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Blood transfusion is a relatively common OSCE station. It is essential that you practice the various compulsory steps required to safely administer a blood transfusion. This blood transfusion OSCE guide provides a systematic approach to safely arranging and administering a blood transfusion. Check out the blood transfusion OSCE mark scheme here.


Collecting the initial blood sample

1. Ask the patient’s name and date of birth, comparing this to their identity bracelet, ensuring they match

2. Collect blood sample into the appropriate sample bottle for blood grouping (often pink)

3. Copy the patient details from the identity bracelet onto the bottle AT THE BEDSIDE!

4. Sign the blood bottle, to confirm you personally obtained the sample

5. Complete the corresponding blood transfusion form:

  • Include all relevant patient details  (name / DOB / hospital number/ ward)
  • Check if the patient has any special requirements for blood  (CMV negative / irradiated)
  • If you require a crossmatch, document the number of units of blood required
  • Document your full name and sign to confirm you’ve taken the blood and performed the necessary checks

6. Send the bloods to the lab for analysis of blood type and cross matching if required


How to prescribe the blood transfusion

1. Each unit of blood needs to be prescribed separately

2. This will need documenting accurately:

  • The way in which this is done varies between hospitals
  • Often blood is prescribed on the fluid balance chart
  • Blood is prescribed as “PACKED RED CELLS”
  • You should document time and date of infusion, as well as the reason for transfusion

3. Generally a unit of blood is transfused over a 2-3 hour period (in a non-urgent scenario)

4. You should arrange to have the blood delivered to the ward

5. Blood needs to be given within 30 minutes of leaving the refrigeratorso avoid any delay


How to check the blood transfusion

1. Request another nurse or doctor to go through the checking procedure with you

2. Ensure patient details on bracelet, notes and blood compatibility report all match EXACTLY!

3. Check blood group and serial number on blood bag matches the compatibility report

4. Check the expiry date and time on the unit of blood to ensure it has not expired

5. Inspect blood bag for:

  • Signs of tampering
  • Leaks
  • Discolouration 
  • Clots

Do not administer blood if any of these are noted!


Administering the blood

1. The patient obviously will require a cannulasee our cannulation article here

2. Attach the giving set to the blood bag and run some blood through the tubing to expel any air

3. Once all air has been expelled, attach the other end of the giving set to the cannula port

4. Set the drip rate to match the amount of time you want to give the blood over

5. You and a colleague should document the time and date the transfusion was started and sign to confirm all checks were carried out


Monitor the patient

Monitoring the patient is a crucial part of the transfusion process.

The patients baseline observations should be taken at 0, 15, 30 mins from onset of transfusion.

Observations can then be done on an hourly basis and again when the transfusion has finished.

Regular observations allow early detection of transfusion related reactions.


Transfusion reactions

Immediate reactions <24 hours

1. Immune – ABO incompatibility / TRALI / anaphylaxis

2. Non-immune – bacterial infection / fluid overload

 

Delayed >24 hours

1. Immune – DHTR / FNHTR / post-transfusion purpura / GvHD 

2. Infections – viral / malaria / prions

 

Transfusion reactions explained

Acute haemolytic transfusion reaction (ABO incompatibility)

  • Anti-A/B antibodies activate the complement pathway and the release of inflammatory cytokines.
  • Early signs are fever, hypotension, anxiety, and red-coloured urine.
  • Late signs are generalised bleeding, caused by disseminated intravascular coagulation, and hypotension.

Transfusion related acute lung injury (TRALI)

  • Pathophysiology not fully understood but antibodies to human neutrophils antigens and human leukocyte antigens have been implicated.
  • The typical presentation of TRALI is the sudden development of dyspnea, severe hypoxemia (O2 saturation <90% in room air), hypotension, and fever that develop within 6 hours after transfusion and usually resolve with supportive care within 48 to 96 hours.

 

Anaphylaxis

  • Occurs because recipient is allergic to protein components in donor transfusion
  • Typically causes more than one of the following: an itchy rash, throat or tongue swelling (angioedema), shortness of breath, vomiting, lightheadedness, and low blood pressure.
  • The symptoms typically come on over minutes to hours and can result in death

 

Fluid overload

  • Each unit of blood is equivalent to 450 ml of fluid and therefore may cause fluid overload if the patient has multiple transfusions.
  • Those most at risk include the elderly and particularly those with congestive cardiac failure

 

Delayed haemolytic reaction

  • Antibodies to minor antigens such as Rhesus or Kidd
  • A haemolytic reaction can occur between 3 and 14 days as a result of a secondary immune response, with a drop in haemoglobin level, fever, jaundice, or haemoglobinuria.

 

Febrile non-haemolytic transfusion reactions (FNHTR)

  • Associated with fever but not directly with haemolysis.
  • It is most commonly caused by antibodies directed against donor leukocytes and HLA antigens. This is in contrast to transfusion-associated acute lung injury, in which the donor plasma has antibodies directed against the recipient HLA antigens, mediating the characteristic lung damage
  • Mainly occurs in multiply transfused patients or women with multiple previous pregnancies

 

Post-transfusion purpura (PTP)

  • An adverse reaction to a blood transfusion or platelet transfusion that occurs when the body produces alloantibodies to the introduced platelets’ antigens.
  • These alloantibodies destroy the patient’s platelets leading to thrombocytopenia, a rapid decline in platelet count.
  • PTP usually presents 5–12 days after transfusion, and is a potentially fatal condition.

 

Graft vs host disease (GvHD)

  • Graft-versus-host disease is a medical complication following the receipt of transplanted tissue from a genetically different person.
  • Immune cells (white blood cells) in the donated tissue (the graft) recognize the recipient (the host) as foreign (nonself). The transplanted immune cells then attack the host’s body cells.
  • GvHD can occur after a blood transfusion if the blood products used have not been irradiated or treated with an approved pathogen reduction system.

REVIEWED BY

Dr Sandeep Potluri

SpR in Haematology


References

1. Covin RB, Evans KS, Olshock R, Thompson HW (2001). “Acute hemolytic transfusion reaction caused by anti-Coa”. Immunohematology17 (2): 45–9. PMID 15373591.

2. Noizat-Pirenne F, Bachir D, Chadebech P, et al (December 2007).“Rituximab for prevention of delayed hemolytic transfusion reaction in sickle cell disease”Haematologica 92 (12): e132–5.doi:10.3324/haematol.12074PMID 18055978

3. Silliman C, Paterson A, Dickey W, Stroneck D, Popovsky M, Caldwell S, Ambruso D (1997). “The association of biologically active lipids with the development of transfusion-related acute lung injury: a retrospective study”. Transfusion 37 (7): 719–26. doi:10.1046/j.1537-2995.1997.37797369448.xPMID 9225936.

4. Addas-Carvalho M, Salles TS, Saad ST (June 2006). “The association of cytokine gene polymorphisms with febrile non-hemolytic transfusion reaction in multitransfused patients”Transfus Med 16 (3): 184–91. doi:10.1111/j.1365-3148.2006.00665.xPMID 16764597