Nursing care of the patient before, during, and after transfusion of blood and its components: management principles

INTRODUCTION

Blood and its components are key elements of the therapeutic process in modern medicine. In Poland, approximately 1.7 million transfusions of these products are performed each year [1]. Blood transfusions are an invaluable part of therapy, especially in situations where other treatments prove insufficient. However, transfusion is associated with the risk of adverse reactions, which is why it is so important to strictly follow medical procedures and ensure adequate supervision of the patient during and after transfusion. It is extremely important that medical personnel, including nurses, are properly knowledgeable and certified in blood transfusion.
This article will discuss key aspects of nurses’ management before, during, and after transfusion of blood and its components. In particular, procedures for preparing the patient for transfusion, controlling the course of the transfusion, and actions in case of adverse reactions will be discussed. Nurses, as the ones responsible for the execution of these procedures, must have not only a thorough theoretical knowledge derived from current legislation, but also practical skills, regularly updated through courses as specified in the Regulation of the Minister of Health of May 16, 2017 on the training of nurses and midwives transfusing blood and blood components [2]. This knowledge is crucial to ensure patient safety and quality nursing care. Therefore, the purpose of this article is to present the current standards of practice to ensure professional and effective care for patients treated with blood and its components.

GENERAL RULES

According to current regulations in Poland, transfusion can only be performed by a nurse or midwife who has the necessary certificates. These are granted after completing a training course organized by organizational units of the public blood service, such as the Regional Centers for Blood Donation and Blood Treatment (RCKiK). The training includes both theoretical and practical parts, and is valid for 4 years. Basic training includes both theoretical and practical parts. In order to maintain the validity of the certificate, it is necessary to update the knowledge in the form of supplementary training (at least once every 4 years) [2]. According to studies, regular staff training is the most effective way to increase the safety of a patient requiring a transfusion [3].
There are a number of key activities to ensure that the entire transfusion procedure is carried out correctly. Among the tasks of nurses and midwives performing transfusions of blood and blood components are:
• collection of blood samples from the patient with referral for an ABO test, crossmatch test, and possible analysis of an adverse post-transfusion reaction;
• identification of the recipient and detailed inspection of the documentation prior to transfusion to rule out errors and ensure data compliance;
• assessment of compatibility of the blood component with the recipient’s blood type, which is critical to transfusion safety (Tables 1 and 2);
• transfusion of blood or its component ordered by a physician according to current procedures and standards;
• continuous observation of the patient both during and after the transfusion and intervening in the event of any adverse reactions in the patient;
• completing documentation of the transfusion process.
Meticulous execution of these steps is essential to ensure patient safety.

PRE-TRANSFUSION MANAGEMENT

The nurse’s involvement in the process of transfusion of blood components begins at the time of collection of the material for immunohematological testing. Studies have shown that knowledge of the preparatory steps for transfusion is at a much lower level than knowledge of the transfusion process itself and the post-transfusion period [4].
The first step in the crossmatch process is the proper identification of the patient from whom the samples are taken and the correct collection of blood and labeling of the test tubes. Correct identification is the basis for ensuring patient safety. Although its importance is often trivialized, this is where the greatest number of errors occur and can lead to adverse incidents [5]. Usually, the material is venous blood drawn on EDTA, which should be described in the presence of the patient with the name and surname (in capital letters), the patient’s PESEL (national identification) number (in the absence of a PESEL number, the date of birth), and the date and time the sample was taken. If it is not possible to identify the patient, it should be described with the symbol “NN”, gender symbol, patient’s number from the hospital register, or unique identification number [6]. It is unacceptable to describe the tubes before blood collection. A single patient should be collected simultaneously, as this minimizes the risk of identification error. The person performing the collection submits their stamp and signature on the referral and writes the date and time the sample was collected. These are crucial, as the result of the cross-matching is valid for 48 hours after sample collection [6]. The blood sample, along with a completed referral and an individual request for blood from a doctor, should be delivered to the blood bank as soon as possible.
When the ordered blood component is ready for pickup from the blood bank, it is necessary to make sure that the patient’s condition allows for transfusion. The patient’s body temperature, blood pressure, and heart rate are measured [7]. If the doctor decides that the patient’s condition allows transfusion, the ordered component can be picked up. Upon pickup, a visual inspection of the blood container is necessary. The compatibility of the component data with the data on the result of the patient’s confirmed ABO test for whom the component is intended and with the data on the result of the crossmatching should also be assessed [8]. The blood component must be transported to the ward as soon as possible in the designated container [7].
In the ward, at the patient’s bedside, before connecting the bag, the doctor and the nurse are required to check:
• the compatibility of the patient’s data (name, PESEL, or date of birth) with the data on the result of the crossmatch test;
• compatibility of the patient’s confirmed ABO test result with the blood group on the container’s label and, in the case of transfusion of the RBCs (red blood cells) and GCs (granulocyte concentrates), additionally with the blood group stated in the result of the crossmatch test;
• the correspondence of the donation number on the container with the donation number in the result of the crossmatch test;
• whether the unit of blood or blood component was prepared in accordance with the special instructions provided in the prescription sheet (e.g., whether the component is leukocyte-reduced or irradiated);
• the expiration date of the blood component and the expiration date of the compatibility test [6].
Verification of these data is confirmed by the signature of the verifiers on the result of the compatibility test or the blood bank component release document [6]. Transfusion cannot be started if the doctor is not present at the patient’s bedside.

TRANSFUSION PROCEDURE

Planned transfusion should take place when the doctors and nurses or midwives are fully staffed [6]. Before the procedure, the patient’s (and/or his legal representative’s) informed consent to the transfusion is required. The transfusion of blood or blood components (with the exception of platelet concentrates [PCs], plasma and cryoprecipitate, which should be connected to the patient immediately upon arrival at the ward) should be started no later than 30 minutes after their delivery. When connecting the first and each subsequent blood component, the doctor responsible for the transfusion must be present [6].
The patient should be in a comfortable position, the hand to which the infusion is connected should lie comfortably, and the puncture itself must be secured. An additional second venous access should be provided in case the patient requires additional intravenous (IV) drug administration. Connecting the blood component is not very different from initiating an IV infusion. The first step is to connect the apparatus with a filter. For routine transfusions, 20- or 22-gauge needles are usually used [9]. If the patient requires it, a 24-gauge needle can be used [10]. Next, the tubes should be filled with calcium-free solution that is isotonic to the blood, such as 0.9% sodium chloride [9]. After this step, the blood component can be connected.
For the first fifteen minutes, blood should be transfused slowly, for example 2 ml/min [9]. This is a very important moment, as the majority of post-transfusion reactions occur within this time. The patient should be instructed to report any concerning symptoms, in particular to observe for the following: chills, shortness of breath, rash, skin redness, or pain in the limbs or lumbar region [6]. Studies show that properly informing the patient of possible signs indicating a post-transfusion reaction significantly reduces the risk of serious complications [11].
The most common symptoms of acute post-transfusion reactions and their causes are shown in Table 3 [12].
If the first 15 minutes went smoothly, temperature, heart rate, and blood pressure should be measured again in the patient [6]. If the patient is stable and shows no signs of post-transfusion reaction, the blood component flow rate can be increased.
A single unit of RBC cannot be transfused for more than 4 hours, while PCs, cryoprecipitate, and plasma cannot be transfused for more than 30 minutes. If it is necessary to transfuse more than one blood component, they must be collected consecutively from the blood bank, and the transfusion set must be changed each time. Exceptions where transfusion of more than one unit with one kit is allowed are massive transfusion and transfusion of several units of cryoprecipitate [6].
When alarming symptoms are observed, transfusion should be stopped immediately – the doctor should be notified of the patient’s condition and temperature, and pulse and blood pressure should be measured. The patient should also be asked whether the symptoms subside when the component is no longer transfused. Then it is necessary to re-check the match between the patient’s data and the data on the container and on the result of the compatibility test or the component release document from the blood bank. If the suspicion that the symptoms indicate a serious adverse reaction is confirmed, the container must be disconnected along with the transfusion set, but the venipuncture must be maintained and the transfusion of the 0.9% NaCl solution or other infusion fluid must be performed through a new set. It will also be necessary to take samples from the new injection for immunohematology and bacteriological testing, which, together with the residual of the component and the protocol prepared by the doctor, will be handed over to the blood bank [6].

POST-TRANSFUSION MANAGEMENT

When the transfusion is completed, it is necessary to re-measure the patient’s temperature, pulse and blood pressure [6]. The residual of the component, along with the kit used for the transfusion, should be secured (usually tightly packed in a medical waste bag) and described with the date and time of completion of the transfusion and the patient’s initials. In this form, it is stored in the blood bank in specially prepared, validated refrigerators, at 2-6°C, for 72 hours [13]. After the transfusion, the nurse or midwife must make an entry in the transfusion book. Each entry must be checked and confirmed by the physician responsible for the transfusion [6].
Patients must remain under observation for at least 24 hours if they stay in the ward, or 2 hours if they are admitted for same-day hospitalization or are discharged from the ward [6]. Post-transfusion (acute) reactions usually occur up to 24 hours after transfusion [14]. For this reason, if a patient is discharged from the hospital before 24 hours, they must be advised to report to the emergency room if symptoms of a post-transfusion reaction occur [6]. During the observation period, special attention should be paid to patients who have received more units of blood, as this is associated with a higher risk of cardiac complications, respiratory complications, postoperative infection, or death [14]. All post-transfusion reactions need to be reported to the physician in charge of the transfusion, who will evaluate the severity of the reaction. If it is severe, they are required to report it to a public blood service unit within 24 hours [15].

ACUTE POST-TRANSFUSION REACTIONS

The responsibility for correctly recognizing symptoms of post-transfusion reactions falls largely on the nurse transfusing the blood component and caring for the patient after the transfusion. Patients requiring transfusion are usually not healthy individuals, so it is important to correctly differentiate between symptoms that may indicate an adverse transfusion reaction and those based on the patient’s current health status.

FEBRILE NON-HEMOLYTIC TRANSFUSION REACTION (FNHTR)

This is the most common post-transfusion reaction [16]. It usually occurs within 30 minutes up to 2 hours of the start of the transfusion, but can appear even within the first 5 minutes [17]. Symptoms of FNHTR include fever, chills, flushing, headache, increased respiratory rate, and anxiety. In patients with febrile illnesses, it is most difficult to determine what is causing the increase in temperature: the underlying disease or the transfusion [14]. Nevertheless, transfusion should be stopped immediately, as it may turn out that the temperature rise is a symptom of a more serious reaction [18].
To lower the patient’s body temperature, the doctor may order antipyretics. To prevent FNHTR, leukocyte-reduced blood products may be used [14].

ACUTE HEMOLYTIC REACTION

The prevalence of acute hemolytic reaction is estimated to be about 1 in 70,000 transfusions [18]. Its classic occurrence includes the onset of three symptoms: fever, side pain, and hemoglobinuria, which appear within an hour of the start of the transfusion. Other possible symptoms include agitation, chills, burning sensation at the infusion site, chest tightness, headache, nausea, vomiting, shortness of breath, red or swollen skin, tachycardia, and hypotension [18].
Transfusion should always be discontinued if an acute hemolytic reaction is suspected. IV fluids should be continued to reduce complications associated with free hemoglobin in the bloodstream and to counteract hypotension and maintain adequate renal perfusion [14, 18]. The most common cause of acute hemolytic reaction is transfusion of incompatible blood components, so the best way to prevent it is to correctly identify the patient at every stage of the process [14].

ALLERGIC REACTION

The second most common post-transfusion reaction in adults (the most common in children) is an allergic reaction [16]. Typically, symptoms can be seen during the transfusion or 2 to 4 hours afterwards. They show up more often with transfusion of blood components containing plasma [19]. Symptoms indicating a reaction include urticaria, pruritus, and, in more severe cases, angioedema and respiratory distress [14].
Intervention for post-transfusion allergic reaction depends on the severity of the symptoms. The doctor may order antihistamines and, for more severe reactions, hydrocortisone. If, after administration, the symptoms subside and no respiratory symptoms are observed, the doctor may decide to resume the transfusion. If the patient develops generalized urticaria, transfusion should not be resumed [14].

ANAPHYLACTIC REACTION

Anaphylactic reactions are extremely rare. Generally, they occur within a short time from the start of the transfusion [14]. They are more frequently observed during transfusion of PCs (63 per 100,000 transfusions), than during transfusion of plasma and RBCs (4.3 per 100,000 transfusions) [20]. Signs of anaphylaxis include respiratory distress, hypotension, flushing, nausea, and vomiting.
If an anaphylactic reaction occurs, steps should be taken to maintain oxygenation and stabilize the patient’s blood pressure. It may be necessary to administer epinephrine. Under no circumstances should transfusion be resumed [14].

TRALI (TRANSFUSION-RELATED ACUTE LUNG INJURY)

TRALI is a rare but very serious transfusion complication. Its mortality rate is the highest of all post-transfusion reactions and is estimated at 5-25% [21]. TRALI has a rapid onset: acute dyspnea and hypoxia occur, and the patient’s saturation drops below 90%. Symptoms begin during or at the end of the transfusion, but can appear up to 6 hours after the procedure. Other signs include hypotension, tachycardia, fever, and shivering [14].
At the present time, there are no established treatments for TRALI. Due to the severity of the reaction, rapid response team intervention may be required. Supportive treatment includes oxygenation of the patient, ventilation, and continuous extracorporeal membrane oxygenation (ECMO) of the blood. Medication may be necessary to maintain blood pressure. Although pulmonary edema is common in patients with TRALI, diuretics should be avoided, because they can aggravate hypotension [14, 21].

TACO (TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD)

The prevalence of TACO is estimated to range from 1% (in admitted patients) to 11% (in critically ill patients) [22]. Due to similar symptoms, it is often difficult to distinguish TACO from TRALI, especially in the elderly. Symptoms of TACO, which can appear up to 12 hours after transfusion [22], include shortness of breath, wheezing, coughing, headache, and/or hypertension. In addition, jugular venous distension and crackles on auscultation may be noted [14].
When TACO is diagnosed, the doctor should order diuretics for the patient to reduce the intravascular volume. Placing the patient in an upright position with elevated feet and providing supplemental oxygenation may be helpful in ensuring adequate airflow to the lungs [14].

BACTERIAL INFECTIONS

Transfusion-associated bacterial infections are extremely rare due to the strict eligibility criteria for blood donor candidates. However, it is possible to draw blood from a donor during a period of asymptomatic bacteremia. Also, improper decontamination of the patient’s skin before connecting the transfusion set, or the use of an unsterile set, can result in infection. Symptoms of bacterial infection may be observed from a few minutes after the start of transfusion up to 24 hours after the transfusion. Initially, these include an increase in body temperature and shivering, followed by a drop in blood pressure, nausea, vomiting, diarrhea, abdominal pain, shock, respiratory distress, hemoglobinuria, and renal failure [17].

CONCLUSIONS

Nurses are involved in the greatest number of steps in the transfusion process, making them the most vulnerable to error. Studies show that most serious adverse reactions are the result of mistakes made on the hospital ward [5]. Regular updating of knowledge related to transfusion of blood components, starting with correct identification of the patient and ending with correct recognition of symptoms of post-transfusion reactions in the blood recipient, is crucial to ensure patient safety, but also to avoid making a medical error.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References