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									                                                            Applies To: All HSC Hospitals and UNMCC
                                                            Responsible Department: Nursing, Blood Bank

 Title: Transfusion of Blood or Blood Products                                          Procedure
 Patient Age Group:          ( ) N/A        (x ) All Ages      ( ) Newborns         ( ) Pediatric     ( ) Adult

This document standardizes the transfusion of packed red blood cells and/or other blood

   AACN, 5th edition
   Atterbury, C., Wilkinson, J., (2000). Blood Transfusion. Nursing Standard London. RCN
    Publishing Company, Ltd.
   Intravenous Administration Set Change. (1998). Standards: Clinical Management.
    Journal of IV Nursing. Philadelphia: Lipincott, Williams & Wilkins
   Merenstein and Gardner, 6th edition, 2006, Handbook of Neonatal Intensive Care, Mosby
   Perry, A.G. & Potter, P.A. (2006) Clinical Nursing Skills & Techniques (6th ed). Elsevier
    Mosby, St. Louis

1. It is the responsibility of the Licensed Independent Practitioner (LIP) to write a complete order
    containing the following:
          1.1. Type of blood product to be administered
          1.2. The number of units to be administered
          1.3. Duration of transfusion (if less than 4 hours)
          1.4. The practitioner will also write the order for specimen collection for blood typing
               and crossmatching
                   1.4.1 Neonates who have always been patients, after the first crossmatch, do not
                         get re-crossmatched for four calendar months.
2. The LIP should consider including the following information in the order:
          2.1. Reason for blood product administration
          2.2. How soon the blood product should be administered.
          2.3. Special preparation of the blood product (e.g. irradiation, leukocyte reduction).
          2.4. Pre-medications, if required (e.g. benadryl or acetaminophen)
3. The ordering LIP is responsible for obtaining informed consent. However, it is essential for
    nurses to understand the components of informed consent so as to effectively address patient
    and/or family questions or concerns, or to identify when additional information should be
    provided to the patient and/or family prior to blood product administration.
 4. Whomever collects the blood sample must assure that the blood tube is correctly labeled with
          4.1. Patient’s identification: name, MRN and date of birth
          4.2. Date and time of the specimen collection
          4.3. Initials of the one collecting the specimen
5. Use of the rapid infuser or blood warmer is considered a “procedure”. The clinician using this
    special equipment is responsible for learning the steps, rationale, and special considerations
    for their use.
Title: Transfusion of Blood or Blood Products
Owner: Nursing Practice Council
Effective Date: 4/9/08
Doc. # 2301
                                                  Page 1 of 5
6. All patients must wear their identification bracelets at all times.

1. Obtain Informed Consent
         1.1. The patient/parent/guardian may withdraw consent at any time. This should be
              documented carefully. If withdrawal of consent and resultant cessation of blood
              product administration poses any risk to the patient, the risks of suspending
              treatment should be explained to the patient/parent/guardian and documented in the
              medical record. When in doubt, contact the hospital's Administration Representative
              or Health Sciences Center legal counsel for guidance and further action.
3. Pre-medicate the patient as ordered.
4. Two licensed personnel are required for verification of the patient’s name and medical record
   number on their patient identification bracelet against the name and medical record number of
   the patient on the blood product slip. The information must be identical or the transfusion
   cannot be started.
5. The same two licensed personnel should then check the blood product against the
   practitioner's order. The type of blood product, the blood type, unit number, and expiration
   date on the blood product container is checked against the same information on the blood
   product slip. The information on the container and slip must be identical, or the transfusion
   cannot be initiated. Blood bank should be notified, and the container and slip returned. Blood
   bank should then be notified when information is not identical.
6. Only Registered Nurses (RN), Graduate Nurses (GN), and LIPs may administer the blood
   product after it has been verified.
7. Once all information has been verified, both licensed personnel will sign the blood product
   slip and the slip should remain on the bag until the blood has been infused.
8. The bag should be inspected for the following:
         8.1. No obvious penetration of the bag, such as leaking of the blood product from the bag.
         8.2. Color of the blood product (e.g. no clumping or cloudiness with platelets).
         8.3. For Neonates labeling should include: leukoreduced, irradiated
9. If the clinician has any doubts as to the storage bag's integrity, the blood product should not be
   administered. Instead, contact the Blood Bank for information on how to proceed. All blood
   transfusions must be initiated within 15 minutes after the blood product arrives on the patient
   care unit, and completed within 4 hours. If initiation of transfusion is delayed, the blood
   products must be returned to the Blood Bank. Do not store any blood product in an inpatient
   or outpatient refrigerator. For outpatient clinics outside of the hospital—blood may only be
   stored in the cooler it arrives in from the blood bank for up to four hours. For outpatient
   clinics inside the hospital only one unit at a time will be delivered by Blood Bank.
10. When feasible, it is recommended that that an 18-gauge catheter be inserted with no smaller
     than a 22-gauge. A 22-gauge may affect the rate of infusion as adjustment may be needed to
     avoid hemolysis. In pediatrics and neonates, a 24-gauge catheter is acceptable.
11. Long-term venous access devices, peripherally inserted central catheters (PICC) or long-arm
     catheters may be used for blood product administration if the lumen is at least a 20-gauge. If
     smaller, alternative venous access should be obtained.
     11.1 1.9 Fr. PICCs can be used for neonates.
12. Prior to blood product administration, the patient's heart rate, blood pressure, respiratory rate,
     temperature and oxygen saturation should be obtained and documented. Baseline breath
     sounds should also be auscultated and documented.

Title: Transfusion of Blood or Blood Products
Owner: Nursing Practice Council
Effective Date: 4/9/08
Doc. # 2301
                                                  Page 2 of 5
13. Patients who have had a febrile reaction to blood product administration in the past may have
    pre-medication orders written. These medications are given as prophylaxis against another
    febrile reaction. Pre-medications may include antipyretics, antihistamines, and
    hydrocortisone. Oral medications are given 30 minutes before the start of the infusion, while
    IV medication can be given immediately prior to blood product administration.
14. All blood and blood components must be infused through a filter.
         14.1. The long Y-type blood component recipient set includes a filter that filtrates to 170
               microns. All blood and blood components may be infused through this filter.
         14.2. Pediatrics: packed RBC’s are given with the short Y-tubing blood component
               infusion set.
         14.3. The filter single type blood recipient set has a filter that filtrates to 170 microns, but
               has a small surface space; thus, only fresh frozen plasma, platelets, cryoprecipitate
               (AHF), and granulocytes may be infused through this tubing.
15. Each filter is intended for 2-4 units of blood, as long as you are infusing the same product
    (i.e. do not mix clotting factors to prevent clotting). Note that the set should be cleared with
    NS between units. Administration sets used for blood and/or blood components shall be
    changed immediately upon suspected contamination or when the integrity of the product has
    been compromised. These administration sets shall be changed utilizing aseptic technique
    and universal precautions. Blood product administration sets that are associated with a
    suspected transfusion reaction should NOT be discarded.
16. Packed Red Blood Cells and cryoprecipitate and plasma may be infused with a pump,
    provided correct blood tubing is utilized. It is contraindicated to administer platelets by
17. Blood warmers may be ordered when the patient has suffered massive blood loss and will
    require massive amounts, and rapid infusion of blood products, or in neonates requiring
    exchange transfusions.
18. Blood components must not be “piggybacked” into the primary IV solution.
19. Normal saline is the only fluid compatible with blood products.
20. Medication is never added to the blood product container.
21. Never spike the blood product container more than once.
22. It is recommended that the initial rate of blood product infusion during the first 15 minutes of
    infusion be approximately 10-15 drops per minute in order to assure that the patient only
    receives a minimal amount of blood product should a transfusion reaction occur. If no
    reaction develops, the infusion rate should be in accordance with the physician order, and be
    completed within 4 hours.
23. The RN or LIP should remain with the patient the first 15 minutes of the blood product
24. After 15 minutes, vital signs should be done and at least hourly, and upon completion of
     blood product administration.
         24.1. Vital signs are done a minimum of every 30 minutes on neonates.
25. Vital signs should be taken more frequently if the patient is experiencing any problems.
26. Documentation of blood product administration should at minimum contain the following
         26.1. Patient/family education
         26.2. Confirmation of informed consent
         26.3. Pre-transfusion assessment and vital signs
         26.4 Patient identification and blood product verification
         26.5 Date/time the administration began and ended

Title: Transfusion of Blood or Blood Products
Owner: Nursing Practice Council
Effective Date: 4/9/08
Doc. # 2301
                                                  Page 3 of 5
        26.6. Frequent vital signs during infusion
        26.7. Post-transfusion assessment and vital signs
        26.8. Type of blood product administered
        26.9. Amount of blood product administered
        26.10 Applicable laboratory values pre-and post-transfusion
        26.11 Occurrence of transfusion-related complications and interventions taken
27. When the blood product has been infused, and the final patient assessment is made, one part
     of the slip will be retained as part of the patient's permanent record, and the other portion
     returned to the Blood Bank.
28. Once the blood product has infused, post-transfusion lab work is usually obtained.
29. Managing Transfusion Reactions—Administration of blood products is always associated
    with the risk of the patient developing some type of transfusion reaction. While every effort
    is made to decrease the risk of this occurring, the clinician must be able to recognize when a
    transfusion reaction develops and select appropriate interventions to prevent further patient
        29.1. The RN, GN, LIP shall attempt to recognize the patient who is at higher risk for the
               development of a transfusion reaction in order to potentially prevent the reaction
               from occurring by assessing the patient more frequently or intervening more
               29.1.1. Multiparous females and multiply transfused patients (of either sex) are
                       predictably at greater risk of reactions.
               29.1.2. The worst kind of reaction, which can be fatal and the most difficult to
                       manage, is an ABO incompatible transfusion resulting most commonly from
                       clerical error in patient identification either at the time of specimen
                       collection or administration of the blood.
30. Regardless of the type of acute transfusion reaction, the following should occur:
        30.1. Stop the transfusion immediately
        30.2. Assess and stabilize the patient.
        30.3. Monitor vital signs, especially BP and urine output.
        30.4. Assess the patient carefully for airway maintenance and respiratory effort
        30.5. Hang new IV tubing and remove the blood tubing.
        30.6. Keep the vein open with normal saline.
        30.7. Notify both the physician and the blood bank.
        30.8. At the bedside, re-verify the patient's identification, blood slip, and blood product
               information for possible errors.
        30.9. Collect appropriate lab samples as directed (especially a urine sample).
        30.10. Send the unused blood product and tubing to the blood bank with the blue
                 requisition copy attached
        30.11. All transfusion events should be documented in the nursing record including:
                 30.11.1. Time the transfusion started and ended
                 30.11.2. Type of component and unit number
                 30.11.3. Fluid volume infused
                 30.11.4. Vital signs before, during and after the infusion
                 30.11.5 Other significant assessment findings including patient statements
                 30.11.6. Patient’s response to the transfusion
                 30.11.7. Any physician notifications
                 30.11.8. Nursing interventions

Title: Transfusion of Blood or Blood Products
Owner: Nursing Practice Council
Effective Date: 4/9/08
Doc. # 2301
                                                  Page 4 of 5
                   30.11.9 Complete all relevant data entry fields on the Patient Safety Net (PSN),
                           accessible on the UNM Hospitals Intranet.
                   30.11.10 Complete the transfusion reaction form and send along with the unused
                            blood product and tubing with the blue requisition copy.

                                  SPECIAL CONSIDERATIONS
          Blood Transfusion of Uncross Matched Blood
           In an emergency situation a LIP may order for the transfusion of uncross
             matched blood.
           The blood is obtained from the blood bank or the designated blood
           An attending LIP must sign the blood slip form in the section, “ I request the
             blood be made available before completion of compatibility testing”.
           The patient’s label is placed on all sections of the requisition
           The RN, GN, or LIP administering the blood must sign in the transfusionist
             section with the time started and ended. (There is not a second transfusionist
             signature required.)
           The unit # must be included in the nursing documentation.

1. Replaces “BLD BK Transfusion of Blood or Blood Products Policy”, 11/27/2006

                   .Resource/Dept                                             Internet/Link
 Clinical Education

            Item                                    Contact                               Date          Approval
 Owner                         Nursing Practice Council
                               Blood Bank
                               Clinical Education
                               CRTC Nurse Manager
                               Unit Based Educators
                               Nursing Practice Council
 Committee(s)                                                                                               Y
                               Clinical Operations Committee
 Nursing Officer               Judy Spinella, Chief Nursing Officer                                         Y
 Official Approver             Judy Spinella, MSN, MBA, RN, FCHE                                            Y
 Official Signature
 Effective Date                                                                     4/9/08
 Origination Date                                                                   5/82
 Issue Date                    Clinical Operations Policy Coordinator


Title: Transfusion of Blood or Blood Products
Owner: Nursing Practice Council
Effective Date: 4/9/08
Doc. # 2301
                                                  Page 5 of 5

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