Pharm Basics, part 9: Blood Transfusions
by Cathy Parkes August 13, 2021 Updated: August 09, 2023 4 min read
This article focuses on blood transfusions, including blood type compatibility, types of blood products, and possible reactions to a blood transfusion.
This series follows along with our Pharmacology Basics and Safe Medication Administration Flashcards for Nursing Students, which are intended to help RN and PN nursing students build a strong foundation going into Pharmacology and as preparation for the ATI, HESI, and NCLEX.
What is a blood transfusion?
A blood transfusion is a common and safe medical procedure in which healthy blood is given to a patient through an intravenous (IV) line that has been inserted in one of their blood vessels.
Blood type compatibility
Blood types are determined by the presence or absence of specific antigens — substances that trigger an immune response if they are foreign to the body. Because some antigens will trigger the body's immune system to attack transfused blood, safe blood transfusions depend on careful typing and cross-matching.
A handy table showing compatibility is included in our Pharm Basics flashcards!
Types of blood products
Blood products come in a variety of types, depending on the needs of the patient. And each blood product has a different infusion time.
Packed red blood cells (PRBCs)
Packed RBCs are made from a unit of whole blood by centrifugation and removal of most of the plasma. They are typically given in situations where the patient has either lost a large amount of blood or has anemia. PRBCs are infused over a two- to four-hour period, with a maximum of four hours.
Fresh-frozen plasma is usually administered to correct deficiencies in a patient’s ability to form clots. Plasma is infused much faster than PRBCs — between 15 and 30 minutes. Fresh-frozen plasma must be administered within two hours of thawing.
Platelets are cells that circulate within the blood. When they recognize damaged blood vessels, they bind together as part of the healing process. Platelets are also infused quickly in a transfusion — between 15 and 30 minutes.
Nursing best practices for blood transfusions
When performing a blood transfusion on a patient, first confirm the patient’s ID, their blood compatibility, and the expiration date of the blood product with another RN.
Make sure to use a 20-gauge or larger IV catheter — preferably an 18-gauge catheter.
Also, before ordering the blood product, check the patency of the IV to ensure it is working properly. This avoids having the blood product sent up, only to discover after setting up the IV that it has infiltrated or is not working properly, causing a delay that would damage or ruin the blood product.
Prime the blood transfusion administration set with normal saline only, that is 0.9% NaCl. Do not prime the line with any other type of fluid.
Never administer medications through an IV line that is transfusing blood. Just as with TPN (where the line is only for TPN), when a patient is receiving a blood transfusion, that line is just for blood.
If the blood is not administered within 30 minutes of delivery to the patient’s room, it must be sent back to the blood bank.
Remember, when administering packed red blood cells, complete the administration within four hours.
Take the patient’s vital signs before administration of the blood, and then stay with the patient for the first 15 minutes of administration to monitor for transfusion reactions. If they are doing well after 15 minutes, take their vital signs again to make sure everything is still okay.
Blood transfusion reactions
It is possible that the patient experiences an adverse reaction to their blood transfusion. Reactions can include: mild allergic, anaphylactic, febrile, septic, and acute hemolytic reactions, as well as circulatory overload.
General nursing care
In the event of a patient experiencing a serious reaction to their blood transfusion, stop the infusion. Then, administer 0.9% NaCl through a separate line, notify the provider, and send the blood bag to the lab for analysis.
It is important to administer the saline through a new line because there will still be blood in the tubing of the old line, and we do not want any more of that blood going into the patient.
A mild allergic reaction to a blood transfusion is marked by symptoms that can include itching, flushing (redness), and urticaria (hives).
In response to a mild allergic reaction, diphenhydramine (Benadryl) may be administered.
An anaphylactic reaction is very serious. Symptoms include wheezing, dyspnea (difficulty breathing), hypotension (low blood pressure), and decreased oxygenation (the patient’s SpO2 will be decreased).
If the patient experiences a febrile reaction, they may have symptoms such as fever, chills, hypotension, tachycardia, and tachypnea (abnormally rapid breathing). Antipyretics may be ordered to alleviate this type of reaction.
The symptoms of a septic reaction may include fever, chills, and abdominal pain.
In response, it may be necessary to collect cultures, in order to discern the exact nature of the reaction. Also, administer antibiotics as ordered. Check out our Pharmacology Flashcards to learn more about antibiotics.
An acute hemolytic reaction is usually due to the transfusion of incompatible red blood cells.
A patient with an acute hemolytic reaction will experience low back pain, as well as fever and chills, tachycardia, tachypnea (abnormally rapid breathing), and hypotension.
Collect labs and specimens, and give the patient IV fluids as ordered by the provider.
A circulatory overload reaction to a blood transfusion is usually due to excessive fluid intake or volume overload.
A patient suffering from circulatory overload may exhibit signs such as dyspnea, tachycardia, tachypnea, crackles (crackling sounds in the lungs), hypertension, and distended jugular veins, all of which are the signs of fluid volume excess.
Usually, despite this reaction, the patient may continue to receive blood, but at a decreased infusion rate. Note that when slowing the infusion rate, the transfusion must still be completed within four hours.
Other treatments for circulatory overload include raising the head of the bed and monitoring the patient’s oxygenation and vital signs. In addition, the provider may order diuretics to be provided to the patient.
I am Cathy with Level Up RN. In this video, we are going to talk about blood transfusions. So I highly recommend that you review the different blood types and for each blood type, who they can give to and who they can receive from. So that information is contained in our pharmacology basic stack. And I was personally tested on that type of information on the NCLEX, so definitely worth a review. Let's talk about the different types of blood products that we may need to give our patient, and the infusion time associated with each of those blood products. So for packed red blood cells, we would infuse those over two to four hours, so a maximum of four hours. With fresh frozen plasma, we infuse those much faster. So those will be infused between 15 and 30 minutes, and they need to be administered within two hours of thawing. Then we have platelets, and those are also infused between 15 and 30 minutes. So whenever we're going to do a blood transfusion on a patient, we want to confirm the patient's ID, their blood compatibility, and the expiration date of the blood product with another RN. We're going to want to make sure the patient has a 20-gauge or larger IV catheter, so ideally, they would have an 18-gauge, but a 20-gauge will likely work as well. And you always want to check the patency of that IV and make sure it's working properly before you call and have that blood product sent up, because that can definitely happen where you're like, "Yeah. I'm ready for it. Send it up." And then you go and set it all up, and you realize, "Oh. That IV has infiltrated, or not working properly." So definitely check the IV first.
You want to prime the blood transfusion administration set with normal saline only. So 0.9% NaCl. So we're not priming the line with any other type of fluid other than that normal saline. And then, you never want to administer medications through the line that is getting blood. So just like with TPN, when a patient is getting TPN, that line is just for TPN. When a patient is getting blood, that line is just for blood. If the blood is not administered within 30 minutes of you receiving it, it needs to be sent back to the blood bank. And, like I mentioned before, we definitely need to administer packed red blood cells within four hours. And then, we're going to take the patient's vital signs before administration of the blood, and we're going to stay with the patient for the first 15 minutes of administration to make sure they don't have a reaction. And if they are doing fine after 15 minutes, we're going to take all those vital signs again to make sure everything looks okay.
Now, let's talk about blood transfusion reactions. If your patient has a serious reaction to their blood transfusion, you're going to want to stop the infusion. You're going to want to administer 0.9% NaCl through a separate line. So why don't we administer the saline that we used to set up the blood transfusion, through that blood transfusion administration set? Well, you have tubing there that's going into the patient that is full of blood. So if your patient's having a reaction, and you're like, "Okay. I'm going to clamp the blood, and I'm going to open up the NaCl," all that blood still has to get into the patient before they're going to get that normal saline, and we don't want any more blood going into the patient, so that is why we want to administer 0.9% NaCl through a separate line.
Okay, now that you understand the general steps that we would take in the case of a blood transfusion reaction, let's talk about specific reactions and what symptoms you may see, and what medications you may need to give in response to those reactions. So first of all, we have a mild allergic reaction. And symptoms of this reaction can include itching, flushing, and urticaria. In response to a mild allergic reaction, we may be able to give the patient diphenhydramine which is Benadryl to help mitigate those symptoms. In the case of an anaphylactic reaction, which of course is very serious, the patient may have symptoms such as wheezing, dyspnea, hypotension, and decreased oxygenation, so their SpO2 will be decreased. In response to this type of reaction, we will likely be giving epinephrine and corticosteroids as ordered by the provider. If the patient has a cerebral reaction, they may have symptoms such as fever, chills, hypotension, tachycardia, and tachypnea, and you would anticipate giving antipyretics as ordered for this type of reaction. With a septic reaction, your patient may have symptoms such as fever, chills, and abdominal pain. In response to that, you may need to collect cultures and administer antibiotics as ordered. If your patient is having an acute hemolytic reaction, that's going to cause low back pain as well as fever and chills, tachycardia, tachypnea, and hypotension, so you may need to collect labs and specimens and give them IV fluids as ordered by the provider.
And then finally with a circulatory overload reaction to the blood transfusion, your patient may have signs such as dyspnea, tachycardia, tachypnea, crackles, hypertension, and distended jugular veins, so all the signs of fluid volume excess. This is the one type of reaction where, in all likelihood, we can keep giving them the blood transfusion, but we need to decrease the infusion rate. So if your patient is having circulatory overload-type symptoms, you want to raise the head of the bed, slow that infusion rate, although you still need to give it within four hours, like we talked about before. You're also going to monitor their oxygenation and their vital signs. And then the provider may order diuretics for you to provide the patient as well.
Are you guys ready for a quiz? I have three questions to test your knowledge on the information I just covered. So first question, what do you use to prime the blood transfusion administration set? If you said 0.9% NaCl you are correct. Number two, low back pain, fever, tachycardia, and tachypnea are signs of what blood transfusion reaction? The answer is an acute hemolytic reaction. Question number three, a blood transfusion needs to be completed within "blank" hours. The answer is four. So I hope you did well on that. This concludes our pharmacology basics video playlist. I hope it was super helpful for you guys. Good luck with studying, and take care.
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