SARASOTA MEMORIAL HOSPITAL

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1 SARASOTA MEMORIAL HOSPITAL TITLE: NURSING PROCEDURE ORDERING, OBTAINING, IDENTIFICATION AND ADMINISTRATION OF BLOOD PRODUCTS (RBC, CRYOPRECIPITATE) BLOOD REACTIONS ADULTS AND PEDIATRICS DATE: REVIEWED: PAGES: 01/79 4/18 1 of 17 PS1094 ISSUED FOR: RESPONSIBILITY: RN, LPN I*, LPN II Nursing PURPOSE: 1. To provide guidelines to ensure the positive identification of the patient and blood or blood components. 2. To provide procedures for the ordering and obtaining, identification, and administration of red blood cells, platelets, fresh frozen plasma, and cryoprecipitate for the adult and the pediatric patient. 3. To provide a procedure for a blood reaction. KNOWLEDGE BASE: 1. A physician s order is required for the administration of blood components. 2. Informed Consent for administration of Blood: Informed consent is the responsibility of the physician. Once the physician has secured informed consent for the patient, the nurse can complete the consent form. a. For medical patients, a single informed consent for blood and/or blood products is sufficient for any course of therapy, which may include more than one transfusion during the admission. b. For recurring medical outpatients receiving a series of blood and/or blood component transfusions, including, but not limited to, hematology/oncology patients, a single informed consent is valid for six (6) months. c. The consent for surgery and special procedures is valid for the administration of blood during surgery and postoperatively, up to 72 hours after the procedure is completed. 3. The administration of blood and blood products utilizing a central line (including PICC lines) must be administered using an electronic pump.

2 PAGE: 2 of NOTE: If emergency blood replacement is necessary, an electronic pump may not be used as the transfusion may require a pressure bag, etc. to transfuse the blood rapidly. NOTE: Platelets may be infused by gravity or may be hung via electronic pump. 5. Exception for Pediatrics: Infusion must be administered via electronic pump except for emergencies as noted above. 6. Licensed Practical Nurses (LPN I)* may only monitor rates and sites of infusing blood components. 7. Red Blood Cells provide a source for carrying oxygen to tissues and mass for volume replacement. Each unit of RBCs contains approximately 325 ml and after administration should raise the adult recipient s hematocrit about 3% (if not actively bleeding). 8. Transfusion reactions can result from a single or massive transfusion of blood and blood components. Although many reactions occur during or shortly after administration, other adverse effects can develop days, weeks, or even months after transfusion. NOTE: Transfusion reaction requires immediate recognition and prompt nursing action to prevent further complications. EXCEPTIONS: DEFINITIONS: Neonatal Intensive Care Unit Perioperative Services (Pre-op, OR, PACU) 1. Informed Consent: Consent voluntarily given without coercion or undue influence by an authorized person after a sufficient explanation and disclosure of the subject matter involved has been provided. The information should enable that person to have a general understanding of the treatment or procedure, the medically acceptable alternatives and benefits, and the substantial risks and hazards inherent in the proposed treatment or procedure. 2. Allogeneic: Regular Blood Bank inventory. 3. Blood Identification Number: A unique bar coded ID number which is simultaneously applied to the patient s Blood Bank Identification Band insert and the patient s

3 PAGE: 3 of 17 Blood Bank Clot during the specimen collection process. The Blood Bank also places the patients unique Blood Identification Number on any red cells that have been cross-matched to the patient. The Blood Identification Number links the Blood Bank Specimen collection process with the process for patient identification and administration of red blood cells. 4. Blood Bank Identification Band: A soft plastic armband that is red in color and allows for the patient to be given a unique bar coded ID number that will be found on the armband s insert. 5. Blood Product Unit Number: A number assigned by the Blood Bank to the Blood Product during the blood donation process that identifies the source of the product. 6. Read back : A method of preventing errors in which information relayed to one person is repeated and verified by a second person as a means of confirming its accuracy. PATIENT EDUCATION: 1. Explain the procedure to the patient and/or support person (and/or parent/legal guardian for pediatrics). Verify that informed consent for the administration of blood products has been obtained. Informed consent is the responsibility of the physician. 2. Instruct the patient and/or support person (and/or parent/legal guardian for pediatrics) to report any chills, shaking, flushing, hives, shortness of breath, and/or discomfort at the infusion site during or after the transfusion. For outpatients, provide the written instructions for reporting adverse delayed reactions after discharge. EQUIPMENT: Assemble the following: 1. Existing IV access with an appropriate intravenous device. A 20-gauge or larger cannula is preferable for blood administration. Exception: For pediatric patients, use the largest gauge that is appropriate for age and available vein size. 2. Blood set with Y-tubing and filter primed with Normal Saline; extension set. 3. IV infusion pump (unless infusing by gravity).

4 PAGE: 4 of Blood Warmer and tubing (if cold antibodies (cold agglutinins) are present. Refer to nursing procedure (blo05) Using Warmer for Warming Blood/IV Fluids. PROCEDURE: I. Ordering and obtaining blood and blood components: 1. Order a Blood Bank clot (BBC) on the computer when: a. No previous blood bank clot collected for the current admission. b. Previous blood bank clot has expired. The BBC expiration time is determined by the patient s status at the time the BBC was drawn: 1) In-Patient The blood bank clot specimen is good for three (3) days. It is good until 23:59 on the third day. NOTE: The date of collection is day 0. If a specimen is collected on Monday, red blood cells cross-matched using that specimen may be transfused until 23:59 on Thursday. 2) Pre-Admission Testing (PAT) The blood bank clot specimen is good for seven (7) days. It is good until 23:59 on the seventh day as long as the patient has not been pregnant or transfused within the last three months. NOTE: The date of collection is day 0. If a specimen is collected on Monday, red blood cells cross-matched using that specimen may be transfused until 23:59 on the following Monday. NOTE: Contact the Blood Bank (ext. 1733) for any questions about blood that is already crossmatched prior to removing the blood band and drawing a new BBC. NOTE: Blood availability should be checked for all surgical patients. Contact the Blood Bank for any questions regarding blood availability. (Refer to SMH Policy 01.LAB.12 Specimen Label Stop Proc.)

5 PAGE: 5 of Order blood components in the Blood Administration order set on the computer system. a. If the order for blood cross-match, product or transfuse is entered by a HUC, LPN I, or PCT/MST, the order will automatically go to a pending verify status. It is the responsibility of the RN or LPN II to click on the to verify flag and verify the order. When this is done, the RN or LPN II is verifying the intent of the order and plan for the patient. b. When placing an order for the blood product a reason for blood must be entered this is information entered by the physician or received from the physician. NOTE: The MD order Transfuse blood does not order the blood product or crossmatch. Nursing will verify blood products are ordered and resulted and ready in SCM. 1) Check patient s chart for autologous and/or designated blood unit slips. 2) If available, order autologous units first. 3) If available, order designated units second (include designated unit information in comments). 4) Order allogeneic (Blood Bank) units last. 5) If for any reason it is suspected that the infusion of RBCs cannot be completed in the four (4) hour time limit, blood may be ordered in two (2) smaller units. Prior to infusion, enter the request into the comment field of the Blood Requisition. The four (4) hour time limit will apply to the smaller unit sent. NOTE: When allogeneic units are set up for a patient who is known to also have autologous and/or designated units, a label will be affixed to each unit that states: ALERT: Do not use until autologous units are transfused. 3. Notifications from Blood Bank when blood components are ready. a. Components which contain red blood cells (i.e., packed red blood cells) must be crossmatched. In the SCM Orders Tab, results of the BBC and Red Blood Cells will be displayed as Final Result or Modified Result. In the SCM Results Tab, the crossmatched unit will show the status as Ready, Issued, Transfused, Returned to BB, or Cancelled along with the unit number and the BBC expiration date and time (23:59).

6 PAGE: 6 of 17 b. Platelets, fresh frozen plasma and cryoprecipitated AHF must be prepared just prior to transfusion. These products will be prepared after they are requested in the computer. The Blood Bank will notify the nursing unit by telephone when the products are ready. c. If patient has a cold antibody (cold agglutinins) a blood warmer should be used to warm the unit. In the SCM Results tab, either for the type and screen, antibody ID or crossmatch, depending on where in the testing the cold antibody is detected, there will be a PLUS (+) sign button to the left of the result that needs pressed to view the cold antibody (cold agglutinins) report. One of the following comments will be made depending on how the cold antibody is detected and a decision is made by the physician if a blood warmer is needed for their patient. 1) Patient currently has cold antibodies detected at 4 o C. Cardiac surgery patients may benefit from a blood warmer and need special consideration. 2) Patient currently has cold antibodies detected at 4 o C and/or room temperature. Use of blood warmer is advisable. Cardiac surgery patients may need special consideration. 3) Historic cold antibody. NOTE: Refer to nursing procedure (blo05) Using Warmer for Warming Blood/IV Fluids. 4. Prior to requesting the blood and when it has been established that the blood or blood components are available and ready, assess the patient, including the following: a. Skin condition. b. Level of comfort. c. Baseline vital signs, including temperature. 5. Verify informed consent has been obtained. 6. Request blood or blood components from the Suncoast Communities Blood Bank (SCBB) on the computer when ready to transfuse. NOTE: Request platelets, FFP and cryoprecipitate 20 to 30 minutes before you are ready to infuse.

7 PAGE: 7 of During daytime hours, send a designated transporter (e.g., volunteer) to pick up blood from the Blood Bank by following these steps: a. Order a product release order set through the computer for a volunteer to pick up the blood from Blood Bank at the same time the request for blood is entered. b. Order a volunteer for blood pick-up or call the volunteer dispatch office extension 1015 to make sure they received notification/requisition for blood pick-up. If the blood is emergent, make sure you alert the Volunteer Dispatcher to expedite it. c. A volunteer or hospital personnel will then take the blood requisition or a patient ID label with the specific blood product requested (printed/handwritten) and where the product is going to Blood Bank and will present it to the Blood Bank Tech. d. The Blood Bank Tech will verify the patient name, Visit ID Number and product requested on the requisition or patient ID label (printed/handwritten) are the same on the blood bag tag to ensure it is the right patient. NOTE: Remember that blood has to be delivered to the unit (or to a satellite blood refrigerator) and initiated within 30 minutes after leaving Blood Bank. EXCEPTION: Sarasota Memorial Infusion (SMI) unitbased volunteers may use a patient ID label in place of a blood requisition sheet when picking up the blood. Computer requisitions and a volunteer dispatch will not be ordered when SMI unit-based volunteers pick up blood products. The procedure above will be followed when the SMI unit-based volunteers are unavailable. 8. During off shifts hours, requested blood products may be sent via a special padded pneumatic tube. a. When the tube carrier arrives with the blood, remove the blood and the accompanying shipping request form. Sign the shipping request and immediately return it to the Blood Bank in the same carrier tube. b. When the pneumatic tube system is down or when components cannot be sent in the tube system, hospital personnel or volunteers may be sent to obtain the blood products. The person picking up a blood product must

8 PAGE: 8 of 17 present a blood requisition or a patient ID label with the specific blood product requested (printed/handwritten) and where it is going to the Blood Bank Tech. c. If the blood needs to be sent back, call the Blood Bank (ext. 1733) and request a special padded tube carrier so that the blood can be safely tubed back to them. 9. When the computer system is down and nursing needs to get the blood/blood component: a. Send a written request containing the patient s name, hospital admission number, patient location, where the product is going, and the component requested to the Blood Bank via pneumatic tube carrier or by transporter. b. Call the volunteer dispatch and the volunteer will write the patient s full name, DOB, and admission number on a piece of paper and present it to the Blood Bank Tech to use for verification. PROCEDURE: II. Patient Identification (for blood/blood components): 1. Check any special message labels on the blood unit (e.g., Alert: Autologous and/or designated donor units were donated for this patient. Please check availability.) NOTE: Autologous units are identified by the following: 1. A card with the patient s name and unit number presented to the nurse by the patient. 2. Secondary tag attached to the unit, which contains the unit number, patient s name and the patient s signature. 3. Label attached to the blood unit, which specifies For Autologous Use Only. Designated units are identified by the following: 1. A card with the patient s name and unit number presented to the nurse by the patient. 2. Secondary tag attached to the unit, which contains the unit number, and the patient s name. A second nurse is needed to verify the following steps: 2. Confirm that there is a signed blood consent form or the physician has documented that a medical emergency exists, and the patient is unable to consent and legal

9 authorization is unavailable. PAGE: 9 of Check the physician s order against the product received. a. Ensure that the component type (e.g., red blood cells, platelets, plasma) agrees with the physician s order and check for the unit s expiration date. b. For cross-matched components (e.g., autologous blood, leukocyte reduced red blood cells), ensure that the Blood Unit Number is listed in the patient s chart and matches the Blood Unit Number on the product. 4. Identify the correct patient with two sources of information by verifying their full name and date of birth as per SMH policy 01.PAT.09 Patient Identification: Inpatient/Outpatient. Ensure the Blood ID Band is on the patient s wrist as this band has their Blood ID Number on it. Refer to SMH Policy Blood Bank Identification Bands for the application of these bands. 5. At the patient s side, verify that all information identifying the blood product with the intended recipient has been matched in the presence of the patient, item by item. The recommended steps for this area are: a. Using read back verification, one nurse reads the product unit number, component type and blood type from the product label with a second nurse, CCP, CRNA or MD comparing it with the product bag tag. b. Use read back verification for each of the following steps: One nurse reads the patient s full name, date of birth, or hospital identification number from the product bag tag while the other nurse (one of whom must be an RN), perfusionist, CRNA or MD reads the same information from the patient s hospital ID band. Also verify that the Blood Bank ID band is on the patient and has the correct name. If the patient is able, ask the patient to state his/her name. The blood ID number on the Blood ID Band must match the blood ID number on the blood bag tag. NOTE: DO NOT PROCEED WITH THE TRANSFUSION IF THESE BLOOD ID NUMBERS DO NOT MATCH. c. The Blood bag tag must be signed by the two staff members who verified the blood and the patient immediately after verification. The bag tag must remain attached to the unit until transfusion is complete.

10 PAGE: 10 of 17 d. In the event the patient s hospital admission number has changed (example: patient converted from outpatient to inpatient status or the initial blood specimen was drawn and identified during a preadmission testing number and then the patient is admitted prior to the scheduled procedure), a new order must be requested with the new admission number and a new specimen with the correct admission number and a new blood ID number must be collected. The blood product must be returned to Blood Bank Immediately. EXCEPTION: Sarasota Memorial Infusion: Outpatient blood bank clots may be delivered via courier to the Blood Bank. Therefore, patient ID labels will not be available at the time of blood ID banding. In lieu of patient ID labels, the staff will write the full name of the patient and date of birth on the Blood Bank band and this will be used as a second identifier along with the Blood Band number prior to blood administration. 6. Verify that the product has not reached the expiration date/time and that the cross-match has not expired. NOTE: If any errors or discrepancies are noted, do not use the blood product. Notify the blood bank of the discrepancy and return the blood product to the blood bank immediately. PROCEDURE: III. Administration of Blood Products (RBC, platelets, FFP, Liquid plasma, cryoprecipitate) 1. Document on the blood bag tag, the date, the time the unit was started, the patient s initial vital signs and the signatures/printed names of the transfusionist and verifying nurse (one of whom must be an RN). 2. Perform hand hygiene. Don gloves. 3. For electronic pump infusion, verify that the Y tubing of the blood set has been primed with saline. Using aseptic technique, attach the blood bag to the other side of the Y tubing. Clamp tubing on saline side and open clamp on blood bag side to allow blood to infuse. Insert tubing into the pump and program the rate according to the patient s current condition/medical history. 4. For gravity infusion, verify that the Y tubing of the blood set has been primed with saline. Using aseptic technique,

11 PAGE: 11 of 17 attach the blood bag to the other side of the Y tubing. Clamp tubing on saline side and open clamp on blood bag side to allow blood to infuse. Exception: Patients who are receiving blood products while being actively dialyzed by the hemodialysis staff. Exception For Pediatric: Normal saline is used to flush the primary tubing. All blood transfusions received from Blood Bank in a syringe are pre-filtered in the Blood Bank and do not require a filter. This small amount may be infused using a syringe pump and regular medication tubing. Usual pediatric blood dosing is 10 ml/kg /dose. Begin infusing blood slowly at no greater than ¼ of total infusion rate per hour. Remain with the patient during the first ten (10) minutes and observe closely for signs of complications. Regulate maximum infusion rate via infusion pump at 5mL/kg/hr over 2-4 hours (usual rate), or as ordered by the physician. 3. Ensure electronic regulator has been cleared of all previous settings. Begin infusing blood slowly at no greater than 2 ml/minute (blood tubing is 10 drops/ml so 2 ml/min equals 20 drops per minute which equates to 120 ml/hour on the electronic controller). (NOTE: Blood infuses independently, not concurrently with normal saline.) 4. The blood start time is when the blood actually reaches the patient. The nurse should note the ml of normal saline infused prior to the blood reaching the patient. 5. Remain with the patient while the first 15 to 30 ml of blood infuses. Assess and document the patient s vital signs after ml of blood transfused on the blood bag tag. Vital signs should be taken and documented more often whenever indicated. Document any abnormal findings in the EMR. During this time, observe patient closely for signs of complications. 6. Observe the patient during the transfusion at least every thirty minutes, or more often if indicated. Verify that the blood is infusing continually. Adjust drip rate as needed and according to the patient s current condition. NOTE: A unit of blood must be infused within four (4) hours. If the patient is transferred to a procedural department, another unit, or is at shift change, use hand-

12 PAGE: 12 of 17 off communication regarding the time the blood needs to be finished. Blood tubing and primary tubing used for blood administration is only good for four (4) hours. 7. Transfuse blood completely. Flush with normal saline to clear tubing. 8. Perform hand hygiene. Don gloves. 9. Following the transfusion, complete the bag tag, including the time the unit is finished, patient s vital signs and volume transfused. Remove the bag tag from the blood bag and file it in the Lab section of the medical record. 10. Continue with patient s previous intravenous orders, insert a PRN adapter or discontinue the IV access as per the patient s orders. 11. Place the empty blood bag and used tubing in a Biohazardous waste bag, take to the Soiled Utility Room and dispose of in a waste container designated for biohazardous waste. These containers will be lined with red plastic bags. EQUIPMENT: (for blood reaction) IV. BLOOD REACTIONS Assemble the following: 1. Possible Transfusion Reaction Report (is available in the Transfusion Reaction order set ) 2. Urine specimen container PROCEDURE: (for blood reaction) 1. As soon as a blood reaction is suspected, stop the transfusion. Wash hands and don non-sterile gloves Change the tubing and NS setup and maintain a patent IV access. Maintain the venous access with normal saline (NS) infusion at a maximum of 50 ml per hour. 2. Assess the patient including vital signs and record vitals on the Transfusion Reaction Report. Institute emergency measures as indicated by the patient s status. 3. Notify the physician immediately. 4. Monitor vital signs every fifteen minutes or as indicated by the severity and type of reaction until symptoms subside.

13 PAGE: 13 of Compare the labels on all blood containers to corresponding patient identification forms to ensure transfusion was the correct blood component and document as such. 6. Notify the Suncoast Communities Blood Bank of a possible transfusion reaction via SCM (or telephone if SCM is down). Print a copy of the Possible Transfusion Reaction Report. Have the RN complete the form and send it to the Suncoast Communities Blood Bank along with the remainder of the unit, the administration set and the normal saline. 7. Order and collect blood specimen (lavender tube) and indicate in the comment section possible transfusion reaction. 8. Collect the first post-transfusion urine specimen. In SCM, select Transfusion Reaction-Urine. In the comment section, add Possible Transfusion Reaction and print. Send the slip and collected urine specimen to the Laboratory immediately. 9. Continue to assess and monitor the patient including Intake and Output, and vital signs until the patient condition is stable. 10. For additional information regarding Blood Reactions, refer to Attachment B at the end of the procedure. DOCUMENTATION: 1. Suncoast Communities Blood Bank Blood Product ID Tag: Transfusionist and witness signature, blood transfusion start and stop times, vital signs as indicated, and if reaction has/has not occurred. 2. Intake and Output Flowsheet: Record the volume infused including the normal saline flush used. 3. Nursing Reassessment Flowsheet: Document the patient responses to treatment pre and post transfusion and any signs of reaction and action taken. REFERENCE: American Association of Blood Banks, American Red Cross, America s Blood Centers. Circular of Information for the Use of Human Blood and Blood Components. (2017, October). Retrieved December 28, 2017, from

14 PAGE: 14 of 17 Byrne, K. (Ed.). (2017) Hospital Accreditation Standards. Oakbrook Terrace, IL: The Joint Commission. ISBN-10: SMH Corporate Policy. Administration of blood and blood products. (00.PAT.00). Informed Consent/Refusal To Consent: For Surgery, Special Procedures, the Administration of Blood and/or Blood Components. (00.RSK.14). Sarasota, FL: Author. SMH Policies. Patient Identification: Inpatient/Outpatient. (01.PAT.09). Blood Bank Identification Bands. (01.PAT.67). Specimen Label Stop Procedure (01.LAB.12) SMH: Author. SMH Nursing Procedure. Packed RBC s for the Neonatal Patient (nur18). Using Warmer for Warming Blood/IV Fluids (blo05) SMH: Author. ATTACHMENT: Refer to Attachment A for specific information for blood products. Refer to Attachment B for information regarding the most common types of blood reactions REVIEWING AUTHOR (S): Mary E Geary PhD, RN, Executive Director, Quality, Patient Safety Officer Lisa Baumgardner, DNP, CNS-BC, PCCN, Manager, Education Melissa Shelton, PhD, RN, Nursing Quality Program Coordinator Elizabeth Brott, MSN, RN, CNOR, Nursing Quality Specialist Spence Hudon RN, BSN, BS, CNML, Clinical Manager, Cardiac Acute/Heart Failure Sue Key, MT(ASCP), Director, Transfusion Services, Suncoast Blood Bank Harold Vore, MT (ASCP) Administrative Director, Laboratory Services APPROVAL: Clinical Practice Council 4/5/18

15 PAGE: 15 of 17 Attachment A: BLOOD COMPONENT SPECIFIC INFORMATION Blood Products/Volume RBC 1 bag is approx. 300 ml Product Information Allogeneic RBC are products from regular blood bank inventory. Autologous RBC are products collected from the patient prior to surgery. Transfusion Time (All blood must be infused within 4 hours) 2-4 hours or as patient can tolerate (not to exceed four hours) Crossmatch/ No Crossmatch Needed Crossmatch Flush Bag Needed YES Use bag of Normal Saline for priming and flushing Platelets 1 bag is approx. 250 ml FFP/Liquid plasma 1 bag is approx. 300 ml Aliquot (smaller amounts) Blood can be ordered in aliquots to prevent volume overload Apheresis is a unit obtained from a single donor Anticoagulated clear liquid portion of blood. Requires minutes of thawing if FFP minutes or as patient can tolerate 1-2 hours or as patient can tolerate No Crossmatch needed No Crossmatch needed YES Use bag of Normal Saline flushing YES Use bag of Normal Saline for flushing Cryoprecipitate Antihemophilic Factor 1 bag is approx. 100 ml It is a preparation containing Factor VIII and fibrinogen from a unit of whole blood. Provided in pools of 5 units. Requires minutes of thawing minutes or as patient can tolerate No Crossmatch needed NO Flush with 10 ml Normal Saline after infused NOTE: There are additional nursing procedures for the following blood components on the PULSE: 1. Albumin (blo08) 2. Factor VIII, Factor IX (blo09) 3. IV Gamma Globulin (IgG) (med07)

16 Attachment B: PAGE: 16 of 17 FIVE TYPES OF THE MORE FREQUENT BLOOD REACTIONS TYPE REACTION HEMOLYTIC PREVENTIVE MEASURES Verify identification. Monitor patient closely for the first 10 minutes of transfusion. SIGNS & SYMPTOMS Onset of symptoms usually in first 10 minutes of transfusion. Burning along vein. SUGGESTED NURSING ACTIONS Stop the transfusion. Change blood tubing. Notify MD. Use only approved solutions (0.9% Sodium Chloride Injection USP). Do not add any drugs or medications to blood products. Avoid overheating or freezing of the blood. Use only approved devices for warming. Flushing, fever, chills. Flank pain. Chest pain, tachypnea. Labored respirations. Shock. Treat shock. Blood, urine specimens as stated in procedure. Order and collect blood specimen (lavender tube). Avoid bacterial contamination. ALLERGIC Note allergy history particularly of previous transfusion. Administer antihistamine per physician s order prior to transfusion. Hives (more than one or two). Pruritus. Respiratory symptoms are rare, e.g., asthma, glottal edema. Stop transfusion. Notify MD. Treat life-threatening conditions (edema, shock, respiratory distress). FEBRILE Keep patient comfortably warm during transfusion. Administer antipyretic per order prior to transfusion. Chills & fever usually one hour or more into transfusion and usually greater than a 2 degree F rise. Headache. Stop transfusion. Notify physician. Leuko-reduced or washed packed cells reduce chance of febrile reaction. Flushing. Tachycardia.

17 Attachment B (Continued): PAGE: 17 of 17 TYPE REACTION BACTERIAL PREVENTIVE MEASURES Maintain aseptic techniques. SIGNS & SYMPTOMS Shaking, chills and fever. SUGGESTED NURSING ACTIONS Stop transfusion. Maintain blood in controlled cool temperature. Do not use blood warmed greater than room temperature except in cases of hypothermia. Do not infuse blood for longer than 4 hours. Abdominal & extremity pain. Vomiting. Bloody diarrhea. Notify MD. Treat shock per symptoms. Broad spectrum antibiotic treatment as ordered. Monitor vital signs & fluid/electrolyte balance. CIRCULATORY OVERLOAD Infuse at a rate per patient tolerance. Use of less volume packed cells for compensated, elderly or infants. Dry cough. Labored breathing. Rales at lung bases. Pulmonary edema. Stop transfusion. Sit patient up. Notify physician. Monitor & assess. TRANSFUSION RELATED ACUTE LUNG INJURY (T.R.A.L.I.) Shortness of breath. Low blood pressure. Chills Fever. Pulmonary edema. Treat symptomatically per orders. Stop transfusion. Respiratory support (oxygen, etc.). Notify physician, monitor and assess. Treat symptomatically.