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Pre‐procedural considerations

Equipment

Intravenous access

Blood components may be administered through a peripheral cannula or via a central venous access device. Where possible, one lumen should be reserved for the taking of blood specimens and blood component administration for the duration of therapy.

Administration sets

All blood components must be transfused through a sterile blood component administration set with an integral mesh filter (170–200 μm) that is CE marked. Blood administration sets should be changed at least every 12 hours or after every second unit for a continuing transfusion (Loveday et al. [137]; see also local guidance). Administration sets used for blood components must be changed immediately upon suspected contamination or when the integrity of the product or system has been compromised. Platelets and plasma components may be administered through a normal blood administration set or through a platelet set. Platelets should never be administered through an administration set that has previously been used for transfusion of red cells or other blood component as this may cause aggregation of platelets in the administration set (Norfolk [202]). Administration sets used for blood components must be changed using aseptic technique, observing standard precautions and in line with the manufacturer's instructions (RCN [228]).

Infusion devices

Either gravity or electronic infusion devices may be used for the administration of blood components. There are a variety of electronic infusion devices available and it is therefore essential that healthcare professionals using any type of infusion device are competent in their use. Only blood component administration sets compatible with the infusion device should be used. Rapid infusion devices that are CE marked may be used when large volumes have to be infused rapidly. Typically, devices can infuse from 6 to 30 L an hour and usually incorporate a blood‐warming device (Norfolk [202]).

Blood‐warming devices

In cases where there will be rapid transfusion of red cells, warming is recommended. Red cells removed from cold storage and then transfused rapidly can cause hypothermia (Norfolk [202]). The rapid transfusion of cold blood components is cautioned against as it may cause impaired coagulation and cardiac arrhythmias (Norfolk [202]).
However, whichever device is chosen, the temperature should be maintained below 38°C. Warming in excess of this can cause haemolysis of red cells and can denature proteins and increase the risk of bacterial infection. Blood warmers must always be used and maintained according to the manufacturer's guidelines. Blood components must never be warmed by improvisation, such as putting the pack into hot water, in a microwave or on a radiator, as uncontrolled heating can damage the contents of the pack (McClelland [151], Norfolk [202]). The use of water baths also increases the risk of bacterial contamination. Therefore, certain safety measures must be adhered to:
  • Water baths must be drained after each use and stored dry and empty.
  • Blood warmers must be drained after each use and stored dry and empty.
  • When needed, water baths and blood warmers should be refilled with sterile water.
  • A protective sterile over‐bag to thaw blood and blood products reduces the entry of contaminants through microscopic punctures or breaks in the seal.
  • The product should be used immediately after it has been thawed.
All devices should be serviced as per hospital health and safety policies, MHRA guidance and manufacturers’ guidelines.

Blood component request

The details on the blood component request form and the sample tube are the only direct contact between the clinical area and the blood transfusion laboratory. The accuracy and completeness of this information are therefore of vital importance (Estcourt et al. [74]). Incorrect or inadequate patient identification has the potential to result in blood being issued to the wrong patient, possibly leading to ABO‐incompatible transfusions. In the 2017 SHOT report, there were 789 instances of ‘wrong blood in tube’ (WBIT) and one case where WBIT led to an incorrect blood component being transfused (Bolton‐Maggs [27]).
Inadequately or mislabelled samples are up to 40 times more likely to contain blood from the wrong patient (BCSH [16]). A WBIT is usually identified in the laboratory by comparing the current patient group to previous group results, so the patients most at risk from this error are those who only have one sample sent and where blood is issued based on that sample. The British Committee for Standards in Haematology has produced guidelines advocating that when a patient has not had their blood group tested by the current blood transfusion laboratory on a previous occasion, they should have a second separate sample sent before the blood is issued (BCSH et al. [18]). This guidance does not apply to the emergency provision of blood or when waiting for a second sample to be processed would cause patient harm. It is also not necessary to implement the recommendation if the hospital has a secure electronic patient identification system (discussed below) in place (BCSH et al. [18]). The collection of the blood sample from the patient and the subsequent labelling of the sample tube should be performed as a continuous, uninterrupted event at the patient's side, involving one patient and one member of staff only (Robinson et al. [236]).
The NBTC ([177]) has produced standardized adult indication codes (Box 12.9) for transfusion; these codes can also be used as an audit tool that can be incorporated into the transfusion request (Robinson et al. [236]).
Box 12.9
National Blood Transfusion Committee clinical indication codes for transfusion

Red cell concentrates

Dose: in the absence of active bleeding, use the minimum number of units required to achieve the target level of haemoglobin (Hb). Consider the size of the patient; assume an increment of 10 g/L per unit for an average 70 kg adult.

R1: acute bleeding

Acute blood loss with haemodynamic instability. After normovolaemia has been achieved or maintained, frequent measurement of Hb (including via near‐patient testing) should be used to guide the use of red cell transfusion (see suggested thresholds below).

R2: Hb 70 g/L stable patient

Acute anaemia. Use an Hb threshold of 70 g/L and a target Hb of 70–90 g/L to guide red cell transfusion. Follow local/specific protocols for indications such as following cardiac surgery, in traumatic brain injury or in acute cerebral ischaemia.

R3: Hb 80 g/L if cardiovascular disease

Use an Hb threshold of 80 g/L and a target Hb of 80–100 g/L.

R4: chronic transfusion‐dependent anaemia

Transfuse to maintain an Hb that prevents symptoms. Try an Hb threshold of 80 g/L initially and adjust as required. Haemoglobinopathy patients require individualized Hb thresholds depending on age and diagnosis.

R5: maintain Hb >110 g/L in radiotherapy

There is limited evidence for maintaining an Hb of 110 g/L in patients receiving radiotherapy for cervical and possibly other tumours.
Source: Adapted from NBTC ([177]).

Specific patient preparation

Wristbands for patient identification and transfusion

In 2007, the NPSA issued Safer Practice Notice No. 24: Standardising Wristbands Improves Patient Safety. This notice stated that only the following core identifiers should be used on patients’ identification bands:
  • last name
  • first name
  • date of birth
  • NHS number.
Patients should have their identification confirmed on admission to the unit and one wristband attached to their wrist. If a wristband is removed for any reason, for example to gain intravenous access via a cannula, it is the responsibility of the person removing it to ensure that a correctly completed wristband is then reapplied.

Electronic systems for patient identification and transfusion

Wristbands can now hold patient information in an electronic format, such as in a bar code or a radiofrequency identification (RFID) tag. Electronic systems offer improved security and patient safety (Kaufman et al. [125], Robinson et al. [236]) by removing the element of human error from the process. At the point of taking a sample for pre‐transfusion testing, the patient is identified through the usual process of stating their name and date of birth, but there is the added safety of scanning the bar code or RFID tag on the wristband.
These electronic systems can be used during collection and administration. During administration, the blood component and the wristband are scanned to confirm that the right component is being given to the right patient. Safer Practice Notice No. 14: Right Patient, Right Blood (NPSA [203]) recommended that all NHS trusts and independent sector organizations responsible for administering blood should risk assess their transfusion procedures and look at the feasibility of using bar codes and other electronic identification and tracking systems for patients, samples and blood components. In a key recommendation, SHOT stated that electronic blood systems should be the standard towards which all trusts aim (Bolton‐Maggs [27]).

Informed consent

Nurses must ensure that patients have been informed of the proposed transfusion, have had an opportunity to raise any concerns, understand the risks and benefits of the transfusion, have agreed to the transfusion, and are available for the transfusion. Pre‐transfusion/baseline observations (including blood pressure, temperature, pulse and respiratory rate) must be undertaken and documented, and it must be ensured that there is patent venous access prior to administering the transfusion (Robinson et al. [236]).

Pre‐transfusion/bedside check

While professional accountability measures must be taken at every stage by the personnel involved, the final barrier to wrong blood administration is at the bedside. The final bedside check is the last chance to ensure the right patient receives the right blood and it is therefore essential that this check is performed thoroughly prior to the transfusion of each component (Norfolk [202], Robinson et al. [236]).
To ensure that each blood component is used to its full advantage, local hospital policy should be followed with regard to correct handling, storage, transportation and administration of blood components. If unused, the component should be returned to the transfusion laboratory as quickly as possible to maximize the opportunity for it to be used for another patient.
The written order for the blood component must be checked to ensure that it is correctly completed and that it contains all the information outlined in Box 12.10.
Box 12.10
Essential information for a blood transfusion request
  • Patient core identifiers (see Procedure guideline 12.18: Blood product request)
  • Date (and time if appropriate) the blood component is required
  • Type of blood component to be administered
  • Any clinical special transfusion requirements, for example irradiation or administration via a blood warmer
  • Volume or number of units to be transfused (for paediatric transfusions, exact number in mL)
  • Time over which each unit is to be transfused (for paediatric transfusions, exact rate or length of time over which the specified volume is to be transfused)
  • Any special instructions, for example concomitant drugs required, such as diuretics
  • Signature of the authorizer (‘prescriber’) (Robinson et al. [236])
Procedure guideline 12.18

Blood product request

Procedure guideline 12.19

Blood sampling: pre‐transfusion

Procedure guideline 12.21

Blood component administration

Table 12.25  Prevention and resolution (Procedure guidelines 12.18, 12.19, 12.20 and 12.21)
ProblemCausePreventionAction
Unable to collect patient informationUnknown unconscious patientDo not transfuse unless clinically essential. The patient must be allocated a unique patient identifier; NHS Improvement ([182]) mandates that trusts develop a system with an estimated date of birth and a ‘name’ based on a non‐sequential phonetic alphabet. This information must be used in conjuction with the patient's sex for transfusion requests.Assign the unique hospital identification number to all requests and samples (Robinson et al. [236]).
Major incidentDo not transfuse unless clinically essential. As above if transfusion is essential.Use unique major incident identification number for all requests and samples. The transfusion laboratory also needs patient sex, minimum identification (‘unknown male/female’) and patient incident or hospital number. Follow local policy for major incidents.
Patient unable to communicate verbally
Follow hospital policy for identification of patients unable to confirm identity verbally. Consider the introduction of a photo identification card.
Ensure interpreting services are available if appropriate.
Confirm identity with a relative or second member of staff (SNBTS [261]).
Patient does not have an identity bandIdentity band has been removed or is no longer legibleAlways follow local policy and never use secondary identifiers such as bed numbers, notes or request forms that the patient may be carrying (Murphy et al. [170]). If a member of staff removes a patient's identification band, they are responsible for ensuring that it is replaced.All inpatients are required to wear an identity band; therefore, replace identity band and reconfirm identity (NPSA [204]).
Patient is in an outpatient settingFollow hospital policy for the identification of patients.Ensure the patient has a correctly completed identification wristband prior to commencing a transfusion.
Unable to obtain verbal confirmationPatient unconsciousEnsure hospital policy for the identification of unconscious patients is followed.Confirm identity with a relative or second member of staff or use a unique patient identifier.
Patient unable to communicate verballyDisease or language barrierFollow hospital policy for the identification of patients unable to confirm their identity verbally. Consider the introduction of photo identification cards. Ensure interpreting services are available if appropriate.Always follow local policy and never use secondary identifiers such as bed numbers, notes or request forms that the patient may be carrying (Murphy et al. [170]).
Infusion slows or stopsVenous spasm due to cold infusionApply a heat pad prior to the transfusion to reduce venous spasm.Apply a warm compress to dilate the vein and increase blood flow.
OcclusionCheck patency prior to administration. Always use a pulsatile flush ending with a positive pressure flush.Flush gently with 0.9% sodium chloride and resume infusion. If occlusion persists, consider resiting cannula. For a central venous access device occlusion, see Chapter c17: Vascular access devices: insertion and management.
Elevation of the patient's temperature of less than 2°C after commencing a unit of blood with no other symptoms, and temperature falls if the blood is stoppedFebrile non‐haemolytic transfusion reactionTake a history to identify whether the patient has had a reaction previously.Stop the transfusion and observe the patient's temperature, pulse and blood pressure. If the patient has no other signs or symptoms, give paracetamol and continue the transfusion at a slower rate and observe more frequently (Norfolk [202]).
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