Blood Transfusion (BT) - Complete Procedure

Overview

PART 1 - Blood Typing (BT) - Pre-Transfusion Tests

1. ABO & Rh Blood Grouping

• Draw venous blood from the patient into a red-topped, non-anticoagulated tube (no serum separator gel)
• Label the tube with the patient's name, date, and the signature of the person drawing the sample
• Blood bank tests determine ABO type (A, B, AB, O) and Rh factor (positive or negative)

2. Antibody Screen (Type & Screen)

• Patient's plasma is screened for unexpected antibodies that could react against donor antigens
• A type and hold (T&H) alerts the blood bank to keep appropriate units available without committing them to a specific patient
• A type and crossmatch (T&C) takes ~45 minutes and restricts that unit to your specific patient

3. Crossmatch

• Donor's red cells are mixed with the patient's serum
• If clumping (agglutination) or hemolysis occurs, the blood is incompatible - do not transfuse
• No reaction = compatible unit - safe to transfuse

1. Is in shock
2. Has symptomatic anemia (Hb < 10 g/dL)
3. Has documented blood loss > 1000 mL
4. Requires emergency blood-losing surgery (e.g., thoracotomy)

PART 2 - Blood Components Available for Transfusion

PART 3 - Pre-Transfusion Preparation

• Confirm clinical indication (anemia, active hemorrhage, coagulopathy, etc.)
• Review patient history for previous transfusion reactions and religious prohibitions
• Obtain informed consent

• Temperature, pulse, blood pressure, respiratory rate, and oxygen saturation
• These serve as reference for detecting reactions during transfusion

• Insert an 18G or larger peripheral IV cannula (large bore)
• For hemorrhagic shock: two large-bore cannulae at different sites
• Use a Y-type blood administration set (one arm for blood, one for normal saline)

• Flush the line with 0.9% normal saline (never dextrose - dextrose causes hemolysis)
• Do NOT use lactated Ringer's (LR) in large volumes - can promote clot formation (small amounts <150 mL are acceptable)

• Blood must be collected and transfusion started within 30 minutes of release from the blood bank
• Each unit must be transfused within 4 hours of removal from refrigerated storage
• Inspect the bag for: clots, discoloration, bag integrity, expiration date
• Never warm blood in a microwave; use an approved blood-warming device if needed (warmed to 35-37°C)

• Physician's order
• Patient's informed consent
• Patient's full name and identification number (at least 2 patient identifiers)
• Patient's blood group (ABO and Rh) on the unit label
• Donor unit number
• Expiration date of the blood unit
• Compatibility tag/crossmatch label on the unit
• Visual inspection of the blood bag

PART 4 - Transfusion Administration (Step-by-Step)

• Patient should be seated or lying down comfortably
• Ensure IV site is patent - flush with normal saline first

• Connect the blood bag to the Y-set
• Close the normal saline line clamp, open the blood line clamp
• Blood flows via gravity; hang the bag ~1 meter above the patient

• Initial rate: 25-50 mL for the first 15 minutes (approximately 2 mL/min or 120 mL/hour)
• The nurse must remain at the bedside during this entire period
• Most serious transfusion reactions occur within the first 15 minutes

• Vital signs at: baseline → 15 min → 30 min → 1 hour → completion
• Ask the patient to report any unusual sensations immediately: chills, flushing, itching, dyspnea, chest or back pain, headache

• Increase to the prescribed rate after 15 minutes of uneventful transfusion
• Stable adult patients: 1 unit PRBC over 1.5 to 2 hours (3-4 mL/kg/hr)
• Hemorrhagic shock: no rate limit - use pressure bag or rapid infuser (up to 300 mL/min via 14G IV)
• Cardiac failure patients: use furosemide at the start to prevent volume overload

• Once the unit is complete, flush the line with normal saline
• Document time started, time completed, volume infused, and patient's response

PART 5 - Transfusion Rates (Summary)

• 7 mL of whole blood per kg body weight raises Hb by ~1 g/dL
• 1 unit of PRBCs raises adult Hb by approximately 1 g/dL

PART 6 - If a Transfusion Reaction is Suspected

1. Keep the IV line open with new normal saline tubing connected directly to the cannula
2. Do NOT flush saline through the existing blood tubing (this pushes residual blood into the patient)
3. Take vital signs
4. Notify the physician immediately
5. Send the blood bag, tubing, and a patient blood sample + urine sample to the blood bank for analysis
6. Fill out a transfusion reaction report form
7. Do NOT discard the blood bag or tubing

PART 7 - Special Situations

• Activate the Massive Transfusion Protocol (MTP)
• Give FFP and platelets in a 1:1:1 ratio with PRBCs
• Watch for: hypocalcemia (citrate toxicity), hyperkalemia, hypothermia, dilutional coagulopathy
• Use blood warmers to prevent hypothermia (blood stored at 4°C)

• Use a syringe pump for small volumes; avoid peristaltic pumps (cause hemolysis)
• Do NOT exceed 20 mL/kg total volume in any 24-hour period
• Use peripherally sited cannulae; Silastic central lines block easily

• Blood stored at ~4°C can cause hypothermia and cardiac arrhythmias if given rapidly
• Use approved blood-warming coil devices - warm to 35-37°C
• Never use a microwave or improvised heating

Quick Reference Checklist

• Consent obtained
• Blood group + crossmatch done
• Large-bore IV patent and flushed with normal saline
• Two-nurse verification complete
• Baseline vitals recorded
• Blood bag inspected (expiry, integrity, color)
• Transfusion started within 30 min of blood bank release
• First 15 min: slow rate, nurse at bedside
• Vitals at 15 min, 30 min, 1 hr, completion
• Each unit completed within 4 hours
• Post-transfusion vitals and documentation done

• Pye's Surgical Handicraft, 22nd Edition
• Roberts and Hedges' Clinical Procedures in Emergency Medicine
• Rosen's Emergency Medicine: Concepts and Clinical Practice
• NCBI Blood Product Administration Table (Nursing Advanced Skills)
• Nurseslabs - Blood Transfusion Therapy