Describe the nurse’s role before blood transfusion and in monitoring the patient during blood transfusion to prevent or manage hazards.

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The Nurse's Role in Blood Transfusion: Pre-Transfusion Preparation and Monitoring

Blood transfusion is not a routine procedure - it is, as Pye's Surgical Handicraft states, "a serious undertaking" that should be regarded "as a form of transplantation of regenerative tissue." The process carries significant hazards, and the nurse holds the primary responsibility for safety at every stage.

Part 1: The Nurse's Role BEFORE Blood Transfusion

1. Verify the Physician's Order and Obtain Informed Consent

A physician's order is required to prepare, dispense, and administer any blood component. Before the transfusion begins, the nurse must verify that a valid order exists. Equally important, informed consent must be obtained - the patient must be told the risks, benefits, and alternatives to transfusion. As Henry's Clinical Diagnosis and Management by Laboratory Methods notes, "the physician's order and the patient's consent for transfusion should also be verified" before proceeding.

2. Patient Identification - the Most Critical Step

Transfusion of an incorrect blood unit is potentially fatal. The vast majority of serious transfusion reactions result from clerical errors, not biological incompatibility. The identification process must include:

At least two unique recipient identifiers (e.g., full name and registration/hospital number)
Comparison with a permanent identifier such as a wristband
The unit identifier on the blood container must be checked against the transfusion form or attached tag
The ABO and Rh type on the unit label must agree with the associated documentation and be compatible with the patient's recorded blood type
The expiration date and time of the component must be verified

A best practice endorsed by Tintinalli's Emergency Medicine is to use two qualified individuals to independently verify patient identity and unit details before starting any transfusion. Bar-code identification by one individual is an acceptable alternative.

3. Inspect the Blood Unit

Before spiking the bag, the nurse must visually inspect the blood component for:

Signs of contamination: discoloration, clumps, gas formation (bubbles), particulates, purple discoloration (red cells), green discoloration or clumping (platelets)
Clot formation within the bag
Integrity of the bag (no leaks)

Any abnormality means the unit must not be administered and must be returned to the blood bank.

4. Establish Appropriate IV Access

Venous access must be established before the blood component is issued from the blood bank. Key points:

Peripheral access with an 18-gauge needle or catheter is typically sufficient
Smaller catheters can be used but high-pressure flow through a small lumen may cause hemolysis
Central venous access is preferred for high-volume administration or long-term therapy
In neonates, Silastic central venous catheters block readily and peripherally sited cannulae are preferred

5. Record Pre-Transfusion Baseline Observations

Observations must be performed and documented before transfusion as a baseline. These include:

Temperature
Pulse rate
Blood pressure
Respiratory rate
Oxygen saturation

This baseline is essential - any rise in temperature, drop in blood pressure, or change in respiratory rate during the transfusion can only be recognized as significant if a pre-transfusion baseline exists.

6. Use the Correct Administration Set and Filter

All blood components must be administered through a filter intended to retain clots and particles, typically with a 170-260 μm pore size
The administration set must contain a drip chamber, an attached compatible IV solution, and a flow rate controller
During surgery, a microaggregate filter (40 μm) is used routinely to reduce the metabolic burden of processing aggregates of fibrin and cellular debris
Leukocyte reduction filters may be used for RBCs or platelets to reduce febrile reactions, HLA alloimmunization, and CMV transmission
Transfusions should not be started overnight unless urgently needed

7. Select the Correct IV Fluid

The choice of co-infusing fluid matters greatly:

Normal saline (0.9% NaCl) is the preferred and safest solution for all transfusions
Calcium-containing solutions (e.g., Ringer's Lactate) must be avoided - they reverse citrate anticoagulants and can precipitate clotting in the line
RBCs must not be administered with 5% dextrose, hypertonic saline, or hypotonic saline - these can cause hemolysis
Medications must not be added to blood components under any circumstances

8. Blood Warming (When Indicated)

Refrigerated blood components (RBCs or plasma) may need to be administered through a blood-warming device when given rapidly. Transfusion of cold components faster than 100 mL per minute for 30 minutes may increase the risk of cardiac arrest. Blood-warming devices must have a visible thermometer and audible alarm to avoid exceeding temperature limits. Blood should never be warmed with tap water, conventional microwave ovens, or unapproved devices.

9. Use of Pumping Devices

Blood should not be transfused using a peristaltic pump (e.g., IVAC-type) as the pumping action can cause hemolysis. Approved pressure devices (syringe pumps) may be used when flow under gravity is insufficient.

Part 2: Monitoring DURING Transfusion to Prevent and Manage Hazards

Critical First 15 Minutes

The nurse must start the transfusion slowly (approximately 2 mL/minute for the first 15 minutes) and remain at the bedside during this period. This is because severe reactions - acute hemolysis, anaphylaxis, sepsis - can manifest after only a small volume has entered the circulation. After 15 minutes with no adverse signs, the rate may be increased.

Required observations at 15 minutes after starting must be documented.

Observation Schedule

Observations (temperature, pulse, BP, respiratory rate, oxygen saturation) are documented at:

Baseline - before starting
15 minutes after starting each unit
End of transfusion of each unit

Transfusion Rate and Time Limits

Red cell transfusion should ideally be completed within 2 hours and must be completed within 4 hours of removal from the blood bank (risk of bacterial proliferation at room temperature)
Platelet and plasma transfusions should be given as quickly as tolerated, typically 30-60 minutes
Any transfusion not completed within 4 hours must be discarded

Recognizing and Managing Transfusion Hazards

Categories of Transfusion Reactions

Reaction Type	Timing	Key Features
Acute haemolytic	Immediate	Rigors, fever, hypotension, haemoglobinuria, back/chest pain, oliguria
Febrile non-haemolytic	During/after	Fever, chills (most common reaction, antibodies to WBC/platelet antigens)
Anaphylaxis	Immediate	Urticaria, wheeze, stridor, angioedema, hypotension
Bacterial contamination	During	Acute fever, rigors, hypotension, septic shock
Circulatory overload (TACO)	During/after	Dyspnoea, hypertension, pulmonary oedema
TRALI	Within 6 hours	Severe hypoxia, non-cardiogenic pulmonary oedema
Extravascular haemolysis	Delayed (days)	Unexplained anaemia, jaundice, fever
Disease transmission	Weeks-months	Hepatitis B/C, HIV, CMV, EBV

Immediate Management of ANY Suspected Transfusion Reaction (Box 24.2 - Scott-Brown's)

Stop the transfusion immediately - this is always the first step
Assess the patient: Airway, Breathing, Circulation (ABC)
Maintain venous access with physiological saline - keep the line open
Check the identification of the patient and compatibility of the blood component - rule out wrong blood/wrong patient error
Inspect the component for clumps or discoloration
Assess for evidence of blood loss
Unless the reaction appears to be mild allergic or febrile, perform: full blood count, renal and liver function tests, blood culture (if temperature rise), direct Coombs test, repeat group and screen, and urine for haemoglobinuria
Inform the transfusion laboratory immediately
Return blood components to the transfusion laboratory (unless mild allergic or febrile only)
Report to the national haemovigilance scheme (e.g., SHOT in the UK)

Specific Hazard Responses

Acute Haemolytic Reaction (most dangerous - up to 10% mortality)

Caused by ABO-incompatible blood, usually due to clerical error
Features: pain at infusion site, chest/back pain, hypotension, haemoglobinuria, fever, rigors, oliguria within 1 hour
Immediate action: stop transfusion, maintain urine output, manage shock, prevent acute kidney injury, notify blood bank

Anaphylaxis

Immediate: intramuscular adrenaline, intravenous chlorpheniramine, intravenous hydrocortisone
Future transfusions to be discussed with immunologist and haematologist

Bacterial Contamination

Immediately take blood cultures from patient
Start broad-spectrum antibiotics
Return component to lab for microbiological testing
Alert blood bank to recall other components from the same donor

TRALI (Transfusion-Related Acute Lung Injury)

Occurs mainly after platelets or FFP
Due to anti-leucocyte antibodies in donor plasma reacting with recipient's neutrophils and pulmonary endothelium
Severe hypoxia may develop immediately or at any point during transfusion
Manage as non-cardiogenic pulmonary oedema; may require ICU-level respiratory support

Circulatory Overload (TACO)

Particularly a risk in the elderly and those with cardiac disease
The increased oxygen-carrying capacity "must not be attained at the expense of precipitating cardiac failure in the elderly by volume overloading"
Monitor fluid balance; consider diuretics; slow or stop transfusion

Summary: Key Nurse Responsibilities at a Glance

Before:

Confirm order and informed consent
Double-check patient identity with two identifiers (ideally two nurses)
Match blood unit to patient documentation (ABO, Rh, unit ID, expiry)
Inspect blood bag for contamination or abnormalities
Establish adequate IV access (18G or larger peripheral, or central line)
Record baseline vital signs
Prime set with normal saline through correct filter
Prepare warming device if indicated

During:

Start slowly (2 mL/min) and remain at bedside for first 15 minutes
Record observations at 15 minutes and at end of each unit
Ensure transfusion completes within 4 hours of issue
Remain alert to any complaint of discomfort, back pain, rigors, dyspnoea, or rash

If reaction occurs:

Stop transfusion immediately
Call for medical assistance
Maintain IV access with normal saline
Recheck identification details
Follow the ABC reaction protocol above
Document everything and report to the blood bank

Sources:

Henry's Clinical Diagnosis and Management by Laboratory Methods - Transfusion Administration section
Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Acute Transfusion Reactions (Box 24.2)
Tintinalli's Emergency Medicine - Blood Transfusion chapter
Parikh's Textbook of Medical Jurisprudence - Blood Transfusion Reactions
Pye's Surgical Handicraft (22nd ed.) - Blood Transfusion chapter

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