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Blood Transfusion – Nursing Notes

        Blood transfusion is a potentially life-saving yet high-risk therapy. Nurses play a critical role in ensuring patient safety, preventing errors, and identifying complications promptly.

ABO Compatibility
  • Blood groups are classified as A, B, AB, and O
  • Blood groups are determined by the antigens (agglutinogens) present on the surface of red blood cells (RBCs) and the antibodies (agglutinins) present in the plasma.

Group

RBC Surface Antigens

Plasma Antibodies

A

A antigen

Anti-B

B

B antigen

Anti-A

AB

A & B

None

O

None

Anti-A & Anti-B

  • A patient must not receive blood which contains antigens that are against their plasma antibodies.
  • Eg. Group A patient must never receive Group B or AB blood as the B antigen on donor RBCs will react with the patient’s Anti-B antibodies → causes agglutination and hemolysis → dangerous transfusion reaction.
  • Crossmatching ensures no agglutination occurs
  • Universal RBC donor = O negative.
  • Universal RBC recipient = AB positive.
  • ABO incompatibility reaction usually occurs within the first 50 mL of blood.

Plasma Compatibility (Reverse Rule)

  • In plasma transfusions, antibodies matter more than RBC antigens.
  • O plasma contains Anti-A & Anti-B → safest only for O group.
  • AB plasma has no antibodies → considered the universal plasma donor.
  • Universal plasma donor = AB plasma.

 

Rh Compatibility
  • Rh factor refers to the D antigen on red blood cells.
  • If the D antigen is present → Rh-positive (Rh⁺); if absent → Rh-negative (Rh⁻).
  • Rh⁻ persons naturally have no anti-D antibodies, but can develop them if exposed to Rh⁺ blood.
Compatibility Rules:
  1. Rh+ can receive from Rh+ and Rh–.
  2. Rh– can receive only Rh–.
  3. If Rh– receives Rh+, anti-D antibodies form, increasing risk of future hemolytic reactions.
Universal Donor/Recipient with Rh: 
  • O negative → Universal donor; AB positive → Universal recipient.
Clinical Significance
  • First accidental Rh+ transfusion in Rh– → usually mild;
  • Subsequent exposure → severe hemolytic reaction.
  • Pregnancy: Rh– mother with Rh+ fetus → risk of Hemolytic Disease of the Newborn (HDN).
      • Prevention: Anti-D immunoglobulin (RhoGAM) given at 28 weeks and within 72 hours postpartum if the baby is Rh+.

Blood components

             In modern transfusion therapy, blood is rarely given as whole blood. Instead, it is separated into specific components so that patients receive only what they need—making transfusion safer, more efficient, and reducing wastage.

Whole Blood Unit = 450 mL blood + 50 mL anticoagulant.

Components: 

  1. Packed Red Blood Cells (PRBCs) – Increase hemoglobin & oxygen-carrying capacity , stored at 2–6°C, 35–42 days.
  2. Platelets – Used in thrombocytopenia, Stored at room temperature, agitated gently, viable for 5 days.
  3. Fresh Frozen Plasma (FFP) – Contains clotting factors, no platelets, Stored at –18°C or lower up to 1 year, Must be infused within 2 hours of thawing.
  4. Cryoprecipitate – Derived from FFP, rich in Factor VIII & fibrinogen. Stored frozen up to 1 year; Once thawed, use immediately.
  5. Granulocytes – Rarely used; given for neutropenic patients with sepsis unresponsive to antibiotics.

Role of the Nurse in Blood Administration

  1. Ensure large-bore IV access (≥19G).
  2. Double-check patient & product with another licensed nurse.
  3. Prime line only with normal saline.
  4. Start transfusion within 30 min of receiving blood.
  5. Stay with patient for first 15 minutes or 50 mL.
  6. Infuse PRBCs over 2–4 hrs (not >4 hrs).
  7. Vital signs: baseline, 15 min, 30–60 min intervals, and 1 hr post-transfusion.
  8. Use a blood warmer if rapid, massive transfusion required.

Acute Transfusion Reactions(<24 hrs)

1. Acute Hemolytic Reaction (Most Dangerous)

  • Cause: ABO/Rh incompatibility.
  • Symptoms: chills, fever, back pain, hemoglobinuria, hypotension, shock.
  • Management: Stop transfusion, maintain BP, diuretics, dialysis if needed.

2. Febrile Non-Hemolytic Reaction (Most Common)

  • Cause: Recipient antibodies reacting to donor leukocytes/cytokines.
  • Symptoms: fever, chills, headache.
  • Management: acetaminophen, do not restart unless ordered.

3. Allergic Reaction (Mild)

  • Cause: Hypersensitivity to plasma proteins in donor blood.
  • Symptoms: flushing, itching, urticaria.
  • Management: antihistamines; restart only if mild and ordered.

4. Severe Allergic / Anaphylaxis

  • Cause: IgA deficiency; Severe reaction in IgA-deficient patients exposed to donor IgA.
  • Symptoms: wheezing, shock, cardiac arrest.
  • Management: epinephrine, steroids, oxygen, CPR if required.

5. Circulatory Overload (TACO)

  • Cause: rapid/excessive transfusion.
  • Symptoms: dyspnea, pulmonary edema, frothy sputum, hypertension.
  • Management: stop infusion, O₂, diuretics, slow infusion.

6. Sepsis

  • Cause: contaminated blood, esp. platelets.
  • Symptoms: high fever, chills, hypotension, shock.
  • Management: cultures, antibiotics, vasopressors.

7. TRALI (Transfusion-Related Acute Lung Injury)

  • Cause: donor anti-leukocyte antibodiesdamaging recipient lungs.
  • Symptoms: sudden hypoxemia, pulmonary edema (non-cardiogenic).
  • Onset: within 2–6 hrs.
  • Management: O₂, corticosteroids, ventilation.

8. Massive Transfusion Reaction

  • Cause: High blood volume replaced in 24 hrs.
  • Complications: hypothermia, hypocalcemia, hyperkalemia, coagulopathy.
  • Management: warm blood, correct electrolytes, IV calcium.

Nursing Actions During Acute Reaction

  1. Stop transfusion immediately.
  2. Maintain IV line with normal saline.
  3. Notify physician and blood bank.
  4. Recheck identifiers.
  5. Monitor vitals & urine output.
  6. Send blood bag/tubing to lab.
  7. Collect blood/urine specimens.
  8. Document reaction.

Delayed Transfusion Complications

  1. Delayed hemolytic reaction: Destruction of transfused RBCs days to weeks later due to minor antigen incompatibility.
  2. Iron Overload: Repeated transfusions causing excess iron deposition in organs → chelation therapy needed.
  3. Graft-vs-Host Disease: Donor lymphocytes attack recipient tissues (rare, immunocompromised patients), prevented by irradiating donor blood.
  4. Infectious risks: Hepatitis B, C, HIV, malaria, syphilis, etc. (rare with modern screening).

High-Yield Exam Points

  1. Always check blood product with another nurse.

  2. Most dangerous error → patient misidentification.

  3. Never transfuse incompatible blood; risk of acute hemolytic reaction.

  4. Start Slowly – First 15 minutes is critical; monitor for reaction signs.

  5. Never use dextrose/LR with blood, do not add meds to blood.

  6. At first sign of reaction: stop transfusion, maintain IV with NS, call MD.

  7. Complete PRBC transfusion within 4 hours.

  8. PRBC unit → Increase Hb by 1 g/dL, Hematocrit by 3%.

  9. Platelets stored at room temp, infused in 15–30 min.

  10. Cryoprecipitate → rich in Factor VIII & fibrinogen.

  11. Avoid aspirin in thrombocytopenic patients.

  12. Post-Transfusion Care – Monitor vitals, urine output, and signs of delayed reactions.

  13. Rh Immunoprophylaxis – Give anti-D (RhoGAM) to Rh⁻ mothers after  birth of Rh+ve babies.

  14. Special Blood Products – Irradiated (prevents GVHD), leukoreduced (reduces febrile reactions).

  15. Always use a blood administration filter to remove clots/debris.

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