Whole blood transfusion replenishes both the volume and the oxygen-carrying capacity of the circulatory system. You may also transfuse packed red blood cells (RBCs) from which 80% of the plasma has been removed; this, however, restores only the oxygen-carrying capacity. Both types of transfusions treat decreased hemoglobin levels and hematocrit.
Two nurses must identify the patient and blood products before administering a transfusion to prevent errors and a potentially fatal reaction. It is essential that the right blood be given to the right patient at the right time. (See Transfusion complications.) If the patient is a Jehovah's Witness, a transfusion requires special written permission.
Blood recipient set (filter and tubing with drip chamber for blood or combined set) 
I.V. pole gloves gown face shield multiple-lead tubing whole blood or packed RBCs 250 mL of normal saline solution venipuncture equipment, if necessary (should include 20G or larger catheter) optional: ice bag, warm compresses.
Avoid obtaining either whole blood or packed RBCs until you're ready to begin the transfusion. Prepare the equipment when you're ready to start the infusion.
Explain the procedure to the patient, make sure he has signed an informed consent form, and record baseline vital signs.
Obtain whole blood or packed RBCs from the blood bank within 30 minutes of the transfusion start time. Check the expiration date on the blood bag and observe for abnormal color, RBC clumping, gas bubbles, and extraneous material. Return outdated or abnormal blood to the blood bank.
ID issues
Compare the name and number on the patient's wristband with those on the blood bag label. Check the blood bag identification number, ABO blood group, and Rh compatibility. Also, compare the patient's blood bank identification number, if present, with the number on the blood bag. Identification of blood and blood products is performed at the patient's bedside by two licensed professionals according to the facility's policy.
Don gloves, a gown, and a face shield. Using a Y-type set, close all the clamps on the set. Then insert the spike of the line you're using for the normal saline solution into the bag of saline solution. Next, open the port on the blood bag and insert the other spike. Hang the bags on the I.V. pole, open the clamp on the line of saline solution, and squeeze the drip chamber until it's half full.
If the patient doesn't have an I.V. line in place, perform a venipuncture using a 20G or larger diameter catheter. Avoid using an existing line if the needle or catheter lumen is smaller than 20G. Central venous access devices also may be used for transfusion therapy.
Shaken, not stirred
If you're administering whole blood, gently invert the bag several times to mix the cells.
Attach the prepared blood administration set to the venipuncture device and flush it with normal saline solution. Then close the clamp to the saline solution and open the clamp between the blood bag and the patient. Adjust the flow clamp closest to the patient to deliver the blood at the calculated drip rate.
Remain with the patient and watch for signs of a transfusion reaction, such as fever, chills, and wheezing. If such signs develop, record vital signs and stop the transfusion. Infuse saline solution at a moderately slow infusion rate and notify the doctor at once. If no signs of a reaction appear within 15 minutes, you'll need to adjust the flow clamp to the ordered infusion rate. A unit of RBCs may be given over 1 to 4 hours as ordered. Review the facility policy on blood transfusion for specific information. This is a high-risk procedure that requires strict adherence to the policy guidelines.
After completing the transfusion, you'll need to put on gloves and remove and discard the used infusion equipment. Then remember to reconnect the original I.V. fluid, if necessary, or discontinue the I.V. infusion.
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Return the empty blood bag to the blood bank and discard the tubing and filter in the appropriate container per facility policy.
Record the patient's vital signs.
Although some microaggregate filters can be used for up to 10 units of blood, always replace the filter and tubing if more than 1 hour elapses between transfusions. Blood transfusion sets should be changed after a maximum of 6 hours.
After an RBC or plasma transfusion, a new blood administration set should be used to infuse platelets.
Once a unit of blood has been removed from controlled storage, the transfusion should be commenced immediately on delivery to the clinical area. If the transfusion cannot be initiated promptly, the blood should be returned to the hospital transfusion laboratory for storage, unless the transfusion to the intended recipient can be completed within 4 hours. Blood should be returned to the hospital transfusion laboratory for documented disposal if out of controlled storage for more than 30 minutes.
Routine warming of blood is not indicated. Patients who would benefit from warmed blood are adults and children receiving massive infusion and infants requiring an exchange transfusion.
For rapid blood replacement, a pressure bag may be needed.
If you're administering packed RBCs with a Y-type set, you can add saline solution to the bag to dilute the cells by closing the clamp between the patient and the drip chamber and opening the clamp from the blood. Then lower the blood bag below the saline solution container and let 30 to 50 mL of saline solution flow into the packed cells. Finally, close the clamp to the blood bag, rehang the bag, rotate it gently to mix the cells and saline solution, and close the clamp to the saline container.
There are over 70 steps in the blood administration process. It is essential to adhere to all steps to prevent errors that could be fatal. The most frequently occurring errors are involving:
patient identification
sampling/labeling of the crossmatch sample
removal of blood from the fridge before transfusion
checking the identification of both the patient and the blood component at the bedside. (See Documenting blood transfusions.)
Outline