Blood Transfusions & Blood Products

Blood and Blood Product Transfusions

• Transfusions with whole blood or its components may be needed to replace blood lost due to injury or disease.
• Blood components for transfusion include packed RBCs, washed RBCs (WBC-poor RBCs), white blood cells (WBCs), fresh frozen plasma, albumin, clotting factors, cryoprecipitate and platelets.

Transfusion Types

• Standard donation transfusions use compatible donor blood.
• Autologous transfusions use the client's own blood, collected in anticipation of future transfusions, and is only used by them.
• Clients can donate blood up to 6 weeks before surgery, and weekly if hemoglobin and hematocrit levels remain stable.
• Intraoperative blood salvage involves saving and reinfusing sterile blood lost during surgery.
• Reinfusion of salvaged blood must occur within 6 hours of collection.

Potential Diagnoses Requiring Transfusions

• Excessive blood loss might need packed RBCs.
• Anemia (Hgb less than 6, or 6-10 g/dL depending on findings) might need packed RBCs.
• Kidney failure might need packed RBCs.
• Fresh frozen plasma is used for coagulation factor deficiencies like hemophilia.
• Platelets are for thrombocytopenia/platelet dysfunction.
• Cryoprecipitate is for Hemophilia A.
• Albumin is for burns and hypoproteinemia.

Platelet Transfusion

• Platelets do not require blood type matching.
• Platelet infusion bags contain 200 to 300 mL.

Platelet Transfusion Nursing Actions

• Platelets are fragile and must be infused immediately after being brought to the client's room.
• Infusion time for platelets is 15 to 30 minutes, using a special transfusion set with a small filter and short tubing.
• Vital signs should be taken before, 15 minutes after the start, and upon completion of the infusion.

Plasma Transfusion

• Plasma is frozen immediately after donation to create fresh frozen plasma (FFP).
• FFP should be transfused immediately after thawing, while clotting factors are still active.
• ABO compatibility is required for FFP transfusions to avoid reactions.
• Infuse 200 mL of FFP rapidly over 15-30 minutes through regular Y-set or straight filtered tubing.

White Blood Cell Transfusion (Granulocyte)

• Immunocompromised clients are at high risk for severe reactions, and rarely receive WBC transfusions.
• If the client is also receiving amphotericin B, there should be a 4-6 hour gap between its administration and the WBC transfusion, because amphotericin B can hemolyze WBCs.
• Infuse WBCs suspended in 400 mL of plasma over 45-60 minutes and take vital signs every 15 minutes; a provider's presence may be required.

Washed RBCs (WBC-poor packed RBCs)

• Infuse 200 mL of washed RBCs over 2-4 hours.
• Washed RBCs should be administered to clients with a history of transfusion reactions or hematopoietic stem cell transplants.

Preprocedure Considerations

• Incompatibility carries major concerns, making adherence to blood transfusion protocols critical.
• Type and cross matches are required for packed red blood cells, and these blood products are also typed and cross-matched for antigens.
• Plasma products are typed for ABO compatibility, but not cross-matched for antigens; WBCs and platelets in plasma can carry ABO antigens.
• Blood typing is based on the presence of antigens.

Blood Type Compatibility

• Rh-negative clients lack the Rh antigen, not developing antibodies unless sensitization occurs, so Rh-positive blood can cause a reaction post-sensitization.

Nursing Actions (General)

• Explain the procedure.
• Assess vital signs and temperature before the transfusion.
• Remain with the client for the initial 15-30 minutes due to the high risk of severe reactions during this time.
• Review lab values pre-transfusion and compare to post-transfusion.
• Verify the prescription for a specific blood product.
• Obtain consent if needed.
• Get blood samples for compatibility via type and cross-match.
• Check for a history of blood-transfusion reactions.
• Establish large-bore IV access using an 18- or 20-gauge needle.
• Obtain blood products from the blood bank, checking for discoloration, bubbles, or cloudiness.
• Two RNs (or an RN and a PN, depending on the facility) must verify the correct blood product and client by matching hospital identification numbers.
• The nurse completing verification must be one of the nurses administering the blood product.
• Prime the blood administration set with 0.9% sodium chloride only; never add medications.
• Use Y-tubing with a filter to transfuse blood.
• Start the transfusion and use a blood warmer if needed; initiate within 30 minutes of obtaining the product to reduce bacterial growth risks.

Older Adult Clients

• Use no larger than a 19-gauge needle.
• Assess kidney function, fluid status, and circulation before the transfusion, as older adults are at higher risk of fluid overload.
• Use blood products less than 1 week old.
• Explain the reason for the transfusion.

Intraprocedure Nursing Actions

• Stay with the client for the first 15-30 minutes, since most reactions occur during this period.
• Monitor vital signs and infusion rate per facility policy.
• For older adults, assess vital signs every 15 minutes and watch for changes indicating fluid overload or transfusion reaction; administer the transfusion over 2-4 hours and withhold other IV fluids unless necessary.
• Notify the provider immediately if reaction indicators arise.

Postprocedure Nursing Actions

• Obtain vital signs after completion.
• Dispose of the blood-administration set according to facility policy.
• Complete paperwork, and file in the appropriate places.
• Document the client’s response.

Acute Hemolytic Transfusion Reaction

• Onset is immediate or can manifest in subsequent transfusions, and involves incompatible blood products.
• As little as 10 ml of a blood product can cause a reaction.
• The signs and symptoms range from mild to life-threatening.
• The response can result in disseminated intravascular coagulation (DIC) or circulatory collapse.
• Findings include fever, chills, low-back pain, tachycardia, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and a sense of doom.
• Stop the transfusion if this reaction occurs.
• Remove the blood tubing from the IV access, avoiding further infusion into the circulatory system.
• Start an infusion of 0.9% sodium chloride using new tubing.
• Monitor vital signs and fluid status.
• Send the blood bag and administration set to the laboratory for testing.

Febrile Transfusion Reaction

• Onset of a febrile transfusion reaction normally happens within 2 hours of starting the transfusion.
• It is caused by anti-WBC antibodies, common in clients with multiple transfusions.
• Findings include chills, an increase of 1° C (2° F) or greater from the pretransfusion temperature, hypotension, and tachycardia.
• For nursing actions, use a WBC filter, stop the transfusion and give antipyretics, and initiate an infusion of 0.9% sodium chloride using new tubing.

Allergic Transfusion Reaction

• Allergic transfusion reaction onset is during or up to 24 hours after transfusion; it is caused by sensitivity to a blood product component.
• Mild reactions include itching, urticaria and flushing.
• Anaphylaxis may include bronchospasm, laryngeal edema, hypotension, and shock.

Anaphylactic Reaction - Nursing Actions

• Stop the transfusion.
• Administer epinephrine, corticosteroids, vasopressors, oxygen, or CPR if indicated.
• Remove the blood tubing from the client’s IV access.
• Start an infusion of 0.9% sodium chloride using new tubing.

Mild Reaction - Nursing Actions

• Stop the transfusion.
• Infusion of 0.9% sodium chloride using new tubing
• Give an antihistamine, like diphenhydramine.
• Restart the transfusion slowly, if prescribed.

Bacterial Transfusion Reaction

• Onset is during or up to several hours after transfusion, and involves contaminated blood products.
• Wheezing, dyspnea, chest tightness, cyanosis, hypotension, and shock may occur.
• Stop the transfusion.
• Give antibiotics and IV 0.9% sodium chloride using new tubing.
• Send a blood culture specimen to the lab for analysis.

Circulatory Overload

• Circulatory overload can happen anytime during the transfusion and results from a transfusion rate that is too rapid for the client, especially in older adults or those with increased circulatory volume.
• Findings include crackles, dyspnea, cough, anxiety, jugular vein distention, and tachycardia, and can progress to pulmonary edema.
• Slow or stop the transfusion depending on severity.
• Position the client upright with feet lower than the level of the heart.
• Give oxygen, diuretics, and morphine as prescribed.