Monitoring and Assessing a Patient Receiving A Blood Transfusion
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Updated 25 Oct 2021
This article will look at how to monitor and assess a patient receiving a blood transfusion.
What is 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 2020).
Blood Components
There are several blood components. These include:
Red Cells
These are required to increase the oxygen-carrying capacity of the blood. Once collected from blood storage, red cells should be transfused within four hours.
Plasma
The liquid part of blood. It is transfused as fresh frozen plasma (FFP).
Platelets
These are required for the prevention and treatment of haemorrhage in patients with platelet function defects. Each platelet has a shelf life of five days from the date of donation.
All patients receiving a blood transfusion must wear a patient identification band. In Australia, at least three of the following approved identifiers must be used:
Name (family and given names)
Address
Date of birth
Gender
Medical record number
Individual healthcare identifier.
(ACSQHC 2019a)
This information must be legible and accurate.
In an emergency situation, the patient identifiers may be unknown. In this situation, the patient should be labelled as ‘unknown male’ or ‘unknown female’ using an emergency number. Remember to follow local policies and procedures (ANZSBT & ACN 2018).
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 their full name and date of birth. These must exactly match the information on the patient’s wristband and any other associated paperwork required at that 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 was 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 your organisation’s policies on how to achieve this.
Equipment
Equipment used during a blood transfusion should include the following:
Standard peripheral intravenous cannula, central line or PICC line
Blood administration set:
Blood components must be administered using a blood administration set
To prevent bacterial growth, the blood administration line should be changed at least every 12 hours, or after completion of the prescribed blood transfusion
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
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, with 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 the patient’s clinical notes. This is to provide baseline observations in order 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, the patient’s vital signs (heart rate, blood pressure, temperature and respiration rate) should be monitored and recorded. Follow your organisation’s policy on how often vital signs should be measured.
Patients should be involved in their care; they should be well-informed of the potential risks of undergoing the transfusion because they may be the first to become aware of any adverse reactions. They should also be advised to report any adverse effects (the 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.
These occur when the patient is transfused with incompatible red cells. Acute haemolytic transfusion reactions are most commonly caused by errors in obtaining or labelling group and antibody screen samples, collecting wrong blood for the wrong patient, or failure to carry out the required bedside checks before the blood is administered (Jevon 2012).
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
Hypotension/hypertension
Tachycardia
Collapse.
Transfusion-Related Lung Injury (TRALI):
TRALI is mostly associated with a transfusion of plasma containing white cell antibodies that react with the patient’s white cells. Symptoms usually occur within 6 hours of transfusion (Jevon 2012) and include:
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 a 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.
Conclusion
Full documentation must be completed at every stage of the blood transfusion in the patient’s clinical records. Patients should also be monitored throughout their blood transfusion to ensure quick identification of any adverse effects.
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/
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