Blood Transfusions: RPNs in Canada

• Blood transfusions involve intravenously administering blood or blood components from a donor to a recipient.
• Registered practical nurses (RPNs) in Canada are critical to blood transfusions.
• RPNs enhance patient safety and contribute to well-being during transfusions.

RPN Role in Blood Transfusion

• RPNs in Canada play a vital role in blood transfusions under the order of a physician or nurse practitioner.
• They are involved in various stages, including pre-transfusion assessment, administration, monitoring, and documentation.
• Specific responsibilities are determined by provincial/territorial regulations, employer policies, and their own competence.

RPN Scope of Practice

• RPNs need to follow regulatory body standards for blood transfusions.
• RPNs work under a registered nurse (RN) or physician, based on provincial rules and facility policies.
• RPN duties include: confirming blood product and patient ID, monitoring patients during/after transfusion, detecting and handling transfusion reactions, recording all relevant data, and giving blood products through IV lines.

Transfusion Protocols

• Transfusion protocols are standardized guidelines that outline the steps involved in blood transfusions.
• They ensure patient safety, prevent errors, and promote best practices.
• Protocols cover areas like patient identification, blood product verification, administration techniques, and management of adverse reactions.

Blood Types and Compatibility

• The ABO blood group system classifies blood into four main types: A, B, AB, and O.
• The Rh factor is another important consideration, with individuals being either Rh-positive or Rh-negative.
• Compatibility between donor and recipient blood types is crucial to prevent transfusion reactions.
• Type O-negative is known as the universal donor, as it can be transfused to individuals with any ABO blood type.
• Type AB-positive is the universal recipient, as they can receive red blood cells from any ABO blood type.

Prerequisites and Education

• RPNs learn about blood transfusions in their nursing programs.
• Education includes blood groups and compatibility, blood product types (packed red blood cells, platelets, plasma), transfusion steps and rules, and possible issues and how to handle them.
• Ongoing education is needed to stay up-to-date on transfusion practices.
• RPNs should know the latest guidelines from groups like Canadian Blood Services.

Pre-Transfusion Assessment

• Review the physician's or nurse practitioner's order for the blood transfusion, including the type of blood product, volume, and rate of infusion.
• Check the patient's medical history for any previous transfusion reactions, allergies, or medical conditions that may increase the risk of complications.
• Obtain informed consent from the patient or their authorized representative, explaining the risks and benefits of the transfusion.
• Assess the patient's intravenous access site to ensure patency and suitability for blood administration.
• Ensure that pre-transfusion blood samples have been collected and sent to the laboratory for compatibility testing.

Pre-Transfusion Responsibilities

• Verification includes checking the doctor's orders for the transfusion (including product type, rate, and pre-medications), the patient's identity using two factors (name, health card number), blood compatibility by matching blood type and Rh factor on the blood bag to the patient's information, the blood product expiry date, and visually checking the blood bag for issues like clots or discoloration.
• Patient education involves explaining the process, risks, benefits, and reaction symptoms to report.
• Baseline vital signs (temperature, pulse, blood pressure, respiratory rate) should be taken before starting.
• Establish an 18-20 gauge IV line.

Blood Product Verification

• Before administering the blood product, carefully verify the information on the blood bag label with the patient's identification and the transfusion order.
• Confirm the ABO blood type and Rh factor of the donor blood and the recipient blood.
• Check the blood bag for any signs of damage, such as leaks, discoloration, or clots.
• Use a two-person verification process, where two qualified healthcare professionals independently verify the information.

During Transfusion Responsibilities

• Blood product administration: blood given through a special blood administration set with a filter, using only 0.9% normal saline solution with blood transfusions (other IV solutions may cause cell damage), and starting the transfusion slowly at 1-2 mL/min for the first 15 minutes.
• Patient monitoring: watch the patient closely for the first 15 minutes; check vital signs often (every 5-15 minutes) at first, then every 30-60 minutes, as per policy; and watch for transfusion reaction signs such as fever and chills, rash or hives, shortness of breath, chest pain, back pain, tachycardia, and hypotension.

Administration Techniques

• Use appropriate blood administration sets with filters to remove any clots or debris from the blood product.
• Start the transfusion slowly, typically at a rate of 2 mL/minute for the first 15 minutes, and closely monitor the patient for any signs of reaction.
• If no adverse reactions occur, the transfusion rate can be increased to the prescribed rate, according to the physician's or nurse practitioner's order.
• Never add any medications or solutions to the blood bag, except for 0.9% normal saline, which may be used to dilute the blood product if necessary.
• Complete the transfusion within four hours to minimize the risk of bacterial contamination.

Patient Monitoring

• Vigilant patient monitoring is essential during and after blood transfusions to detect any adverse reactions.
• Baseline vital signs (temperature, pulse, blood pressure, respiration rate) should be recorded before starting the transfusion.
• Monitoring continues throughout the transfusion, with regular checks every 15 minutes initially, then every 30 minutes, and hourly thereafter.
• Watch for signs and symptoms of transfusion reactions, such as fever, chills, rash, itching, shortness of breath, chest pain, or back pain.
• Any adverse reactions should be promptly reported to the physician or nurse practitioner.

Transfusion Reactions

• If a reaction is suspected: stop the transfusion right away, keep IV access open with normal saline, contact the doctor or RN, follow facility rules for handling reactions, monitor vital signs, give supportive care, send the blood bag and set to the lab for testing, and document the reaction and actions taken.
• Transfusion reactions are adverse events that can occur during or after a blood transfusion, ranging from mild to life-threatening.
• Reaction types:
  • Febrile non-hemolytic transfusion reaction (FNHTR): most common, caused by cytokines; includes fever/chills, usually due to antibodies against donor white blood cells.
  • Allergic reaction: antibodies react to proteins; symptoms range from hives to anaphylaxis; caused by antibodies against donor plasma proteins, resulting in itching, rash, and hives.
  • Hemolytic transfusion reaction: very serious, recipient's antibodies attack donor's cells; causes fever, chills, back/chest pain, dark urine; occurs when incompatible red blood cells are transfused, leading to rapid destruction of the recipient's red blood cells.
  • Transfusion-related acute lung injury (TRALI): rare but life-threatening; donor antibodies react with recipient's neutrophils, causing lung issues; includes dyspnea, hypoxia, fever; a severe reaction characterized by acute respiratory distress and pulmonary edema.
  • Transfusion-associated circulatory overload (TACO): occurs when transfusion is too fast, causing fluid overload, especially in those with heart or kidney problems; includes dyspnea, cough, edema; occurs when the transfusion rate is too rapid, leading to fluid overload and heart failure.
  • Delayed hemolytic transfusion reactions (DHTR): occur days or weeks after the transfusion, due to the development of antibodies against minor red blood cell antigens.
  • Post-Transfusion Purpura (PTP): A rare reaction that occurs 5-12 days after transfusion, characterized by a sudden drop in platelet count, leading to purpura (bruising) and bleeding.
• Adverse reactions to blood transfusions are unfavorable responses that occur in a patient as a result of receiving a blood transfusion.
• These reactions can range from mild to life-threatening.
• Recognizing, monitoring, and managing these reactions are critical components of safe transfusion practices in Canada.
  • Acute Hemolytic Transfusion Reaction (AHTR): A severe, potentially fatal reaction caused by ABO-incompatible blood being transfused, resulting from the recipient's antibodies attacking the donor's red blood cells, leading to hemolysis. Symptoms include fever, chills, chest pain, back pain, anxiety, and dark urine.
  • Febrile Non-Hemolytic Transfusion Reaction (FNHTR): One of the most common transfusion reactions, characterized by a rise in temperature of 1°C or more associated with the transfusion, without evidence of hemolysis, often caused by cytokines that accumulate during blood storage or by recipient antibodies reacting to donor leukocytes.
  • Allergic Reactions: Vary in severity and can manifest as urticaria (hives), itching, flushing, or, in severe cases, anaphylaxis. Mild reactions are usually caused by recipient antibodies reacting to donor plasma proteins. Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate intervention.
  • Transfusion-Related Acute Lung Injury (TRALI): A serious but rare complication characterized by acute respiratory distress occurring during or within 6 hours of a transfusion, caused by donor antibodies reacting to recipient leukocytes, leading to pulmonary edema. Symptoms include shortness of breath, rapid breathing, cyanosis, and fever.
  • Transfusion-Associated Circulatory Overload (TACO): Occurs when the patient's circulatory system is unable to handle the volume of blood being transfused, common in patients with pre-existing cardiac or renal conditions, and in elderly individuals. Symptoms include shortness of breath, cough, chest discomfort, and elevated blood pressure.
  • Delayed Hemolytic Transfusion Reaction (DHTR): Occurs more than 24 hours post-transfusion, often caused by alloantibodies formed from previous transfusions or pregnancies, and may result in a gradual decrease in hemoglobin levels.

Management of Transfusion Reactions

• If a transfusion reaction is suspected, immediately stop the transfusion and maintain intravenous access with normal saline.
• Assess the patient's vital signs and general condition.
• Notify the physician or nurse practitioner immediately and follow their orders.
• Administer medications as prescribed, such as antihistamines, antipyretics, or vasopressors.
• Send blood samples and the remaining blood product to the laboratory for investigation.
• Document the transfusion reaction and the interventions taken.

Post-Transfusion Responsibilities

• Monitor vital signs after transfusion per facility policy.
• Record the total blood volume given, the time finished, and patient response.
• Watch for any delayed reactions.
• Dispose of the blood bag and set per policy.

Documentation

• Accurate records are vital for patient safety and legal reasons.
• Records should have pre-transfusion assessment (vital signs, education, IV access), blood product details (type, Rh factor, unit number, expiry date), transfusion start/end times, rate, volume, monitoring data (vital signs, reaction symptoms), any actions taken during transfusion, and how the patient responded.
• Document all aspects of the blood transfusion in the patient's medical record, including the date and time of the transfusion, the type and volume of blood product transfused, the patient's vital signs, and any adverse reactions observed.
• Record the batch number and expiry date of the blood product.
• Document the patient's response to the transfusion and any interventions taken to manage adverse reactions.

Special Considerations

• Pediatric patients: doses and rates must be carefully calculated based on weight and condition.
• Geriatric patients: higher risk for TACO because of heart/kidney issues. Give transfusions slowly and monitor closely.
• Patients with heart or kidney problems: also at higher risk for TACO, need careful monitoring.
• Pregnant women: need extra care because of potential Rh incompatibility.
• Jehovah's Witnesses: may refuse transfusions for religious reasons. Respect their choice and offer alternatives.
• Patients with a history of transfusion reactions may require premedication with antihistamines or corticosteroids before future transfusions.
• Immunocompromised patients may require irradiated blood products to prevent transfusion-associated graft-versus-host disease (TA-GVHD).
• Neonates and infants may require special considerations for blood volume and transfusion rates.

Legal and Ethical Considerations

• Informed consent is needed before any transfusion.
• Patients can refuse transfusions, even if life-saving.
• Nurses must follow beneficence (doing good), non-maleficence (doing no harm), autonomy (respecting rights), and justice (fairness).
• Errors during transfusions can be very serious.
• Follow all rules to prevent problems.
• Report any errors right away per protocol. The Canadian Patient Safety Institute is a resource.

Regulatory Guidelines

• Blood transfusions are regulated by various guidelines and standards to ensure safety and quality.
• In Canada, the Canadian Standards Association (CSA) and Health Canada provide regulatory oversight.
• These guidelines cover all aspects of the transfusion process, from donor screening to blood product storage and handling.
• Healthcare organizations must adhere to these regulations and have their own policies and procedures in place.
• Blood transfusion practices in Canada regulated by Health Canada through the Blood Regulations, and are overseen by the Canadian Blood Services (CBS) and Héma-Québec.
• These organizations set standards for blood collection, testing, processing, storage, and distribution.
• Hospitals and healthcare facilities must adhere to these standards to maintain accreditation and ensure patient safety.
• Regular audits and inspections are conducted to verify compliance with regulatory requirements.
• Reporting of adverse transfusion reactions is mandatory and helps to monitor and improve the safety of transfusion practices across the country.
• Non-compliance can result in penalties, including fines and suspension of transfusion privileges.

Additional Notes

• RPNs should know Canadian Blood Services' resources.
• Ongoing learning is needed.
• Know your facility's transfusion policies.

Continuing Education

• RPNs should participate in ongoing education and training to maintain their competence in blood transfusion practices.
• Stay updated on the latest guidelines, protocols, and best practices.
• Seek opportunities to enhance their knowledge and skills in blood transfusion therapy.

Monitoring Protocols

• Pre-Transfusion: Verify the physician's order for the transfusion, confirm patient identity using two independent identifiers, check the compatibility of the blood product with the patient's blood type, obtain baseline vital signs (temperature, pulse, blood pressure, respiration), and assess the patient's history of previous transfusions and reactions.
• During Transfusion: Initiate the transfusion slowly, observing the patient closely for the first 15 minutes, monitor vital signs regularly (e.g., every 5-15 minutes initially), and then every 30 minutes to hourly, depending on the patient's condition and institutional policies, and observe for any signs of adverse reactions, such as fever, chills, hives, or difficulty breathing.
• Post-Transfusion: Continue to monitor the patient's vital signs, assess the patient for any delayed reactions, and document the transfusion in the patient's medical record, including the date, time, blood product details, and any reactions observed.

Reporting Mechanisms

• Any suspected transfusion reaction must be reported immediately to the transfusion service or blood bank.
• Follow the hospital's or healthcare facility's specific protocol for reporting adverse reactions.
• Complete the necessary documentation, including a transfusion reaction investigation form.
• The transfusion service will conduct an investigation to determine the cause of the reaction and implement corrective actions.
• In Canada, serious adverse events related to blood transfusions must be reported to the Canadian Blood Services (CBS) or Héma-Québec, depending on the province.

Patient Safety Guidelines

• Proper Patient Identification: Use two independent identifiers to verify the patient's identity at every step of the transfusion process; this is crucial to prevent ABO-incompatible transfusions.
• Double-Check Blood Products: Verify the blood product label against the patient's information and the transfusion order; ensure that the blood type and Rh factor are compatible.
• Use of Blood Warmers: Blood warmers should be used when transfusing large volumes of blood rapidly, especially in cases of trauma or surgery, to prevent hypothermia.
• Leukoreduction: Use leukoreduced blood products to reduce the risk of FNHTRs and cytomegalovirus (CMV) transmission.
• Pre-medication: Administer pre-medications, such as antihistamines or antipyretics, to patients with a history of allergic or febrile reactions.
• Education: Educate patients about the signs and symptoms of transfusion reactions and instruct them to report any unusual symptoms immediately.