SOP: Care of the Patient Receiving a Blood Product
Approved by NPC on 9/15/2011
National Institutes of Health
Clinical Center
Nursing and Patient Care Services
Standard of Practice: Care of the Patient Receiving a Blood Product
I.
Essential Information
A. TYPENEX
1. The Typenex Barcode band system is a 2nd identification verification system for transfusions. Each Typenex Barcode band is
coded with a unique number that specifically links the patient with the collected Type and Antibody Screen (TAS) specimen and
the dispensed blood component.1
2. A Typenex Barcode band is not required when infusing plasma, platelets, or cryoprecipitate because these products contain a
minimal number of red blood cells.
B. BLOOD DRAW
1. A current TAS will display under the CRIS results tab, Transfusion Medicine section including collection and expiration dates.
2. An order requisition does not need to accompany TAS as long as the specimen collection tube is labeled with specimen barcode
label and Typenex Barcode label.
3. The cross-match sample expires on 11:59 pm on the third day after the blood is drawn, (e.g. a sample drawn anytime on Tuesday
the 23rd will expire at 11:59 pm on Friday the 26th).
4. For patient safety the “right patient” is identified using the patient’s first and last name and date of birth (DOB). The major cause
of acute transfusion related death is error in identification.2
C. BLOOD ADMINISTRATION
1. Each blood product administration requires 2 orders: a component order and infusion order.
2. Blood products encompass red blood cells, plasma, platelets and granulocytes. Refer to Cellular Therapy Procedure for
administration of cellular components.
3. Granulocytes need to be infused as soon as DTM verbalizes that the product is ready. Due to the deteriorating viability of the
product, timely infusion is critical. Unless otherwise stated by an Attending MD, the infusion takes priority over all medical testing
and patient requests (i.e. ADL’s).
4. Granulocytes may be issued that are “out of group” (i.e. ABO of patient not compatible with granulocytes). Granulocytes that are
incompatible with a patient’s blood type undergo red cell reduction by sedimentation. Granulocyte bag and product comment in
results tab will indicate “component sedimented to reduce incompatible RBC.” This indicates the product is acceptable to give.
Page Department of Transfusion Medicine (DTM) Fellow on call or patient’s Licensed Independent Practitioner (LIP) if more
clarification is needed.
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SOP: Care of the Patient Receiving a Blood Product
Approved by NPC on 9/15/2011
5. Optimally a patient is transfused in their assigned patient care unit (PCU).
6. All red blood cells, platelets, and granulocytes are irradiated prior to transfusion.
7. A leukocyte reduction filter may be used to prevent febrile reactions, decrease risk of Cytomegalovirus (CMV) transmission and
decrease the incidence of allo-immunization.3
8. Leukocyte reduction filters are not to be used when administering granulocytes. Use approved blood administration IV tubing set.
9. The practice of co-administration of all blood products and PCA opioids in the same dedicated lumen should be avoided. If no
other Venous Access Device (VAD) is available to allow for separate administration, consult with patient’s LIP and DTM. If
approved by DTM, the LIP must place an order for co-administration. Demerol (meperidine) can NEVER be co-administered
with RBC and granulocytes as studies clearly showed that it causes hemolysis.
10. Symptoms of an immediate adverse reaction are usually manifested during infusion of the initial 50 ml. If an incompatible
transfusion is terminated early, acute renal necrosis and death may be prevented.
11. Blood Products Competency required.
II.
Assessment
A. Pre transfusion
1. Assess for a valid TAS in the results tab, Transfusion Medicine, prior to drawing a new TAS and replacing Typenex Barcode
band.
2. Assess baseline vital signs no more than 60 minutes prior to transfusion of product.
3. Notify LIP if patient is febrile to determine if transfusion can wait or antipyretic is indicated as a pre-medication.
4. Assess the appearance of the blood product; if appearance is suspicious return it to DTM.
5. Verify all identification is attached to the bag including a RadSure label that reads “Irradiated.”
6. All red blood cells and platelets are leuko-reduced prior to or concurrent with infusion, check for label indicating leuko-reduced or
use a leuko-reduction filter
7. Blood warmer, if needed.
B. During Transfusion
1. Observe patient within eye sight for the first 15 minutes.4
2. Monitor patient for signs and symptoms of adverse reaction during transfusion. Common adverse symptoms include: fever,
chills/rigors, nausea/vomiting, hives/itching, headache, dyspnea, wheezing, hypertension, hypotension, hemoglobinuria,
hemoglobinemia, shortness of breath and back pain.
a. Report new symptoms to the LIP and DTM Fellow.
b. Report temperature increase of 1 degree C and at least 38 degrees Celsius to the LIP and DTM Fellow.
c. Hives and itching in the absence of other symptoms need not be reported to DTM. After reporting to LIP, interventions and
resolution of symptoms, the transfusion may be resumed.
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SOP: Care of the Patient Receiving a Blood Product
Approved by NPC on 9/15/2011
C. Post Transfusion
1. Continue to monitor patient and educate patients to monitor for signs and symptoms of possible transfusion related adverse
reaction.
2. Transfusion Related Acute Lung Injury (TRALI) has emerged as the leading cause of transfusion associated morbidity /mortality
and is considered under diagnosed and underreported. TRALI is an immune mediated complication, characterized by acute
hypoxemia and non-cardiopulmonary edema during or within 6 hours after a transfusion. For this reason symptoms should be
reported and considered as possible TRALI.5, 6
3. Any of the above described common adverse symptoms occurring 1-6 hours post transfusion should be considered as a possible
transfusion reaction.
a. Report new onset of symptoms to LIP and DTM fellow.
b. Report temperature increase of 1degree C and at least 38 degrees C to LIP and DTM Fellow.
III. Interventions
A. TAS specimen
1. Once confirmation of expired specimen or no specimen is obtained, TAS is collected via largest needle appropriate for patient (20
gauge needle for adults/22 or 23 gauges for children) and minimum blood volume of 1 ml (range 1-6 ml).
2. If a Typenex Barcode band must be removed by a licensed healthcare professional for clinical care or a clinical emergency (e.g.
insertion of an arterial line or upper extremity edema), the Typenex Barcode band can be re-attached using the R3 reattachment
system. Using this system will ensure that all identification information remains visible on an alternate upper or lower extremity.
Reattachment must be placed as soon as clinically reasonable but before the end of the shift by the licensed healthcare professional
who removed it, in accordance with patient identification procedures.
3. If the Typenex Barcode band cannot be re-attached by the same licensed healthcare professional due to a clinical emergency that
requires immediate transfer of the patient, the individual who removed the Typenex Barcode band will hand it directly to the
receiving nurse so that it can be promptly re-attached after the clinical situation has stabilized.
B. Blood Component Administration
1. The patient must remain on their assigned PCU for the first 15 minutes of the transfusion. A patient may leave PCU after the first
15 minutes if the transfusion has been tolerated without complications and the patient is accompanied by a licensed healthcare
professional.
2. If patient care must be transferred during a transfusion, assure a handoff occurs with a licensed healthcare professional competent
to administer blood products.
3. Insert appropriate size catheter to transfuse product without damaging vein but allow infusion at appropriate flow rate (20 gauge
for adults and 23 gauge for children). If a 23 gauge catheter is used the product may not infuse within 4 hours, thus product can
be issued in smaller aliquots.
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SOP: Care of the Patient Receiving a Blood Product
Approved by NPC on 9/15/2011
4. Allow 30-60 minutes elapse time for oral pre-medication and 10 minutes for IV pre-medication prior to administration of blood
product.
5. Allow 4 hours between completing amphotericin and beginning transfusion of granulocytes or vice versa. All other blood
products are to be separated from amphotericin by 2 hours.
6. If the blood component cannot be transfused within 30 minutes of arrival from DTM, it must be returned to DTM to avoid
7.
8.
9.
10.
11.
12.
wasting of the product. Blood products are never to be placed in the refrigerator or otherwise stored on the PCU. The nurse will
receive an alert in CareFusion if the issued time has expired.
Maintain all identification on the blood product at all times. If a product is returned to DTM, all identification must be intact. If
any discrepancy is noted in identification of patient and product, notify DTM at once and return the blood product until the
discrepancy is resolved.
Prime and flush tubing with 0.9% sodium chloride solution only.
The administration set is changed every 4 hours.
a. To avoid obstructing the in-line filter, no more than 2 units of blood should be administered through an administration set.
b. PRBC administration sets can be used for a second unit of blood if the second transfusion can be completed within 4 hours
of initial tubing set-up.
If a transfusion reaction occurs, 0.9% sodium chloride solution is transfused from a stopcock to avoid infusing additional blood
product in the tubing.
If a leukocyte reduction filter is used, do not flush filter with 0.9% sodium chloride solution, and use one filter per unit of blood.
Special Considerations:
Product
Infusion Tubing
RBC
Standard blood product
administration set*
Leukocyte reduction filter
Yes
and Standard Blood product
administration set
Standard Blood product
Yes
administration set
Leukocyte reduction filter
Yes
and tubing
RBC
Platelets
Platelets
Granulocytes
Standard Blood product
administration set
Approved
Infusion Pump
Yes
Yes
Special Considerations
If Leuko-reduced prior to issue
Do not prime or flush added
leukocyte reduction filter with
0.9% sodium chloride
If Leuko-reduced prior to issue
Do not prime or flush added
leukocyte reduction filter with
0.9% sodium chloride
Every 30 min gently agitate bag
to prevent sedimentation
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SOP: Care of the Patient Receiving a Blood Product
Approved by NPC on 9/15/2011
Fresh Frozen
Plasma
13.
14.
15.
16.
Standard Blood product
administration set
Yes
a. Infusion rates are patient and product specific, based on patient’s clinical status and LIP orders. Adults - Initial Infusion
rates:
i. Platelets or Plasma: Adjust rate to infuse 5 ml/min (120-300 ml/h) during the first 15 minutes.
ii. Whole blood, packed RBC and granulocytes: 1-2 ml per minute (60-120 ml/hr) for the first 15 min.
iii. For patients at risk of fluid overload: adjust rate of PRBC to 1ml/kg/hr.
b. Adults infusion rates after initial 15minutes:
i. Platelets: To infuse over 45 minutes to one hour as indicated by patient status and clinical indication. Adjust rate to
120-400 ml/hr.
ii. PRBCs: To infuse over 2 hours but not to exceed 4 hours. Adjust rate to 120-240 ml/hr.
iii. Granulocytes: 120-150 ml/hr over about 2 hours.
c. Pediatrics- Initial infusion rates:
i. Platelet or Plasma: rate is adjusted to deliver 5% of total volume in the first 5 minutes.
ii. Whole blood, PRBCs or granulocyte infusions: adjust rate of flow to infuse 5% of total volume in the first
15minutes. Volume of blood products (excluding granulocytes) to be transfused should be ordered based on the
child’s weight, i.e. 10-15 ml/kg. See appendices A and B.
d. Pediatrics- Infusion rate after initial 15 minutes:
i. Platelets: 4-8 ml/kg/hr up to 300 cc /hr as tolerated by status of patient.
ii. Plasma: 1-2 ml/minute; over less than 4 hours.
iii. PRBCs: 2-5 ml/kg/hr. (See Appendices A and B)
iv. Granulocytes: over 2-3 hours (based on 200 ml volume).
Volume reduction of blood products in pediatric population is based on policy and/or clinical indications.
a. Per DTM policy, platelets are volume reduced for children < 40 kg; plasma will be reduced to 2 ml/kg but not less than 30
ml.
b. Platelets may also be volume reduced based on clinical indications, such as cardiac status or history of repeated allergic
reactions.
If patient experiences a transfusion reaction during transfusion, immediately stop transfusion.
a. Maintain patency of the line with 0.9% sodium chloride.
b. Notify LIP and DTM.
Provide outpatients with written information on “Delayed Transfusion Reaction. (Appendix C)
Obtain 10-60 minute post HLA matched transfusion CBC for post-count, or if indicated/ordered by LIP for any other transfusion.
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SOP: Care of the Patient Receiving a Blood Product
Approved by NPC on 9/15/2011
IV. Documentation
A. Vital signs can be recorded in CareFusion Transfusion Verification prior to a blood component being issued and then imported when
the infusion begins as long as vital signs are not taken more than 60 minutes before beginning the transfusion.
B. If more than one blood component is being given, the pre-transfusion checklist can be imported from the previous blood component as
long as the checklist is not more than 2 hours old. If the nurse opts to import the prior pre transfusion checklist, verification of
information is required prior to import.
C. Vital signs from the end of one product can be used for the start of another product via import route if not more than 60 minutes
between products and with one minute between documented timeframes.
D. Vital Signs will interface to the CRIS vital sign observation flowsheet.
E. CareFusion Transfusion Report will be filed as a PDF in CRIS under Documents tab.
F. Transfusion workup results for individual patients can be found in the “DTM Consult” in CRIS results tab.
G. Document patient education in CRIS.
V. References
1. Pagliaro, P., Turdo, R., & Capuzzo E. (2009). Patients’ positive identification systems. Blood Transfusion, 7, 313-8.
2. Aulbach, R., Brent, K., Custard, K., Gecomo, J., & Ong, J, (2010). Blood Transfusions in Critical Care: Improving Safety through
Technology and Process Analysis. Critical Care Nursing, 179-190.
3. Circular of Information for the use of human blood and blood components. Revised December 2009.
4. Robeck, J., Combs, M., Grossman, B., Hillyer, C., AABB Technical Manual, 16th edition.
5. Federico, A., (2009). Transfusion Related Acute Lung Injury. Journal of Peri Anesthesia Nursing, 24 (1), 35-40.
Napolitano, L., Kurek, S., Luchette, F., et al., (2009). Clinical Practice Guideline: Red blood cell transfusion in adult trauma and critical care.
Critical Care Medicine 337(12), 3124-57.
Approved:
//s//
____________________________
Clare Hastings, RN Ph.D., FAAN
Chief, Nursing and Patient Care Services
Formulated: 9/2011
Implemented: 9/2011
Revised
Reviewed:
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