Blood transfusion is the intravenous administration of compatible human blood or its components into a patient’s circulatory system. This vital medical procedure aims to replace lost or deficient blood elements, thereby restoring blood volume, oxygen-carrying capacity, and/or correcting clotting abnormalities.

CATEGORIES OF BLOOD COMPONENTS

1. Whole Blood:

   • Description: Contains all blood components (red blood cells, white blood cells, platelets, plasma).

   • Indication: Severe, acute blood loss (e.g., major trauma, massive hemorrhage) and hypovolemic shock (dangerously low blood volume).

   • Purpose: Restore overall blood volume and increase hemoglobin levels, enhancing oxygen-carrying capacity.

2. Packed Red Blood Cells (PRBCs):

   • Description: Red blood cells separated from whole blood, with most plasma removed.

   • Indication: Anemia (e.g., aplastic anemia, sickle cell disease, severe malaria-induced anemia) and conditions requiring increased oxygen-carrying capacity without significant fluid volume expansion (e.g., some cardiac patients).

   • Purpose: Increase red blood cell count to improve tissue oxygenation without causing circulatory overload.

3. Platelet Concentrate:

   • Description: Concentrated platelets separated from whole blood.

   • Indication: Thrombocytopenia (low platelet count) leading to increased bleeding risk or active bleeding.

   • Purpose: Increase platelet count to improve hemostasis. Platelets initiate clotting in conjunction with coagulation factors (e.g., prothrombin, fibrinogen) to stop bleeding.

4. Plasma (Often Fresh Frozen Plasma – FFP):

   • Description: The liquid portion of blood, separated from cells, containing clotting factors, albumin, and other proteins.

   • Indication:

     • Replacement of clotting factors in deficiencies (e.g., liver disease, DIC).

     • Reversal of warfarin anticoagulation.

     • Volume expansion in shock (hypovolemic, septic), extensive burns, or severe hemorrhage.

     • Temporary volume expansion pending cross-matched blood.

   • Purpose: Expand blood volume and provide clotting factors and other essential plasma proteins.

SITUATIONS REQUIRING BLOOD TRANSFUSIONS

• Severe Anemia: Critically low red blood cell count, often due to:

  • Pregnancy-related complications (e.g., iron deficiency).

  • Sickle Cell Disease.

  • Complicated Malaria.

  • Anemia unresponsive to other treatments.

• Preoperative Optimization: To correct anemia or low blood volume before surgery.

• Extensive Burns: To replace lost fluids, proteins, and blood cells.

• Postoperative Recovery: Following surgeries with significant blood loss (e.g., laparotomy, open reduction of internal fractures, total abdominal hysterectomy).

• Trauma: Significant blood loss from accidents (e.g., road traffic accidents).

• Blood Clotting Factor Deficiencies: To provide missing coagulation factors.

IMPORTANT CONSIDERATIONS

• Blood Type Compatibility: ABO blood group (A, B, AB, O) matching is crucial.

• Rh Factor Compatibility: Rh factor (positive or negative) must be compatible. Rh-negative recipients should receive Rh-negative blood. Rh-positive recipients can receive Rh-positive or Rh-negative blood.

• Crossmatching: Laboratory testing to confirm compatibility between donor and recipient blood.

• Potential Risks:

  • Allergic reactions (mild to anaphylaxis).

  • Febrile non-hemolytic transfusion reactions.

  • Acute hemolytic transfusion reactions (AHTR).

  • Transfusion-Associated Circulatory Overload (TACO).

  • Transfusion-Related Acute Lung Injury (TRALI).

  • Infections (e.g., hepatitis, HIV, bacterial sepsis), though rare due to rigorous screening.

• Alternatives: Erythropoietin (stimulates RBC production), iron supplements, tranexamic acid (reduces bleeding), volume expanders, autologous transfusion.

• Informed Consent: Typically required after explaining risks, benefits, and alternatives.

REQUIREMENTS FOR BLOOD TRANSFUSION (Equipment)

• Blood administration set with an in-line filter (typically 170-260 microns).

• Large-bore IV cannula (e.g., 18-20 gauge preferred for adults).

• Prescribed unit of blood/component from the blood bank.

• 0.9% Sodium Chloride (Normal Saline) for priming and flushing.

• Observation chart (for vital signs) and fluid balance chart.

• Patient’s medical record with transfusion order.

• IV pole.

• Gloves and other PPE.

PROCEDURE FOR BLOOD TRANSFUSION

The administration technique is similar to standard IV infusion, with heightened vigilance.

• Post-Transfusion Handling: Do not rinse the empty blood bag. Retain it on the ward per facility policy (often 24 hours) for investigation if a delayed reaction occurs.

• Documentation: Meticulously record:

  • Date and time transfusion started and completed.

  • Blood product unit number(s).

  • Volume transfused.

  • Names of healthcare professionals verifying and initiating.

  • Patient’s baseline and ongoing vital signs.

  • Any reactions and interventions.

  • Urine output.

• Saline Administration: 0.9% Sodium Chloride is used to prime the tubing before transfusion and flush the line after completion. Blood products should NOT be mixed with or administered through the same line as medications (unless specifically indicated) or other IV solutions (especially dextrose-containing solutions, which can cause hemolysis, or Ringer’s lactate, which contains calcium and can cause clotting).

POSSIBLE COMPLICATIONS OF BLOOD TRANSFUSION

• Allergic Reaction:

  • Cause: Immune response to plasma proteins in transfused blood.

  • Signs & Symptoms: Itching, flushing, hives (urticaria), dyspnea, wheezing, hypotension, anaphylaxis.

  • Management: Stop transfusion immediately. Notify physician. Administer antihistamines, corticosteroids, or epinephrine as prescribed. Maintain airway.

• Febrile Non-Hemolytic Reaction:

  • Cause: Recipient antibodies against donor leukocytes or cytokines released during storage.

  • Signs & Symptoms: Fever (rise of ≥1°C), chills, headache, malaise.

  • Management: Stop transfusion. Notify physician. Administer antipyretics as prescribed. Rule out hemolytic reaction or sepsis.

• Acute Hemolytic Transfusion Reaction (AHTR):

  • Cause: ABO incompatibility (e.g., Type A blood to Type B recipient) causing intravascular hemolysis. Potentially life-threatening.

  • Signs & Symptoms: Rapid onset of fever, chills, shivering, headache, lower back/flank pain, chest pain, nausea, vomiting, dyspnea, hypotension, tachycardia, hemoglobinuria (red/brown urine), signs of shock, DIC, acute kidney injury.

  • Management: Stop transfusion immediately. Notify physician urgently. Maintain IV access with normal saline. Treat shock. Send remaining blood unit, new patient blood samples, and urine specimen to lab. Administer diuretics as prescribed. Provide supportive care.

• Transfusion-Associated Circulatory Overload (TACO):

  • Cause: Volume administered too rapidly or in excess of circulatory capacity, especially in patients with cardiac or renal impairment or chronic anemia.

  • Signs & Symptoms: Dyspnea, orthopnea, cough, cyanosis, tachycardia, hypertension, distended neck veins, pulmonary edema (crackles on auscultation).

  • Management: Stop or slow transfusion significantly. Notify physician. Place patient upright. Administer oxygen and diuretics as prescribed. Monitor vital signs.

• Bacterial Contamination/Sepsis:

  • Cause: Contamination of blood product or administration equipment.

  • Signs & Symptoms: High fever, chills, rigors, hypotension, nausea, vomiting, shock.

  • Management: Stop transfusion immediately. Notify physician and blood bank. Obtain blood cultures from patient and blood unit. Administer broad-spectrum antibiotics, IV fluids, and vasopressors as prescribed.

• Transfusion-Related Acute Lung Injury (TRALI):

  • Cause: Donor antibodies reacting with recipient leukocytes, leading to increased pulmonary capillary permeability and non-cardiogenic pulmonary edema.

  • Signs & Symptoms: Acute respiratory distress, hypoxemia, fever, hypotension, bilateral pulmonary infiltrates on chest X-ray, occurring during or within 6 hours of transfusion.

  • Management: Stop transfusion. Notify physician. Provide aggressive respiratory support (oxygen, mechanical ventilation if needed).

• Delayed Hemolytic Transfusion Reaction:

  • Cause: Recipient antibodies (often to minor antigens) causing extravascular hemolysis, typically 3-14 days post-transfusion.

  • Signs & Symptoms: Unexplained fever, jaundice, falling hemoglobin, positive direct antiglobulin test (DAT).

  • Management: Usually supportive; notify physician and blood bank.

• Transmission of Infectious Diseases:

  • Cause: Transmission of viral (e.g., Hepatitis B/C, HIV), bacterial, or parasitic (e.g., malaria) agents.

  • Prevention: Minimized by rigorous donor screening, deferral policies, and laboratory testing of donated blood.

THE NURSE’S ROLE: BEFORE, DURING, AND AFTER BLOOD TRANSFUSION

Before Blood Transfusion:

1. Verify Order: Confirm valid physician’s order in patient’s record.

2. Informed Consent: Ensure informed consent is obtained per facility policy.

3. Patient Education: Explain procedure, purpose, benefits, potential risks, and answer questions.

4. IV Access: Establish patent IV access with an appropriate gauge cannula (e.g., 18-20g).

5. Pre-transfusion Sample: Ensure a blood sample for type and crossmatch has been sent to the lab.

6. Baseline Vitals: Record baseline vital signs (temperature, pulse, respirations, blood pressure).

7. Retrieve Product: Obtain blood product from blood bank according to policy.

8. Verification (Two-Person Check at Bedside):

   • Confirm patient identity using at least two identifiers (e.g., name, medical record number, date of birth) against the compatibility label/tag.

   • Match blood product information on the bag label with the compatibility label/tag and patient’s record: patient name, MRN, ABO/Rh type of patient and unit, unit number, expiration date.

   • Inspect blood unit for leaks, clots, discoloration, or unusual appearance.

9. Gather Supplies: Assemble blood administration set, normal saline, IV pole.

10. Pre-medication: Administer any prescribed pre-medications (e.g., antihistamines, antipyretics).

11. Prime Tubing: Prime blood administration set with 0.9% Sodium Chloride.

During Transfusion:

1. Connect & Initiate: Connect blood product to tubing and begin transfusion slowly (e.g., 2 mL/min or 120 mL/hr for first 15 minutes, per policy).

2. Initial Monitoring: Remain with patient for the first 15 minutes. Monitor vital signs per protocol (e.g., before starting, after 15 minutes, then hourly or per policy, and upon completion).

3. Observe for Reactions: Continuously observe for signs/symptoms of adverse reactions. If suspected, stop transfusion immediately, maintain IV line with saline, notify physician and blood bank.

4. Regulate Flow Rate: After initial observation period (if no reaction), adjust flow rate to prescribed rate (usually to complete within 4 hours for PRBCs/Whole Blood).

5. Site Assessment: Regularly inspect IV site for phlebitis, infiltration, or leakage.

After Transfusion:

1. Flush Line: Once unit is infused, flush IV line with 0.9% Sodium Chloride.

2. Disconnect & Dispose: Disconnect set. Dispose of used blood bag and tubing according to biohazard waste policy. (Retain bag if policy dictates for post-transfusion reactions).

3. Post-Transfusion Vitals: Record vital signs upon completion.

4. Monitor: Continue monitoring patient for delayed reactions.

5. Documentation: Complete all transfusion documentation accurately and promptly.

6. Patient Comfort: Thank patient and ensure comfort.

Important Administration Time Guidelines:

• Whole Blood & PRBCs: Administer over approximately 2-4 hours per unit (not exceeding 4 hours from removal from controlled temperature storage).

• Plasma (FFP), Platelets, Cryoprecipitate: Typically administered more rapidly, often over 15-60 minutes per unit, based on patient’s clinical condition and tolerance.