POLICY: Blood products must be administered in accordance with the procedures defined below. PURPOSE: To provide guidelines or the issue, initiation and termination of transfusion of blood products as well as the procedures required in the event of a suspected transfusion reaction. Physicians, Residents, Licensed Allied Health Professionals (defined as an Advanced Practice Nurse, Physician Assistant, Nurse Midwife or Certified Registered Nurse Anesthetist who is operating within his/her scope of practice as defined in N.J.A.C. 8:43G-1.2 and as authorized pursuant to AtlantiCare Regional Medical Center s Medical Staff Bylaws to collaborate with or practice under the supervision and direction of a Physician) and Nurses. Only a licensed Physician, Resident, Licensed AHP, or Registered Nurse may initiate a blood product transfusion. Order Verification Consent Preparing for Transfusion Product Verification Nursing Responsibilities Prior to Requesting Delivery of the Blood Product Exceptions Pre-Transfusion Administration EFFECTIVE DATE: 1/98 1
Initiation of Transfusion Nursing Considerations Termination of Transfusion Documentation of Blood Product Tag Transfusion Reaction PROCEDURE: ORDER VERIFICATION: 1. There must be an order for transfusion (located under Nursing Patient Care Section), prior to obtaining the blood product. The order must specify a. type of product b. amount c. rate of administration NOTE: An order must be obtained to interrupt an existing IV infusion for blood product administration. 2. Autologous and Directed Donors: a. Check the order for Autologous and/or Directed Donors. Notify the Transfusion Service prior to picking up the blood product that Autologous and/or Directed Donors should be available for the patient. EFFECTIVE DATE: 1/98 2
CONSENT: 1. Informed consent for the transfusion of blood products must be obtained from the patient/legal surrogate, signed by the Physician, Licensed AHP or Resident, patient, and witness prior to obtaining the blood product. a. Authorization and consent are required for transfusion of: Whole Blood, Packed Cells, Fresh Frozen Plasma, Cryoprecipitate and Platelets except in an emergency situation. b. Authorization and consent are not required for transfusion of: Albumin, Immune Globulin, Factors, and Antithrombin III. These products are obtained from the pharmacy. PREPARING FOR TRANSFUSION: The following must be performed by the Transfusionist. The Transfusionist must be a licensed Physician, Licensed AHP, or Registered Nurse. 1. Blood products are obtained from the Transfusion Service. a. The Transfusion Service will notify the unit whenever blood products are ready (prepared for the patient). b. Exception as outlined on page 9. 2. Prior to requesting blood products from the Transfusion Service: EFFECTIVE DATE: 1/98 3
a. Verify that a valid Informed Consent for Transfusion is available (i.e. signed and dated). 3. Provide patient/family/guardian education prior to the transfusion, if possible. a. Inform the patient/family of the: Kind of blood component that will be transfused. Reason for the transfusion. Approximate duration of the transfusion. Expected outcome. Frequent observations required pre-and-during transfusion. 4. Ask the patient/family/guardian, if possible, to immediately report if they notice any changes in the patient s condition during or after the transfusion (i.e. transfusion reactions). 5. Obtain and assemble all necessary equipment for the transfusion: a. IV pump b. Blood tubing and filter c. Additional equipment may include: 0.9% normal saline 10cc syringes of 0.9% normal saline flushes. Blood warmers can only be used in the ER, OR and ICU (may be used for large volume or exchange transfusion). EFFECTIVE DATE: 1/98 4
NOTE: All transfusionists should check to assure that the patient has an armband on before obtaining blood products from Transfusion Service. All outpatients who have their pre-transfusion testing prior to the day of transfusion MUST keep their armband on until they are transfused. If the patient arrives and the armband is missing the pre-transfusion testing must be performed before products will be issued. PRODUCT VERIFICATION: 1. Issue of Blood Products from the Transfusion Service a. Eligible Personnel: Person Issuing Blood Product: Any laboratory employee, who has been instructed in the proper procedure, may issue a blood product. Person Blood Product Being Issued To: Any individual who is an employee of AtlantiCare or Acuity Specialty Hospital of NJ may pick up a blood product from the Transfusion Service, as long as it has been documented that they have been instructed in the proper procedure. 2. Blood Issue Form: Individuals picking up a blood product must present a completed blood issue form # 25145. A patient label may be utilized in the upper section of the form. In the absence of a patient label the required items must be handwritten on the blood issue form. a. Patient's name as it appears on the ARMC patient identification band. EFFECTIVE DATE: 1/98 5
b. Location where transfusion is to occur. NOTE: If there is no location on the patient label, you must write the location on the issue form. If there is a location on the patient label that is NOT the transfusing location (i.e. OR, etc), you must write the correct location on the issue form and cross out the incorrect location. c. Date of Birth (DOB). See NOTE #1. d. Products Requested: Indicate the number of products being requested next to the applicable product on the issue form. e. Special Requirements (i.e. irradiated, CMV negative, etc.) NOTE #1: For specimens that are received and identified as patient s registered utilizing the Trauma pack information (Trauma, Alpha 1), the Trauma number and medical record number are the patient s unique identifiers. Once the patient has been identified and the registration has been changed, the patient s name and date of birth will be used to uniquely identify the patient. 3. Issuing/ Receiving Blood Products from the Transfusion Service: a. The individual issuing the blood product, along with the person receiving the blood product: Must verify the information on the unit tag against the information on the blood issue form and blood product label. Transfusion Service staff must read aloud the information being verified. 4. Blood Issue Form/Blood Product Tag Patient's Name EFFECTIVE DATE: 1/98 6
Patient's Medical Record Number or other identifying number, where applicable Patient s Date of Birth. See NOTE #1under Blood issue form above. 5. Blood Product Tag/Blood Product Label Donor Unit Number Donor Type and Rh Recipient Type and Rh Expiration Date and time (if applicable) of Unit NOTE: If there is any discrepancy the blood product will not be issued until the discrepancy is resolved. 6. The individual issuing the blood product must record: Donor Number Type and Rh of the Unit Date and Time Issued and Their Initials a. The individual issuing the blood product must inspect the blood product before release for abnormal color and/or appearance (i.e. brown, purple or green plasma, presence of clots, etc.). If unacceptable, do not release the unit and place the unit in quarantine. b. If abnormal appearance or color is noted with products being removed from the OR refrigerator, these products should be returned immediately to the Transfusion Service. EFFECTIVE DATE: 1/98 7
c. The individual issuing the blood product will verify the location on the blood issue form and will record the location on the transfusion tag if different than that already on the transfusion tag. d. The individual, to whom the blood product is being issued, must sign the blood issue form. NURSING RESPONSIBILITIES PRIOR TO REQUESTING DELIVERY OF THE BLOOD/PRODUCT: 1. Ensure adequate venous access: a. If current IV cannot be interrupted for transfusion, start another IV. 1. A PICC line may be used for infusing blood products via an infusion pump through a catheter size of 4 French or larger. 2. Exceptions require a practitioner s order. 2. Assess patient and record vital signs. a. Report any abnormal finding to prescriber. 3. Determine if the patient has a history of transfusion reactions and requires pre-transfusion medications. a. Administer medications as ordered. EFFECTIVE DATE: 1/98 8
4. Blood products should be picked up immediately prior to transfusion with the transfusion to be initiated within 20 minutes from release from the Transfusion Service, and completed within four hours. NOTE: If the transfusion is not started within 20 minutes (excluding Blood/Blood products issued in the validated TS cooler), the blood product can still be transfused as long as the four hour time limit is not exceeded. If it is determined that a delay will cause the four hour time limit to be exceeded, the un-spiked blood/blood product must be returned to Transfusion Services once that determination is made. 5. Do not store any blood product in unmonitored unit refrigerators or at room temperature. 6. Only one unit at a time will be released for any one patient with the exception of the following: EXCEPTIONS: Multiple units for OR patients. These units must be placed in the validated cooler or monitored refrigerator (used for Mainland Heart cases only) immediately. Multiple units may be released in a validated Transfusion Service cooler for STAT MASSIVE TRANSFUSION. Refer to STAT MASS protocol, policy #3972. Multiple units for ED, TRAUMA ADMITTING AREA, CRITICAL CARE, and L&D patients in a validated Transfusion Service cooler or with multiple accesses in which the units are to be administered simultaneously. EFFECTIVE DATE: 1/98 9
Multiple units of platelets. Multiple units (2) packed in the validated TS transport container for transport to another facility by the Specialty Care Transport Unit (SCTU). NOTE: The unit picking up the blood must notify the transfusion service that the blood/blood products are for transport to another facility. NOTE: For emergent situations, multiple units may be released at once for MEDICAL/ SURGICAL/ TELEMETRY patients in the validated cooler and must have been initiated with a Physician/AHP order. 7. For issue of blood products for heart surgery refer to OR Heart Refrigerator, policy number 705. 8. Only one patient s blood product will be issued to a single individual. If an additional patient from the same floor/unit/location requires a blood product, a staff person must first pick up and deliver the product for the first patient, and then return to the Transfusion Service to pick up a blood product for the second patient. 9. Return of unused units: Return validated Transfusion Service (TS) coolers/ OR coolers within 4 hours. Coolers are only TS coolers. Return units stored in the monitored OR Heart Refrigerator or in the validated cooler as soon as patient is released or discharged from the OR. (DO NOT KEEP BLOOD OVERNIGHT IN THE OR REFRIGERATOR OR BEYOND THE DESIGNATED TIME IN THE COOLERS). Units issued and not utilized in transport by the SCTU. EFFECTIVE DATE: 1/98 10
Units must be hand-delivered to a technologist. Units are not to be left in the department or refrigerator without notification of Transfusion Service personnel. 10. For emergency issue of blood products, refer to the policy Emergency Release of Blood, policy #688. 11. For Emergency Medical Services Transport: Blood product transfusions shall be completed according to the policy during transport. Blood products being sent with the SCTU shall be verified by the sending ARMC facility per policy prior to transport and maintained in an ARMC approved transport container. Should it become necessary to transfuse any additional blood/blood products during transport the blood/blood product will then be verified by the transport RN and EMS technician according to ARMC policy. If a blood transfusion reaction is suspected, the Medical Command physician will be notified and the anaphylaxis policy initiated. PRE-TRANFUSION: 1. Recipient Identification a. Ask the patient to state his/her name and birth date if able. Do not ask, Are you Mr.? or Is your birth date? b. Check that the patient s full name and birth date on the transfusion tag matches exactly the stated name on the ARMC patient s identification band. c. Check that the medical record number on the transfusion tag matches exactly the medical record number on the ARMC patient s identification band. EFFECTIVE DATE: 1/98 11
NOTE: SCTU if transfusing a patient from a non-armc facility utilize the armband from the sending facility. 2. Unit Identification a. Check that the birth date on the transfusion tag matches the birth date on the ARMC patient s identification band. NOTE: For patients that are registered utilizing the Trauma pack information (Trauma, Alpha 1) the Trauma number and medical record number are the patient s unique identifiers. Once the patient has been identified and the registration has been changed, the patient s name and date of birth will be used to uniquely identify the patient. For patients that have been identified with a Typenex band, the identifier becomes the Typenex band number in lieu of the hospital medical record number. b. Check that the donor number on the blood product label matches the donor number on the transfusion tag. c. Compare the ABO group and Rh type on the blood product label against the ABO group and Rh type of the donor unit on the blood product tag. These MUST be ABO match and Rh type. d. Compare the ABO group and Rh type on the blood product label against the ABO group and Rh type of the patient on the blood product tag. These MUST be ABO compatible. EFFECTIVE DATE: 1/98 12
e. Check that the expiration date and time (if applicable) on the blood product label matches the expiration date on the transfusion tag. Verify that product has not expired. f. Check the interpretation of the Crossmatch Transfusion Tag. This should read compatible or least incompatible. NOTE: A physician/ahp and patient must sign for least incompatible blood prior to issue from the Transfusion Service. NOTE: If the Crossmatch Transfusion Tag has not been completed at the time of issue, an Emergency Transfusion Tag will be attached to the blood product. The Physician/Licensed AHP must sign the emergency transfusion tag prior to the initiation of the transfusion. g. If all information is correct, the two licensed providers must sign the transfusion tag to verify that these checks have been completed and are correct. h. Check the blood product for unusual color or appearance. Avoid transfusion if the cells or plasma have discoloration, the plasma is opaque or muddy, or there are clots or abnormal masses in the liquid blood. NOTE: If there is any discrepancy, the blood product must be returned to the Transfusion Service until the discrepancy can be resolved. Under no circumstances may blood products be placed in the unit refrigerator EFFECTIVE DATE: 1/98 13
or kept on the unit, unless issued in a validated cooler. Unused blood not issued in a validated cooler must be returned to the Transfusion Service immediately. ADMINISTRATION: 1. Prior to Initiation of Transfusion a. Vital Signs - Vital signs will be taken and documented as follows and will be documented directly on the transfusion tag. The transfusion tag must remain attached to the blood product throughout the entire transfusion process. Use the same route for temperature assessment throughout the transfusion. Within 15 minutes prior to initiation of transfusion (baseline) 15 Minutes After Initiation of Transfusion Upon Completion of Transfusion NOTE #1: Patient's are at risk for a transfusion reaction when an increase in temperature is noted. An increase in temperature is considered an increase of greater than 1 degree Celsius or 2 degrees Fahrenheit over the temperature immediately before transfusion (baseline). Patients who are being warmed require documentation of warming on the tag as an indication to why there is a temperature increase. NOTE #2: Documentation of vital signs for emergent transfusions (transfusion of one unit in less than 15 minutes) will be completed by indicating emergent in the vital sign section of the transfusion tag. EFFECTIVE DATE: 1/98 14
NOTE #3: For any other patient care area where vitals signs are recorded in the patient s medical record rather than on the transfusion tag, it must be indicated on the transfusion tag where the vital signs are recorded ( anesthesia record, perfusion record, etc.). INITIATION OF TRANSFUSION: Ensure that all pre-transfusion protocols have been performed. Infusion pump may be used to transfuse blood products. The IV infusion pumps that are used for blood product administration will be quality tested by the department of biomedical engineering on a quarterly basis and the reports will be sent to the department of transfusion services. Exceptions to Administering Blood via Infusion Pump Stat Mass (i.e. active bleed) Emergent/rapid administration (i.e. via pressure delivery device Level 1or with a pressure bag) Transfusion administered in <30 minutes or 1 hour Blood Administration via Gravity Blood Administration via Infusion Pump 1. Obtain a Y-set administration set with in-line 1. Obtain Primary Set tubing, Blood Secondary Set 170 micron filter and a bag of normal saline with 170 Micron filter, a bag of normal saline solution solution. and an IV pump. 2. Close all flow clamps. 2. Confirm the cassette flow stop and roller clamp are 3. Under aseptic conditions insert the vented piercing spike of the Y-set into 250-ml of normal saline solution, open the clamp and prime the tubing. Squeeze the top portion of the drip closed. 3. Under aseptic conditions insert the Primary Set tubing into 250-ml of normal saline solution. EFFECTIVE DATE: 1/98 15
chamber (avoiding the filter) until the fluid level is even with the top of the filter. Close the clamp. 4. Gently invert the blood product bag several times. 5. Expose the blood bag's port and insert the piercing spike. Open the bloodline clamp and fill the drip chamber with blood product until the filter is completely covered. Close the clamp. 6. Tap the drip chamber to expel any residual air within the filter. Adjust the fluid level if necessary. 7. Open all clamps between the blood bag and the patient and adjust the flow clamp closest to the patient to deliver 10 drops per minute. Do not use upper roller clamps to adjust flow rate. 4. Open the cassette flow stop, roller clamp and prime the tubing. Tap the back check valve and cassette while holding in an inverted position to expel any residual air. Return the cassette to upright position. Assure all air is expelled from the administration set. 5. Gently invert the blood product bag several times. 6. Expose the blood bag s port and insert the piercing spike of the Secondary set into the blood. Open the bloodline clamp and fill with blood product until the filter is completely covered. Close the clamp. 7. Turn infusion pump on and set pump to volume to be infused. EFFECTIVE DATE: 1/98 16
8. After infusion is completed close the blood product line clamp. Open normal saline line clamp and flush the filter and tubing. Maintain a normal saline solution infusion to KVO if an additional blood product is to be administered. If no additional blood product is to be administered, reconnect the original IV fluid, insert a male adapter, or discontinue the IV. 8. Load the cassette into the cassette carriage. The cassette carriage closes automatically in approximately ten seconds. *Remember to use the LOAD/EJECT button to open and close the cassette carriage. 9. Open clamp to the blood product. 10. After infusion is completed, clamp all lines; disconnect from patient. Flush Peripheral per Policy #1061-Catheter Flushing. *ONLY 0.9% NORMAL SALINE SOLUTION IS PERMISSABLE WITH BLOOD PRODUCT AND COMPONENT ADMINISTRATION. DO NOT ADD DRUGS OR ANY OTHER FLUIDS WITH, OR IN CONJUNCTION WITH, THE TRANSFUSION. NOTE: Emergent transfusion of blood or administering blood via infusion pump should not utilize the Clave system (i.e. any transfusion requiring infusion in less than 2 hours). The IV line for an emergent transfusion should be connected directly to the patient s IV access. 1. The nurse initiating the transfusion will record the date and time the transfusion is started on the tag. EFFECTIVE DATE: 1/98 17
2. Neonatal and Pediatric Units: The blood product may be drawn through blood administration set with an inline filter, an appropriate size syringe and prime extension tubing may be utilized. All blood transfusions on the pediatric unit may be given via an infusion device. If the volume to be transfused is greater than 60 ml, an IV infusion pump will be used. If the volume is less than 60 ml a syringe pump will be used. 3. The transfusionist will remain with the patient for the first 15 minutes after the start of the infusion because catastrophic events such as anaphylactic reactions or massive hemolysis due to ABO incompatibility usually become apparent after a very small volume enters the patient's circulation. 4. If patient exhibits any signs/symptoms indicative of a serious transfusion reaction, STOP THE TRANSFUSION IMMEDIATELY. A physical assessment MUST be performed. If the attending Physician or Licensed AHP is not available, call a Transfusion MET. The SCTU must call Medical Command Physician (MCP). (See definition for serious transfusion reaction on page 22 of policy under Transfusion Reaction section). 5. If administering via gravity and no unusual signs or symptoms are apparent, increase the flow rate to 20 drops per minute, or that specified in the Physician/Licensed AHP order. 6. Assess the patient and record the patient's blood pressure, pulse, temperature and respiration as indicated. EFFECTIVE DATE: 1/98 18
NURSING CONSIDERATIONS: 7. A Registered Nurse must accompany a patient receiving a blood product transfusion upon transfer (i.e. internal, external). 8. In an emergent situation when multiple units are administered simultaneously, the transfusionist must remain with the patient until the transfusion is complete. 9. The rate of infusion varies with the patient's blood volume, hemodynamic condition and cardiac status. The Physician/AHP will specify the infusion rate. For rapid infusion with an external pressure device, only large-bore catheters should be used. External pressure devices should be equipped with a pressure gauge, and the pressure exerted should not be above 300 Torr. Blood pressure cuffs may not be used as external pressure devices. NOTE: All packed red blood cells received in this facility are leukoreduced, except in times of extreme shortages. Whole blood is not leukoreduced. The label on the front of the blood product will indicate if the product is leukoreduced. 10. The transfusion must be completed within 4 hours from the time of issue of the blood product from the Transfusion Service and prior to component expiration. Infusion must not exceed this 4-hour time limit. If blood product or components have not been infused within 4 hours, discontinue the transfusion. Indicate on the transfusion tag that complete unit was not infused and record the estimated amount infused. If the physician has requested that a smaller volume be infused within the four hour period, the Transfusion Service can divide the unit appropriately. A Physician/Licensed AHP EFFECTIVE DATE: 1/98 19
order is required for "divided units". NOTE#1: Blood products issued in validated coolers are to be transfused within 4 hours from the start of transfusion. NOTE#2: Blood products infused via gravity at a rate of 1 drop per 4-5 seconds will ensure that the transfusion is complete within 4 hours. NOTE #3: Physician s order for transfusion must state product, amount, and rate to be transfused during transport and documentation to accompany the SCTU RN. 11. Care should be taken with patients at risk for volume excess (renal impaired, CHF patients, etc). 12. If the blood product is not flowing freely via gravity, attempt the following: Ensure 20 gauge or larger bore catheter is being utilized. Flush line with 3cc of NSS as necessary. Reposition the patient s arm as necessary. Raise the height of the pole. Start a new line if the above is ineffective 13. If a patient is being transferred before a blood product has finished infusing, document on the top of the transfusion tag that the patient has been transferred and to what location. The SCTU and the unit receiving the transferred patient are responsible for completion of transfusion tag. EFFECTIVE DATE: 1/98 20
14. Transfusion of patients with cold agglutinin disease should be attempted with caution, starting at a slow rate of infusion initially and discontinuing the procedure if a significant reaction is imminent. A blood warmer during administration is useful, as is performing the entire transfusion at 37C whenever feasible. TERMINIATATION OF TRANFUSION: 1. Record the date and time the transfusion was completed. Circle whether, or not, the transfusion was complete ( yes or no ), and if transfusion was not complete, indicate on the blood product tag the approximate amount transfused. 2. Circle the appropriate place on the blood product tag to indicate if the recipient did or did not ( yes or no ) have a transfusion reaction. 3. After stopping/completing the transfusion, unless a transfusion reaction is observed, the blood product bag, and attached administration set, and needle, should be discarded according to the established procedures for disposing of regulated medical waste and needles. 4. In the case of a transfusion reaction, the blood product bag and attached administration set MUST be hand delivered to the Transfusion Service. 5. If additional transfusions have been ordered, obtain the next unit of the required blood product from the Transfusion Service. 6. Repeat the above procedure at the completion of each blood product transfusion. EFFECTIVE DATE: 1/98 21
7. Upon discharge of a patient who has received a recent blood transfusion, Blood Transfusion Discharge Instructions (#91160): are available in English and Spanish listing possible indications for post transfusion complications. The form should be signed by the patient or responsible party then copied. The original signed form should be placed on the chart and the copied form to the patient or responsible party. DOCUMENTATION ON BLOOD PRODUCT TAG: 1. All components of the blood bag product tag must be completed at the termination of the transfusion. 2. The entire tag (both portions) should be hand delivered to Transfusion Service to be reviewed. Once the tag is approved as correctly completed by Transfusion Services, one copy will be returned to you to place on the patient s medical record. NOTE: If the transfusion has been completed during transfer in the SCTU, the tag will be returned by the unit receiving the patient. TRANFUSION REACTION: DEFINITION: 1. Transfusion reaction is any unfavorable event occurring in a patient during or immediately following (1-2 hours) transfusion of blood products that can be related to that transfusion. Any of the symptoms listed below that occur during the transfusion EFFECTIVE DATE: 1/98 22
or within 2 hours following transfusion with no apparent clinical cause is to be considered indicative of a possible transfusion reaction and investigated accordingly. NOTE: In case of urticaria (hives) alone, the transfusion may be completed after assessment of the patient and communication with the patient s physician or Licensed AHP. The transfusion reaction form must still be returned to the Transfusion Service for follow-up as mild reactions may progress to serious reactions. In severe (will be decided by the physician performing the assessment) cases of uticaria or if the symptoms do not subside, a complete transfusion reaction work up MUST be completed. The transfusion should be discontinued. 2. A transfusion reaction is a serious event. Although symptoms usually occur in groups, a single symptom may indicate an adverse event. If a patient displays any of the unexpected symptoms below, evaluation by a Physician or Licensed AHP is required. If the attending or Licensed AHP is not available, a Transfusion MET intervention is required. The SCTU will contact the MCP. Each symptom should be reviewed to determine if it is related to the transfusion or an expected therapeutic clinical response (i.e. a decrease in BP after dialysis or receiving antihypertensive medication or an increase in temperature while on a warming blanket). If symptom(s) is/are determined to be expected therapeutic clinical response(s), documentation on the blood tag is required. Transfusion reaction signs/symptoms may include: GUIDE TO TRANSFUSION REACTIONS EFFECTIVE DATE: 1/98 23
Any patient receiving a transfusion of blood or blood products is at risk for a transfusion reaction. A transfusion reaction may be immediate, occurring during the transfusion or within several hours of the completion of the transfusion, or delayed. The chart below describes immediate and delayed reactions. Reaction Causes Signs and symptoms Prevention Nursing interventions Immediate reactions Hemolytic Administration of incompatible blood Increase in temperature from baseline (>1 o C or >2 o F); chest pain, dyspnea, facial flushing, fever, chills, nausea, vomiting, tachycardia hypotension, lower back pain, bloody oozing at the infusion or surgical incision site Carefully confirm the patient's identity against the blood or blood product. Monitor the patient at the start of the transfusion of each unit. Correctly label all blood samples and blood request forms. Monitor the patient carefully for the first 15 minutes of any transfusion. Administer IV fluids, oxygen, epinephrine, and a vasopressor as ordered. Observe the patient for signs of coagulopathy. Reaction Causes Signs and symptoms Prevention Nursing interventions EFFECTIVE DATE: 1/98 24
Septic Reaction Contamination of blood product Febrile Bacterial lipopolysaccharides Antileukocyte recipient antibodies directed against donor white blood cells Rapid on set of chills, high fever, vomiting, abdominal cramping, diarrhea, hypotension, shock Increase in temperature from baseline (>1 o C or >2 o F); chills/rigors; headache and vomiting palpitation, cough, tachycardia Use careful technique when collecting or administering blood. Change blood tubing and filter at least every 4 hours. Transfuse blood or blood product within 30 minutes of receiving. Complete transfusion of blood within 4 hours. Premedicate the patient with antipyretics. Limit the number of transfusions the patient receives, if possible. Provide broad-spectrum antibiotics, as prescribed. Monitor the patient for fever for several hours after completion of transfusion. Obtain blood cultures from a site other than the IV infusion site. Keep all blood bags and tubing and send them to the blood bank. Relieve the symptoms with an antipyretic. If the patient requires further transfusions, consider using a leukocyte removal filter. Transfusionrelated Granulocyte antibodies Hypoxemia; hypotension, There's no known Provide oxygen as acute in the donor or recipient increase in temperature prevention. needed. lung injury (TRALI) cause complement and histamine release from baseline (>1 o C or >2 o F), severe respiratory distress within 6 hours of transfusion, chills, hypotension Monitor pulse oximetry. Prepare for intubation and ventilatory support and hemodynamic monitoring. Reaction Causes Signs and symptoms Prevention Nursing interventions EFFECTIVE DATE: 1/98 25
Anaphylactic reaction Transfusionassociated circulatory overload (TACO) Allergen in donor blood Hypotension, urticaria, fever, nausea, vomiting, anaphylaxis (facial swelling, laryngeal edema, respiratory distress) in extreme cases, anxiety Rapid infusion of blood Excessive volume of transfusion Dyspnea, orthopnea, cough, tacycardia, hypertension, headache, chest tightness, chills,, tachypnea, hypoxemia, jugular vein distention Administer antihistamines if the patient has history of allergic reaction. Infuse at the slowest rate needed while keeping total transfusion time in mind. Ask the blood bank to divide unit into smaller aliquots. Administer antihistamine, corticosteroid, or epinephrine as ordered. Prepare for intubation and respiratory support if the patient develops anaphylaxis. Monitor intake and output, breath sounds, and blood pressure. Administer diuretics as needed. Occurs within 2 to 6 hours after transfusion Elderly patients and those with history of cardiac disease are at higher risk. When a possible transfusion reaction occurs: 1. Stop the transfusion immediately. 2. Keep the IV access open with 0.9% normal saline solution. 3. Report the suspected reaction to the Transfusion Service and Attending Physician immediately. If the attending Physician or Licensed AHP is not available, call a Transfusion MET. The SCTU will contact the MCP. EFFECTIVE DATE: 1/98 26
4. Upon notification, the Transfusion Service will order the transfusion reaction workup in the computer and send the Transfusion Reaction Investigation form to the unit. 5. Perform Post Transfusion Identification Check at the patient s bedside. Confirm that transfusion tag matches patient wristband and transfusion tag matches product. Document on the reaction form that this clerical check has been performed. 6. Complete Investigation of Suspected Transfusion Reaction Form (issued by the Transfusion Service). Follow instructions and document accordingly. NOTE: In some cases, after the physical assessment of the patient, the physician may decide to continue with transfusing the products, if clinically indicated. The Investigation of Suspected Transfusion Reaction Form MUST be completed and signed by the licensed physician with documentation on the form stating that the patient is not having a reaction. The Transfusion reaction workup consisting of the Transfusion Reaction Investigation form and a properly hand written EDTA (purple) tube MUST be returned to the Transfusion service within 30 minutes of the original notification. The transfusion may be completed once the patient has been assessed. Return the bag to the Transfusion Service at the completion of the transfusion. 7. Treat signs/symptoms per Physician's or Medical Resident s orders and monitor and record. 8. Record the stop date and time on transfusion tag and mark reaction yes. NOTE: In cases of urticaria (hives), the transfusion may be completed after assessment of the patient. The transfusion reaction form must still be returned to the Transfusion EFFECTIVE DATE: 1/98 27
Service for follow-up. 9. A suspected transfusion reaction is considered a medical emergency. Obtain a patient blood sample in one purple top tube hand labeled, and a urine sample. Hand deliver the blood product bag with attached administration set, completed transfusion tag, blood and urine sample, and completed Transfusion Reaction Investigation form to the Transfusion Service within 30 minutes of initial notification. The Transfusion Service will call at 20 minutes after they are notified in order to remind the floor to send the form down at 30 minutes. NOTE: The Investigation of Suspected Transfusion Reaction Form requires the individual completing the form to print both their name and the name of the Physician performing the assessment in the applicable locations. 10. If review of transfusion tag returned within 24 hours show a temperature increase of >1C or >2F in which a suspected transfusion reaction was not reported to the Transfusion Service, notification will be made to the floor that a transfusion reaction investigation is being initiated by the Transfusion Service and the investigation will be completed. For transfusion tags received more than 24 hours after transfusion, a direct antiglobulin test (DAT) will be requested by the Transfusion Service. NOTE #1: Should a patient experience a suspected transfusion reaction at the Cancer Care Center (CCC), requiring emergency intervention, the RN will activates the EMS system (911) and monitor the patient until arrival. Once the patient is stabilized by EMS, the RN will notify the attending physician of the situation. An AED is available at the CCC. EFFECTIVE DATE: 1/98 28
NOTE #2: In the event that reaction takes place during SCTU transport, patient will be stabilized in transport and Transfusion reaction investigation will take place upon arrive by the accepting facility. DEFINITIONS: AtlantiCare: AtlantiCare is defined as AtlantiCare Health System, Inc., or AtlantiCare Regional Medical Center, or AtlantiCare Behavioral Health, Inc., or AtlantiCare Foundation, Inc., or AtlantiCare Health Plans, Inc., or AtlantiCare Health Services, Inc., or AtlantiCare Surgery Center, LLC, or InfoShare, or any AtlantiCare affiliate. AtlantiCare affiliate: AtlantiCare affiliate is defined as an organization associated with another AtlantiCare organization as a subordinate, subsidiary, or member. EFFECTIVE DATE: 1/98 29