What are the steps to perform a blood transfusion on a patient?

How to Perform a Blood Transfusion

Pre-Transfusion Patient Identification and Safety Checks

Positive patient identification is the single most critical safety step—most serious transfusion errors resulting in ABO incompatibility occur due to failure of bedside identity verification. 1

• Verify the patient has TWO identification wristbands in place containing four core identifiers: first name, last name, date of birth, and patient identification number 1
• All staff involved in blood administration must be trained and competency-assessed per local policy 1
• Perform identity verification at the patient's bedside immediately before transfusion—never in advance 1

Manual Bedside Checking Process (if electronic system unavailable)

• Match all four core identifiers on the compatibility label attached to the blood component with the patient's wristband identifiers 1
• Verify the compatibility label blood group and 14-digit donation number matches the label on the blood component itself 1
• Visually inspect the blood component for leakage, discolouration, clots, or clumps—do not transfuse if any abnormalities present 1
• Check the expiry date and time 1
• If ANY discrepancies exist, do not proceed and immediately contact the transfusion laboratory 1

Blood Product Selection Based on Clinical Urgency

Emergency Issue (Immediate Need)

• Group O RhD negative red cells are the first choice for immediate life-threatening hemorrhage when the patient's blood type is unknown 1
• Group O RhD positive red cells are acceptable for male patients to preserve O negative stock 1
• Group specific blood can be issued in approximately 10 minutes after blood sample reaches the laboratory—this represents a reasonable balance between speed and safety in massive hemorrhage 1

Standard Issue

• Full serological cross-match takes approximately 45 minutes 1
• Pre-transfusion testing determines ABO/RhD status and detects red cell antibodies 1

Intravenous Access and Equipment Setup

• Establish large-bore IV access—ideally 8-Fr central venous access in adults for massive transfusion scenarios 1
• If central access fails, consider intra-osseous or surgical venous access 1
• Attach appropriate IV connection tubing to the blood component unit 1
• Use blood administration sets with inline filters 1

Baseline Laboratory Testing

Before initiating transfusion, obtain baseline blood samples for: 1

• Complete blood count (FBC)
• Prothrombin time (PT)
• Activated partial thromboplastin time (aPTT)
• Clauss fibrinogen (not derived fibrinogen, which is unreliable)
• Cross-match

Transfusion Administration Protocol

Timing and Rate

• Complete red cell transfusion within 4 hours of removal from controlled refrigerated storage 1, 2
• Blood removed from the fridge must not be returned if unused 1
• In patients at risk for transfusion-associated circulatory overload (TACO)—particularly those >70 years, with heart failure, renal failure, or hypoalbuminemia—use slower transfusion rates 3, 2

Active Patient Warming

• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1
• Hypothermia impairs coagulation factor function and platelet activity 1

Vital Signs Monitoring Schedule

Monitor heart rate, blood pressure, temperature, and respiratory rate at these specific timepoints: 3, 4

• Pre-transfusion baseline
• 15 minutes after starting transfusion (critical period for acute reactions)
• At completion of transfusion
• 15 minutes post-transfusion

The first 10 minutes of infusion are the highest risk period—immediate reactions typically occur within the first minute 3

Recognition of Acute Transfusion Reactions

Clinical Signs Requiring Immediate Action

Watch for: 3, 4

• Tachycardia (>110 beats/min)
• Rash or urticaria
• Breathlessness or respiratory distress
• Back pain or chest tightness
• Fever
• Hypotension

Immediate Management Algorithm

If ANY suspected transfusion reaction occurs: 3, 4

1. STOP the transfusion immediately—do not wait to confirm reaction type
2. Maintain IV access with normal saline
3. Administer high-flow oxygen (high FiO₂) 3
4. Monitor vital signs every 5-15 minutes 4
5. Contact transfusion laboratory immediately 4
6. Send post-reaction blood samples: CBC, direct antiglobulin test (Coombs), repeat cross-match, PT, aPTT, fibrinogen 3

For anaphylaxis specifically: 3

• Call emergency/resuscitation team
• Administer epinephrine 0.3 mg IM into anterolateral mid-thigh (may repeat once)

For suspected TACO (fluid overload with pulmonary edema): 3, 4

• Stop transfusion
• Administer diuretic therapy
• Provide oxygen support

For suspected TRALI (non-cardiogenic pulmonary edema): 3, 4

• Stop transfusion
• Provide critical care respiratory support
• Do NOT give diuretics (ineffective and potentially harmful)

Documentation Requirements

• Document every transfusion in the patient record—100% traceability is a legal requirement 1, 3
• Record: patient identifiers, blood component type, donation number, start/stop times, vital signs, any reactions 1
• Inform the patient before discharge that they received blood products—this removes them from the donor pool 1, 3
• Notify the patient's general practitioner 3

Special Considerations for Massive Hemorrhage

Component Therapy Ratios

• Maintain platelets at ≥75 × 10⁹/L 1
• Administer fresh frozen plasma at 30 ml/kg as reasonable first-line response (at least 15 ml/kg minimum) 1
• Consider fibrinogen concentrate 30-60 mg/kg for rapid fibrinogen replacement (faster than cryoprecipitate which requires thawing) 1

Adjunctive Pharmacotherapy

• Administer tranexamic acid IV in clinical situations where increased fibrinolysis is anticipated (trauma, obstetric hemorrhage) 1
• Monitor and correct hypocalcemia and hypomagnesemia, which commonly occur with massive transfusion 1

Common Pitfalls to Avoid

• Never skip the bedside identity check—this is where most fatal errors occur 1
• Do not use derived fibrinogen levels; insist on Clauss fibrinogen 1
• Do not transfuse blood that has been out of controlled storage >4 hours 1
• Do not give diuretics for TRALI (only for TACO) 3, 4
• Do not delay transfusion to achieve "normal" blood pressure in ongoing hemorrhage—restore organ perfusion first 1