated blood eliminates most transfusion-
associated risks.
o This type of blood source is typically coordinated in the setting of a pre-arranged,
elective surgery, when the physician anticipates a need for a post-operative blood
transfusion.
o To allow for the adequate time needed for testing and processing, it is important to
remember that autologous blood must be donated at least 3 days prior to the surgical

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 date.
o Limitations for autologous donations also include a low hemoglobin level (< 11 g/dL) or
certain cardiac conditions.
• Autotransfusion
o May be used to define the use of autologous blood
o Is the collection of blood from an actively bleeding site and the reinfusion of this blood to
the same patient to maintain blood volume

• Donor Specific Blood

o Also known as donor directed and predesignated blood donation
o Blood source is donated from a friend or family member for a particular patient
o Blood donation must occur at least 48 hours prior to transfusion
o Has not been shown to be safer than bank blood
• Bank Blood
o Bank blood is a blood product that is donated by the public
o Prior to donating blood, the donor must meet donor eligibility criteria

All donated blood and blood products are tested according to national
guidelines.
(Society for the Advancement of Blood Management (SABM), 2018)

Blood Testing
Ensuring that the U.S. blood supply remains safe is the ultimate responsibility of the nation's more
than 3,000 blood establishments, which collect and process approximately 14 million units of donated
whole blood each year (The American Red Cross, 2018).

Blood transfusions are protected by layers of overlapping safeguards. Some of these safeguards
include accurate blood typing and crossmatch testing. The ABO system, Rh factors, and blood cross-
matching are critical factors in blood transfusion safety (The U.S. Food and Drug Administration
(FDA), 2018).

While the U.S. has practices in place to safeguard the public, in some countries where blood is
available, the risk of transfusion-transmissible infections still occurs due to poor selection practices,
the use of untested blood and poor blood donor recruitment (World Health Organization (WHO),
2018).

The absence of adequate testing increases the possibility of transmitting infectious diseases such as
HIV, hepatitis viruses, syphilis and Chagas disease (WHO, 2018).

Test Your Knowledge

The absence of adequate testing increases the possibility of transmitting infectious diseases such as:
A. HIV
B. Hepatitis viruses
C. Syphilis
D. All the above

Rationale: The absence of adequate testing increases the possibility of transmitting infectious
diseases such as HIV, hepatitis viruses, syphilis and Chagas disease (WHO, 2018).

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Risk of Infection
Hepatitis
Hepatitis is the most common transfusion-transmitted infection. High risk factors for hepatitis can be
identified through pre-donation screening questions that make certain patients ineligible to donate,
thereby helping decrease the chances of transmitting hepatitis.
• Hepatitis B: 2%
• Hepatitis C: 90%
o The risk of acquiring hepatitis C is approximately 1 in 103,000 transfusions
• All blood and blood products can transmit hepatitis except albumin
• Tests that detect both hepatitis B and C can produce false-negative results
o Allowing some hepatitis cases to go undetected
o These viruses have a long seronegative period when they are undetectable
 Donors may test negative for hepatitis but are infected with the virus
 By the time the hepatitis is detected, the donor blood may already be in use.

Human Immunodeficiency Virus (HIV)

Less than 20 HIV cases per year are transfusion-related; however, this virus remains one of the most
feared transfusion-transmitted infections. Identification of high-risk behaviors among potential donors
and the improved use of sensitive lab assays have decreased the risk of HIV infection.
• The estimated risk of acquiring HIV is 1 in 493,000 transfusions
• HIV specific antibodies are not detectable until 6 to 12 weeks after exposure

Cytomegalovirus (CMV)
All leukocyte-containing blood products transmit the virus; therefore, most regional blood banks
leukocyte reduce blood products prior to sending the blood to hospital blood banks, thus reducing the
risk of CMV transmission.
• 60% of donors have the virus
• CMV in critically ill patients is the major cause of increased morbidity and mortality

Test Your Knowledge

The most commonly transferred infection during a blood transfusion is:
A. Cytomegalovirus
B. HIV
C. Hepatitis B
D. Hepatitis C

Rationale: Hepatitis is the most common transfusion-transmitted infection. High risk factors for
hepatitis can be identified through pre-donation screening questions that make certain patients
ineligible to donate, thereby helping decrease the chances of transmitting hepatitis.
• Hepatitis B: 2%
• Hepatitis C: 90%
o The risk of acquiring hepatitis C is approximately 1 in 103,000 transfusions
• All blood and blood products can transmit hepatitis except albumin
• Tests that detect both hepatitis B and C can produce false-negative results
o Allowing some hepatitis cases to go undetected
o These viruses have a long seronegative period when they are undetectable
 Donors may test negative for hepatitis but are infected with the virus
 By the time the hepatitis is detected, the donor blood may already be in use

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Blood Typing
Human blood is grouped according to the presence or absence of specific antigens (A & B). In
addition, the blood is tested for Rh antigen, antibodies, and for compatibility.
To prevent an acute hemolytic transfusion reaction (AHTR), blood for transfusion must be of a
compatible ABO blood type.

Did You Know?

Type O- (negative) blood or packed red blood cells (RBC) are considered the universal donor and
may be used for any patient in an emergent situation
Type AB + (positive) patients are considered the universal recipient and can receive blood from any
blood type
(AABB, 2012 & 2018)

Test Your Knowledge

Which blood type indicates a universal donor?
A. O neg
B. O pos
C. AB pos
D. AB Neg
Rationale:
Type O (negative) blood or packed red blood cells (RBC) are considered the universal donor and
may be used for any patient in an emergent situation
Type AB + (positive) patients are considered the universal recipient and can receive blood from any
blood type
(AABB, 2012 & 2018)

Rh Factor Testing
The presence or absence of the Rh antigen on the surface of the RBCs determines the classification
of Rh-positive or Rh-negative. Rh factor is the next most important antigen associated with blood
transfusion and ABO compatibility.

• Rh- (negative) – the antigen is NOT present

o May develop antibodies to Rh antigen if given Rh + (positive) blood
o Should always receive Rh – (negative) blood
• Rh+ (positive) – the antigen IS present If present, the person is considered Rh-positive.
o Rh-positive patients may receive either Rh-positive or Rh-negative blood.

The table indicates the most common ABO and Rh factor types in the general population.

Blood Types

Blood Type % of General

(ABO & Rh) Population
O+ 35%
O-* 7%
A+ 35%

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 A- 7%
B+ 8%
B- 2%
AB + ~ 4%
AB - 2%
*Universal donor
~Universal recipient

Recipient/Donor Compatibility
The table below indicates general guidelines for ABO/Rh compatibilities. Be sure to review your
facility’s blood bank policy and procedure to ensure safe transfusion practices.

Recipient/Donor ABO and Rh Compatibility Guidelines

RECIPIENT DONOR DONOR DONOR

Blood Type PRBC PLASMA PLATELETS
A A, O A, AB A, AB
B B, O B, AB B, AB
AB AB, A, B, O AB only AB, A, B*
O O O, A, B, AB O, A, B, AB
Rh positive Rh positive Rh positive
Rh Positive
Rh negative Rh negative Rh negative
Rh Negative Rh positive* Rh positive Rh positive*
Rh negative Rh negative Rh negative
O negative AB positive or negative AB negative
Unknown
AB positive*
* Special consideration should be used when transfusing this blood type
Crossmatching
After typing for major ABO and Rh antigens, the blood is subjected to a Coomb’s serum test to
ascertain if there are any additional antigens in either the banked blood or the recipient’s blood that
might lead to a transfusion reaction.

Typing blood does not identify the many potential minor antigens present in blood. These antigens
may occur naturally; however, many occur when the patient has received multiple blood transfusions.
Crossmatching consists of the mixing of the recipient’s serum with the donor’s RBCs in a saline
solution followed by the addition of the Coomb’s serum test.

Did You Know?

Only blood products containing RBCs need to be cross matched. Plasma products DO NOT
need to be cross matched but should be ABO compatible.

Additional blood testing includes:

• Human T-Lymphotropic Virus, Types I and II
• Hepatitis B & C
• HIV-1 & HIV ½
• Trypanosoma cruzi (t. cruzi and anti-T. cruzi assay)
• West Nile Virus
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 • Zika
As other diseases are identified, they may be added to this list.
(FDA, 2018a)

Blood and Blood Products

Healthcare professionals need to be familiar with the many different types of blood products available.
Blood can be modified into the following products:
• Whole blood
• Packed red blood cells (PRBC)
• Platelets
• Plasma
• Cryoprecipitate
• Granulocytes

The following table provides general guidelines and special considerations for each product.

BLOOD AND BLOOD PRODUCT GUIDELINES

Product/Volume Compatibility Indications Infusion Special
Requirements Dose/Rate Considerations
Whole Blood Crossmatch Hemorrhage Per physician ABO compatibility not
Volume based on required Exchange order necessary for infants
the desired final ABO & Rh transfusion under 4 months of age
hematocrit Compatibility Blood filter required
(150-230 micron)
Packed RBC Crossmatch Anemia 10-15 mL/kg ABO compatibility not
200-400 mLs required every Blood loss necessary for infants
72 hours Decrease in Rate: over 2 under 4 months of age
ABO & Rh oxygen carrying hours or as Blood filter required
Compatibility capacity (need to ordered (150-230 micron)
increase Hgb/Hct) May be infused via
gravity or infusion pump
Platelets Crossmatch Low platelet count 5-10 mL/kg Blood filter required
Single donor not necessary with bleeding (150-230 micron)
30-40 mLs ABO & Rh Thrombocytopenia Rate: as fast May be infused via
Plateletpheresis Compatibility Acute leukemia as tolerated gravity or infusion pump
200-400 mLs Bone marrow Store at room
aplasia temperature
Plasma Crossmatch Bleeding patients 10-30 mL/kg Blood filter required
Fresh Frozen and and ABO & Rh with low (150-230 micron)
thawed Compatibility coagulation Rate: as May be infused via
200-500 mLs not necessary factors indicated by gravity or infusion pump
Anticoagulant clinical Contains plasma
reversal situation proteins, fibrinogen, &
factors V, VIII, & IX

Cryoprecipitate Crossmatch Low fibrinogen 1-2 units/10 Blood filter required

10-25 mLs per and ABO & Rh kg (150-230 micron)
single unit Compatibility May be infused via
3-10 units may not necessary Rate: as fast gravity or infusion pump
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 be pooled as tolerated Contains fibrinogen &
together factor VII
May be reconstituted by
adding 10 mLs of 0.9
saline directly to bag
and kneading gently
Granulocytes Crossmatch 10 mL/kg/day Must be ordered 3-5
With Platelets: not necessary days in advance of
200-400 mLs ABO & Rh Rate: slowly transfusion
Without Compatibility over 4 hours Blood filter required
platelets: (150-230 micron)
100-200 mLs Do not use PALL
microaggregate filter
May be infused via
gravity or infusion pump

Test Your Knowledge

What blood or blood product needs to be crossmatched?
A. RBC
B. Plasma
C. Platelets
D. Cryoprecipitate

Rationale: Only blood products containing RBCs need to be cross matched. Plasma products
DO NOT need to be cross matched but should be ABO compatible.

Additional Facts
• All blood and blood products contain some cellular debris, thereby requiring an in-line filtration
during administration. See the section on filters for more information.
• All blood and blood product tubing should be primed with 0.9% saline
o Dextrose solutions may lyse RBCs and decrease RBC survival
o The calcium contained in the Lactate Ringers (LR) solution may cause clotting
• Medications and other solutions should not be added to the blood product
• Blood and blood products should be infused through a separate line
• A blood warmer is recommended for use with multiple blood transfusions
• Whole Blood:
o O negative blood is used in emergent situations when it is not prudent to wait for a full
type and crossmatch
• Packed Cells:
o 80% of plasma has been removed
o Transfusion with PRBC may help avoid potential circulatory overload
o Transfusions are not appropriate when the hemoglobin is greater than 10g/dL unless
the clinical condition indicates
o Each unit of PRBC raises the hematocrit by approximately 3%
• Leukocyte reduced PRBC
o In most cases, blood products are leukocyte reduced prior to leaving the regional blood
bank, therefore a PALL filter or leukoreduction filter is no longer necessary
o A physician order is no longer required for this type of blood (washed PRBCs)
o Check with your facility’s blood bank to determine if leukocyte reduced PRBCs are the
normal issue from your regional blood bank
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 • Washed PRBC
o A special solution removes white blood cells and plasma proteins
o Used for patients previously sensitized to transfusions
o A physician order is required for this type of blood
• Cytomegalovirus (CMV) Negative Blood
o Does not contain CMV antibodies
o Leukocyte reduced products are considered CMV safe and equivalent to CMV negative
blood
o May be used for premature infants, intrauterine transfusions, and CMV negative
patients with an immunosuppressed system or at-risk patients
(AABB, 2012 & 2018)

Test Your Knowledge

The type of blood product that may not require a special order is:
A. Washed platelets
B. Washed PRBC
C. Leucocyte reduced PRBC
D. Leucocyte reduced platelets

Rationale: Leukocyte reduced PRBC

• In most cases, blood products are leukocyte reduced prior to leaving the regional blood bank,
therefore a PALL filter or leukoreduction filter is no longer necessary
• A physician order is no longer required for this type of blood (washed PRBCs)
• Check with your facility’s blood bank to determine if leukocyte reduced PRBCs are the normal
issue from your regional blood bank

Blood Administration Filters

Most standard blood administration tubing has a built-in 170-230 micron filter designed to remove
debris and clots. This tubing must be used for administration of all blood and blood components. The
entire surface of the filter must be filled with the component to improve flow rates. Each standard
blood administration set with built-in filter can be used for the transfusion of up to 4 units of PRBC or
for a maximum of 4 hours of total hang time (AABB, 2012 & 2018).

Leukocyte removal filters are used for leukocyte removal from the RBCs when pre-filtered products
are not available. Filters are generally issued from the blood bank. Each filter can be used for only
one unit of RBCs.

Microaggregate filters are a 40-micron filter. These filters are used in conjunction with auto-
transfusions.

Test Your Knowledge

Filters are generally issued from the blood bank. Each filter can be used for only one unit of RBCs is
the definition of which type of filter?
A. Microaggregate
B. Leukocyte removal
C. PALL
D. In-line

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Rationale: Leukocyte removal filters are used for leukocyte removal from the RBCs when pre-filtered
products are not available. Filters are generally issued from the blood bank. Each filter can be used
for only one unit of RBCs.

Nursing Considerations

Blood Product Administration & timing

Whole Blood (RBC’s, Must be hung within 30 minutes of removal from blood bank
WBC’s, Plasma & refrigerator
electrolytes. Max hang time 4 hours from removal from blood bank refrigerator
Must be stored in a blood bank refrigerator
Recommended total infusion time in otherwise healthy adult: 1.5 to
2 hours
Packed RBC’s Must be hung within 30 minutes of removal from blood bank
(PRBCs) refrigerator
Max hang time 4 hours from removal from blood bank refrigerator
Must be stored in a blood bank refrigerator
Recommended total infusion time in otherwise healthy adult: 1.5 to
2 hours
Can be split into smaller amounts (aliquots)
Platelets Must be stored at room temperature
Max hang time 4 hours
Fresh Frozen Plasma Must be utilized within 24 after thawing
Max hang time 4 hours from thawing
Must be stored in a blood bank refrigerator
Recommended total infusion time in otherwise healthy adult: 1.5 to
2 hours
(AABB, 2012 & 2018)

Consider the following prior to starting a transfusion:

• Premedication
o If a patient reports prior reactions to a transfusion
o If the blood bank reports antibodies
• Diuretics or infuse the blood or blood product at a slower rate (max: 4 hours)
o If there is a risk of fluid overload
• Leucocyte reduced or irradiated blood
o History of non-hemolytic reactions
 These reactions are mediated by donor leucocytes in the plasma, causing
sensitization to human leucocyte antigens
o In organ transplant patients
(AABB, 2012 & 2018)

Test Your Knowledge

Which blood or blood product requires a filter?
A. All products
B. None, as they are filtered at the blood bank
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 C. Leukocyte reduced
D. Autologous
Rationale: Most standard blood administration tubing has a built-in 170-micron filter designed to
remove debris and clots. This tubing must be used for administration of all blood and blood
components.

Safe Blood Administration

The following steps indicate an example of how to safely administer blood and blood products.

Step One: Does the patient have a signed blood transfusion consent?
• Patients have the right to refuse blood and blood products
• Some facility blood banks will require a copy of the consent to be sent to the blood bank along
with the blood component order
• Obtain informed consent if one is not in the medical record
When a patient is not able to sign a consent for blood products, and the patent’s condition indicates
an emergent need for a transfusion, consult your institution’s policy on emergency transfusion
consent.
• Most emergency consents include:
o Two physicians’ signature (one should be an independent physician- not involved in the
patient’s care
o Written informed consent from the patient or family should be obtained at the first
available time
Some patients may refuse blood and blood components based on cultural and religious reasons. A
refusal of consent for blood products should be in the medical record.
• Facilities need a court order to give blood to these patients
• Usually there is a liaison who can help healthcare workers understand these beliefs and when
it is necessary to try for a court order

Step Two: Compare the blood or blood component request to the order
• Does the order read:
o Type and cross: matching banked blood to the patient’s sample
 This blood is ready to be issued in the event of need
o Transfuse/administer: Patient requires a transfusion of the matched blood
• These orders may not be interchanged. Both are needed to safely administer blood and blood
products

In the event that a transfusion of blood or blood products is needed emergency and the type and
cross cannot be done, consult your institution’s policy on emergency universal donor blood
transfusions.

Step Three: Start or ensure the patient has the appropriate size vascular access device and
that it is patent, prior to obtaining the blood or blood product

Step Four: At the blood bank, using two unique patient identifiers, verify that the blood being
issued is for the correct patient
• Some facilities allow blood to be delivered to the unit either by transporters or by the
pneumatic tube system
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 o Know your facility’s policy and procedure
• Each state and facility may have regulations or policies mandating who may pick up, transport,
and verify blood products
o Know the regulations of your state and facility policies

Step Five: Explain the procedure to the patient.

Step Six: At the patient bedside, with a second verifier, verify that the patient is the correct
patient for the transfusion
• Know your state and facility policy regarding who can verify the blood product
o The most common error made, is the use of unlicensed personnel at the bedside
verification of patient and blood product
• Using the blood bank arm band, patient identification arm band, bar code, and the blood
product identification, verify that the following are correct:
o Patients full name
o Medical record number or other designated number
o Blood bank armband number
o Unit number
o Blood component type
o ABO/RH type compatibility
o Expiration date
• Both verifiers should sign the blood product identification slip
• The blood product identification slip should remain attached to the product until the transfusion
is complete

Step Seven: Obtain supplies

• Blood tubing with an inline microaggregate filter (170 micron)
• Non-sterile gloves
• Normal saline
• Infusion pump with tubing (if applicable)
• Blood warmer and tubing (if applicable)

Step Eight: Obtain baseline vital signs including patient temperature

• Obtain the patient's blood pressure, heart rate, respiratory rate and temperature
• Obtaining an accurate temperature is important since febrile reactions are the most common
reaction to blood transfusions

Step Nine: Start infusion and remain in room until next set of vital signs are taken
• The AABB suggests that the nurse remain in the room to observe for signs of immediate
reaction to the transfusion

Step Ten: Obtain serial vital signs during and after transfusion
• The AABB suggests:
o Vital signs are taken within 15 minutes after the start of the infusion and every hour
there after until one hour after the transfusion is discontinued

Step Eleven: Discontinue the transfusion

• Following your facility’s policy document:
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 o Transfusion amount
o Vital signs
o Evidence or no evidence of suspected transfusion reaction
(AABB, 2012 & 2018)

Most fatal reactions occur from human error. The most important step in preventing such
error is to follow your facility's policies and procedures for administering blood products.

Test Your Knowledge

The AABB suggests that vital signs are taken:
A. Every 5 minutes x3, every 15 minutes x 4, every 30 minutes x2 and hourly there after until the
infusion is complete
B. Before the transfusion and every hour until the infusion is complete
C. Within 15 minutes after the start of the infusion and every hour there after until one hour
after the transfusion is discontinued
D. Every thirty minutes until the infusion is complete

Rationale: The AABB suggests: Vital signs are taken within 15 minutes after the start of the infusion
and every hour there after until one hour after the transfusion is discontinued

Transfusion Reactions
Transfusion reactions occur rarely and the most common adverse reactions from blood transfusions
are allergic and febrile reactions, which make up over half of all adverse reactions. The Centers for
Disease Control and Prevention along with the National Healthcare Safety Network monitor the
adverse events. To understand more about this process, visit: https://www.cdc.gov/nhsn/acute-care-
hospital/bio-hemo/

Blood transfusion reactions occur when the recipient's immune system launches a response against a
component of the transfused product and can be an acute, delayed, or late reaction.
These reactions are further classified as hemolytic or non-hemolytic.
• Acute: occurs within the first few minutes of the start of the transfusion
• Delayed: occurs hours to days after the transfusion
• Late: Undetected reactions occurring more than 48 hours after the transfusion
• Hemolytic: Red blood cell destruction occurs
• Non-hemolytic: all other reactions
(AABB, 2012 & 2018)

Signs and Symptoms

Type of Reaction Cause Signs & Symptoms

Administration of excessive volume Distended neck veins, difficulty
or at a rate faster than the breathing, cough, severe headache,
Circulatory Overload
circulatory system can tachycardia
accommodate
Antibodies directed against donor Chills, fever, hemoglobinuria,
leukocytes, HLA antigens and pre- vomiting, diarrhea, hypotension
Febrile, nonhemolytic formed cytokines in the donor
plasma because of leukocyte
breakdown.
Pyrogenic Bacterial contamination of blood or Chills, fever, hemoglobinuria,
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 blood product vomiting, diarrhea, hypotension
Allergy to soluble product in donor Flushing, itching, hives, rash,
Allergic
plasma wheezing
Infusion of IgA proteins or other Coughing, respiratory distress,
compound into a recipient who has hypotension, nausea, vomiting,
Anaphylactic
developed antibodies to this diarrhea, loss of consciousness
compound
Triggered by an antigen/antibody Fever, chills, chest/back pain,
reaction caused by the transfusion hypotension, hemoglobinuria,
of incompatible blood components generalized bleeding, decrease
Hemolytic
urinary output (less than 1cc/kg/hr),
respiratory distress, pain at infusion
sight
Passive transfer of donor white Respiratory distress with pulmonary
TRALI (Transfusion-
blood cell antibodies reacting with edema in the absence of fluid
Related Acute Lung
recipient’s white cells. overload, fever, chills, and
Injury)
hypotension are often present
Alloimmunization: Immune Alloimmunization: Fever, decreasing
response to foreign antigens on hemoglobin, newly positive antibody
Delayed Transfusion
RBCs, WBCs or platelets. screen and/or DAT, platelet
Reaction (less than 24
refractoriness, delayed hemolytic
hours post transfusion
reaction, hemolytic disease of the
fetus or newborn
Delayed Transfusion Hemolytic: Anamnestic immune Hemolytic: fever, decreasing
Reaction (more than response to red cell antigens hemoglobin, newly positive antibody
24 hours post screen, mild jaundice
transfusion)
Donor lymphocytes engraft in Erthroderma, maculopapular rash,
Graft vs. Host recipient and mount attack on host anorexia, nausea, vomiting,
Disease tissue diarrhea, hepatitis, pancytopenia,
fever
Post Transfusion Patient’s platelet antibodies (usually Thrombocytopenic purpura,
Purpura anti-HPA-1) destroy donor platelets bleeding, 8-10 days after transfusion
Multiple transfusions with obligate Diabetes, cirrhosis, cardiomyopathy
Iron Overload iron overload in transfusion-
dependent patient
(AABB, 2012 & 2018)

Test Your Knowledge

A reaction to a soluble product in the donor’s plasma is a(n):
• Acute reaction
• Delayed reaction
• Allergic reaction
• Anaphylactic reaction

Rationale: Allergic: Allergy to soluble product in donor plasma

Anaphylactic: Infusion of IgA proteins or other compound into a recipient who has
developed antibodies to this compound

Management of Transfusion Reactions

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Your facility should have a policy describing the process for dealing with a transfusion reaction.
Common practices include:
• Stopping the infusion immediately
• Maintain airway, breathing & circulation
• Notify blood bank and physician
• Vital sign regimes such as: Monitor vital signs every 5-15 minutes or as indicated by the
severity and type of reaction
• Note evidence of oliguria or anuria: hemoglobin deposits in the renal tubules can cause renal
damage
• Be sure to keep the blood administration set intact and send to the lab unless otherwise
specified in your facility’s policy.

Test Your Knowledge

A soon as a transfusion reaction is suspected, the transfusion should be immediately stopped.
A. True
B. False

Rationale: Your facility should have a policy describing the process for dealing with a transfusion
reaction. Common practices include:
• Stopping the infusion immediately
• Maintain airway, breathing & circulation
• Notify blood bank and physician
• Vital sign regimes such as: Monitor vital signs every 5-15 minutes or as indicated by the
severity and type of reaction
• Be sure to keep the blood administration set intact and send to the lab unless otherwise
specified in your facility’s policy.

Conclusion
Administration of blood and blood products is a common nursing activity; however, it carries with it
certain risks. Knowledge about blood products and adherence to appropriate procedures for blood
administration is critical. Recognition of reactions and rapid treatment is essential for the safe
administration of blood products.

The nurse is the central healthcare provider performing the pre-administration assessment, safely
infuses the product, monitors for potential adverse outcomes, and supports the patient through the
entire process.

Although accurate typing and testing of donor blood have made transfusions increasingly safer,
healthcare professionals should be aware that there are still many early and late transfusion reaction
risks associated with the transfusion process.

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References
AABB. (2012). Primer of Blood Administration. Retrieved from:
https://www.bloodcenter.org/webres/File/Hospital%20.pdf%20forms/primerofbloodadministration.pdf

AABB. (2018). Standards for Blood Banks and Transfusion Services. 31st Ed. Bethesda, MD.

American Red Cross (2018). Blood Facts & Statistics. Retrieved from:
https://www.redcrossblood.org/learn-about-blood/blood-facts-and-statistics

Society for the Advancement of Blood Management. (SABM). (2018). Autotransfusion. Retrieved
from: https://www.sabm.org/glossary/autotransfusion

The History of Blood Transfusion Medicine. (2005). Retrieved from http://www.bloodbook.com/trans-

history.html

The History of Blood Banking (2013). Retrieved from http://www.bloodbook.com/banking.html

The Joint Commission (2015). National Patient Safety Goals Effective January 1, 2015. Retrieved
from http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf

United States Food and Drug Administration. (2018). Blood and blood products. Retrieved from:
https://www.fda.gov/BiologicsBloodVaccines/BloodBloodProducts/default.htm

United States Food and Drug Administration. (2018a). Infectious disease tests. Retrieved from:
https://www.fda.gov/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/LicensedProduc
tsBLAs/BloodDonorScreening/InfectiousDisease/default.htm

World Health Organization (WHO). (2018). Blood Transfusion Safety. Retrieved from
http://www.who.int/bloodsafety/clinical_use/en/

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