3. Learning Objectives
1. Review a prioritized focused assessment on the patient
experiencing a suspected transfusion reaction
2. Perform priority interventions to manage care for the patient
experiencing a suspected transfusion reaction
3. Discuss effective communication when managing the care of
the patient experiencing a suspected transfusion reaction
SCENS
4. Why?
• The Joint Commission: 2016 National Patient Safety Goals
• Interdisciplinary guidelines to reduce variability in transfusion practices
• VHA Directive 2011-011: Transfusion Verification and Identification
Requirements for All Sites
• VHA Directive 1185: Transfusion Utilization Committee and Program
• VHA Handbook 1106.01: Pathology and Laboratory Medicine Service (P & LMS)
Procedures
• Vista Blood Establishment Computer software (VBECS)
• Infusion Nurses Society Standards of Practice
SCENS
6. Allergic
• Urticaria
• May cause laryngeal edema
and/or bronchospasm
• May continue the infusion with
antihistamines per healthcare
provider
• Anaphylaxis
• Dyspnea
• Stridor
• Cardiovascular instability
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7. Other Types of Transfusion
Reactions
• Febrile
• Transfusion related acute lung injury (TRALI)
• Volume overload
• Bacterial contamination
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8. Other Types of Transfusion
Reactions continued…
• Hypotensive
• 10mm Hg drop in BP
• During transfusion
• Resolves with discontinuation of transfusion
• Graft vs. Host
• Rash, fever, diarrhea, cytopenia, and liver
dysfunction
• 3-4 weeks post transfusion
Non-immune hemolysis
• Hemoglobinemia and hemoglobinuria
• Post Transfusion Purpura
• Profound thrombocytopenia
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10. DR ABCE Approach
• Danger
• Response
• Airway
• Breathing
• Circulation
• Disability
• Exposure
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• Allergies
• Medications
• Past medical history
• Last oral intake
• Events leading up to
deterioration
11. Priority Interventions
• Priority interventions
–Stop transfusion immediately
–Disconnect transfusion and tubing
–Connect normal saline infusion with new tubing at 30 mL per hour
–Notify healthcare provider immediately
–Notify the lab/blood bank
–Transfusion reaction protocol
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12. Transfusion Reaction Protocol
• Transfusion reaction protocol
–Package donor bag blood product with all
attached including tubing and IV solution in
facility specific container/biohazard bag with
required label including documentation
–Blood specimens for the lab
–Urine specimen
• Documentation
• Preparation and Handling of the blood product
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13. Priorities
• Safety
• Infection control
• Identify risk factors
• Monitor time of start of infusion
• Anticipate any potential needs
• Provide patient education
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14. Potential Issues
• Policies and procedures
• Protocols
• Equipment
• State licensure
• Scope of practice
• Certifications
• Job descriptions
• Accountability
• Documentation
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15. Summary
1. Reviewed a prioritized focused assessment on the patient
experiencing a suspected transfusion reaction
2. Discussed priority interventions to manage care for the patient
experiencing a suspected transfusion reaction
3. Demonstrated effective communication when managing the
care of the patient experiencing a suspected transfusion
reaction
SCENS
17. Postoperative:
Transfusion Reaction
Manuel Garcia
Seventy seven (77) year old male four (4) hours status post colon resection for removal of
a sigmoid colon mass 4 hours ago by Dr. Moore. Vital signs are stable and he is on 2 liters
of oxygen via nasal cannula. He has a midline abdominal incision with a dry sterile
dressing. Bowel sounds are hypoactive. He has an 18 gauge IV in his right antecubital
with Lactated Ringers at 125 mL/hr. His Foley is draining clear yellow urine. His
hemoglobin of is 6.8 mg/dL and hematocrit 21 mg/dL. Dr. Moore is aware. He just
examined him and is entering orders.
Past Medical History:
• Hypertension, hemorrhoids,
constipation, and rectal bleeding
Past Surgical History:
• Hemorrhoidectomy
Medications:
• Lisinopril 2.5 mg one time a day
• Docusate sodium 100 mg one time a day
Allergies:
• Sulfa
SCENS
Editor's Notes
Life-threatening
Acute and unexpected
Interdisciplinary guidelines to reduce variability in transfusion practices
The Joint Commission: 2016 National Patient Safety Goals
Goal 1: Accuracy of patient identification
Eliminate transfusion errors related to patient misidentification
Goal 2: Effectiveness of communication among caregivers
Written procedures
Timeliness
Universal Protocol
Preprocedure verification process
VHA Directive 2011-011: Transfusion Verification and Identification Requirements for All Sites
VHA Handbook 1106.01: Pathology and Laboratory Medicine Service (P & LMS) Procedures
The VHA Handbook 1050.01: VHA National Patient Safety Improvement Handbook
Patient safety alerts
Patient safety measures
Emphasize prevention rather than punishment
VHA Handbook 1106.01: Pathology and Laboratory Medicine Service (P & LMS) Procedures
Vista Blood Establishment Computer software (VBECS)
Infusion Nurses Society Standards of Practice
By human error**
Acute (sudden) Fever, chills, lumbar pain, chest pain
Hemoglobinemia and hemoglobinuria
Hematuria (RBCs in the urine) vs. Hemoglobinemia and hemoglobinuria (No RBCs despite positive positive dipstick test)
Sense of impending doom
Disseminated Intravascular Coagulation (DIC)
Delayed (4-8 days post-transfusion)
Falling hematocrit
Positive direct antiglobulin (Coombs) test
Febrile
Rise in temperature of 1.8˚F from baseline
Transfusion related acute lung injury (TRALI)
Sudden non-cardiogenic pulmonary edema
Volume overload
Diuretics between
Bacterial contamination
Hypotension, shock, fever, chills, nausea and vomiting, respiratory distress
4 hour window to give the blood
Recognize adverse transfusion reaction symptoms
Pertinent assessment data
Vital signs compared to baseline
Back pain
Lung sounds
Urinary output
Skin
Urticaria?
Purpura?
Identify the patient and compare information with transfusion product
Communication and collaboration
Keep the patient informed
ISBAR
Get help
Delegate when possible based on scope of practice and job description
Follow transfusion reaction protocol
Danger
Ensure the area is safe
Remove any potentially dangerous items, meds, etc.
Response
Check to see if the patient is responsive
If responsive, make the patient comfortable
Airway
Open and assess the airway
Look, Listen and Feel
Breathing
Check for breathing
Lung sounds?
High flow oxygen mask
Look Listen and Feel
Circulation
Heart rate
Blood pressure
Pulses
Does the patient have a good IV?
Urine output?
Give IV fluid bolus for hypotension
Colloid or crystalloid
Disability
Conscious or unconscious
Treat cause if applicable
Exposure
Keep the patient covered to maintain dignity and minimize heat loss
Top to toe examination
Gross neurological deficit examination
Signs of hemorrhage, bruising, infection, injury, etc.
Collateral history
A- Allergies
M- Medications
P- Past medical history
L- Last oral intake
E- Events leading up to deterioration
Priority interventions
Stop transfusion immediately
Disconnect transfusion and tubing
Connect normal saline infusion with new tubing at 30 mL per hour
Notify healthcare provider immediately
Notify the lab/blood bank
Safety
Infection control
Identify risk factors
Identify patient allergies
Monitor time of start of infusion
No more than 4 hours or per protocol
Anticipate any potential needs
Equipment
Supplies
Medications
Assistance
Provide patient education
Facility specific transfusion reaction protocol
Transfusion reaction protocol
Package donor bag blood product with all attached including tubing and IV solution in facility specific container/biohazard bag with required label including documentation
Blood specimens for the lab
Urine specimen
Documentation
VistA Blood Establishment Computer Software (VBECS) in CPRS
Transfusion reaction worksheet
Preparation and Handling of the blood product
<Discuss the process of preparing the blood product >
Safety
Infection control
Identify risk factors
Monitor time of start of infusion
No more than 4 hours or per protocol
Anticipate any potential needs
Equipment
Supplies
Medications
Assistance
Provide patient education
Keep the patient informed
Policies and procedures
Protocols
Monitoring
Equipment
State licensure
Scope of practice
Certifications
Job descriptions
Accountability
Documentation
