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Administration of blood products is one of the many responsibilities we have as nurses. Almost 21 million blood components are transfused each year in the U.S (1), each with the potential for harm. Unfortunately, many preventable transfusion errors occur each year. Staying up to date on blood administration is the best way for nurses to avoid potentially deadly consequences of transfusion errors.  

Introduction

You float to an oncology unit and are assigned three patients receiving blood. Does this scenario make your heart rate increase? Some nurses give blood daily, others are less familiar and may need a reminder of the basics of the administration of blood products.  

The goal of the course is to teach safe administration of blood products. 

Giving blood can be a daunting task, but if you remember the basics, you will feel a lot more confident. Before diving in, let's look at some interesting blood facts by the Red Cross (1): 

• Approximately 36,000 units of red blood cells are needed every day in the U.S. 
• Nearly 21 million blood components are transfused each year in the U.S. 
• The average red blood cell transfusion is approximately three units. 
• The blood type most often requested by hospitals is type O. 
• A single-car accident victim can require as many as 100 units of blood. 
• Each year, an estimated 6.8 million people in the U.S. donate blood. 
• About 45% of people in the U.S. have Group O (positive or negative) blood; the proportion is higher among Hispanics (57%) and African Americans (51%). 
• Type O negative red cells can be given to patients of all blood types. Because only 7% of people in the U.S. are type O negative, it's always in great demand and often in short supply.  
• Type AB positive plasma can be transfused to patients of all blood types. Since only 3% of people in the U.S. have A.B. positive blood, this plasma is usually in short supply. 

Pre-Infusion / Pre-Administration of Blood Products

There are many steps before the infusion starts; the most important is to verify, verify, verify (1, 3, 5). 

Verify the physician's order.
No order? No blood – it's that simple.  

Common blood orders include whole blood, red blood cells, and leukocyte-reduced RBC. 

Whole blood is the simplest, most common type of blood donated. It's also the most flexible because it can be transfused in its original form or separated into specific components such as red cells, plasma, and platelets. Whole blood is used to treat patients who need blood components, such as those who have large volume blood loss from trauma or surgery.  

Red blood cells (RBCs) are prepared from whole blood by removing the plasma. RBCs are used to treat anemia without increasing the patient's blood volume too much. Patients who benefit most from transfusion of red blood cells include those with kidney failure or gastrointestinal bleeding and trauma.  

Leukocyte-reduced RBCs are prepared by removing leukocytes (white blood cells) by filtration after donation before the RBCs are stored. This is done because, over time, the leukocytes can deteriorate, which can trigger adverse reactions in the patient who receives them.  

Verify the patient has signed a blood consent.  

The only time you can transfuse blood without consent is for emergency treatment. In this rare situation, the physician will order to infuse blood emergently without a concrete written order. 

Pre-Infusion Checklist

1. Check if premedication is required.
   A premedication such as acetaminophen and/or diphenhydramine may be required for patients that have acquired antibodies from multiple transfusions in the past. An example of this are sickle cell patients.
2. Check for special requirements (such as CMV negative). 
   Special requirements may be needed for patients that have acquired antibodies from prior reactions or illnesses such as cancer.
   
3. Verify if the patient has had a history of blood transfusion reactions in the past. 
   If they have had a history, find out they type of reaction they had and make sure this information is shared with the ordering physician.
   
4. Discuss the order with the patient and explain the process to the patient. 
   Even though they signed a consent, this is a new part of their treatment plan and must be included. The ordering physician is typically responsible for explaining the procedure and teaching about the signs and symptoms of transfusion reaction. Of course this can vary based on facility policy, so make sure you are familiar with the requirements at your workplace. As the nurse, you will also need to reinforce this education with the patient to ensure there are no gaps in knowledge. There is more discussion on this topic below.
   
5. Verify the patient has an active type and cross. 
   Blood cannot be distributed without this information unless in an emergent situation. Type and cross screens are valid for three days.
   
6. Review the patient's morning laboratory reports.
   Key labs to monitor include potassium, as it may rise with transfusion, BUN/Cr to ensure kidney function, and the ability to clear fluids, hemoglobin, and hematocrit for the severity of the anemia, PT/PTT/INR/Platelets to evaluate the coagulation status of your patient. 

Assess Your Patient

Why is your patient getting blood? You must document this as well and be able to understand the whole clinical picture. This is important so that you as the nurse can develop a baseline to really know if anything changes with your patient during the infusion process. 

It is important to understand how to perform the following key assessments in addition to baseline vitals.  

• Neurological Assessment – Alert and oriented to what? Baseline? Any changes?
  
• Pulmonary Assessment – What are their breath sounds like? Any crackles? How are their respirations at rest? What did the morning chest x-ray look like? Are they on oxygen? How much? What is the pulse oximetry reading? Any weight gain overnight? Pedal edema?
  

Any patient at risk for fluid volume overload needs to be identified (such as patients with heart failure or renal disease). If you are concerned with your patient experiencing fluid volume overload during the administration of blood products, discuss this with the ordering healthcare provider. Options may include slow administration of the blood product or premedicating with furosemide.  

Baseline Vital Signs (1, 3, 5) 

• Temperature – The patient should be afebrile. If they are febrile, do not order blood or administer blood unless the physician orders to transfuse despite their knowledge of fever. 
• Heart Rate – Rate, rhythm, and pulse quality should be documented. 
• Respirations – Rate and rhythm should be documented. 
• Blood Pressure – Is it "normal" for the patient? What is the trend? 

Determine IV Access 

An IV for blood should be 20 gauge or larger in adults. The larger the IV, the quicker blood can be administered. The IV line should be used for blood only. Nothing else can transfuse with blood (1, 3, 5). 

Blood tubing can be primed with 0.9 normal saline. Normal Saline is the only fluid  in which blood products can be infused. Blood tubing has a 170-200 micron filter. Blood tubing needs to be replaced with every unit of blood or every 4 hours, whichever comes first (1, 3, 5). Depending on your institution, priming with normal saline may not be required. Blood warmers and/or blood pumps may be optional or mandatory per the policy at your facility.

Infusion / Administration of Blood Products

Once the blood is removed from the blood bank, it should be infused within 30 minutes or returned (1). Blood must be infused within 4 hours (1, 3,5).  

Now that you have the blood in hand and a patient with a great IV, grab your nearest Nurse, Medical Doctor (MD), or appropriate second verifier (Determined by your institution) and verify, verify, verify (1, 3,5). 

Blood Verification Checks: 

• Patient name 
• Medical record number 
• Date of birth 
• Patient blood type 
• Donor blood type 
• Unit/pool/lot number 
• Product type 
• Special preparations 
• Rh factor 
• Expiration date and time of blood 
• Visually inspect bag for damage 
• Visually inspect blood for color difference or clots 

*Remember: This is a suggestion of the main points of a blood infusion checklist. The definitive checklist you should administer blood by is determined by your individual institutional policy.  

Prior to administration, two licensed personnel should verify the correct blood product and match it with the patient. This should be done at the patient's bedside using the identifying band on the patient for verification as well as the patient themselves (if  possible)(1, 3, 5).  

The Importance of Two-Step Verification  

Did you know that the most frequent error leading to transfusion of ABO incompatible blood occurs during patient identification at the bedside? As a result, although the blood is labeled appropriately, it is transfused to someone other than the correct recipient (4). 

In fact, the problem with transfusion errors led to one of the 2020 National Patient Safety Goals to "eliminate transfusion errors related to patient misidentification" (6). To prevent this from occurring, The Joint Commission now requires (before initiating a blood or blood component transfusion):  

• Match the blood or blood component to the order of the physician or provider.  
• Match the patient to the blood product.  
• Use a two-person verification process (6). 

When using a two-person verification process, one individual conducting the identification verification is the qualified transfusionist who will administer the blood or blood component to the patient (6). When using a two-person verification process, the second individual conducting the identification verification is qualified to participate in the process, as determined by the hospital (6). 

Now that you have verified blood and are infusing the product, it is not the time to go to lunch. Stay with the patient during the first 15 minutes of transfusion to monitor for any immediate reaction and start the infusion slowly. Vital signs should be repeated at 15 minutes after the beginning of the transfusion, during the procedure per facility policy, at the conclusion, and one hour after the transfusion (1, 3, 5). 

The rate of the actual infusion should be based on a) if a rate was ordered b) ensuring the infusion is complete within the 4 allotted 4 hour time frame, and c) nursing judgment related to the patients hemodynamic and pulmonary status.

Reassessment of Vital Signs 

• Neurological Assessment – Changes in baseline neurological assessment including lethargy, confusion, or any decrease in Glasgow Coma Scale, may be a sign of a transfusion reaction. 
• Pulmonary Assessment – Any changes from baseline? Oxygen requirement changes? Saturation changes? Signs of increased pulmonary secretions or pulmonary edema? These are signs of fluid overload and may be a sign of transfusion reaction.  
• Temperature – Increase is a sign of transfusion reaction. 
• Heart Rate – Tachycardia or arrhythmias may be a sign of transfusion reaction. 
• Respiration – Increase in respirations may be a sign of transfusion reaction or of fluid volume overload. 
• Blood Pressure – Increase in B.P. may be a sign of fluid overload, a significant decrease is a sign of a transfusion reaction. 
• IV Access – Still patent? Infusing without difficulty? At the prescribed rate?
  

Blood Transfusion Reactions

Why do you have to stay in the room and reassess everything in 15 minutes? 

Because, if the patient is going to experience an acute blood transfusion reaction, it is usually within the first few minutes of infusion.  

There are many signs and symptoms of blood transfusion reaction for hemolytic and non-hemolytic reactions (3):  

If a reaction is suspected, the transfusion should be immediately stopped, blood products and tubing removed, and the intravenous line kept open with normal saline. The provider should be notified immediately and the patient monitored. Remaining blood products and tubing should be taken to the laboratory (1, 3, 5). Refer to facility policy and procedure for documentation and other requirements. Labs will need to be drawn as part of a suspected transfusion reaction work up. 

If all goes well, continue to monitor the patients as needed during the remainder of the infusion. If there are no changes after 15 minutes in assessments or vital signs, vital signs should be repeated at the conclusion and one hour after the transfusion (1, 3, 5) and procedure per facility policy.

Post-Infusion / Post-Administration of Blood Products

Once the administration of blood products is complete, obtain a set of vital signs. Compare to baseline and 15-minute vital signs. Complete documentation: 

• Start/Stop time 
• Pre, 15 minute and post infusion vital signs 
• Blood volume infused 
• 0.9NS volume infused 
• Signs & Symptoms of transfusion reaction 
• Reason for transfusion 
• Answer "yes" or "no" to suspected transfusion reaction 
• Document in the notes how the patient tolerated the infusion 
• Properly dispose of blood and blood tubing in a red waste container 
• Flush the IV access with saline 

Now wait – you aren't done yet! Let's remember that non-acute blood transfusion reactions can take place hours after the infusion, so continue to monitor and assess your patient closely. Remember to document the one-hour post-infusion vital signs and complete any post-infusion labs that may have been ordered. 

Having knowledge about any skill improves your confidence and ultimate results in safe patient care. Hopefully, this has improved your knowledge of the administration of blood products and increased your confidence in performing this procedure! 

Institutional Policies on the Administration of Blood Products 

All organizations have different policies, it is important to review your institutional policy regarding the administration of blood products. It is your responsibility to learn your institution’s policies regarding the administration of blood products and to follow them appropriately. Documentation is per institutional policy and should include the reason for the infusion as well. Every institution has a procedure for releasing blood products. Follow the institutional policy to obtain the blood to have it to infuse in a timely manner.

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