Administration of Blood Products

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Administration of blood products is one of the many responsibilities we have as nurses. Almost 21 million blood components are transfused each year in the U.S (1), each with the potential for harm. Unfortunately, many preventable transfusion errors occur each year. Staying up to date on blood administration is the best way for nurses to avoid potentially deadly consequences of transfusion errors.  

Introduction

Administration of blood products is one of our many responsibilities as nurses. Around 14 million blood components are transfused annually in the U.S. [6], each with potential harm. Unfortunately, many preventable transfusion errors occur each year. Staying current on procedures for administering blood products is the best way for nurses to avoid the potentially deadly consequences of transfusion errors.  

You float to an oncology unit and are assigned three patients who receive blood. Does this scenario increase your heart rate? Some nurses administer blood and blood products daily, while others are less familiar and may need a reminder of the administration basics.  

The goal of the course is to teach safe administration of blood products. 

Administering blood can be daunting, but if you remember the basics, you and your patient will be safe. Before diving in, let's look at some exciting blood facts by the Red Cross [1,2] 

• Approximately 29,000 units of red blood cells are needed daily in the U.S. 
• Around 16 million blood components are transfused each year in the U.S. 
• The average red blood cell transfusion is about three units. 
• The blood type O is the most often requested by hospitals.  
• A victim from a single car may require as many as 100 units of blood. 
• An estimated 6.8 million people in the U.S. donate blood annually. 
• About 45% of Americans. have Group O (positive or negative) blood; 57% of Hispanics and 51% of African Americans also have Type O 
• 7% of the U.S. population has type O negative blood, which is always in high demand since it can be given to patients of all blood types.  
• Type AB plasma can be transfused to patients of all blood types, and only 4% of people in the U.S. have A.B. blood. 

Pre-Infusion / Pre-Administration of Blood Products

There are many steps before the infusion starts; the most important is to verify, verify, verify [3,4,6,7].  

Verify the physician's order.  

No order? No blood – it's that simple.  

Standard blood orders include whole blood, red blood cells, and leukocyte-reduced RBC. 

Whole blood is the simplest, most common type of blood donation. It's also the most flexible because it can be transfused in its original form or separated into specific components such as red cells, plasma, and platelets. Whole blood treats patients needing blood components, such as those with significant blood loss from trauma or surgery.  

Red blood cells (RBCs) are prepared from whole blood by removing the plasma. RBCs treat anemia without increasing the patient's blood volume too much. Patients who benefit most from transfusion of red blood cells include those with kidney failure or gastrointestinal bleeding and trauma.  

Leukocyte-reduced RBCs are prepared by removing leukocytes (white blood cells) by filtration after donation before the RBCs are stored. This is done because, over time, the leukocytes can deteriorate, triggering adverse reactions in the patient who receives them.  

Verify the patient has signed a blood consent.  

The only time you can transfuse blood without written consent is for emergency treatment. In this rare situation, the physician may verbally order to infuse blood emergently without a concrete written order. 

Pre-Infusion Checklist

• Check if premedication is required. 

• Premedication such as acetaminophen and or diphenhydramine may be required for patients who have acquired antibodies from multiple transfusions in the past. An example of this is sickle cell patients.  

• Check for special requirements (such as CMV negative).  

• Special requirements may be needed for patients who have acquired antibodies from prior reactions or illnesses like cancer. 

• Verify if the patient has had a history of blood transfusion reactions.  

• If they have had a history, find out their reaction and ensure this information is shared with the ordering physician. 

• Discuss the order with the patient and explain the process to the patient.  

• Even though they signed a consent, this is a new part of their treatment plan and must be included. Include teaching about signs and symptoms of transfusion reaction. More discussion on this topic is below. 

• Verify the patient has an active type and cross.  

• Blood can only be distributed with this information if in an emergent situation. Type and cross screens are typically valid for three days. 

• Review the patient's morning laboratory reports.  

• Pivotal labs to monitor include potassium, as it may rise with transfusion; BUN/Cr to ensure kidney function; hemoglobin and hematocrit for the severity of the anemia; PT/PTT/INR/Platelets to evaluate the coagulation status of your patient. 

Assess Your Patient

Why is your patient getting blood? It would help if you documented this to understand the clinical picture. As the nurse, this is important so you can develop a baseline to know if anything changes with your patient during the infusion process. 

It is essential to understand how to perform the following critical assessments in addition to baseline vitals.  

• Neurological Assessment – Alert and oriented to what? Is the patient at their baseline neurological status? Any changes?
• Pulmonary Assessment – What are their breath sounds like? Any crackles? How are their respirations at rest? What did the morning chest x-ray look like? Are they on oxygen? How much? What is the pulse oximetry reading? Any weight gain overnight? Pedal edema? 

Any patient at risk for fluid volume overload needs to be identified (such as patients with heart failure or renal disease). If you are concerned that your patient is experiencing fluid volume overload while administering blood products, discuss this with the healthcare provider who ordered it. Options may include slow administration of the blood product or premedicating with furosemide [7,8].  

Baseline Vital Signs (1, 3, 5) 

• Temperature – The patient should be afebrile. If they are febrile, do not order or administer blood unless the physician orders to transfuse despite their knowledge of fever. 
• Heart Rate – Rate, rhythm, and pulse quality should be documented. 
• Respirations – Rate and rhythm should be documented. 
• Blood Pressure – Baseline blood pressure should be documented for the patient. Is it "normal" for the patient? What is the trend? 

Determine IV Access 

The IV gauge for routine blood infusions should be 20 gauge or larger in adults, and for rapid transfusions, nurses may use a 16 to 18-gauge IV [7]. The larger the IV, the quicker blood can be administered. The IV line should be used for blood only. Nothing else can be transfused with blood [7]. 

Blood tubing must always be primed with 0.9% normal saline. Normal Saline is the only fluid in which blood products should be infused. Blood tubing, called Y tubing, has a 170-260 micron filter. Blood tubing must be replaced with every unit of blood or every 4 hours, whichever comes first and depends on hospital protocols [7]. Depending on your institution, blood warmers and pumps may be optional or mandatory. 

Infusion / Administration of Blood Products

Once the blood is removed from the blood bank, it should be infused within 20 to 30 minutes, or returned blood must be infused within 4 hours [7,8] 

Now that you have the blood in hand and a patient with a grand IV, grab your nearest Registered Nurse (RN), Medical Doctor (MD), or appropriate second verifier (Determined by your institution) and verify, verify, verify ([5,6,7]. 

Typical Blood Verification Checks include: 

• Patient name 
• Medical record number 
• Date of birth 
• Patient blood type 
• Donor blood type 
• Unit/pool/lot number 
• Product type 
• Special preparations (i.e.; Leuko-reduced)
  
• Rh factor 
• Expiration date and time of blood 
• Visually inspect bag for damage 
• Visually inspect blood for color difference or clots 

*Remember: This is a suggestion of the main points of a blood infusion checklist. Your institutional policy determines the definitive checklist by which you should administer blood. *

Before administration, two licensed personnel should verify the correct blood product and match it with the patient. This should be done at the patient's bedside using the identifying band on the patient for verification as well as the patient themselves (if possible) [5,6,7]. 

The Importance of Two-Step Verification  

Did you know that the most frequent error leading to transfusion of ABO-incompatible Blood occurs during patient identification at the bedside? As a result, although the blood is labeled appropriately, it is transfused to someone other than the correct recipient [4]. 

The problem with transfusion errors and accurate patient identification led to one of the 2024 National Patient Safety Goals to "use at least two patient identifiers when providing care, treatment, and services” [10]. To prevent this from occurring, The Joint Commission requires (before initiating a blood or blood component transfusion):  

• Match the blood or blood component to the order of the physician or provider.  
• Match the patient to the blood product.  
• Use a two-person verification process [9].
  

When using a two-person verification process, one individual conducting the identification verification is the qualified transfusionist who will administer the blood or blood component to the patient [9]. When using a two-person verification process, the second individual conducting the identification verification is qualified to participate, as determined by the hospital [9]. 

Now that you have verified blood and are infusing the product, it is not the time to go to lunch. Stay with the patient during the first 15 minutes of transfusion to monitor for any immediate reaction and start the infusion slowly. Vital signs should be repeated 15 minutes after the beginning of the transfusion, during the procedure per facility policy, at the conclusion, and one hour after the transfusion [7,8]. 

The rate of the actual infusion should be based on a) if a rate was ordered, b) ensuring the infusion is complete within the allotted 2-4 hour time frame, and c) nursing judgment related to the patient's hemodynamic and pulmonary status [7]. 

Reassessment of Vital Signs 

• Neurological Assessment – Changes in baseline neurological assessment, including lethargy, confusion, or any decrease in Glasgow Coma Scale, may indicate a transfusion reaction. 
• Pulmonary Assessment – Any changes from baseline? Oxygen requirement changes? Saturation changes? Signs of increased pulmonary secretions or pulmonary edema? These are signs of fluid overload and may indicate a transfusion reaction.  
• Temperature – An increase is often a sign of a transfusion reaction. 
• Heart Rate – Tachycardia or arrhythmias may signify a transfusion reaction. 
• Respiration – An increase in respiration may be a sign of a transfusion reaction or fluid volume overload. 
• Blood Pressure – An increase in B.P. may be a sign of fluid overload, but a significant decrease is a sign of a transfusion reaction. 
• IV Access – Still patent? Infusing without difficulty? At the prescribed rate? [8]. 

Blood Transfusion Reactions

Why must you stay in the room and reassess everything in 15 minutes? 

If the patient is going to experience an acute blood transfusion reaction, it usually takes place within the first few minutes of infusion.  

There are many signs and symptoms of blood transfusion reactions for hemolytic and non-hemolytic reactions  [6,7,8]. 

If a reaction is suspected, the transfusion should be immediately stopped, blood products and tubing removed, and the intravenous line kept open with normal Saline. The provider should be notified immediately, and the patient should be monitored. The remaining blood products and tubing should be taken to the laboratory [5,7,8]. Refer to facility policy and procedure for documentation and other requirements. Labs must be drawn as part of a suspected transfusion reaction workup. 

If all goes well, continue to monitor the patient according to your facility’s protocol during the remainder of the infusion. If there are no changes after 15 minutes in assessments or vital signs, vital signs should be repeated at least every hour and at the conclusion [7,8]. Again, refer to your facility policy, as this can vary. 

Post-Infusion / Post-Administration of Blood Products

Once the administration of blood products is complete, obtain a set of vital signs. Compare to baseline and 15-minute vital signs. If you haven’t already done so, complete documentation: 

• Start/Stop time 
• Pre, 15-minute, and post-infusion vital signs 
• Blood volume infused 
• 0.9% Normal Saline volume infused 
• Signs & Symptoms of transfusion reaction, if any 
• Reason for transfusion 
• Answer "yes" or "no" to suspected transfusion reaction 
• Document in the notes how the patient tolerated the infusion 
• Properly dispose of blood and blood tubing in a red waste container 
• Flush the IV access with Saline
  

Now, wait – you aren't done yet! Remember that non-acute blood transfusion reactions can occur hours after the infusion, so continue to monitor and assess your patient closely. Remember to document the one-hour post-infusion vital signs and complete any post-infusion labs that may have been ordered [7,8].  

Knowledge about any skill improves your confidence and results in safe patient care. Hopefully, this has improved your understanding of the administration of blood products and increased your confidence in performing this procedure! 

Institutional Policies on the Administration of Blood Products 

All organizations have different policies, it is important to review your institutional policy regarding the administration of blood products. It is your responsibility to learn your institution’s policies regarding the administration of blood products and to follow them appropriately. Documentation is per institutional policy and should include the reason for the infusion as well. Every institution has a procedure for releasing blood products. Follow the institutional policy to obtain the blood to have it to infuse in a timely manner.

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