What observations and monitoring are required immediately following the commencement of a blood transfusion?
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What is this article about?Blood transfusion is the transfer of blood components from one person to another. It is a potentially life-saving procedure that helps replace blood lost due to surgery, illness bleeding or severe injury.  Learning you'll loveAn Ausmed Subscription will unlock access to 1,000+ learning resources. High quality education helps you provide high quality care. ContentsTest Your Knowledge
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Meet the educatorLydia Nabwami Lydia Nabwami is registered nurse who has worked in various healthcare settings including cardiac ward, cardiac critical care unit (ITU), general ITU, A&E department, nursing homes and community nursing. She uses her experience as a RN to write well-researched content that helps to attract and motivate audiences. Lydia is also a freelance writer for hire with specialisation in health writing and has helped numerous companies with their content needs. Her work has appeared on sites such as Caring Village, Reachout, Lisa Nelson RD and more. When she isn’t writing, you can find her listening to motivational speeches, keeping active or playing with her two daughters. Contact Lydia or visit her website at Lnwritingservices.co.uk for more information on her services. View Profile Here's some further inspirationPractice AreasAusmed PremiumTo access this resource, sign up for Ausmed Premium. With Premium, you’ll have unlimited access to everything you need to take your education and care to the next level. Sometimes I find it really hard to make time for my learning, but I was blown away by how easy it is with the Ausmed app. I can fit it in during breaks or on the bus to work. - Maria, Registered Nurse This two-part unit explores the monitoring of patients receiving a blood transfusion. This first part outlines the importance of making careful checks before the transfusion, as well as that of monitoring a patient receiving a transfusion. AUTHORS Claire L. Thompson, RN, is transfusion liaison nurse, National Blood Service, Leeds and Newcastle; Carole Edwards, MSc, RN, is transfusion practitioner; Lynn Stout, RN, is transfusion practitioner; both at Better Blood Transfusion Programme, Scottish National Blood Service, Aberdeen. Thompson CL et al (2008) Blood transfusions 1: how to monitor for adverse reactions. Nursing Times; 104: 2, 32–33.
During the blood transfusion process, patient observations typically include recording vital signs – temperature, pulse and blood pressure. The purpose of undertaking these observations is to ensure that an acute transfusion reaction can be recognised early and dealt with in a timely manner, thereby helping to reduce or prevent transfusion-associated morbidity or mortality. However, there is little evidence on how frequently these vital signs should be measured. In a systematic review of vital signs in hospital patients, Evans et al (2001) reported that observational practices were not evidence-based. The British Committee for Standards in Haematology (BCSH) also comments that it is not clear what the optimum type and frequency of observations for transfusion should be (BCSH, 1999). In addition, national and international audits of transfusion practice have demonstrated wide variations in monitoring practices (Royal College of Physicians and National Blood Service, 2005; Gray et al, 2003; Evans et al, 2001). A national comparative audit of bedside transfusion practice in 2005 found that, of 8,000 transfusions, 15% had no record of vital signs having been performed during the transfusion and 34% had no record of observations within the first 30 minutes, which is the period when adverse reactions would be most likely to occur (RCP and NBS, 2005). Errors in transfusionOver the past few years the Serious Hazards of Transfusion Scheme (SHOT) has focused on improving the safety of blood administration at the bedside, looking specifically at sampling, collection and administration. Since 1996 the most common SHOT report is the incorrect blood component transfused (IBCT), and all of these cases are preventable. In the 2005 SHOT report (Stainsby et al, 2005), 485 (79%) reports of IBCT were reported, which resulted in two patients dying and four patients experiencing major morbidity. Of these IBCT incidents reported, the most common error (that could have prevented these outcomes) was failure to carry out the bedside check. Before any blood is transfused, it is vital that the correct patient identification procedure has taken place using the patient’s wristband. However, it should also be noted that not all blood transfusion reactions can be avoided. Stainsby et al (2005) reported 121 immunological reactions to blood components. It is, therefore, essential that nurses are vigilant while monitoring patients during the transfusion process so any change to their condition can be detected and managed early. Nurses must understand the implications of any changes in patients’ signs and symptoms while receiving a blood transfusion. The purpose of undertaking routine observations on patients receiving In addition, in a review of transfusion fatalities, Mummert and Tourault (1994) concluded that 50% of these fatalities might have been avoided if several steps had been taken to ensure earlier recognition and action. This has also been endorsed by Fitzpatrick and Fitzpatrick (2001). Monitoring techniquesAs indicated, the early recognition and management of adverse effects of transfusion is essential to optimise treatment and reduce patient morbidity and mortality. It is crucial that healthcare practitioners monitor patients receiving transfusion and are able to recognise and act on early signs and symptoms of an adverse event. Current literature shows little evidence to indicate the optimal manner and frequency of recording vital signs to ensure detection of serious illness or adverse effects of transfusion. A survey reported by Burroughs and Hoffbrand (1990) also indicated that recording vital signs had become a routine procedure unrelated to perceived individual patient needs. Zeitz and McCutcheon (2003) reported: ‘It appears the policies that nurses use to determine their practice are, in the most part, determined by clinical experience and exist to protect the organisation rather than improve patient outcome’. The most severe adverse effects of transfusion, such as haemolytic reaction and anaphylactic reaction, will usually occur within the first 15 minutes of starting transfusion. In 1999 the BCSH issued guidelines for the administration of blood and blood components and the management of patients who had had a blood transfusion, which suggest those vital signs that should be recorded and how often (see box, left). Visual observationsWhile the monitoring of vital signs is important, the benefit of visual observation of patients must not be overlooked. Whedon (1995) emphasised the importance of general clinical observation, reporting that patients’ symptoms are more likely to be experienced before there is any change in their vital signs. Castledine (2006) advised that practitioners should involve patients in their clinical care. Patients may be the first to be aware of any adverse effects of the transfusion. Nurses should empower patients by ensuring that they are well informed of the potential risks of having the transfusion and by advising them to report any adverse effects (Atterbury and Wilkinson, 2000). It is, therefore, essential that patients who are undergoing a transfusion are in an area where they can be easily observed and can attract nurses’ attention if needed. Other safety issuesIn reviewing out-of-hours blood transfusions, Tinegate et al (2007) suggested there could be additional risk when performing blood transfusions outside of routine hours. In their study, 28% of blood transfusions occurred outside of routine hours. SHOT data has shown that 37% of transfusion incidents occur during this time. To ensure the safe and appropriate monitoring of patients receiving blood transfusion and early detection of adverse effects, it is important that all healthcare staff monitoring patients should ensure:
ConclusionThe SHOT reports have shown that the risk to patients of receiving the incorrect blood component is real and, although transfusion reactions are fortunately quite rare, clinical staff should always remain vigilant. The prompt detection of signs and symptoms and early action to manage an adverse event or reaction to transfusion can help prevent morbidity and mortality. To this end, it is imperative that practitioners:
Until further evidence is available to indicate
the optimal timing of blood transfusion observations, it is essential Part 2 of this unit, on causes of transfusion reactions and their clinical presentation, will appear in next week’s issue. Suggested Transfusion observations
Further observations should be at the discretion of each clinical area, dependent on, for example:
Source: British Committee for Standards in Haematology (1999) British Committee for
Standards in Haematology (1999) The administration Castledine, G. (2006) Blood transfusion: poor technique, record keeping and communication. British Journal of Nursing; 15: 7, 369. Fitzpatrick, T., Fitzpatrick, L. (2001) Nursing management of transfusion reactions. In: Popovsky, M.A. (ed) Transfusion Reactions. Bethesda, Royal College of Physicians (Clinical Effectiveness and Evaluation Unit) and National Blood Service (2005) National Comparative Audit of Blood Transfusion. London: RCP and NBS. Stainsby, D. et al (2005) Annual Report 2005: Serious Hazards of Transfusion (SHOT). Manchester: SHOT. Tinegate, H. et al (2007) Where and when is blood transfused? An observational study of the timing and location of red cell transfusions in the North of England. Vox Sanguinis; 93: 229–232. The full reference list for this part of the unit is available in Portfolio Pages What should I monitor after blood transfusion?Upon completion of the transfusion, the patient's vital signs (temperature, pulse, respirations, and blood pressure) should be recorded, and compared with the previous values. The ordering physician or designee who is familiar with the patient should be available by telephone to handle any complications.
When should you undertake the first observation after commencing the transfusion?Patients should be directly observed during the first 15 minutes of transfusion as some life-threatening reactions may occur after the infusion of only a small amount of blood.
What are the nursing responsibilities after blood transfusion?If blood transfusion reaction occurs: STOP THE TRANSFUSION. Place the client in Fowler's position if with Shortness of Breath and administer O2 therapy. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Notify the physician immediately.
What should your immediate actions be in the event of a blood transfusion reaction?As soon as you suspect a transfusion reaction: Stop the transfusion immediately and activate emergency procedures if required. Check and monitor the patient's vital signs. Maintain intravenous (IV) access (do not flush the existing line and use a new IV line if required).
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