BLOOD TRANSFUSION THERAPY

PRINCIPLES OF TRANSFUSION THERAPY

Because of the potentially life-threatening consequences of blood type ABO incompatibility and disease
transmission through blood products, transfusion therapy is limited to occasions when it is absolutely
necessary and stringent screening techniques are used before transfusion begins.

Blood product procurement, storage, preparation, and testing are regulated by the Food and Drug
Administration, the American Association of Blood Banks, and the Joint Commission on Accreditation of
Healthcare Organizations.

Blood Compatibility

Antigens

 The surface membrane of the red blood cell (RBC) is characterized by glycoproteins known as
antigens.

 More than 400 different antigens have been identified on the RBC membrane.

 There are fewer than a dozen clinically significant antigens, and of these, only two antigenic
systems (ABO and Rh) require routine prospective matching before the transfusion.

 The ABO blood group system is clinically the most significant because A and B antigens elicit the
strongest immune response.

 The presence or absence of A and B antigens on the RBC membrane determines the person's
ABO group. The ability to make A or B antigens is inherited.

 Antibody formation without specific exposure to antigen is unique to the ABO system. Antibody
directed against the missing antigens is produced by age 3 months in neonates.

Blood Group Antigens and Antibodies of ABO System

BLOOD ANTIBODY ON ANTIBODY IN APPROXIMATE FREQUENCY OF OCCURRENCE IN
GROUP RBC PLASMA POPULATION
A A anti-B 45%
B B anti-A 8%
AB A and B None 3%
O None anti-A and anti-B 44%

Antibodies

 Antibodies (or immunoglobulins) are proteins produced by B lymphocytes; they consist of two
light and two heavy chains that form a Y shape.

 Antibodies generally have a high degree of specificity, and interact only with the antigen that
stimulated their production.

 The five classes of immunoglobulins are determined by differences in their heavy chains:
immunoglobulin (Ig) G, IgA, IgM, IgD, IgE.

 The interaction of antibodies and antigens triggers an immune response, the humoral immune
response.
  Antibodies against the A and B antigens are large IgM molecules. When they interact with and
coat the A and B antigens on the RBC surface, the antibody/RBC complexes clump together
(agglutinate).

 Antibody/RBC complexes also activate the complement cascade, resulting in the release of
numerous active substances and RBC lysis. The large antibody/RBC complexes also become
trapped in capillaries, where they may cause thrombotic P.963 complications to vital organs,
and in the reticuloendothelial system, where they are removed from circulation by the spleen.

 The extent of the humoral response elicited by anti-A and anti-B interaction with A and B
antigens depends on the quantity of antibody and antigen.

Blood Transfusion Options

1. Autologous Transfusion

 Before elective procedures, the patient may donate blood to be set aside for later transfusion.
Patients may donate one unit every 3 to 4 days up to 3 days prior to surgery provided
hemoglobin greater than 11 g/dL.

 Autologous RBCs can also be salvaged during some surgical procedures or after trauma-induced
hemorrhage by use of automated cell-saver devices or by manual suction equipment.

 Autologous blood products must be clearly labeled and identified.

 Autologous transfusion eliminates the risks of alloimmunization, immune-mediated transfusion

reactions, and transmission of disease, making it the safest transfusion choice.

NURSING ALERT

Patients who do not meet standard criteria for blood donation may still be eligible to donate autologous
blood before elective surgeries. The nurse should encourage suitable candidates to consider this
underused option.

2. Homologous Transfusion

 With this most common option, volunteer donors' blood products are assigned to patients
randomly.

 Before donation, volunteer donors receive information about the process, potential adverse
effects, tests that will be performed on donated blood, postdonation instructions, and education
regarding risk for human immunodeficiency virus (HIV) infection and signs and symptoms.

 Donors are screened against eligibility criteria designed to protect donor and recipient

General Blood Donor Eligibility Criteria:

Age 17 years
Weight Minimum 110 lb (49.9 kg)
Vital signs Afebrile, normotensive, pulse 50-100, blood pressure < 180/100 mm Hg
Hemoglobin 12.5 g/dL
History Travel, exposures, and past illnesses or events may defer or disallow
blood donation. Examples: travel to malarial areas, living in areas
exposed to bovine spongiform encephalopathy, blood transfusion or
tattoo within 12 months, recent surgery or pregnancy, corneal
 transplant, history of hepatitis or unexplained jaundice, history or most
cancers, history of behaviors at high risk for human immunodeficiency
virus.
Immunizations Recent attenuated and live vaccines generally result in deferral.
Illnesses A variety of current illnesses may defer or disallow blood donation.
Examples: clotting disorders, sickle cell disease, systemic lupus
erythematosus, multiple sclerosis, Lyme disease.

Directed Transfusion

 In directed transfusion, blood products are donated by a person

for transfusion to a specified recipient.

 This option may be used in certain circumstances (eg, a parent

who provides sole transfusion support for a child), but in
general, no evidence exists that directed donation reduces
transfusion risks.

Screening for Infectious Diseases

 Routine laboratory testing is performed to identify antigens or

antibodies in donor blood that may indicate prior exposure to
specific blood-borne diseases.

 Such testing supplements other principles of donation designed

to decrease the risk of disease transmission via blood products,
including the use of volunteer donors, the exclusion of high-risk
populations, and the screening of donors via health and social
history.

 Through the use of donor screening and blood testing the risk of
infections transmitted with donated blood is < 1%.

 Specific conditions screened for include:

o Hepatitis: tests for the presence of hepatitis B core and

surface antibodies and hepatitis C viral titer.

o HIV-1 and HIV-2: tests for prior exposure to the virus.

 All blood products in the United States have

been screened since the test first became
available in 1985. Current tests include testing
for antibodies with enzyme-linked
immunosorbent assay or enzyme immunoassay,
or antigen with the P24 test. Nucleic acid testing
is becoming more widely used and provides a
mechanism to look for the presence of HIV-1
and HIV-2 before antibody formation

 Because antibody to the virus is not

produced until at least 6 weeks after
exposure, donor screening and exclusion of
high-risk groups (eg, homosexual men, I.V.
drug abusers, prostitutes, and sexual
 partners of high-risk people) remain
important parts of preventing transmission
of HIV via blood products.
 A low risk of HIV transmission (estimated to
be 1/100,000 units of blood) remains.
o Cytomegalovirus (CMV): tests for the antibody
against CMV.
 Approximately 50% to 75% of blood donors
have been exposed to CMV and 10% to 20%
carry CMV virus in white blood cells (WBCs).
 Patients with impaired immune function
(eg, bone marrow and organ transplant
recipients, premature babies) are at risk for
CMV infection from transfused blood.
o Syphilis: tests for the presence of antibody against
the spirochete.
o Bacteria: contamination of blood products with
bacteria may occur during and after collection of
blood. This risk is managed by maintenance of
sterile technique during phlebotomy and blood
processing procedures, correct storage techniques,
visual inspection of blood products, and limitation
on shelf life.
o Other infections that may be transmitted via blood
transfusions include human T-cell lymphoma virus
(HTLV) 1 and 2, malaria, babesiosis, Chagas'
disease, and yersinia.
o Although the risk appears remote, variant
Creutzfeldt-Jacob disease can be transmitted via
blood transfusions, which has led to restrictions on
donation by individuals who have lived in areas
with bovine spongiform encephalopathy or mad
cow disease.

ADMINISTRATION OF WHOLE BLOOD AND BLOOD COMPONENTS:

Whole blood and blood components are administered to increase the amount of oxygen being delivered
to the tissues and organs, to prevent or stop bleeding because of platelet defects or because of
deficiencies or coagulation abnormalities, and to combat infection caused by decreased or defective
WBCs or antibodies. (See Procedure Guidelines 27-1, page 966, and Standards of Care Guidelines)

General Considerations:

 A unit of whole blood is usually separated into its various component parts shortly after
collection.

 Less than 3% of the blood collected nationwide is transfused as whole blood.

o The use of blood components conserves the limited supply of blood, provides optimal
therapeutic benefit, and reduces the risk of circulatory overload.

o Due to the risks, blood components should be administered only with informed consent
and meticulous identification procedures.
1. Whole Blood

Description

Consists of RBCs, plasma, plasma proteins, and approximately 60 mL anticoagulant/preservative solution

in a total volume of approximately 500 mL.

Indications include acute, massive blood loss of greater than 1,000 mL, requiring the oxygen-carrying
properties of RBCs and the volume expansion provided by plasma. In general, even acute loss of as much
as one-third of a patient's total blood volume (1,000 to 1,200 mL) can be safely and rapidly replaced
with crystalline or colloidal solutions.

Nursing and Patient Care Considerations

 For rapid infusions of large volumes of whole blood, additional steps may be taken to deliver
product rapidly and safely.

o A small-pore (20 to 40 µm) filter may be used to remove microaggregates (platelets,

WBCs) that have been identified in the lungs of massively transfused patients.

o An approved blood warmer may be indicated to prevent hypothermia and cardiac

arrhythmias associated with the rapid infusion of refrigerated solutions.

o Electromechanical infusion devices to deliver blood at high flow rates can hemolyze
RBCs and should be used with caution.

 Observe closely for the most common acute complication associated with whole blood
transfusion circulatory overload (rise in venous pressure, distended neck veins, dyspnea, cough,
crackles at bases of lungs).

STANDARDS OF CARE GUIDELINES

BLOOD TRANSFUSION

When administering whole blood or blood components, ensure the following:

 Follow up on results of complete blood count and report to health care provider so appropriate
blood product can be ordered based on patient's condition.

 Contact the blood bank with health care provider's order and ensure timely delivery of blood
product.

 Establish a patent I.V. line with compatible I.V. fluid.

 Use appropriate administration setup, filter, warmer, etc.

 Obtain baseline vital signs.

 Make sure proper blood product is given to the right patient.

 Transfuse at prescribed rate during prescribed time, as tolerated by patient.

 Observe for acute reactions–allergic, febrile, septic, hemolytic, air embolism, and circulatory
overload–by assessing vital signs, breath sounds, edema, flushing, urticaria, vomiting,
headache, back pain.

 Notify patient's health care provider or available house officer if signs of reaction or other
abnormality arise.
  Be aware of delayed reactions and educate patient on risk and what to look for: hemolytic, iron
overload, graft-versus-host disease, hepatitis, and other infectious diseases.

Footnote

This information should serve as a general guideline only. Each patient situation presents a unique set of
clinical factors and requires nursing judgment to guide care, which may include additional or alternative
measures and approaches.

2. Packed RBCs

Description

 Consist primarily of RBCs, a small amount of plasma, and approximately 100 mL

anticoagulant/preservative solution in a total volume of approximately 250 to 300 mL/unit.

 Packed RBCs are typically contaminated with WBCs that may increase the risk of minor
transfusion reactions and alloimmunization. For patients who receive multiple blood products
during a specific period (eg, patients with leukemia or aplastic anemia), packed RBCs may be
further manipulated to remove WBCs by washing or freezing the product in the blood bank or
by the use of small-pore (20 to 40 µm) leukoreduction filters during administration.

 Indications include restoration or maintenance of adequate organ oxygenation with minimal

expansion of blood volume.

 Dosage: average adult dose administered is 2 units; pediatric doses are generally calculated as 5
to 15 mL/kg.

ADMINISTERING BLOOD AND BLOOD COMPONENTS

EQUIPMENT

 Tourniquet

 Iodine-containing skin antiseptic

 Needle or venous catheter

 Y-type blood infusion set

 170-µ filter

 Normal saline

 Blood product as described

PROCEDURE

Nursing Action Rationale

I. Preparatory phase
1.Inform the patient of the 1.Instruct the patient to report unusual symptoms immediately.
procedure, blood product to be
given, approximate length of time,
 and desired outcome.
2.Obtain and record baseline vital 2.If the patient's clinical status permits, delay transfusion if
signs. baseline temperature is greater than 101.7° F (38.7°C).
3.Prepare infusion site. Select a large 3.Antecubital veins are not recommended for lengthy infusions.
vein that allows patient some Prolonged restriction of arm movement is uncomfortable and
degree of mobility. Start the inconvenient for the patient. In the event of an acute reaction,
prescribed I.V. infusion. the I.V. catheter should be maintained with normal saline.

DRUG ALERT: Crystalloid solutions other than 0.9% saline and all medications are incompatible with
blood products. They may cause agglutination or hemolysis

4.Obtain blood product from blood bank. 4.Platelets are normally cloudy. If the transfusion cannot
Inspect for abnormal color, cloudiness, begin immediately, return product to blood bank. Blood
clots, and excess air. Read instructions on out of proper storage (above 50° F [10° C]) for more
the product label regarding storage and than 30 minutes cannot be reissued. Never store blood in
infusion. Check expiration date. unauthorized refrigerators, such as those on the nursing
unit.

5.Verify patient identification. 5.The majority of acute fatal transfusion reactions are caused
by clerical errors. Patient and product verification is the
  a.Ask the patient to state his or her full
single most important function of the nurse. It is strongly
name and compare with name on the
recommended that two qualified individuals perform this
wrist band. If the patient is unable to
task. Do not proceed with the transfusion if there is a
state his or her name, verify identity
discrepancy. Contact the blood bank immediately.
with an individual familiar with the
patient.
  b Compare the name and ID number on
. the wristband with the bag tag,
transfusion form, and medical order.
c.Confirm ABO and Rh compatibility by
comparing the bag label, bag tag, medical
record, and transfusion form.
  d. Check bag labels for expiration date
and satisfactory serologic testing.

II. Performance phase

1.Start infusion slowly (ie, 2 mL/minute). 1.Institutional policy may vary regarding flow rates and
Remain at bedside 15-30 minutes. If there are patient monitoring. Signs of a severe transfusion
no signs of adverse effect, increase flow to reaction (ie, acute hemolytic, anaphylactic) are usually
the prescribed rate. manifested during infusion of the initial 50-100 mL.
2.Observe the patient closely and check vital 2.Acute reactions may occur at any time during the
signs at least hourly until 1 hour after transfusion
transfusion. Report signs of adverse effect to
health care provider immediately.
3.Record the following information on the 3.Facts relating to the transfusion should be charted
patient's chart: exactly.
  a. Time and names of persons starting and      
 ending the transfusion.
  b. Names of individuals verifying patient ID.      
  c. Unique product identification number.   c. It must be possible to trace each transfusion
product to the original blood donor.
  d. Product and volume infused.      
  e. Immediate response“for example, no      
apparent reaction.
Nursing and Patient Care Considerations

 Infuse at the prescribed rate. Generally, a unit can be given to an adult in 90 to 120 minutes.
Pediatric patients are usually transfused at a rate of 2 to 5 mL/kg per hour.

 To reduce the risk of bacterial contamination and sepsis, RBCs must be transfused within 4
hours of leaving the blood bank.

 Observe closely (particularly during first 15 to 30 minutes) for the most common acute
complications associated with packed RBCs, allergic and febrile transfusion reactions. Signs and
symptoms of the more serious, but rare, hemolytic transfusion reaction are usually manifested
during infusion of the first 50 mL.

3. Platelet Concentrates

Description

 Consist of platelets suspended in plasma. Products vary according to the number of units (each
unit is a minimum of 5.5—1010 platelets) and the volume of plasma (50 to 400 mL).

 Platelets may be obtained by centrifuging multiple units of whole blood and expressing off the
platelet-rich plasma (multiple-donor platelets) or from a single volunteer platelet donor using
automated cell separation techniques (apheresis). The use of single donor products decreases
the number of donor exposures, thus decreasing the risk of alloimmunization and transfusion-
transmitted disease.

 Patients may become alloimmunized to human leukocyte antigens (HLAs) through exposure to
multiple platelet products. Apheresis products from HLA-matched platelet donors may be
necessary. However, HLA-matched transfusions are commonly difficult to obtain because of the
many possible HLA combinations in the population.

 Indications include prevention or resolution of hemorrhage in patients with thrombocytopenia

or platelet dysfunction.

 Platelet transfusions are generally contraindicated in heparin-induced thrombocytopenia, where

they may precipitate arterial thrombosis, and in thrombotic thrombocytopenic purpura where
they may worsen this autoimmune destruction of platelets.

 Dosage: average dose is generally 1 unit of platelets for each 10 kg of body weight; however,
patients who are actively bleeding or undergoing surgical procedures may require more.

Nursing and Patient Care Considerations

 Infuse at the rate prescribed. Generally, the infusion can be completed within 20 to 60 minutes,
depending on total volume.

 Observe closely for the most common acute complications associated with platelet transfusions,
allergic and febrile transfusion reactions.
  Bacterial contamination of platelets, usually skin commensals from the donor's arm, occurs in 4
to 10 per 10,000 units and limits the shelf life of platelet products.

4. Plasma (Fresh or Fresh-Frozen)

Description

 Consists of water (91%), plasma proteins including essential clotting factors (7%), and
carbohydrates (2%). Each unit is the volume removed from a unit of whole blood (200 to 250
mL).

 May be stored in a liquid state or frozen within 6 hours of collection.

 Indications include treatment of blood loss or blood clotting disorders related to liver disease
and failure, disseminated intravascular coagulation (DIC), over-anticoagulation with warfarin
(Coumadin), all congenital or acquired clotting factor deficiencies, and dilutional coagulopathy
resulting from massive blood replacement. Storage in liquid state results in the loss of labile
clotting factors V and VIII, so that only plasma that has been fresh frozen can be used to treat
factor V and VIII deficiencies.

 Dosage: depends on the clinical situation and assessment of prothrombin time, partial
thromboplastin time, or specific factor assays.

Nursing and Patient Care Considerations

 Infuse at the rate prescribed. Generally, the infusion can be completed within 15 to 30 minutes,
depending on total volume.

 Observe closely for the most common acute complication associated with plasma infusion,
volume overload.

5. Cryoprecipitate

Description

 Consists of certain clotting factors suspended in 10 to 20 mL plasma. Each unit contains

approximately 80 to 120 units of factor VIII (antihemophilic and von Willebrand factors), 250 mg
fibrinogen, and 20% to 30% of the factor XIII present in a unit of whole blood.

 Indications include correction of deficiencies of factor VIII (ie, hemophilia A and von Willebrand's
disease), factor XIII, and fibrinogen (ie, DIC).

 Dosage: adult dosage is generally 10 units, which may be repeated every 8 to 12 hours until the
deficiency is corrected or until hemostasis is achieved.

Nursing and Patient Care Considerations

Infuse at the rate prescribed. Generally, the infusion can be completed within 3 to 15 minutes.

6. Fractionated Plasma Products

Description

 Various highly concentrated plasma protein products are commercially prepared by pooling
thousands of single plasma units and by extracting the desired protein. Most techniques involve
heat or chemical treatments, which eliminate the risk of transmitting blood-borne viruses, such
as hepatitis B and HIV.
  Colloid solutions provide volume expansion in situations where crystalloid solutions are not
adequate, such as therapeutic plasma exchange, shock, and massive hemorrhage. They may also
be used in the treatment of acute liver failure, burns, and hemolytic disease of the newborn.

o Albumin is available as a 5% solution, which is oncotically equivalent to plasma, and as a

concentrated 25% solution.

o Plasma protein fraction (PPF) is available as a 5% solution. Rapid infusion of PPF has
been associated with hypotension.

o Albumin and PPF are pasteurized and carry no risk of viral disease. They do not contain
preservatives and should be used immediately after opening.

 Immune serum globulins (ISGs) are concentrated aqueous solutions of gamma globulin that
contain high titers of antibody.

o Must be administered by deep I.M. injection.

 I.V. immunoglobulins (IVIGs) are aqueous solutions of immunoglobulins at a higher

concentration and are given in larger volumes than ISGs.

o Like ISGs, they may be nonspecific or specific.

o Indications include chronic replacement therapy in patients with congenital or acquired

immunodeficiency syndromes, acute autoimmune disorders such as immune
thrombocytopenic purpura, and the treatment of chronic lymphocytic leukemia. Also,
there are numerous investigational uses, such as Guillain-Barré syndrome, myasthenia
gravis, rheumatoid arthritis, and viral infections, such as CMV, adenovirus, and
influenza. IVIGs may also be used to treat platelet alloimmunization.

o IVIGs do not appear to transmit HIV, but have been reported to transmit hepatitis C.

o Administration of IVIG should be closely monitored because of the possibility of

anaphylactic reactions. Dosage and rate of infusion depend on the manufacturer's
formulation.

 Factor VIII concentrate is a lyophilized concentrate used to treat moderate to severe hemophilia
A and severe von Willebrand's disease.

 Factor IX concentrate is a lyophilized concentrate used to treat factor IX deficiency (Christmas

disease).

Nursing and Patient Care Considerations

These products may be distributed by the pharmacy rather than by the blood bank.

Check order and product insert to ensure proper dosage and administration route.

7. Granulocyte Concentrates

Description

 Consist of a minimum of 1 —; 10 10 granulocytes, variable amounts of lymphocytes (usually less

than 10% of the total number of WBCs), 6 to 10 units of platelets, 30 to 50 mL RBCs, and 200 to
400 mL plasma.

 Obtained via apheresis, generally of multiple donors.

 Indications include treatment of life-threatening bacterial or fungal infection unresponsive to

other therapy in a patient with severe neutropenia.
  Dosage: generally 1 unit daily for approximately 5 to 10 days, discontinuing if no therapeutic
response.

Nursing and Patient Care Considerations

 Product must be ABO compatible and, if possible, Rh compatible because of the high
erythrocyte content.
 Transfuse granulocytes as soon as they are available. WBCs have a short survival time,
and therapeutic benefit is directly related to dose and viability.
 Premedicate per order to prevent adverse effects, generally with antihistamine and
acetaminophen. Steroids may also be required.
 Begin the transfusion slowly and increase to the rate prescribed and as tolerated. The
recommended length of infusion is 1 to 2 hours.
 Observe the patient closely throughout the transfusion for signs and symptoms of
febrile, allergic, and anaphylactic reactions, which may be severe. Have emergency
medications and equipment readily available.
 Agitate the bag approximately every 15 minutes to prevent granulocytes from clumping
at the bottom of the bag.
 Do not administer amphotericin products immediately before or after granulocyte
transfusion because pulmonary insufficiency has been reported with concurrent
administration of amphotericin and granulocytes. Many institutions recommend a 4-
hour gap to avoid this risk.

Modified Blood Products

Purpose

 To reduce the risk of specific transfusion-related complications, blood products may

receive further processing or treatment.
o Leukocytes are removed from blood products through filtration, washing, and
freezing to reduce the risk of febrile, nonhemolytic transfusion reactions, and
alloimmunization to HLA.
o Function and proliferation of donor lymphocytes are inhibited by irradiation, to
decrease the risk of posttransfusion graft-versus-host disease (GVHD) in
immunocompromised patients.

Methods

 Filtration
o Standard filters (170 µm) effectively remove gross fibrin clots.
o Microaggregate filters (approximately 40 µm) remove microscopic aggregates
of fibrin, platelets, and leukocytes that accumulate in RBC products during
storage. Their use is recommended during rapid, massive transfusion of whole
blood or packed RBCs to prevent pulmonary complications. They reduce the risk
of CMV transmission and may also decrease the incidence of febrile transfusion
reactions by removing many of the leukocytes present.
o Special leukocyte-depletion filters have been developed for use with platelet
products that remove 80% to 95% of leukocytes and that retain 80% of the
platelets. These filters also reduce the risk of CMV transmission.
 o A product may be filtered before release from the blood bank, but more
commonly is released with the appropriate filter that must be attached to the
standard infusion set at the bedside per manufacturer's or blood bank's
instructions.

 Washing
o Washing RBCs or platelets with a normal saline solution removes 80% to 95% of
the WBCs and virtually all of the plasma to reduce the incidence of febrile,
nonhemolytic transfusion reactions.
o Washing requires an additional hour of processing time, and the shelf life of the
product is reduced to 24 hours after this additional manipulation.

 Freezing
o RBCs can be frozen within 7 days of blood collection, and then remain viable for
7 to 10 years.
o Removal of the hypertonic freezing preservative (glycerol) before transfusion
eliminates all of the plasma and 99% of WBCs.
o Thawing and deglycerolization of RBCs requires an additional 90 minutes of
preparation time and reduces shelf life to 24 hours after this additional
manipulation.
o Freezing is also an effective method of storing rare blood types and autologous
RBCs.
 Irradiation
o Exposure of blood products to a measured amount of gamma irradiation inhibits
lymphocyte function and proliferation without damaging RBCs, platelets, or
granulocytes. This eliminates the ability of transfused lymphocytes to engraft in
the immunocompromised transfusion recipient and the accompanying risk of
posttransfusion GVHD.
o Patients at risk for posttransfusion GVHD include bone marrow and peripheral
stem cell transplant recipients, premature neonates, and patients with
congenital immunodeficiency disorders, Hodgkin's and non-Hodgkin's
lymphomas, and HIV.

TRANSFUSION REACTIONS

Every transfusion of blood components can result in an adverse effect. Reactions can be placed
into two general categories: acute and delayed.

ACUTE REACTIONS:

 Acute reactions may occur during the infusion or within minutes to hours after the
blood product has been infused.
 Acute reactions include allergic, febrile, septic, and hemolytic reactions, air embolism,
and circulatory overload. Patients who also receive multiple blood products within a
short time frame may also be at risk for hyperkalemia, hypocalcemia, and hypothermia.
 Because reactions may exhibit similar clinical manifestations, every symptom should be
considered potentially serious and the transfusion should be discontinued until the
cause is determined.
  When a reaction is suspected, the health care provider should be notified immediately
and blood bags with tubing from all products recently transfused should be returned to
the blood bank for evaluation.
 The following samples should also be obtained if an acute reaction is suspected.
o A clotted blood sample to examine serum for hemoglobin and confirm RBC
group and type.
o An anticoagulated blood sample for a direct Coombs' test to determine the
presence of antibody on the RBCs.
o The first voided urine sample to test for hemoglobinuria.
 Precautions must be taken to avoid the hemolysis of RBCs during venipuncture and
sample collection because this could lead to invalid test results. Whenever possible,
blood samples should be drawn from a fresh venipuncture and not from existing
needles or catheters.
 If the only symptoms are those resulting from a mild allergic reaction (eg, urticaria),
extensive evaluation may not be necessary. In the event of a severe reaction (eg,
hypotension, tachypnea), more tests may be required to determine the cause of the
reaction.

ACUTE REACTIONS to BLOOD TRANSFUSION

ACUTE CLINICAL
REACTION CAUSE MANIFESTATIONS MANAGEMENT PREVENTION
Allergic Sensitivity to plasma  Flushing  Stop transfusion  Before transfusion,
protein or donor  Itching, rash immediately. ask patient about
antibody, which reacts  Urticaria, Keep vein open past reactions. If
with recipient antigen. hives (KVO) with normal patient has history
 Asthmatic saline. Notify of anaphylaxis, alert
wheezing health care health care
 Laryngeal provider and provider, have
edema blood bank. emergency drugs
 Anaphylaxis  Give available, and
antihistamine as remain at bedside
directed for the first 30
(diphenhydramine minutes.
).
 Observe for
anaphylaxis–pre
pare epinephrine
if respiratory
distress is severe.
 If hives are the
only clinical
manifestation, the
transfusion can
sometimes
continue at a
slower rate.
 Send blood
samples and
blood bags to
blood bank.
Collect urine
samples for
testing.

Febrile, Hypersensitivity to  Sudden chills  Stop transfusion  Give antipyretic

nonhemoly donor white blood and fever immediately and (acet-aminophen or
tic cells, platelets, or  Headache KVO with normal aspirin) before
plasma proteins.  Flushing saline. Notify transfusion as
 Anxiety health care directed.
provider and  Leukocyte-poor
blood bank. blood products may
 Send blood be recommended
samples and for future
blood bags to transfusions.
blood bank.
Collect urine
samples for
testing.
 Check
temperature ½
hour after chill
and as indicated
thereafter.
 Give antipyretics
as
prescribed–trea
t symptomatically.

Septic Transfusion of blood or  Rapid onset  Stop transfusion  Do not permit blood
reactions components of chills immediately and to stand at room
contaminated with  High fever KVO with normal temperature longer
bacteria.  Vomiting, saline. Notify than necessary.
diarrhea health care Warm temperatures
 Marked provider and promote bacterial
hypotension blood bank. growth.
 Obtain cultures of  Inspect blood for
patient's blood gas bubbles,
and return blood clotting, or
bags with abnormal color
administration set before transfusion
to blood bank for  Complete infusions
culture. within 4 hours.
 Treat septicemia Change
as administration set
directed–antibi after 4 hours of use.
otics, I.V. fluids,
vasopressors,
steroids.

Circulatory Fluid administered at a  Rise in  Stop transfusion  Concentrated blood

overload rate or volume greater venous and KVO with products should be
than the circulatory pressure normal saline. given whenever
system can  Distended Notify health care positive.
accommodate. neck veins provider.  Transfuse at a rate
Increased blood in  Dyspnea  Place patient within the
pulmonary vessels and  Cough upright with feet circulatory reserve
decreased lung  Crackles at in dependent of the patient.
compliance. base of lungs position.  Monitor central
 Administer venous pressure of
prescribed patient with heart
diuretics, oxygen, disease.
morphine, and
aminophylline.

Hemolytic Infusion of  Chills; fever  Stop transfusion  Meticulously verify

reaction incompatible blood  Lower back immediately–K patient
products: pain VO with 0.9% identification–fro
 Feeling of saline. m sample collection
 Antibodies in head  Notify health care to product infusion.
 fullness; provider and  Begin infusion
recipient's flushing blood bank. slowly and observe
plasma attach  Oppressive  Treat shock, if closely for 30
to transfused feeling present minutes–consequ
red blood cells  Tachycardia,  Draw testing ences are in
(RBCs), tachypnea samples, collect proportion to the
hemolyzing  Hypotension urine sample. amount of
the cells either , vascular  Maintain blood incompatible blood
in circulation collapse pressure with I.V. transfused.
or in the  Hemoglobin colloid solutions.
reticuloendoth uria, Give diuretics as
elial system. hemoglobine prescribed to
 Antibodies in mia maintain urine
donor plasma  Bleeding flow, glomerular
attach to  Acute renal filtration, and
recipient RBCs, failure renal blood flow.
causing  Insert indwelling
hemolysis catheter to
(may result monitor hourly
from infusion urine output.
of Patient may
incompatible require dialysis if
plasma–less renal failure
severe than occurs.
incompatible
RBCs).

DELAYED REACTIONS:

 Delayed reactions occur days to years after the transfusion.

 Delayed reactions include delayed hemolytic reactions, iron overload (hemosiderosis),
GVHD, infectious diseases (eg, hepatitis B, hepatitis C, CMV, Epstein-Barr virus, malaria,
HIV, HTLV).
 Symptoms of a delayed reaction can vary from mild to severe. Diagnosis may be
complicated by the long incubation period between transfusion and reaction and the
complexity of diagnostic tests.

DELAYED REACTIONS To TRANSFUSION THERAPY

DELAYED CLINICAL
REACTION CAUSE MANIFESTATIONS MANAGEMENT PREVENTION
Delayed The destruction of  Fever  Generally, no acute  The
hemolytic transfused red  Mild jaundice treatment is crossmatch
reaction blood cells by  Decreased required, but blood
antibody not hematocrit hemolysis may be sample
detectable during severe enough to should be
crossmatch, but cause shock and drawn
formed rapidly renal failure. If this within 3
after transfusion. occurs, manage as days of
Rapid production outlined under blood
may occur because acute hemolytic transfusion.
of antigen reactions. Antibody
exposure during formation
previous may occur
transfusions or within 90
pregnancy. days of
transfusion
or
 pregnancy.

Iron overload Deposition of iron  Diabetes  Treat      â€“

(hemosiderosis) in the heart,  Decreased symptomatically.
endocrine organs, thyroid function  Deferoxamine
liver, spleen, skin,  Arrhythmias (Desferal), which
and other major  Heart failure and chelates and
organs as a result other symptoms removes
of multiple, long- related to major accumulated iron
term transfusions organ failure through the
(aplastic anemia, kidneys;
thalassemia). administered I.V.,
I.M., or S.C.

Graft-versus-host Engraftment of  Erythematous  Immunosuppressio  Transfuse

disease lymphocytes in the skin rash n with with
bone marrow of  Liver function test corticosteroids, irradiated
immunosuppresse abnormalities cyclosporine A. blood
d patients, setting  Profuse, watery  Symptomatic products.
up an immune diarrhea management of
response of the pruritus, pain
graft against the  Fluid and
host. electrolyte
replacement for
diarrhea

Infectious disease        

Hepatitis B Hepatitis B virus  Elevated liver  Usually resolves  Screen

transmitted from enzymes spontaneously blood
blood donor to (ALT/AST) within 4-6 weeks. donors,
recipient via  Anorexia, malaise Can result in temporarily
infected blood  Nausea and permanent liver rejecting
products. vomiting damage. Treat those who
 Fever symptomatically. may have
 Dark urine had contact
 Jaundice with the
virus. Those
with a
history of
hepatitis
after age 11
are
permanentl
y deferred;
pretest all
blood
products
(EIA).

Hepatitis C Hepatitis C virus  Similar to serum  Symptoms usually  Pretest all

(formerly non-A, transmitted from B hepatitis, but mild. Interferon blood
non-B hepatitis) blood donor to symptoms are and ribavirin may donors (ALT,
recipient via usually less be used to treat anti-HBc
infected blood severe. Chronic chronic liver antibody,
products. liver disease and disease. anti-
cirrhosis may hepatitis C
develop. antibody).

Epstein-Barr Transmitted  Fever  Rest and  Question

virus, through infected  Fatigue supportive prospective
cytomegalovirus, blood products.  Hepatomegaly management. blood
malaria  Splenomegaly donors
regarding
colds, flu,
foreign
travel.

Acquired Human  Night sweats  Combination  Test each

immunodeficienc immunodeficiency  Unexplained antiretroviral donor for
y syndrome virus (HIV) weight loss therapy. HIV
(AIDS) transmitted from  Lymphadenopath antibody.
blood donor to y  Reject
recipient via  Pneumocystis prospective
infected blood pneumonia high-risk
products.  Kaposi's sarcoma donors:
 Diarrhea males who
have had
sex with
another
male since
1977; users
of self-
injected I.V.
drugs; male
or female
partners of
prostitutes;
hemophiliac
s or their
sexual
partners;
sexual
partners of
those with
AIDS or high
risk for
AIDS;
immigrants
from Haiti or
sub-Saharan
Africa.

Human T- HTLV-1  Signs of  HTLV-1-infected  Screen all

lymphotropic transmitted from neuromuscular individuals have a prospective
virus type 1 blood donor to disease low risk of blood
(HTLV-1) recipient via blood  Signs of T-cell developing disease donors for
associated products. leukemia (3%–5%). anti-HTLV-1
myelopathy and Incubation period antibody.
tropical spastic 10-20 years.
paraparesis  Should disease
(HAM/TSP) Adult occur, treat
T-cell leukemia symptomatically.

Syphilis Spirochetemia  Presence of  Penicillin therapy  Test blood

caused by chancre before
Treponema  Regional transfusion
pallidum. lymphadenopath (rapid
Incubation 4-18 y plasma
weeks.  Generalized rash reagin).
Organism
will not
remain
viable in
blood stored
24-48 hours
 at 39.2° F
(4° C).

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PeriAnesthesia Nursing, 17(6), 399-403.

Djulbegovic, B., Seidenfeld, J., Bonnell, C., & Kumar, A. (2003). Nonmyeloablative allogeneic
stem-cell transplantation for hematologic malignancies: A systematic review. Cancer Control,
10(1), 17-41.

Larsen, J., et al. (2004). Symptom occurrence, symptom intensity, and symptom distress in
patients undergoing high-dose chemotherapy with stem-cell transplantation. Cancer Nursing,
27(1), 55-64.

Latchford, T., & Shelton, B.K. (2003). Respiratory syncytial virus in blood and marrow transplant
recipients. Clinical Journal of Oncology Nursing, 7(4), 418-422.

Lewis, I.D. (2002). Clinical and experimental uses of umbilical cord blood. Internal Medicine
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Shivnan, J.C. (2004). Bone marrow transplantation. In Shelton, B.K., et al. (Eds.) Manual of
cancer nursing. Philadelphia: Lippincott Williams & Wilkins.

Simmons, P. (2003). A primer for nurses who administer blood products. Medsurg Nursing,
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Wolf, S. (2000). Are you ready for bloodless medicine? RN, 63(5), 42-46.

Zitella, L. (2003). Central venous catheter site care for blood and marrow transplant recipients.
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