Blood Administration

Scope and Purpose

These guidelines establish evidence-based standards for the safe administration of blood and blood components. They address procedural requirements, patient monitoring, adverse event recognition, and special considerations across clinical settings. These standards apply to whole blood, red blood cells (RBCs), plasma and plasma components, platelets, granulocytes, and cryoprecipitate.

1. Core Standards

1.1 Organizational Requirements

Healthcare organizations must establish and maintain written policies, procedures, and practice guidelines that govern blood administration, the use of infusion devices and ancillary equipment, and the identification, evaluation, and reporting of transfusion-related adverse events.

1.2 Patient and Product Verification

Verification of the correct patient identity and blood product must occur in the physical presence of the patient immediately prior to initiating transfusion. This verification requires an independent double-check performed by two qualified adults.

1.3 Filtration Requirements

All blood and blood components must be transfused through an administration set equipped with a filter designed to retain potentially harmful particles. Standard blood administration sets incorporate a 170- to 260-micron filter for this purpose.

2. Patient Blood Management

2.1 Evidence-Based Transfusion Practice

Patient blood management (PBM) represents an evidence-based, multidisciplinary framework designed to optimize care for patients who may require transfusion. Effective PBM programs guide clinical decision-making regarding appropriate transfusion use, eliminate unnecessary transfusions, and enhance patient safety.

Core PBM strategies include evidence-based transfusion indications, hemoglobin concentration maintenance, coagulation and hemostasis optimization, close postoperative monitoring to minimize oxygen consumption, and anemia prevention through measures such as reducing blood loss from diagnostic sampling.

2.2 Transfusion Thresholds

Current evidence supports the safety of transfusing red blood cells at lower hemoglobin thresholds. A restrictive transfusion strategy (hemoglobin 7.0-8.0 g/dL) is considered safe in both adults and stable, nonbleeding, critically ill children. This approach is supported by systematic review evidence demonstrating equivalent or improved outcomes compared to liberal transfusion thresholds.

2.3 Neonatal Considerations

Patient blood management in neonatal populations requires attention to anemia management, blood conservation strategies, coagulation and hemostasis optimization, surgical and anesthetic technique modifications, and patient- and family-centered decision-making processes.

3. Patient Education and Consent

3.1 Informed Consent

Prior to transfusion, clinicians must provide comprehensive patient and caregiver education and ensure informed consent is obtained. The consent process must include a clear description of risks, benefits, and treatment alternatives. Patients must have the opportunity to ask questions and must understand their right to accept or refuse transfusion.

3.2 Religious and Cultural Considerations

Patients must have the opportunity to discuss religious or cultural beliefs that may affect their decisions regarding blood transfusion. Clinicians should be prepared to discuss bloodless management alternatives when appropriate.

3.3 Educational Content

Patient education should address the transfusion procedure itself (including compatibility testing and vascular access requirements) and the signs and symptoms of transfusion complications. Patients should be instructed to report any unusual sensations, including a vague uneasy feeling, pain, breathing difficulties, hypotension, chills, flushing, fever, nausea, dizziness, rash, urticaria, hives, pruritus, localized angioedema, or dark or red urine.

4. Pre-Transfusion Assessment

4.1 Baseline Physical Assessment

A comprehensive baseline physical assessment must be performed prior to obtaining blood for transfusion. This assessment includes vital signs, respiratory status, skin examination for evidence of rash, and identification of conditions that increase the risk of transfusion-related adverse reactions. Risk factors include current fever, heart failure, renal disease, and predisposition to fluid volume excess.

The assessment must also confirm the presence of an appropriate and patent vascular access device and review current laboratory values. Any symptoms that could later be mistaken for a transfusion reaction should be identified and reported to the healthcare team. Fever may warrant delay of transfusion, as it could mask symptoms of an acute transfusion reaction.

4.2 Predictive Indicators

Research from multicenter retrospective analysis has demonstrated that transfusions associated with febrile reactions showed higher pretransfusion temperatures and pulse rates, while transfusions associated with transfusion-associated circulatory overload (TACO) showed higher pretransfusion respiratory rates. These findings underscore the importance of thorough baseline vital sign documentation.

4.3 Premedication

If premedication is ordered, oral medications should be administered 30 minutes before transfusion initiation, while intravenous medications may be given immediately before starting.

It should be noted that systematic review evidence indicates routine premedication with acetaminophen and antihistamines does not prevent nonhemolytic transfusion reactions. The efficacy of premedication in patients with a history of transfusion reactions remains uncertain and requires further research.

5. Vascular Access Selection

5.1 Peripheral Intravenous Catheters in Adults

For routine transfusions in adult patients, a 20- to 22-gauge peripheral intravenous catheter (PIVC) is acceptable. When rapid transfusion is required, a 16- to 18-gauge catheter may be preferred. Red blood cells can be safely administered through smaller-gauge catheters or needles (24-25 gauge); however, flow rates must be slower, as pressure from rapid transfusion through small catheters may cause hemolysis.

5.2 Peripheral Intravenous Catheters in Pediatric Patients

For neonates, the umbilical vein may be utilized. For other infants and children, a vein large enough to accommodate a 23- to 25-gauge needle or a 22- to 24-gauge catheter should be selected.

5.3 Central Vascular Access Devices

Central vascular access devices (CVADs) are acceptable for blood administration across all patient populations.

5.4 Intraosseous Access

Blood components may be administered via the intraosseous route when other vascular access is not achievable.

6. Patient and Product Verification Protocol

6.1 Timing of Verification

Patient and blood product identification, along with inspection of the blood component for abnormalities, must occur at two points: when the blood component is released from the transfusion service, and in the presence of the patient before preparing the transfusion.

6.2 Required Verification Elements

The verification process must confirm the provider order for transfusion, the patient’s core independent identifiers, ABO group and Rh type, donation identification number, crossmatch test interpretation (if performed), expiration date and time, and date and time of issue.

Special transfusion requirements must also be verified, including irradiated products, cytomegalovirus (CMV)-negative products, leukocyte-reduced products, hepatitis E-negative products, washed cells, platelets in additive solutions, and hemoglobin S-negative products.

Volume requirements must be verified for neonatal, pediatric, and older adult populations.

6.3 Independent Double-Check

Verification requires an independent double-check by two adults in the presence of the patient. In hospital or outpatient settings, both individuals must be trained in recipient and blood component identification. In home settings, this check is performed by the nurse and a responsible adult.

Electronic patient identification technologies have been associated with lower incidence of wrong component transfusions and near misses compared to manual systems.

6.4 Visual Inspection

Each blood component must be visually inspected prior to transfusion. Products should not be used if the container is not intact or if appearance is abnormal, including abnormal color, presence of clots, leakage, excessive air or bubbles, or unusual odor. Abnormal products must be returned to the transfusion service.

7. Administration Procedures

7.1 Infusion Compatibility

No other solutions or medications may be added or infused through the same administration set with blood or blood components. Blood administration sets must not be piggybacked into other infusion administration sets.

7.2 Priming Solution

The administration set used to administer blood or blood components may only be primed with 0.9% sodium chloride or the blood component itself.

7.3 Filtration

All blood components require filtration, with adherence to manufacturer directions for filter use. Standard blood administration sets include a 170- to 260-micron filter designed to remove blood clots and harmful particles.

Microaggregate filters are not used routinely but may be employed for reinfusion of blood shed during high-blood-loss surgical procedures.

Leukocyte reduction filtration is preferably performed prestorage or shortly after blood collection. Bedside leukocyte reduction is less efficient and has been associated with hypotension in some patients. Leukocyte-reduced blood products (RBCs and platelets) decrease the risk of febrile transfusion reactions, human leukocyte antigen (HLA) alloimmunization, allergic reactions, and CMV transmission.

Leukocyte filtration must never be used when transfusing granulocytes or hematopoietic progenitor cells.

7.4 Administration Set Changes

Transfusion administration sets should be changed according to manufacturer directions. While clinical studies establishing maximum set use time are limited, guidance from the Association for the Advancement of Blood & Biotherapies (AABB) indicates that if the first unit requires 4 hours for transfusion, the administration set and filter should not be reused. International guidelines from some countries recommend administration set changes every 12 hours.

Most standard filters have a 4-unit maximum capacity. Manufacturer directions must be followed regarding filter limitations.

8. Transfusion Timing and Rate

8.1 Maximum Infusion Time

Each unit of blood or blood component must be administered and completed within 4 hours. When it is anticipated that a unit cannot be transfused within this timeframe (such as in pediatric patients or adults at risk for fluid overload), the transfusion service should be asked to divide the unit into smaller aliquots.

8.2 Standard Transfusion Durations

The following represent typical transfusion durations: red blood cells are administered over 1-2 hours based on hemodynamic stability; platelets are administered over 1-2 hours; granulocytes are administered over 2 hours; plasma is administered as quickly as tolerated by the patient or over 15-60 minutes; and cryoprecipitate is administered as rapidly as tolerated.

8.3 Infusion Pump Use

Only electronic infusion pumps with a labeled indication for blood transfusion should be used. These devices can deliver blood or blood components without significant risk of RBC hemolysis or platelet damage. Syringe infusion pumps may be used for small-volume transfusions in neonatal and pediatric patients. All use must follow manufacturer directions.

8.4 Rapid Transfusion

Manual pressure cuffs may be used to increase RBC flow rate when rapid transfusion is required. External compression devices should be equipped with a pressure gauge, completely encase the blood bag, and apply uniform pressure against all parts of the container. Pressure must not exceed 300 mm Hg. A standard sphygmomanometer must never be used for this purpose. For rapid infusion, a large-gauge catheter may prove more effective than a pressure device.

9. Blood and Fluid Warming

Blood and fluid warmers should be used when indicated by patient history, clinical condition, and prescribed therapy. Indications include prevention or treatment of intraoperative hypothermia, plasma exchange for therapeutic apheresis, patients with clinically significant cold agglutinins, neonate exchange transfusions, replacement of large blood volumes, vaso-occlusive episodes, and treatment of trauma, hypothermia, or cold exposure.

10. Monitoring During Transfusion

10.1 Vital Sign Protocol

Vital signs must be obtained within 30 minutes prior to transfusion, 15 minutes after blood enters the vein upon transfusion initiation, upon completion of the transfusion, and 1 hour post-transfusion.

Visual assessment for adverse reactions should occur at least every 30 minutes throughout the transfusion. Vital signs must be checked immediately upon identification of any change in patient condition.

10.2 Initial Transfusion Period

Nonemergent transfusions should be initiated slowly, with the clinician remaining near the patient. Major reactions typically appear before the first 50 mL have been transfused. The transfusion rate may be increased after 15 minutes when no signs of reaction are present, ensuring completion within 4 hours. The first 10-15 minutes of any transfusion represent the most critical monitoring period.

11. Acute Transfusion Reactions

11.1 Immediate Response Protocol

Transfusion must be stopped immediately if signs and symptoms of an acute transfusion reaction are present, including fever, chills, tachycardia, chest pain, flank pain, back pain, hypotension, bronchospasm, or dyspnea.

Upon stopping the transfusion, perform a clerical check of the blood component (ABO confirmation), notify the provider and transfusion service, and administer emergency medications as prescribed. Emergency medications must not be administered through the blood administration set. A new administration set must be primed with 0.9% sodium chloride for infusion through the vascular access device.

11.2 Allergic Reactions

Mild allergic reactions may present with pruritus, urticaria, flushing, or wheezing.

11.3 Transfusion-Related Acute Lung Injury

Transfusion-related acute lung injury (TRALI) may present with respiratory failure, hypoxemia, hypotension, and pulmonary edema.

11.4 Transfusion-Associated Circulatory Overload

TACO is the leading cause of transfusion-related morbidity and mortality. Patient risk factors include advanced age and history of cardiac disease or acute or chronic renal failure. Signs and symptoms include dyspnea, jugular venous distention, cough, and increased blood pressure. Onset typically occurs 6-12 hours after transfusion.

12. Special Population Considerations

12.1 Older Adults

Adverse events from red blood cell transfusions occur more frequently in older patients, with TACO representing the most frequent complication.

12.2 Neonates

Immature organ function in neonates is associated with increased risk for metabolic complications and for infectious and immunologic complications.

13. Out-of-Hospital Transfusion

13.1 Program Requirements

Out-of-hospital transfusion settings, including dialysis centers, skilled nursing facilities, outpatient surgery centers, and home settings, require well-planned programs that incorporate all relevant aspects of hospital transfusion practice. Programs must ensure clinicians are educated and trained in transfusion management, transfusion reaction recognition and response, anaphylaxis management, and emergency support.

13.2 Common Adverse Reactions in Out-of-Hospital Settings

Research indicates the most common adverse reactions in out-of-hospital settings are febrile nonhemolytic reactions (28.6%), allergic reactions (26.9%), and TACO (6.3%). These findings emphasize the critical need for patient and caregiver education and established action plans for adverse reactions.

13.3 Written Instructions

Due to the lack of prolonged clinician assessment postinfusion in out-of-hospital settings, provision of written instructions regarding signs and symptoms of transfusion reactions and contact information is essential.

13.4 Home Transfusion Requirements

Home transfusion requires documentation showing no identified adverse events during previous transfusions; immediate telephone access to the provider during transfusion; presence of another competent adult in the home available to assist with patient identification and summon medical assistance if needed; a telephone to contact emergency personnel; ability to transport blood products in appropriate containers; and ability to appropriately dispose of medical waste.

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