Blood Transfusion

Blood transfusion is defined as the process of receiving blood products into ones circulation
intravenously. This is usually done as a life saving maneuver to replace blood cells or blood products lost
through severe bleeding, during surgery when severe blood loss occurs or to increase the blood count in
an anaemic patient. Transfusions usually involve the use of two sources of blood ones own (autologous
transfusion) or someone elses (allogenic transfusion). Blood Transfusion is the transfer of whole blood
or blood components (specific portion or fraction of blood lacking in patient) It involves the use of whole
blood, red blood cells, white blood cells, plasma, clotting factors and platelets. Objective of BT includes:

To increase circulating blood volume after surgery, trauma, or hemorrhage

To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia

To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets,
albumin)

Table 1: Transfusable Blood Components Summary

Whole Blood

Red Blood Cells

Platelets

Plasma

Cryoprecipitated
AHF

COLOR OF THIS BLOOD COMPONENT

Red

Red

Colorless

Yellowish

White

BLOOD COMPONENT SHELF LIFE

21 / 35 Days*

Up to 42 Days*

5 Days

1 Year

1 Year

Room
Frozen
temperature with
constant agitation
to prevent
clumping
KEY USES OF THIS BLOOD TYPE

Frozen

STORAGE CONDITIONS
Refrigerated

Refrigerated

Trauma

Trauma

Surgery

Surgery
Anemia
Any
blood loss
Blood

Cancer
treatments
Organ
transplants
Surgery

Burn
patients

Hemophili
a

Shock
Bleeding
disorders

Von
Willebrand disease
(most common
hereditary

disorders, such as

coagulation

sickle cell

abnormality)
Rich
source of
Fibrinogen

Blood Components
Whole blood transfusion

Description: 450 mL whole blood in 63 mL anticoagulantpreservative solution of which Hb will

be approximately 1.2 g/dL and haematocrit (Hct) 3545% with no functional platelets or labile
coagulation factors (V and VIII) when stored at +2C to +6C.

Indication: Generally indicated only for patients who need both increased oxygen-carrying
capacity and restoration of blood volume when there is no time to prepare or obtain the specific
blood components needed.

Infection risk: Capable of transmitting an agent present in cells or plasma which was undetected
during routine screening for TTIs, i.e. HIV, hepatitis B & C, syphilis and malaria.

Contraindications: Risk of volume overload in patients with: Chronic anaemia and Incipient
cardiac failure.

Administration:
Must be ABO and RhD compatible with the recipient.

Never add medication to a unit of blood.

Complete transfusion within 4 hours of commencement.

Packed RBCs

Description: 150200 mL red blood cells from which most of the plasma has been removed. Hb
concentration will be approximately 20 g/100 mL (not less than 45 g per unit) and Hct 5575%.

Indication: Replacement of red cells in anaemic patients.

Infection risk: Capable of transmitting an agent present in cells or plasma which was undetected
during routine screening for TTIs, i.e. HIV, hepatitis B & C, syphilis and malaria.

Administration:
Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum
of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes,
providing proper refrigeration of remaining blood until needed.
One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%.

Platelets

Description: PCs are prepared from units of whole blood that have not been allowed to cool
below +20C. A single donor unit consists of 5060 mL plasma that should contain 55 x 109
platelets.

Indications: Treatment of bleeding due to: Thrombocytopenia, Platelet function defects, and
Prevention of bleeding due to thrombocytopenia as in bone marrow failure

Infection risk: Bacterial contamination affects about 1% of pooled units.

Contraindications: Idiopathic autoimmune thrombocytopenic purpura (ITP), Thrombotic

thrombocytopenic purpura (TTP), Untreated DIC,

Thrombocytopenia associated with

septicaemia, or in cases of hypersplenism

Administration:
Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of
platelets should raise the recipients platelet count by 6000 to 10,000/mm3: however,
poor incremental increases occur with alloimmunization from previous transfusions,
bleeding, fever, infection, autoimmune destruction, and hypertension.
Do not give platelet concentrates prepared from RhD positive donors to an RhD negative
female with childbearing potential. Give platelet concentrates that are ABO compatible,
whenever possible.

Plasma

Descrition: Fresh Frozen Plasma is plasma prepared from whole blood, either from the primary
centrifugation of whole blood into red cells and plasma or from a secondary centrifugation of
platelet rich plasma. The plasma is rapidly frozen to 25C or colder within 8 hours of collection
and contains normal plasma levels of stable clotting factors, albumin, immunoglobulin and Factor
VIII at a level of at least 70% of normal fresh plasma. It contains all coagulation factors,
including factors V and VIII

Indications:
Replacement of a single coagulation factor deficiency, where a specific or combined
factor concentrate is unavailable or contraindicated.
Immediate reversal of warfarin effect where prothrombin complex concentrate is
unavailable.

Thrombotic thrombocytopenic purpura.

Inherited coagulation inhibitor deficiencies where specific concentrate is unavailable.

C1 esterase inhibitor deficiency where specific concentrate is unavailable.

Massive blood transfusion.

Acute DIC if there are coagulation abnormalities and patient is bleeding.

Liver disease, with abnormal coagulation and bleeding prophylactic use to reduce
prothrombin time (PT) to 1.61.8 x normal for liver biopsy.
Cardiopulmonary bypass surgery use in the presence of bleeding but where abnormal
coag ulation is not due to heparin. Routine perioperative use is not indicated.
Severe sepsis, particularly in neonates (independent of DIC).

Infection risk: Capable of transmitting any agent present in cells or plasma which was
undetected by routine screening TTIs, including HIV, hepatitis B and C, syphilis and malaria.

Administration:
Should be ABO compatible.

Infuse as soon as possible after thawing.

Labile coagulation factors rapidly degrade; use within 6 hours of thawing.

FFP may be beneficial if PT and/or partial thromboplastin time (PTT) >1.5 times normal.

FFP for volume expansion carries a risk of infectious disease transmission and other
transfusion reactions (e.g. allergic) that can be avoided by using crystalloid or colloid
solutions.
Fresh frozen plasma should be administered as rapidly as tolerated because coagulation
factors become unstable after thawing.
Cryoprecipitate

A plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin

Indication: Indicated for treatment of hemophilia A, Von Willebrands disease, disseminated

intravascular coagulation (DIC), and uremic bleeding; Can be used in isolated Factor XIII
deficiency; Ameliorate platelet dysfunction associated with uraemia; Used topically as a fibrin
sealant.

Infection risk: As for plasma, but a normal adult dose involves at least 6 donor exposures.

Administration:
ABO compatible product should be used.

After thawing, infuse as soon as possible.

Must be transfused within 6 hours of thawing.

Granulocytes

It contains basophils, eosinophils, and neutrophils

May be beneficial in selected population of infected, severely granulocytopenic patients (less than
500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged
suppressed granulocyte production.

Albumin

It is a plasma protein.

Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of
circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major
contributor to plasma oncotic pressure.

Factor IX concentrate

A concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large

volumes of plasma.

Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires
pooling from many donors.

Factor VIII concentrate

A concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large

volumes of plasma.

Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis
and HIV transmission.

Prothrombin complex

It contains prothrombin and factors VII, IX, X, and some factor XI.

Indicated in congenital or acquired deficiencies of these factors.

Nursing Interventions
1. Verify doctors order. Inform the client and explain the purpose of the procedure.
2. Check for cross matching and typing. To ensure compatibility
3. Obtain and record baseline vital signs
4. Practice strict asepsis
5. At least 2 licensed nurse check the label of the blood transfusion. Check the following:
o

Serial number

Blood component

Blood type

Rh factor

Expiration date

Screening test (VDRL, HBsAg, malarial smear) this is to ensure that the blood
is free from blood-carried diseases and therefore, safe from transfusion.

6. Warm blood at room temperature before transfusion to prevent chills.

7. Identify client properly. Two Nurses check the clients identification.
8. Use needle gauge 18 to 19 to allow easy flow of blood.
9. Use BT set with special micron mesh filter to prevent administration of blood clots and
particles.
10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction
usually occurs during the first 15 to 20 minutes.
11. Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in
respiratory rate)
12. Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate
medication into the blood transfusion. Do not use blood transfusion lines for IV push of
medication.
13. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose.
Dextrose based IV fluids cause hemolysis.
14. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate,
transfuse quickly (20 minutes) clotting factor can easily be destroyed.
15. Observe for potential complications. Notify physician.

Complications

1. Allergic Reaction it is caused by sensitivity to plasma protein of donor antibody, which reacts with
recipient antigen.
Assess for:

Flushing
Rash, hives
Pruritus
Laryngeal edema, difficulty of breathing
2. Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white cells, platelets or plasma
proteins. This is the most symptomatic complication of blood transfusion
Assess for:

Sudden chills and fever

Flushing
Headache
Anxiety
3. Septic Reaction it is caused by the transfusion of blood or components contaminated with bacteria.
Assess for:

Rapid onset of chills

Vomiting
Marked Hypotension
High fever
4. Circulatory Overload it is caused by administration of blood volume at a rate greater than the
circulatory system can accommodate.
Assess for:

Rise in venous pressure

Dyspnea
Crackles or rales
Distended neck vein
Cough
Elevated BP
5. Hemolytic reaction it is caused by infusion of incompatible blood products.
Assess for:

Low back pain (first sign). This is due to inflammatory response of the kidneys to
incompatible blood.
Chills
Feeling of fullness

Tachycardia
Flushing
Tachypnea
Hypotension
Bleeding
Vascular collapse
Acute renal failure

Assessment findings
1. Clinical manifestations of transfusions complications vary depending on the precipitating
factor.
2. Signs and symptoms of hemolytic transfusion reaction include:
o Fever
o Chills
o low back pain
o flank pain
o headache
o nausea
o flushing
o tachycardia
o tachypnea
o hypotension
o hemoglobinuria (cola-colored urine)
3. Clinical signs and laboratory findings in delayed hemolytic reaction include:
o fever
o mild jaundice
o gradual fall of hemoglobin
o positive Coombs test
4. Febrile non-hemolytic reaction is marked by:
o Temperature rise during or shortly after transfusion
o Chills
o headache
o flushing
o anxiety
5. Signs and symptoms of septic reaction include;
o Rapid onset of high fever and chills
o vomiting
o diarrhea
o marked hypotension
6. Allergic reactions may produce:
o hives
o generalized pruritus
o wheezing or anaphylaxis (rarely)
7. Signs and symptoms of circulatory overload include:
o Dyspnea
o cough
o rales

o jugular vein distention

8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or
insidiously, depending on the disease.
9. Characteristics of GVH disease include:
o skin changes (e.g. erythema, ulcerations, scaling)
o edema
o hair loss
o hemolytic anemia
10. Reactions associated with massive transfusion produce varying manifestations

Nursing Diagnosis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Ineffective breathing pattern

Decreased Cardiac Output
Fluid Volume Deficit
Fluid Volume Excess
Impaired Gas Exchange
Hyperthermia
Hypothermia
High Risk for Infection
High Risk for Injury
Pain
Impaired Skin Integrity
Altered Tissue Perfusion

Planning and Implementation

Help prevent transfusion reaction by:

Meticulously verifying patient identification beginning with type and crossmatch sample
collection and labeling to double check blood product and patient identification prior to
transfusion.

Inspecting the blood product for any gas bubbles, clothing, or abnormal color before
administration.

Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly
during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start
of transfusion).

Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the
risk of bacterial growth at warm room temperatures.

Preventing infectious disease transmission through careful donor screening or performing

pretest available to identify selected infectious agents.

Preventing GVH disease by ensuring irradiation of blood products containing viable WBCs
(i.e., whole blood, platelets, packed RBCs and granulocytes) before transfusion; irradiation
alters ability of donor lymphocytes to engraft and divide.

Preventing hypothermia by warming blood unit to 37 C before transfusion.

Removing leukocytes and platelets aggregates from donor blood by installing a

microaggregate filter (20-40-um size) in the blood line to remove these aggregates during
transfusion.

On detecting any signs or symptoms of reaction:

Stop the transfusion immediately, and notify the physician.

Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access
for possible IV drug infusion.

Send the blood bag and tubing to the blood bank for repeat typing and culture.

Draw another blood sample for plasma hemoglobin, culture, and retyping.

Collect a urine sample as soon as possible for hemoglobin determination.

Intervene as appropriate to address symptoms of the specific reaction:

Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure
associated with RBC hemolysis and hemoglobinuria.

Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics;

leukocyte-poor blood products may be recommended for subsequent transfusions.

In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and
vasopressors as prescribed.

Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as

indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can
sometimes continue but at a slower rate.)

For circulatory overload, immediate treatment includes positioning the patient upright with
feet dependent; diuretics, oxygen and aminophylline may be prescribed.

Nursing Interventions
1. If blood transfusion reaction occurs: STOP THE TRANSFUSION.
2. Start IV line (0.9% NaCl)
3. Place the client in Fowlers position if with Shortness of Breath and administer O2 therapy.

4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs
as often as every 5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids,
and steroids as per physicians order or protocol.
7. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a
result of RBC hemolysis.
8. Blood container, tubing, attached label, and transfusion record are saved and returned to the
laboratory for analysis.

Evaluation
1. The patient maintains normal breathing pattern.
2. The patient demonstrates adequate cardiac output.
3. The patient reports minimal or no discomfort.
4. The patient maintains good fluid balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin integrity, with no lesions or pruritus.
8. The patient maintains or returns to normal electrolyte and blood chemistry values.