BLOOD TRANSFUSION

BLOOD COMPONENT THERAPY vessels and is a major contributor to

plasma oncotic pressure.
• A single unit of whole blood contains • This protein is used to expand the
450 mL of blood and 50 mL of an blood volume of patients in
anticoagulant, which can be hypovolemic shock and, rarely, to
processed and dispensed for increase the concentration of
administration. circulating albumin in patients with
• PRBCs are stored at 4°C (39.2°F). hypoalbuminemia.
With special preservatives, they can • Immune globulin is a concentrated
be stored safely for up to 42 days solution of the antibody
before they must be discarded immunoglobulin G (IgG), prepared
(American Red Cross, 2015a). from large pools of plasma. It
• Platelets must be stored at room contains very little immunoglobulin A
temperature because they cannot (IgA) or IgM.
withstand cold temperatures, and • Intravenous immunoglobulin (IVIG) is
they last for only 5 days before they used in various clinical situations to
must be discarded. To prevent replace inadequate amounts of IgG
clumping, platelets are gently in patients who are at risk for
agitated while stored. recurrent bacterial infection (e.g.,
• Plasma is immediately frozen to those with chronic lymphocytic
maintain the activity of the clotting leukemia, those receiving HSCT). It is
factors within; it lasts for 1 year if it also used in certain autoimmune
remains frozen. Alternatively, plasma disorders, such as idiopathic
can be further pooled and processed thrombocytopenic purpura (ITP).
into blood derivatives, such as Albumin, antihemophilic factors, and
albumin, immune globulin, factor VIII, IVIG, in contrast to all other fractions
and factor IX. of human blood, cells, or plasma, can
Special Preparations survive being subjected to heating at
60°C (140°F) for 10 hours to free
• Factor VIII concentrate them of the viral contaminants that
(antihemophilic factor) is a may be present.
lyophilized, freeze- dried concentrate
of pooled fractionated human
plasma. It is used in treating
hemophilia A.
• Factor IX concentrate (prothrombin
complex) is similarly prepared and
contains factors II, VII, IX, and X. It is
used primarily for the treatment of
factor IX deficiency (hemophilia B).
Factor IX concentrate is also useful in
treating congenital factor VII and
factor X deficiencies.
• Recombinant forms of factor VIII,
such as Humate-P or Alphanate, are
also useful. Because they contain
von Willebrand factor, these agents
are used in von Willebrand disease
as well as in hemophilia A,
particularly when patients develop
factor VIII inhibitors.
• Plasma albumin is a large protein
molecule that usually stays within

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 BLOOD TRANSFUSION
PROCURING BLOOD AND BLOOD
PRODUCTS

Blood Donation
• To protect both the donor and the
recipients, all prospective donors are
examined and interviewed before
they are allowed to donate their
blood.
• The intent of the interview is to
assess the general health status of
the donor and to identify risk factors
that might harm a recipient of the
donor’s blood.
• There is no upper age limit to
donation

Directed Donation
• At times, friends and family of a
patient wish to donate blood for that
person.
• These blood donations are referred
to as directed donations.
• These donations are not any safer
than those provided by random
donors, because directed donors
may not be as willing to identify
themselves as having a history of
any of the risk factors that disqualify
a person from donating blood.
• Therefore, many blood centers no
longer accept directed donations.
Standard Donation
• Phlebotomy consists of venipuncture
and blood withdrawal.
• Standard precautions are used.
• Donors are placed in a semi
recumbent position.
• The skin over the antecubital fossa is
carefully cleansed with an antiseptic

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 BLOOD TRANSFUSION
preparation, a tourniquet is applied, blood components can also be
and venipuncture is performed. collected.
• Withdrawal of 450 mL of blood • Typically, 1 unit of blood is drawn
usually takes less than 15 minutes. each week; the number of units
obtained varies with the type of
Standard Donation
surgical procedure to be performed
• After the needle is removed, donors (i.e., the amount of blood anticipated
are asked to hold the involved arm to be transfused).
straight up, and rm pressure is • Phlebotomies are not performed
applied with sterile gauze for 2 to 3 within 72 hours of surgery. Individual
minutes. blood components can also be
• Arm bandage is then applied. collected.
• The donor remains recumbent until • The primary advantage of autologous
he or she feels able to sit up, usually transfusions is the prevention of viral
within a few minutes. infections from another person’s
• Donors who experience weakness or blood.
faintness should rest for a longer • Other advantages include safe
period. The donor then receives food transfusion for patients with a history
and uids and is asked to remain of transfusion reactions, prevention
another 15 minutes. of alloimmunization, and avoidance
• The donor is instructed to leave the of complications in patients with
dressing on and to avoid heavy lifting alloantibodies.
for several hours, to avoid smoking • It is the policy of the American Red
for 1 hour, to avoid drinking alcoholic Cross that autologous blood is
beverages for 3 hours, to increase transfused only to the donor.
uid intake for 2 days, and to eat • If the blood is not required, it can be
healthy meals for at least 2 weeks. frozen until the donor needs it in the
• Specimens from the donated blood future (for up to 10 years).
are tested to detect infections and to • The blood is never returned to the
identify the specic blood type. general donor supply of blood
products to be used by another
Autologous Donation person.
• A patient’s own blood may be • Needless autologous donation (i.e.,
collected for future transfusion; this performed when the likelihood of
method is useful for many elective transfusion is small) is discouraged
surgeries where the potential need because it is expensive, takes time,
for transfusion is high (e.g., and uses resources inappropriately.
orthopedic surgery). • Moreover, in an emergency situation,
• Preoperative donations are ideally the autologous units available may
collected 4 to 6 weeks before be inadequate, and the patient may
surgery. still require additional units from the
• Iron supplements are prescribed general donor supply.
during this period to prevent • Furthermore, although autologous
depletion of iron stores. transfusion can eliminate the risk of
• Typically, 1 unit of blood is drawn viral contamination, the risk of
each week; the number of units bacterial contamination is the same
obtained varies with the type of as that in transfusion from random
surgical procedure to be performed donors (Stowell & Hass, 2014).
(i.e., the amount of blood anticipated • Contraindications to donation of
to be transfused). blood for autologous transfusion are
• Phlebotomies are not performed acute infection, severely debilitating
within 72 hours of surgery. Individual chronic disease, hemoglobin level
less than 11 g/dL, unstable angina,

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 BLOOD TRANSFUSION
and acute cardiovascular or
cerebrovascular disease.
• A history of poorly controlled
epilepsy may be considered a
contraindication in some centers.

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 BLOOD TRANSFUSION
MANAGEMENT OF PATIENTS WHO DO preoperative autologous donation) and
NOT ACCEPT TRANSFUSION the primary blood components – red
cells, platelets, white cells and
Essentials unfractionated plasma.
• Respect the values, beliefs and • ✦Many Witnesses accept the
cultural backgrounds of all patients. transfusion of derivatives of primary
• Anxiety about the risks of transfusion blood components such as albumin
can be allayed by frank and solutions, cryoprecipitate, clotting
sympathetic discussion with a well- factor concentrates (including brinogen
informed clinician. concentrate) and immunoglobulins.
• Blood Transfusion Services provide a • ✦There is usually no objection to
range of quality assured information intraoperative cell salvage (ICS),
resources for patients, parents and apheresis, hemodialysis, cardiac
their families. bypass or normovolaemic
• Jehovah’s Witnesses decline haemodilution providing the equipment
transfusion of specic blood products, is primed with non-blood uids.
usually, whole blood and primary Recombinant products, such as
blood components. Individuals vary erythropoiesis stimulating agents (e.g.
in their choice and it is important to RHuEpo) and granulocyte colony
clearly establish the preference of stimulating factors (e.g. G-CSF or GM-
each patient. CSF) are acceptable, as are
• Advance Decision Documents must pharmacological agents such as
be respected. intravenous iron or tranexamic acid.
• No one can give consent on behalf of • ✦ Jehovah’s Witnesses frequently carry
a patient with mental capacity. a signed and witnessed Advance
• Emergency or critically ill patients Decision Document listing the blood
with temporary incapacity must be products and autologous procedures
given life-saving transfusion unless that are, or are not, acceptable to
there is clear evidence of prior them.
refusal such as a valid • ✦ A copy of this should be placed in
the patient record and the limitations
Advance Decision Document. on treatment made clear to all
members of the clinical team.
• Where the parents or legal guardians
• ✦ It is appropriate to have a frank,
of a child under 16 refuse essential
condential discussion with the patient
blood transfusion a Specic Issue
about the potential risks of their
Order (or national equivalent) can be
decision and the possible alternatives
rapidly obtained from a court.
to transfusion, but the freely expressed
Jehovah’s Witnesses and blood
wish of a competent adult must always
transfusion
be respected.
• Their decision is not related to
perceived risks of transfusion but is a
scriptural stand based on biblical MENTAL COMPETENCE AND REFUSAL
texts, such as ‘the life of all esh is OF TRANSFUSION
the blood thereof: whoever eat it
shall be cut o’ (Lev. 17:10–16) and 1. An adult has full legal capacity to
‘abstain from the meats oered to make decisions for themselves (the
idols and from blood’ (Acts 15:28–29) right to autonomy) unless it can be
(1–3). shown that they lack capacity to
• ✦Individuals vary in their choice and it make a decision for themselves at
is important to clearly establish the the time the decision needs to be
preference of each patient. made’. No one can give consent on
• ✦Nearly all Jehovah’s Witnesses refuse behalf of a patient with mental
transfusions of whole blood (including capacity.
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 BLOOD TRANSFUSION
In the case of critically ill patients with
temporary incapacity, ex. altered
consciousness after trauma clinicians
must give life-saving treatment,
including blood transfusion, unless there
is clear evidence of prior refusal such as
an Advance Decision Document.

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 BLOOD TRANSFUSION
TRANSFUSION OF PACKED RED BLOOD Abnormal color or cloudiness may be a
CELLS sign of hemolysis.)
4. Make sure that PRBC transfusion is
Preprocedure initiated within 30 minutes after removal
of PRBCs from blood bank refrigerator.
1. Confirm that the transfusion has been
5. For the first 15 minutes, run the
prescribed.
transfusion slowly —no faster than 5
2. Check that patient’s blood has been
mL/min. Observe patient carefully for
typed and
adverse effects. If no adverse effects
cross-matched.
occur during the first 15 minutes,
3. Verify that patient has signed a written
increase the ow rate unless patient is at
consent form per institution or agency
high risk for circulatory overload.
policy and agrees to procedure.
6. Monitor closely for 15–30 minutes to
4. Explain procedure to patient. Instruct
detect signs of reaction. Monitor vital
patient in signs and symptoms of
signs at regular intervals per institution
transfusion reaction (itching, hives,
or agency policy; compare results with
swelling, shortness of breath, fever,
baseline measurements. Increase
chills).
frequency of measurements based on
5. Take patient’s temperature, pulse,
patient’s condition. Observe patient
respiration, blood pressure and assess
frequently throughout the transfusion for
uid volume status (e.g., auscultate lungs,
any signs of adverse reaction, including
assess for jugular venous distention) to
restlessness, hives, nausea, vomiting,
serve as a baseline for comparison
torso or back pain, shortness of breath,
during transfusion.
ushing, hematuria, fever, or chills.
6. Note if signs of increased uid over load
Should any adverse reaction occur, stop
present (e.g.,heart failure), contact
infusion immediately, notify primary
primary provider to discuss potential
provider, and follow the agency’s
need for a prescription for diuretic, as
transfusion reaction standard.
warranted.
7. Note that administration time does not
7. Use hand hygiene and wear gloves in
exceed 4 hours because of increased risk
accordance with standard precautions.
of bacterial proliferation.
8. Use appropriately sized needle for
8. Be alert for signs of adverse reaction:
insertion in a peripheral vein.a Use
circulatory overload, sepsis, febrile
special tubing that contains a blood lter
reaction, allergic reaction, and acute
to screen out brin clots and other
hemolytic reaction.
particulate matter. Do not vent blood
9. Change blood tubing after every 2 units
container.
transfused to decrease chance of
Procedure bacterial contamination.

1. Obtain packed red blood cells (PRBCs) Postprocedure

from the blood bank after the IV line is
1. Obtain vital signs and breath sounds;
started. (Institution policy may limit
compare with baseline measurements. If
release to only 1 unit at a time.)
signs of increased fluid overload present
2. Double-check labels with another nurse
(e.g., heart failure, consider obtaining
or physician to ensure that the ABO
prescription for diuretic as warranted.
group and Rh type agree with the
2. Dispose of used materials properly.
compatibility record. Check to see that
3. Document procedure in patient’s medical
number and type on donor blood label
record, including patient assessment
and on patient’s medical record are
findings and tolerance to procedure.
correct. Confirm patient’s identification
4. Monitor patient for response to and
by asking the patient’s name and
effectiveness of procedure. If patient is
checking the identification wristband.
at risk, monitor for at least 6 hours for
3. Check blood for gas bubbles and any
signs of transfusion- associated
unusual color or cloudiness. (Gas
circulatory overload (TACO); also monitor
bubbles may indicate bacterial growth.
for signs of delayed hemolytic reaction.

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 BLOOD TRANSFUSION
Note: Never add medications to blood or
blood products; if blood is too thick to run
freely, normal saline may be added to the
unit. If blood must be warmed, use an in- line
blood warmer with a monitoring system.

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 BLOOD TRANSFUSION
TRANSFUSION OF PLATELETS OR • Other concurrent health problems
FRESH-FROZEN PLASMA should be noted, with careful attention
to cardiac, pulmonary, and vascular
Preprocedural disease.
1. Confirm that the transfusion has been
prescribed. Physical Assessment
2. Verify that patient has signed a written
consent form per institution or agency • A systematic physical assessment and
policy and agrees to procedure. measurement of baseline vital signs
3. Explain procedure to patient. Instruct and uid status are important before
patient in signs and symptoms of transfusing any blood product.
transfusion reaction (itching, hives, • The respiratory system should be
swelling, shortness of breath, fever, assessed, including careful
chills). auscultation of the lungs and the
patient’s use of accessory muscles.
Setting • Cardiac system assessment should
• Freestanding infusion centers, include careful inspection for any
ambulatory care clinics, physicians’ edema as well as other signs of heart
offices, and even patients’ homes may failure (e.g., jugular venous distention).
be appropriate settings for transfusion. • The skin should be observed for
• Typically, patients who need chronic rashes, petechiae, and ecchymoses.
transfusions but are otherwise stable The sclera should be examined for
physically are appropriate candidates icterus. In the event of a transfusion
for outpatient therapy. reaction, a comparison of findings can
• Verification and administration of the help differentiate between types of
blood product are performed as in a reactions.
hospital setting. Patient Education
• Although most blood products can be
transfused in the outpatient setting, • Signs and symptoms of a reaction
the home is typically limited to include fever, chills, respiratory
transfusions of PRBCs and factor distress, low back pain, nausea, pain at
components (e.g., factor VIII for the IV site, or anything “unusual.”
patients with hemophilia). • Although a thorough review is very
important, the nurse also reassures the
PRE-TRANSFUSION ASSESSMENT patient that the blood is carefully
tested against the patient’s own blood
Patient History
(cross-matched) to diminish the
• The patient history is an important likelihood of any untoward reaction.
component of the pre transfusion • Similarly, the patient can be reassured
assessment to determine the history of about the very low possibility of
previous transfusions as well as contracting HIV from the transfusion;
previous reactions to transfusion. this fear persists among many people.
• The history should include the type of
Complications
reaction, its manifestations, the
interventions required, and whether • Febrile Nonhemolytic Reaction
any preventive interventions were • Acute Hemolytic Reaction
used in subsequent transfusions. • Allergic Reaction
• The nurse assesses the number of • Transfusion-Associated Circulatory
pregnancies a woman has had, Overload
because a high number can increase • (TACO)
her risk of reaction due to antibodies • Bacterial Contamination
developed from exposure to fetal • Transfusion-Related Acute Lung Injury
circulation. (TRALI)
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 BLOOD TRANSFUSION
• Delayed Hemolytic Reaction
• Disease Acquisition

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 BLOOD TRANSFUSION
NURSING MANAGEMENT FOR
TRANSFUSION REACTIONS

• If a transfusion reaction is suspected,

the transfusion must be stopped
immediately and the primary provider
notice.
• A thorough patient assessment is
crucial, because many complications
have similar signs and symptoms.
• The following steps are taken to
determine the type and severity of the
reaction:
• Stop the transfusion. Maintain the IV
line with normal saline solution through
new IV tubing, given at a slow rate.
• Assess the patient carefully. Compare
the vital signs with baseline, including
oxygen saturation. Assess the patient’s
respiratory status carefully. Note the
presence of adventitious breath
sounds; the use of accessory muscles;
extent of dyspnea; and changes in
mental status, including anxiety and
confusion. Note any chills, diaphoresis,
jugular vein distention, and reports of
back pain or urticaria.
• Notify the primary provider of the
assessment findings, and implement
any treatments prescribed. Continue to
monitor the patient’s vital signs and
respiratory, cardiovascular, and renal
status. Notify the blood bank that a
suspected transfusion reaction has
occurred.
• Send the blood container and tubing to
the blood bank for repeat typing and
culture. The patient’s identity and
blood component identifying tags and
numbers are verified.
• If a hemolytic transfusion reaction or
bacterial infection is suspected, the
nurse does the following:
• Obtains appropriate blood specimens
from the patient
• Collects a urine sample as soon as
possible to detect hemoglobin in the
urine
• Documents the reaction according to
the institution’s policy

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