Resource for the Nurse Caring for a Patient Post-Transfusion

This is an educational resource for the nurse caring for a patient post-transfusion.
This is NOT a form to be filled out with patient information.  See patient care policy “Blood/Blood Component Transfusion Reactions” for more information.

TRANSFUSION REACTION MAY BE SUBTLE. IF ANY OF THE SYMPTOMS LISTED BELOW, OR ON OPPOSITE PAGE, DEVELOP DURING OR AFTER TRANSFUSION, REPORT TO VERSAFUSION MEDICAL DIRECTOR AND BLOOD BANK AS A POSSIBLE REACTION, EVEN IF CLINICALLY FELT TO BE UNRELATED TO TRANSFUSION.

Procedure to be followed by transfusionist if a reaction to blood or component is suspected:

1. Notify Versafusion Medical Director and patient’s ordering provider. NOTIFY BLOOD BANK.
2. Start an IV to keep the line open (KVO) with a slow drip of normal saline.
3. Perform clerical check of all labels, forms, and patient ID (also review Typenex on patient armband and unit if red blood cells from transfusion paperwork).
4. Complete Transfusion Reaction Report form, make a copy for the chart, and deliver completed form to Blood Bank with the blood bag, associated IV solutions, and tubing (if possible).
5. Based on the patient symptoms and component transfused, blood bank staff will order/initiate transfusion reaction workup testing and may request post-transfusion specimens be collected.
6. For additional information, see patient care policy, Blood/Blood Component Transfusion Reactions.

Acute Febrile Reaction: If mild increase in temperature, less than 4°F (2°C) increase, but not exceeding 102°F (39°C), and ABSENCE of other potential transfusion reaction symptoms, then transfusion can be continued at reduced infusion rate with provider notification and approval. Once transfusion is complete, report changes to blood bank as a possible febrile reaction.

If additional symptoms of potential transfusion reaction are present/occur, stop transfusion, perform steps above, and report to blood bank as a potential transfusion reaction.

If temperature treated than 102°F (39°C), or greater than 4°F (2°C) rise from baseline, stop transfusion, perform steps above, and consider possible bacterial contamination. Report to blood bank as a possible transfusion reaction.

Urticaria/Itching/Rash-Only: Urticaria is a common occurrence During transfusion (1 in 100 to 500), particularly with plasma containing products (plasma, platelets). If symptom is “rash-only” and no other potential transfusion reaction symptoms are present, then transfusion may be completed with provider notification and approval. Slow rate of infusion and treat as directed by provider. At completion of transfusion, notify Blood Bank of a potential transfusion reaction.

Respiratory Changes: respiratory changes list on page 2 maybe a component of potentially life-threatening reaction such as TACO (transfusion-associated circulatory overload) or TRALI (transfusion-related acute lung injury). For patients at risk of fluid overload, red blood cell unit can be split into two separate parts/aliquots for extending administration of each part/aliquots up to four hours each.

Symptoms of Possible Transfusion Reaction