Learning outcomes
By the end of this section, you should know how to:
▪ prepare and support the patient receiving a blood component
▪ collect a blood component
▪ undertake the final patient identity check before administering a blood component
▪ monitor the patient, and take appropriate initial action in response to a possible transfusion reaction.
Background knowledge required
Revision of the anatomy and physiology of the blood, with a special emphasis on blood groups (seehttp://www.learnbloodtransfusion.org.uk)
Review the adverse effects of blood transfusion, with special emphasis on the incorrect blood component reporting category (seehttp://www.shotuk.org.uk)
Revision of ‘Intravenous therapy’ (seep. 169)
Revision of ‘Aseptic technique’ (seep. 381)
Review current national and European legislation and guidelines on blood transfusion (seehttp://www.transfusionguidelines.org.uk)
Revision of local policy on blood transfusion.
Indications and rationale for a blood transfusion
The term ‘blood transfusion’ is used to describe the transfusion of red cells. Whole blood is rarely transfused nowadays. Red cells are supplemented with other blood components such as fresh frozen plasma or platelet concentrates if required, as this is considered more effective treatment (McClelland 2006).
This practice will refer to the transfusion of red cells, however the same safety issues relate to the administration of all blood components. A ‘blood transfusion’ is the introduction of compatible donor red cells into the circulation of a recipient, and may be indicated for the following reasons:
▪ to support the patient who has lost a large volume of blood
▪ to enable a patient to have surgery that may involve the loss of a large volume of blood
▪ to support a patient receiving treatment for leukaemia or cancer
▪ to maintain or improve the lives of patients with some chronic conditions (Murphy 2005).
Several countries have established a haemovigilance programme to collect data on the serious adverse effects of transfusion. The United Kingdom Serious Hazards of Transfusion (SHOT) scheme was launched in 1996. It is a voluntary scheme covering both NHS and independent hospitals, and aims to use the information gathered to improve safety standards for blood transfusion. The scheme has consistently reported that human error contributes significantly to the morbidity and mortality of patients receiving blood transfusion (SHOT 1998–2005). The majority of these occurred because of an error in patient identification, either at the time of blood component collection from the storage site, or at the patient bedside. Correct identification of the patient is, therefore, the main focus of transfusion safety.
Outline of the procedure
The decision to transfuse a patient is made by a medical practitioner. Wherever possible the medical practitioner should discuss the risks and benefits of the proposed treatment with the patient. The USA and Canada have introduced written patient consent for blood transfusion, however there is no legal requirement in the UK to gain specific consent from the patient, for the transfusion of blood products. All patients, however, have a basic legal and ethical right to determine their treatment, and the patient should receive sufficient information to make an informed decision (Department of Health 2001). If the patient cannot communicate because, for instance, he or she is unconscious, it is essential that the proposed transfusion is explained to the patient’s relative or carer.
When the decision to transfuse the patient is made, a venous blood sample will be taken and sent to the hospital transfusion laboratory along with a request for the blood component required. Tests will be undertaken on the sample to identify the patient’s ABO, RhD group, and if there are any specific antibodies, before selecting a compatible donor unit for issue.
Each of the blood components have specific storage requirements (Table 5.1), and it is the responsibility of the hospital transfusion laboratory to ensure that blood components are stored appropriately (Guidelines for the Blood Transfusion Services in the UK 2005).
| Component | Shelf-life | Storage conditions |
|---|---|---|
| Red blood cells; whole blood | 35 days | 4°C (± 2°C) in an authorised blood fridge |
| Platelets | 5 days | + 22°C (± 2°C) on an agitation rack in the hospital transfusion laboratory |
| Fresh frozen plasma | 2 years | −30°C in the hospital transfusion laboratory |
| Cryoprecipitate | 2 years | −30°C in the hospital transfusion laboratory |
The final patient identification check is normally undertaken by two people, one of whom should be a registered medical practitioner or a 1st or 2nd level registered nurse. This practice has, however, been questioned as it may lead to a diffusion of responsibility and it has been suggested that it may be more appropriate for one registered practitioner to take full responsibility (British Committee for Standards in Haematology Transfusion Task Force 1999). It is therefore important to check current policy regarding the checking of patient identification.
Transfusion reactions
A reaction can occur with all blood components, therefore ensuring the patient’s safety is the most important aspect of caring for a patient during the transfusion (Table 5.2). Any adverse event experienced by a patient should be considered as a possible transfusion reaction. Immediate recognition, and prompt nursing and medical action is required to prevent further complications, and possible death. This is particularly important if the patient is unconscious or cannot report symptoms.
| Type | Cause | Symptoms |
|---|---|---|
| Volume overload | Too much fluid is transfused or component transfused too rapidly | Dyspnoea, hypertension and tachycardia |
| Febrile | An immune response of the recipient to white cell antigens or white cell fragments in the blood component | Headache, mild fever (temperature rise of up to 1.5°C), and a moderate tachycardia without hypotension |
| Allergic, urticarial or anaphylactic | An immune response of the recipient to plasma proteins in the blood component | Urticarial: headache, rash and purititis without hypotension |
| Anaphylaxis: nausea, vomiting, facial swelling, wheezing and laryngeal oedema | ||
| Haemolytic | The majority are the transfusion of an ABO incompatible component | Rigors, loin pain, muscle aches, tachycardia, hypotension and haemoglobinuria |
| Septic shock | A bacterially contaminated component | Chills, high fever, vomiting, abdominal cramps, diarrhoea and signs of shock |
If any transfusion reaction is suspected the transfusion must be Stopped, and urgent medical attention sought. Acute reactions can occur during, or within the first 24 hours of transfusion. Delayed transfusion reactions can occur days, weeks, months or even years later. These include delayed haemolytic reaction, and signs and symptoms of infectious disease such as hepatitis C or human immunodeficiency virus (HIV).
Treatment will depend on the cause and severity of the reaction, and is dictated by the patient’s clinical condition. Close observation and monitoring of the patient should be maintained and this should include temperature, pulse, respiratory rate, blood pressure, blood loss and urinary output. All serious transfusion reactions must be reported to the hospital transfusion laboratory and duty haematologist, to ensure that the appropriate investigation, further management and reporting of the reaction occurs (Blood Safety and Quality Regulations 2005). There will be local policy for the method of reporting. The adverse event should also be documented in the patient’s medical and nursing notes.
