This article will look at how to monitor and assess a patient receiving a blood transfusion.

Blood transfusion is the transfer of blood components from one person to another. It is a potentially life-saving procedure that helps replace blood lost due to surgery, illness, bleeding or severe injury (Mayo Clinic 2018).

Blood Components

There are several blood components, and these include:

• Red cells: required to increase oxygen carrying capacity of the blood. Once collected from blood storage, red cells should be transfused within 4 hours.

• Plasma: the liquid part of blood. Transfused as fresh frozen plasma (FFP).

• Platelets: required for prevention and treatment of haemorrhage in patients with platelet function defects. Each platelet has a shelf life of 5 days from the date of donation.

Importance of Patient Identification:

All patients receiving a blood transfusion must wear a patient identification band. The minimum patient identifiers are last name, first name, date of birth and unique patient identification number (Macmillan Cancer Support 2016). The information must be legible, and accurate.

In an emergency situation, the patient identifiers may be unknown. In this situation, at least one unique identifier – for example, an emergency number or patient’s gender – must be used or follow organisation’s policy.

Patient identification should be checked and confirmed as correct at each stage of the transfusion process. The patient should, whenever possible, be asked to state full name and date of birth. These must match exactly the information on the patient’s wristband and any other associated paperwork required at the stage of the blood transfusion process.

For patients who are unable to respond entirely or are unconscious or confused, verification of the patient’s identification should be obtained from a parent or carer if present.

If there are patient identification discrepancies at any stage of the transfusion process, the information must be verified, and discrepancies investigated and corrected before proceeding to the next stage of the process (Jevon 2012).

Blood Transfusion Documentation

Complete documentation is required at every stage of the blood transfusion process and should include the following steps:

1. Pre-Transfusion:

• Clinical indication for transfusion
• Date of decision
• Full blood count, coagulation screen
• Consent from patient
• Blood component to be transferred and volume

2. Administration:

• Date and time component collected
• Date and time transfusion started
• The donation number of component transfused
• Volume administered
• Identification of staff who started the transfusion
• Observations before and during transfusion

3. Post-Transfusion:

• Date and time component completed
• Evidence of unit being fated
• An indication of whether transfusion achieved the desired effect
• Observations before, during and after transfusion
• Documentation of any reactions that occurred (Jevon 2012).

Traceability:

All blood components should be traceable from the donor to their final destination. Follow organisation’s policies on how to achieve this.

Equipment:

Equipment used during blood transfusion include the following:

1.  Blood can be administered through a standard peripheral intravenous cannula, a central line or PICC line;
2. Blood administration set:
   • Blood components must be administered using a blood administration set;
   • The blood administration line should be changed at least every 12 hours or after completion of the prescribed blood transfusion to prevent bacterial growth;
   • Platelets should not be transfused through an administration set that has been previously used for red cells or other components because this may cause aggregation and retention of platelets in the line
3. Blood warmers;
   • Rapid infusion of red cells soon after their removal from blood refrigeration can lead to arrhythmias, hypothermia, cardiac arrest or impaired blood clotting in surgical or trauma patients;
   • NICE 2008 recommends that all patients undergoing surgery under general or regional anaesthesia, should receive blood components warmed to 37 degrees celsius;
   • Blood should only be warmed using specially designed and regularly maintained blood warming equipment. Blood must never be warmed in a microwave, hot water, or on a radiator.

(Jevon 2012)

Monitoring a Patient Receiving a Blood Transfusion

1. Pre-transfusion:

• Transfusion observations (heart rate, temperature, blood pressure and respiration rate) must be clearly distinguished from other routine observations and should be recorded in patient’s clinical notes. This is to provide baseline observations to ensure prompt recognition and timely intervention, should an adverse effect occur.

2. Administration:

• Many severe reactions occur within the first 30 minutes of commencing a transfusion of a blood component unit (SHOT 2008). Close observation during this period is essential.
• During the blood transfusion process, patients’ vital signs (heart rate, blood pressure, temperature and respiration rate) should be monitored throughout the procedure and recorded. Follow organisation’s policy on how often the vital signs should be measured.
• Patients should be involved in their care; they should be well informed of the potential risks of having the transfusion because they may be the first to be aware of any adverse reaction to the transfusion. They should also be advised to report any adverse effects (call bell should be in reach) and should be in an environment where they can be visually observed.
• For rapid infusion, more frequent observations may be required.

3. Post-transfusion:

• After each blood component has been transfused, record the post-transfusion vital signs. Any routine observation should be continued especially if the patient is critically ill.
• SHOT 2008 recommends that patients be observed during the subsequent 24 hours because, on occasion, transfusion reactions can occur many hours after transfusion is completed.

Adverse Reactions to a Blood Transfusion

Some important transfusion reactions to be aware of include:

Acute Haemolytic Transfusion Reactions:

This happens when the patient is transfused with incompatible red cells. Acute haemolytic transfusion reactions are most commonly due to errors in obtaining or labelling group and antibody screen samples, collecting wrong blood for wrong patient, or failure to carry out the required bedside checks before the blood is administered (Jevon 2012).

Signs and symptoms include:

• Pain at the cannulation site
• Pain in chest, back or abdomen
• Hypotension/hypertension
• Tachycardia
• Pyrexia
• Bleeding
• Collapse
• Haemoglobinuria.

Infusion of a Bacterially Contaminated Unit:

This is more often seen with an infusion of platelets, which are stored at a higher temperature of 22 degrees celsius. The blood component will most probably have a smell and discolouration (Jevon 2012). Common signs include:

• Acute reaction with rigours
• Pyrexia
• Hypo/hypertension
• Tachycardia
• Collapse.

Transfusion-Related Lung Injury (TRALI):

TRALI is mostly associated with transfusion of plasma containing white cell antibodies which will react with the patient’s white cells. Symptoms usually occur within 6 hours of transfusion (Jevon 2012) and include:

• Breathlessness
• A non-productive cough
• Hypotension
• Acute dyspnoea
• Hypoxia.

Allergic Reactions or Anaphylaxis:

Allergic reactions to blood units usually happen at the start of transfusion, and symptoms include:

• Hypotension
• Bronchospasm
• Chest pain
• Abdominal pain
• Dyspnoea
• Nausea
• Vomiting
• Urticaria
• Redness of skin
• Conjunctivitis.

Management of Adverse Transfusion Reactions

• Stop the transfusion immediately and seek medical advice.
• Contact microbiologist for expert advice.
• High concentration oxygen may be needed.
• The patient should be monitored closely.
• The blood component set should be removed and sealed per organisational policy and sent for further investigations.

Further Reading: REPLACE – Seven Steps to Remember During A Massive Blood Transfusion and Blood Transfusion Reactions

Conclusion

Full documentation must be completed at every stage of the blood transfusion in patient’s clinical records. Patients should also be monitored throughout their blood transfusion to ensure quick identification of any adverse effects.

References

• Jevon, P & Ewens, B 2012, Monitoring The Critically Ill Patient, 3rd edn, Wiley-Blackwell, Oxford.
• National Collaborating Centre for Nursing and Supportive Care (UK) 2008, ‘The Management of Inadvertent Perioperative Hypothermia in Adults’, NICE Clinical Guidelines, No. 65, viewed 21 June 2018, https://www.ncbi.nlm.nih.gov/books/NBK53797/
• Macmillan Cancer Support 2016, Blood Transfusions, viewed 21 June 2018, https://www.macmillan.org.uk/information-and-support/treating/supportive-and-other-treatments/supportive-therapies/blood-transfusions.html#18780
• Mayo Clinic 2018, Blood Transfusion, Mayo Clinic, viewed 21 June 2018, https://www.mayoclinic.org/tests-procedures/blood-transfusion/about/pac-20385168
• Serious Hazards of transfusion (SHOT) scheme (1996-2008), SOT Annual Reports 1996-2008, Manchester: SHOT office.

Feature image (CC)  Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org Blundell’s method of blood transfusion “Observations on the transfusion of blood” The Lancet Published: 1828