The procedure for obtaining a blood component from a hospital transfusion service varies from institution to institution. Regardless of the specific institutional procedure, certain essential guidelines must be followed (Table 11-7).

Step 1: Recipient Consent

Recipient consent for transfusion must be obtained from patients who are competent to make such decisions. Documents of informed consent must contain indications, risks/benefits, possible side effects, and alternatives to transfusion with allogeneic blood components (Jorgenson, 2020). Some patients may refuse transfusions, often for religious reasons. Yet, when a blood transfusion is a life-saving intervention, it is difficult to reconcile the respect for the right of self-determination of the patient (Iijima, 2020). The provider may seek ethical support, such as ethics committees, within the hospital. In alignment with the ANA Professional Performance Standard of Ethics, the nurse advocates for patient preferences, the right to informed decision-making, and self-determination (ANA, 2021).

Step 2: Verifying the Provider's Order

The provider's initial order for the clinical laboratory must specify the type of component to be prepared for the patient (e.g., an order for type and crossmatch for RBCs). A second order for the transfusionist should specify:

• The patient's name and other identifiers
• The component to transfuse
• Any special processing required for the component (e.g., washing, irradiation, or filtration)
• The number of units or volume to be administered
• Date and time of infusion
• Flow rate or duration of the transfusion; this may be described in the organizational policy (Jorgenson, 2020)

NOTE: When multiple types of components are transfused, the order should specify the sequence in which they are to be transfused. Orders must specify any premedications to be given before transfusion.

Step 3: Pretransfusion

Laboratory Testing

Once the order has been obtained, the transfusion service initiates a series of steps to ensure the provision of compatible components. The laboratory must have a sample of the patient's blood, which generally must be drawn within 3 days of that of the individual being transfused; the draw date is considered day 0 (Jorgenson, 2020).

Identification Wristband

Most transfusion agencies require patients to be identified with an armband that matches that of the recipient to the intended product. Barcode-based ID systems are available for safety in transfusion.

Testing of Transfusion Recipient's Blood Specimen

ABO group and Rh type must be determined to transfuse ABO- and Rh-compatible components. Compatibility testing, or “crossmatch,” is performed between the recipient's plasma and the donor's RBCs to ensure that the specific unit intended for transfusion to the recipient is not incompatible. Blood samples from the donor and recipient are mixed and incubated under a variety of conditions and suspending medium. If the recipient's blood does not agglutinate the donor cells, compatibility is indicated. Transfusion service personnel are responsible for providing serologically compatible blood for transfusion.

When testing is complete, transfusion therapy can begin. The transfusion service has two objectives: (1) to prevent antigen-antibody reactions in the body and (2) to identify an antibody that the recipient may have and to supply blood from a donor who lacks the corresponding antigen. The testing of donor blood and recipient blood is intended to prevent adverse effects of transfusion therapy.

Labeling of Blood and Blood Components With the Recipient's Information

At the time of issue, the following must be in place:

• A tag or label indicating the recipient's two independent identifiers and the donor unit number; the compatibility test interpretation, if performed, must be attached securely to the blood container.
• A final check of records maintained in the transfusion service for each unit of blood or component must be made:
  • Two independent identifiers, one of which is the patient's name
  • The recipient's ABO group and Rh type
  • The donor unit or pool identification number
  • Donor's ABO group and, if required, Rh type
  • Interpretation of the crossmatch tests (if performed)
  • Date and time of issue
  • Special transfusion requirements (e.g., CMV reduced risk, irradiated, antigen-negative)
• A process must exist to confirm that the identifying information, the request, the records, and the blood or component are all in agreement, and that any and all discrepancies have been resolved before issue (Alquist & Harm, 2020).

Step 4: Vascular Access; Selecting and Preparing the Equipment

It is important to determine whether a central or peripheral IV line is in place and whether it is acceptable for infusion of blood components. Selecting the proper equipment includes the catheter and solution as well as obtaining administration sets, special filters, blood warmers, and electronic monitoring devices.

Vascular Access

The recommendation for catheter size is dependent on how quickly the blood needs to be administered. An 18- to 20-gauge peripheral IV catheter (PIVC) is often the catheter of choice for peripheral transfusions. However, a 22- to 24-gauge PIVC may be used for pediatric patients or those with small or fragile veins, such as in the older adult patient or those who have experienced repeated venipuncture, such as patients with cancer. Central vascular access devices may also be used for transfusions. When smaller catheters are used, it is recommended to slow the transfusion rate to reduce the risk for hemolysis of RBCs (Jorgenson, 2020).

NOTE: It is important that vascular access be obtained before the component is received at the patient's bedside.

Equipment

Solution

It is important to understand what solutions are compatible with blood administration and can be used to prime the blood administration set. The AABB recommends the use of 0.9% sodium chloride for priming the administration set. Never use dextrose in water or hypotonic solutions as they can cause RBC hemolysis as a result of cell swelling. Lactated Ringer's solution is also never used because it contains enough ionized calcium to overcome the anticoagulant effect of CPDA-1 and allows small clots to develop.

AABB allows exceptions if a solution is approved by the FDA and is safe. Plasma-Lyte 148 is also approved by the FDA as compatible with blood components and can be used as a priming solution and may infused concurrently with blood components and as a diluent in RBC transfusion (AABB, 2018; Jorgenson, 2018).

Administration Sets

Blood administration sets are available as a Y-type tubing or as single-lead tubing. Y-type administration sets allow for infusion of 0.9% sodium chloride before and after each blood component. A Y-type set also allows for dilution of RBCs that are too viscous to be transfused at an appropriate rate by allowing for sterile transfer of saline into the unit. Platelets and cryoprecipitate should be infused through a filter similar to the standard blood filter but with a smaller drip chamber and shorter tubing so that less priming volume is needed. A syringe device designed specifically for platelets and cryoprecipitate may also be used to administer these products.

Blood administration sets come with an inline filter. Most routine blood filters have a pore size of 170 to 260 microns designed to remove the debris that accumulates in stored blood. It is necessary to fill the filter chamber completely to use all the surface area. RBC filters are designed to filter 1 unit of whole blood or PRBCs. Filters used for platelets and cryoprecipitate may be used to administer multiple units. Filters are changed for two reasons: debris in the blood clogs the filter pores, slowing the rate, and the risk of bacterial contamination increases when filter-trapped blood particles are maintained at room temperature.

The INS Standards recommend changing the administration set in conjunction with the manufacturers' directions for use (Gorski et al., 2021). There is a lack of clinical studies to establish a maximum time for set use. Guidelines from some countries recommend changing the set every 12 hours (Clinical Practice Improvement Committee, Australian and New Zealand Society of Blood Transfusion, 2018; De Biasio & Rymer, 2017; Loveday et al., 2014). The AABB (2018) references the fact that most standard filters have a 4-unit compacity (and are part of the blood administration set) and state that if the first unit requires 4 hours for infusion, the filter should not be reused; thus, the administration set would be changed at 4 hours.

Special Filters

Microaggregate filters are not used routinely. These second-generation filters were developed to remove leukocytes and to complement or replace the standard clot screen. They have been replaced by third-generation leukocyte-reduction filters. Today, microaggregate filters are used for reinfusion of shed autologous blood collected during or after surgery (Jorgenson, 2020).

Filtration may occur immediately after blood collection in the transfusion service or at the time of administration.

These filters are capable of removing more than 99.9% of the leukocytes present in the unit, which decreases the risk of febrile transfusion reactions, the risk of HLA alloimmunization, and the risk of CMV transmission (Jorgenson, 2020). There are different leukocyte-reduction filters for RBCs and platelets, and it is important to use the correct filter based on the blood component. It is preferred that leukocyte reduction occur before storage shortly after unit collection as compared to bedside filtration. This is because bedside filtration is associated with dramatic hypotension in some patients (Jorgenson, 2020). These filters are more expensive than standard blood filters and require a specific order before use.

Blood Warmers

Blood warmers are rarely needed but may be indicated when rapid transfusion is required. The transfusion of cold components may cause hypothermia and cardiac complications (Jorgenson, 2020). The risk of clinically significant hypothermia is heightened when transfusing via a central vascular access device. Blood warmers are also useful for transfusions to neonates or patients with cold agglutinin syndrome.

NOTE: The AABB Standards state that “warming devices shall be equipped with a temperature sensing device and a warning system to detect malfunctions and prevent hemolysis or other damage to blood and blood components” (Jorgenson, 2020).

Blood is warmed only by using a specifically designed blood/fluid warmer (AABB, 2018). Adhere to the manufacturer's guidelines when using any of the many types of blood and fluid warmers.

INS Standard. Use only a blood or fluid warming device that is indicated for this purpose in accordance with the manufacturers' directions for use (Gorski et al., 2020, p. S72).

NURSING FAST FACT!

Blood components should NEVER be placed in microwave ovens or hot water baths because of damage to RBCs and the lack of temperature control, which may cause fatal complications for the patient.

Electronic Infusion Pumps

Infusion pumps may be used for transfusions. Only pumps designed for the infusion of whole blood and RBCs may be used because some infusion pumps may cause hemolysis. Pumps require the use of pump-compatible tubing. A pump's manufacturer should be consulted for detailed information on the pump's suitability for transfusing blood components.

INS Standard. Electronic infusion pumps that have a labeled indication for blood transfusion should be used. Follow the manufacturers' directions for use (Gorski et al., 2020, p. S192).

Pressure Devices

The use of an externally applied pneumatic pressure device may achieve flow rates of 70 to 300 mL/min, depending on the pressure applied. The device must have a pressure gauge because any pressure in excess of 300 mm Hg may lead to leaking or rupture of the blood container. While the use of pressure devices has been reported to provide only a small increment in component flow rates, it is a safe practice in the majority of RBC transfusions (Jorgenson, 2020). Before use, verify the IV patency of the peripheral IV catheter. For rapid transfusion, a larger catheter gauge will provide better results (Jorgenson, 2020).

INS Standard. External compression devices should be equipped with a pressure gauge, totally encase the blood bag, and apply uniform pressure against all parts of the blood container. Pressure should not exceed 300 mm Hg. A standard sphygmomanometer is never used for this purpose (Gorski et al., 2020, p. S193).

Step 5: Preparing the Patient

Patient preparation begins when the transfusion of a blood component is anticipated. Urgency factors related to the transfusion may affect the amount of time available to prepare the patient for the transfusion. The steps of the nursing process are activated, including assessment and the establishment of new goals and interventions related to the transfusion.

Patient/Family Education

The patient's and the patient's family's understanding of the need for blood, the procedure, and related concerns need to be assessed. Typically, concerns are expressed regarding the risks of disease transmission and their need to be addressed.

The patient should be instructed regarding the length of time for the procedure and the need for monitoring his or her vital signs and physical condition. Signs and symptoms that may be associated with a complication of the component to be given should be explained to the patient and family members. It is not necessary to offer graphic explanations regarding symptoms; rather, a brief description of possible symptoms should be provided, and the patient should be asked to report any different sensations after the transfusion has been started. Because transfusions typically take several hours, preparation includes making the patient physically comfortable.

Assessment

A baseline assessment of the patient should include the following:

• History of previous transfusions and any adverse reactions
• Vital signs; oxygen saturation is often included.
• Presence of any signs or symptoms that might be confused with a transfusion reaction, such as dyspnea, rashes, pruritus, chills, wheezing
• Presence of diseases that increase risk for fluid volume overload (e.g., heart failure) and may require a slower infusion rate (Jorgenson, 2020)

If the vital signs are abnormal, consult with provider before initiating the transfusion. An elevated temperature may destroy cellular components at an increased rate and mask symptoms of a transfusion reaction (Jorgenson, 2020). Premedication with diuretics, antihistamines, or antipyretics may be necessary to help keep the vital signs at acceptable levels.

Assessment of the lungs and renal function should be documented before transfusion. The nurse should review the laboratory data (Hgb, Hct, platelets, clotting times) and anticipate how the component to be administered will affect these values over the next 24 hours. The patient also should be questioned regarding any symptoms he or she may be experiencing that could be confused with a transfusion reaction.

NURSING FAST FACT!

Patient education; assessment, including vital signs; and current symptoms are documented in the medical record.

Step 6: Dispensing and Transporting the Component

As a rule, except in emergency situations, if blood is obtained from an on-site transfusion service, only one product will be issued at a time, and it must be initiated within 30 minutes (usually) or returned to the transfusion service for proper storage (Jorgenson, 2020). The blood component should not be obtained until the patient is ready to receive it. If blood is obtained from an off-site transfusion service, multiple units may be issued at one time. These units will be packaged to provide optimum storage conditions, and time limits for safe initiation will be detailed by the transfusion service.

NURSING FAST FACT!

Placing a unit of blood in the nursing unit refrigerator is never an acceptable practice. Such refrigerators cannot ensure the rigid temperature controls required. Accidental freezing can destroy the unit.

Proper identification is essential to ensure that the blood component is going to the intended recipient. Several items always must be verified and recorded before the transfusion is initiated.

• The order should always be verified before the component is picked up.
• When the blood is issued, the intended recipient's two independent identifiers should be verified (name, date of birth, or patient identification number and/or unique identifier given at the time the crossmatch sample is drawn).
• The donor unit or pool identification number, donor ABO group, and, if required, the Rh type should be verified.
• The notation of ABO group and Rh type must be the same on the primary blood bag label as on the transfusion form. This information is to be recorded on the attached compatibility tag or label.
• The donor number must be identically recorded on the label of the blood bag, the transfusion form, and the attached compatibility tag.
• The color, appearance, and expiration date of the component must be checked.
• The name of the person issuing the blood, the name of the person to whom the blood is issued, and the date and time of issue must be recorded. Organizations may use alternative technology for delivery such as validated pneumatic tube systems, automated blood delivery robots or blood dispensing kiosks in remote sites (Jorgenson, 2020).

Step 7: Initiating the Transfusion

The identification of the unit and the recipient must be verified by the nurse and another health-care provider qualified in performing identification verification (often a second nurse). The transfusion check includes:

• Prescriber's order: Check the blood or component against the prescriber's written order to verify that the correct component and amount are being given. If leukocyte reduction or irradiation was ordered, check that this was performed.
• Transfusion consent form: Check that the form is completed per organizational policy.
• Recipient identification: The name and identification number on the patient's identification band must be identical with the name and number attached to the unit. Usually the barcodes on the unit and the patient's wristband are scanned as part of the identification process.
• Unit identification: The unit identification number on the blood container, the transfusion form, and the tag attached to the unit must agree.
• Blood type: The patient's blood type should be compatible with the unit.
• Expiration: The expiration date and time of the donor unit should be verified as acceptable.
• Compatibility: The interpretation of compatibility testing must be recorded on the transfusion form and on the tag attached to the unit.
• Appearance: The unit should be returned if there is any discoloration, foaming, presence of bubbles, cloudiness, presence of clots or clumps, or loss of integrity of the container (Jorgenson, 2020).

NURSING FAST FACT!

The qualified transfusionist who will administer the blood component verifies the component at the patient's side with another qualified health-care provider; other systems have been developed to prevent misidentification. These include bar coding, radiofrequency identification devices, biometric scanning, mechanical or electronic locks that prevent access to blood containers assigned to unintended recipients, and handheld computers that transfer the blood request and administration data from the bedside to the transfusion service (Jorgenson, 2020, p. 544).

• Unless the exact time is given, the component expires at midnight on the expiration date.
• Identify any discrepancies during any part of the identification process. The transfusion should not be initiated until the transfusion service is notified and any discrepancies are resolved.

Use proper hand hygiene and follow standard precautions when administering blood components; clean gloves are worn. When using a Y-type blood set, spike one port with 0.9% sodium chloride and prime the tubing, being sure to saturate the filter. To administer whole blood or RBCs, spike the blood container on the second port and hang it up. Turn off the 0.9% sodium chloride and turn on the blood component. It is recommended that transfusions of RBCs be started at 1 to 2 mL/min for the first 15 minutes of the transfusion (Jorgenson, 2020). Refer to Procedures Display 11-1 at the end of this chapter.

NURSING FAST FACT!

It is important to recognize that the transfusion, and thus the timing for the 15 minutes, begins when the blood actually enters the vein, not when the 0.9% sodium chloride is turned off.

This small amount is large enough to alert the nurse to a possible severe reaction but small enough that the reaction probably can be successfully treated. If the patient shows signs or symptoms of an adverse reaction, the transfusion must be stopped immediately; only a small amount of blood product will have been infused. After the first 15 minutes has safely passed, the rate of flow can be increased to complete the transfusion within the amount of time indicated by the provider or by policy. The rate of infusion should be based on the patient's blood volume, hemodynamic condition, and cardiac status.

RBC products should be infused within a 4-hour period. When a longer transfusion time is clinically indicated, the unit may be divided by the transfusion service, and the portion not being transfused can be properly refrigerated.

Step 8: Monitoring the Transfusion

The patient's vital signs should be taken within 5 to 15 minutes of initiating the transfusion and then according to organizational policy. There is little evidence requiring routine assessment of vital signs other than before initiation, shortly after starting the transfusion, and after the transfusion (Jorgenson, 2020).

Step 9: Completing the Transfusion

At the completion of the transfusion, the patient's vital signs should be obtained. The bag and tubing are discarded in a biohazard container. At this point, another unit may be infused, the vascular access device may be locked, or a new administration set and solution container may be added.

NURSING FAST FACT!

Do not save previous solutions and tubing that were interrupted to give the blood component; they are considered contaminated. Restart with a fresh set and solution.

Documentation is an important part of the nursing intervention. The documentation in the patient's medical record should include the following:

1.Order for transfusion

2.Documentation of recipient consent

3.Name or type of component

4.Donor unit or pool identification number

5.Date and time of transfusion

6.Pretransfusion and posttransfusion vital signs

7.Volume transfused

8.Identification of the transfusionist

9.Any adverse events possibly related to the transfusion

Some transfusion service departments require that a copy of the completed transfusion form be returned to them. Returning the blood component after an uncomplicated transfusion is not required in all facilities. If disposal is allowed on the unit, use hospital standards in disposing the blood bag in contaminated trash.

NOTE: If an additional unit needs to be transfused, the institution's guidelines should be followed. Blood unit administration must be completed within 4 hours.