Chapter 12: Respiratory care, CPR and blood transfusion
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Source: Produced by Wales Transfusion Practitioner Group, V2: WBS BBT Team Oct 2012. Based on Tinegate et al. ([270]), UK Blood Services ([276]).
Post‐procedural considerations
Immediate care
Patients should be asked to inform a member of staff of any symptoms that may indicate a transfusion‐related adverse event, such as feeling anxious, rigors (shivering), flushing, pain or shortness of breath. Patients should be cared for where they can be visually observed and should be shown how to use the nurse call system. Patients should have their vital signs monitored as indicated in Procedure guideline 12.21: Blood component administration. However, it may be necessary to take additional observations if clinically indicated, such as if the patient complains of feeling unwell or if they develop signs of a transfusion reaction (Tinegate et al. [270]). Guidance for the initial recognition of transfusion reactions is provided in Table 12.26.
Table 12.26 Recognition of transfusion reactions
| Symptoms/signs | Mild | Moderate |
Severe |
|---|---|---|---|
| Temperature | Temperature of ≥38°C and a rise of 1–2°C from baseline temperature | Temperature of ≥39°C or a rise of ≥2°C from baseline temperature | Sustained febrile symptoms or any new, unexplained pyrexia in addition to clinical signs |
| Rigors/shaking | None | Mild chills | Obvious shaking/rigors |
| Pulse | Minimal or no change from baseline | Rise in heart rate from baseline of 10 bpm or more not associated with bleeding | Rise in heart rate from baseline of 20 bpm or more not associated with bleeding |
| Respirations | Minimal or no change from baseline | Rise in respiratory rate from baseline of 10 or more | Rise in respiratory rate from baseline of 10 or more accompanied by dyspnoea/wheeze |
| Blood pressure (hypotension or hypertension) | Minor or no change to systolic or diastolic pressure | Change in systolic or diastolic pressure of ≤30 mmHg not associated with bleeding | Change in systolic or diastolic pressure of ≥30 mmHg not associated with bleeding |
| Skin | No change | Facial flushing, rash, urticaria, pruritus | Rash, urticaria and periorbital oedema; conjunctivitis |
| Pain | None | General discomfort or myalgia, pain at drip site | Acute pain in chest, abdomen or back |
| Urine | Clear normal output | Haematuria, haemoglobinuria, oliguria, anuria | |
| Bleeding | No new bleeding | Uncontrolled oozing | |
| Nausea | None | Nausea or vomiting | |
| Actions | |||
| All mild symptoms/signs present at the same time | STOP the transfusion but leave connected. Recheck the identity of the unit with the patient and inform doctor. If all well, continue at a reduced rate for the next 30 minutes and then resume at the rate of written instuction. Continue to monitor the patient carefully and be alert for other symptoms or signs of a transfusion reaction. Antipyretics may be required. | ||
| One or more moderate symptom/sign | STOP the transfusion but leave connected. Request urgent clinical review, recheck identity of the unit with the patient, and give IV fluids. If symptoms stable or improving over the next 15 minutes, consider restarting the unit. Antihistamines and/or antipyretics may be required. | ||
| One or more severe symptom/sign | STOP the transfusion and disconnect. Request immediate clinical review, recheck identity of the unit with the patient, give IV fluids, inform the transfusion laboratory, and contact the consultant haematologist. | ||
| In all cases where a transfusion reaction is suspected and the transfusion is stopped and disconnected, the implicated unit, complete with giving set, must be returned to the laboratory for further investigation. Follow local transfusion policy and contact the transfusion laboratory for further instructions. bpm, beats per minute; IV, intraveous. |
Many drugs may cause a pyretic hypersensitivity reaction (BNF [24]). There is at present insufficient evidence to offer guidance on the co‐administration of drugs with red blood cell transfusion. A lack of clinical reporting of reactions in patients cannot be taken to indicate safe practice: adverse reactions may be attributed to other causes; subclinical haemolysis or agglutination may occur undetected; and serious adverse effects may be masked by pre‐existing illness in a patient (Murdock et al. [169]).
Ongoing care
On completion of a blood transfusion episode, observations (to include blood pressure, temperature, pulse and respiratory rate) should be taken and recorded. The patient's records should be updated to confirm that the transfusion has taken place, including the volume transfused, whether the transfusion achieved the desired effect (either post‐transfusion increment rates or an improvement in the patient's symptoms) and the details of any reactions to the transfusion. If intravenous fluids are prescribed to follow the transfusion, these should be administered through a new administration set appropriate for the infusion. The traceability documentation confirming the fate of the component should be returned to the laboratory (BSQR [34]).
The 2017 SHOT annual report (Bolton‐Maggs [27]) emphasizes that, on occasion, transfusion reactions can occur many hours and sometimes days after a transfusion is completed. Therefore, for patients receiving a transfusion as a day case, it is important to ensure that they are counselled on the possibility of later adverse reactions and that they have access to clinical advice at all times. SHOT and the BSH recommend that day‐case and short‐stay patients are issued with a contact card facilitating 24‐hour access to appropriate clinical advice, similarly to patients receiving chemotherapy treatments on an outpatient basis (Bolton‐Maggs [26], Robinson et al. [236]).
