UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES

MEDICAL CENTER

PROCEDURE

 

 

PROCEDURE:

107

EFFECTIVE:

7/99

REVISION:

11/06

APPROVAL:

12/06

PROCEDURE FOR ORDERING AND ADMINISTERING BLOOD AND BLOOD COMPONENTS

 

The attached procedure was developed in an interdisciplinary forum with input from Nursing and Blood Bank and reflects current practice in these clinical disciplines.

 

INSTRUCTIONS FOR ORDERING, CHECKING OUT AND TRANSFUSING BLOOD

Transfusions of blood and components are usually carried out by personnel who are not under the direct supervision of the Transfusion Service Medical Director. The Medical Director should participate in writing and reviewing policies for transfusion therapy. Inservice education is necessary to reinforce policies and procedures and disseminate changes. Periodic audits should be done by the Transfusion Service QA Officer or therapeutic nursing staff to assess the competency of personnel administering transfusions. Of particular importance is the identification of the patient at bedside.

 

SPECIMEN:

6ml EDTA (Purple Top)

Neonates 4 ml EDTA tube with 1 ml whole blood 
Printed labels and signed Blood Bank requisition (or echart transmittal form)

 

EQUIPMENT:

 

Adult:

  1. Blood administration set (Y-type, component, or I-Med) (one administration set per unit of blood)

  2. Leukodepletion filters, if required

  3. *Normal Saline, if needed

  4. 20ml to 50ml syringe for administration of cryoprecipitate with syringe adapter

  5. Infusion pump, if ordered

  6. Pressure bag, if ordered

 

* Saline may be hung with blood to facilitate flow. Saline is especially useful in situations where blood is not on a mechanical pump.

 

Nursery Specific:

  1. Tuberculin syringe with Normal Saline

  2. Syringe pump

  3. Filter-Syringe set of appropriate size

 

PROCEDURE

  1. SPECIMEN, REQUISITION, AND ORDERS

KEYPOINT:  Prior to ordering any blood product, it is the responsibility of the RN to ensure there is an order for the blood to be administered and a current Transfusion Consent in the record. A new consent must be obtained for each inpatient admission and at least every six months. Outpatient consents are valid for six months unless there is a change in treating service. If the patient is febrile the Physician must be consulted prior to administration.

 

  1. Place a printed patient label with name, date of birth, date of collection and medical record number on the BB1 form or generate an echart transmittal form. Specify tests and blood components needed on requisition or in echart.

  2. If there is not a current Type and screen (a new specimen is required every 72 hours or after a transfusion reaction) in the Blood Bank a new specimen must be drawn. Print a label to place on the specimen tube. Check label name, date of birth, date of collection and medical record number with patient ID band at bedside. Draw blood and label tube at bedside.

  3. Sign the label and the BB1 form or echart transmittal as the phlebotomist identifying the patient and specimen. Specimens and requisitions can be sent through the tube system or brought to Blood Bank. These specimens are good for three days regardless of whether type and screen or crossmatch is ordered.

  4. Specimens drawn on ER and Labor and Delivery patients require secure line labeling. At bedside verify patient information and write the patient's name, date of birth, medical record number, and date and phlebotomist initials on the long label located near the clip of the secure line. Attach band to patient's arm.

  5. Remove the part of the secure line sticker containing the patient name, date of birth, and medical record number from the band and place on clot tube. Remove and attach strip of numbers to specimen. Place one secure line label on the BB1 form or echart transmittal.

  6. Unsigned tubes and requisitions sent to Blood Bank can be signed after the fact only if the person who drew the blood comes to the Blood Bank and identifies the specimen and paperwork. No specimens or requisitions will be sent through the tube system for corrections or signatures.

  7. If the patient name, date of birth, and medical record number on the tube and requisitions do not match, the specimen will be discarded and a redraw requested. There are no exceptions to this policy.

  8. In the event of rapid bleeding, the patient will be issued O negative or O positive uncrossmatched Red Blood Cells until a satisfactory patient specimen is made available to the Blood Bank.

  9. Component orders or add-on red cells orders can be ordered by using a BB1 form or sent through echart. Component orders require current lab values for PT and PTT if FFP is ordered, platelet count if platelet products are ordered, and fibrinogen if cryoprecipitate is ordered. Component orders should not be filled until this information is received. If there is strong clinical suspicion that the coagulation values are abnormal and components are requested prior to lab values being available, then the components will be issued with subsequent audit of the transfusion event.   In the event of an emergency, phone orders may be placed to the blood bank.  The verbal order must be followed by a hard copy of the order.

 

KEYPOINT: When the RN tubes the specimen to the Blood Bank, he/she will leave the completed check-out slip at the desk with the PSC/designee. The slip will include transaction code (room/bed/chair number) and tube station. The RN will check the appropriate box on the BB check-out form to indicate when the blood is needed. Once the Type and Cross is complete, the BB will call the number designated for that area and tell the PSC/designee the blood is ready.  Upon the direction of the RN, the PSC/designee can then tube the check-out slip to the BB.

  1. RECEIPT OF BLOOD FROM THE BLOOD BANK

  1. Once the check out slip (with the patient name, date of birth, medical record number, nurse's name, transaction code and pneumatic tube station number,) has been sent through the pneumatic tube to the Blood Bank, the blood or product may be obtained in one of 2 ways. Blood may be issued via the tube system or in person, providing the person picking up blood has the required information. If they do not, they may call the floor for it and fill out a card or requisition.

  2. A person carrying food or drink may not receive blood for safety reasons.

  3. If an order has been phoned in for components, the BB1 order sheet is required to check out the blood so the Blood Bank has a copy of the order on file.

  4. Before issued, all information on the blood bag, blood tag, and Blood Bank computer must agree exactly. Blood Bank personnel will verify the blood prior to issue.

  5. Blood products can be issued on different patients at the same time, but only one product per patient can be issued at the same time. Multiple units of blood for a patient may be issued in an emergency to the OR which has monitored refrigerators.

  6. The Blood Bank will call the number designated for that area prior to sending the blood product. If the phone is not answered Blood Bank will hold the product until they are contacted by the floor.  Blood products that are sent through the tube system will be sent using a Transaction Code. The codes are as follows:

·         The Nursing units, including L&D will use the room number.

·         The Nursery will use the code 0035.

·         Stem Cell Apheresis will use 11 plus the room/chair number.

·         Chemotherapy Infusion center will use 8888.

·         Short Stay will use 99 plus the bed number.

·         Surgical services and ED will NOT use the secure transaction code.

 

KEY POINT: The room and chair numbers must be on the checkout slip for the BB to release the product.

 

  1. The nurse will go immediately to the tube system when prompted by the display panel and remove the product. Once blood is issued by the Blood Bank, the transfusion must begin within 15 minutes. If this is not possible, the blood must be returned to the Blood Bank immediately.

  1. ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS - CLERICAL

(Most blood products are leukocyte depleted prior to storage and issue, only rarely will the nursing staff be required to use a leukodepletion filter.)

  1. Ascertain that the physician has obtained consent for blood and/or component transfusion.

  2. To obtain leukocyte or irradiated products first determine if the patient is a bone marrow transplant patient, an oncology patient who has orders for leukocyte depleted products, a patient who has experienced a previous documented febrile nonhemolytic transfusion reaction, or a patient who has received a solid organ transplant.

  3. Educate the patient about the type of component to be administered, possible side effects and the UAMS policy that prohibits leaving the unit with a transfusion running.

  4. At the bedside check the blood with blood tag against the patient's armband with another RN, LPN, or MD.  Check the following: Patient's name (first name, last name, and middle initial), date of birth, medical record number, blood type, blood number, expiration date and secure line numbers if applicable.  The staff shall ask the patient to state his or her name and date of birth.  The patient’s name and date of birth must match with the patient’s armband and sticker.                KEYPOINT: If the patient is confused or mechanically ventilated and no family member is present the ID band will be used as identification. All information on the band and sticker must match exactly before proceeding.

  5. Both persons sign the top paper copy of the blood tag. After signing, tear off only the top copy and use to record vital signs, including pre-transfusion vital signs. This is the part of the blood tag that will be placed in the chart when the transfusion is over.

  6. Leave the cardboard portion of the blood tag attached to the unit of blood throughout the transfusion. This cardboard tag with the two signatures is removed, post- transfusion and returned to the Blood Bank. The Blood Bank does not need a record of the vital signs, only the transfusionist's signatures.

  7. In case of a transfusion reaction, stop the blood immediately. On the back of the blood tag are complete instructions for initiating a transfusion reaction workup.

  1. ADMINISTRATION OF RED BLOOD CELL - PROCEDURAL

Adults

 

  1. Once blood has been checked at bedside, hang Normal Saline and flush line. Normal Saline always precedes and follows blood administration. 1-20ml can be sufficient if patient is fluid restricted. If the patient has a multi-lumen vascular access device administer all blood products through the distal lumen. NO other IV fluids (except Normal Saline) or medications are to be infused in the same lumen as blood products.

  2. If a leukodepletion filter is used, prime the filter directly with red cells. DO NOT PRIME WITH SALINE.

  3. Connect blood to administration set. (See package insert.)  

 

KEYPOINT:  Manufacturer recommends that one administration set be used for each unit of blood.

 

  1. If a Y-set is used:

    1. Close all clamps.

    2. Attach one Y-site to Normal Saline or straight set if using a pump. If using a pump, Normal Saline may be used as the primary set and the blood as the secondary. Open clamps at distal end of tubing and to Normal Saline above "Y".

    3. Fill filter completely with Normal Saline to prevent clot formation.

    4. Close both clamps and connect blood to remaining Y-site and lower below Normal Saline.

    5. Lower blood bag by opening clamps above Y-site to Normal Saline and to Blood (leave distal clamp closed allowing NS to flow into blood bag).

    6. Close both clamps and blood is ready to infuse.

  1. Administer blood and observe closely for first 15 minutes and RECORD VITAL SIGNS AFTER THE FIRST 15 MINUTES. Reaction usually occurs within the first 15 minutes.

  2. Regulate rate of infusion. Start slowly at first. Four hours is the maximum time in which one unit of PRBCs may be hung for transfusion. If the unit of blood cannot be given in less than 4 hours, ask the Blood Bank to split the unit.

  3. Agitate blood gently at frequent intervals to assure mixture of red cells.

  4. If a pressure bag is used, do not exceed 100 mm Hg.   

    

KEYPOINT:  A patient may be transported to another area during a transfusion under the following circumstances:

  • The blood must have been infusing, without S&S of a reaction, for greater than 15 minutes with stable vital signs.

  • The receiving area must have a licensed/approved professional to take over the care of the patient during transfusion.

 

Neonates

 

KEYPOINT: Platelet administration and administration of FFP for neonates follows this procedure.

 

  1. Discontinue any IV fluids or medications and flush I.V. (access must be PIV or UVC, not a PICC) directly with 0.5 ml-1ml Normal Saline with a tuberculin syringe.

  2. Carefully mix blood in blood bag.

  3. Using filter-syringe set, spike blood bag and pull required amount of product through filter into syringe. Draw enough blood to prime tubing in addition to the amount to be infused.

  4. Holding syringe and tubing upright, tap syringe and carefully displace residual air from syringe by gently pushing it back through filter and tubing.

  5. Close clamp on tubing from blood bag.

  6. Remove syringe from set and place syringe in syringe pump. Exact amount of blood to be infused should be in the syringe.

  7. Administer blood and observe closely for the first 15 minutes and RECORD VITAL SIGNS AFTER THE FIRST 15 MINUTES.

  8. Regulate the pump to the rate of infusion ordered for the infant. Four hours is the maximum time in which a red blood cells or whole blood may be transfused.

 

  1. ADMINISTRATION OF COMPONENTS - PROCEDURAL

Blood Bank will send the appropriate administration set for platelets when picking up the product from the Blood Bank. Components sets have the same port size, but may have a different filter chamber size. Follow the same steps for administering red blood cells. (See package insert.)

Platelet Administration:

  1. Obtain platelets with tubing and filter from Blood Bank.

 

KEYPOINT:  If leukocyte free platelets are to be given, no filter is used.

 

  1. Spike bag with tubing and attached filter

  2. Open clamp one-half of the way and run in platelets for 15 minutes and observe for reaction.

  3. After 15 minutes of infusion, take the patient's vital signs.

  4. If stable, open clamp the rest of the way and continue infusion.

  5. The infusion is usually completed within 30-40 minutes.

  6. At the completion of infusion, flush CVL with normal solution followed by heparinized solution.

 

Fresh Frozen Plasma Administration:

  1. Obtain fresh frozen plasma from the Blood Bank.

  2. Spike bag with the tubing.

  3. Open clamp to run "wide open" for 15 minutes, observing for symptoms of volume overload.

  4. After 15 minutes of infusion, take the patient's vital signs.

  5. If stable, continue with infusion until the number of units ordered is infused.

  6. At the completion of infusion, flush CVL with normal saline followed by heparinized solution.

 

Cryoprecipitate Administration:

  1. Obtain a blood component set with a syringe adapter. (A Y-set may also be used with transfusion the same as with platelet transfusion.)

  2. Close both clamps

  3. Attach bag of cryoprecipitate to coupler of syringe set.

  4. Attach syringe to female luer connector and open clamp to bag.

  5. Draw cryoprecipitate into syringe and then close clamp.

  6. Open lower clamp and depress syringe plunger to permit fluid to fill set and expel air.

  7. Administer cryoprecipitate following the same steps as for administering red blood cells.

 

RhoGam Administration:

  1. Inject the entire contents of the vial intramuscularly.

  2. Complete the patient identification card and give it to the patient.

 

  1. DISCONTINUATION OF COMPLETED TRANSFUSION

  1. Flush with Normal Saline.

After transfusion with a leukodepletion filter, the filter is not flushed with saline. The use of saline flushing has been shown to unload leukocytes from the filters.

  1. Take and record vital signs.

  2. Indicate the time finished, as well as no reaction.

  3. Place the top paper copy of the blood tag in the patient's chart.

  4. Return cardboard copy of blood tag to the Blood Bank.

  5. Leave any secure line band in place for 3 days.

 

  1. TRANSFUSION REACTIONS FOR RBC'S

  1. Stop the blood immediately and keep vein open with Normal Saline. Signs/symptoms of transfusion reactions are printed on the back of the blood tag.

  2. Obtain vital signs and notify M.D.

  3. Notify the Blood Bank of reaction and return:

    1. First urine specimen within 15 minutes of reaction to Clinical Lab.  Order transfusion reaction urine in eChart (the urine specimen does not apply to neonates).

    2. One purple-top tube of blood (labeled "post transfusion reaction".) Tubes must be signed by person who drew blood.  Do not draw from arm used for blood transfusion.  Draw carefully to avoid hemolysis.

    3. Return blood bag and tubing to the Blood Bank. DO NOT SEND NEEDLE.  The unit cannot be sent through pneumatic tube.

    4. Completed blood transfusion reaction form.

 

 

  1. TRANSFUSION REACTIONS - PLATELETS, FFP, CRYO (allergic)

These include reactions with hives.

 

  1. Stop transfusion and monitor vital signs.

  2. Inform M.D. and medicate per order.

  3. As symptoms subside, resume transfusion. If symptoms (itching, hives) do not subside with medications, discontinue platelets/FFP/Cryo and follow steps above for red cell reactions.

  4. An allergic transfusion reaction (itching/hives) is the only transfusion reaction where the platelets/FFP/Cryo hanging can be restarted after symptoms have subsided.

  1. SPECIAL TRANSFUSION CONSIDERATIONS

  1. Platelet products and cryoprecipitate are stored at room temperature. They require a special blood component set with short length tubing to minimize loss of product during transfusion.

  2. All transplant patients and neonates are issued red cells and platelets products which have been irradiated. These blood components are labeled with a small purple irradiation sticker. FFP and cryoprecipitate do not require irradiation.

 

REFERENCES:

American Association of Blood Banks, TECHNICAL MANUAL, 14th Edition, Bethesda, MD., 2002.

American Association of Blood Banks, "STANDARDS for BLOOD BANKS and TRANSFUSION SERVICES",

22nd Edition, Bethesda, MD., 2003.

Office of the Federal Register, Code of Federal Regulations, Title 21, Washington: 2000.

 Manual: ADMINISTRATIVE, VOLUME VI