What is the step‑by‑step blood transfusion protocol a nurse should follow to ensure patient safety and manage transfusion reactions?

Blood Transfusion Protocol for Nurses

Pre-Transfusion Verification and Preparation

The nurse must perform positive patient identification using at least four core identifiers on the wristband before initiating any transfusion. 1

• Verify patient identity at the bedside using four core identifiers (name, date of birth, medical record number, and blood type) against the blood component label 1
• Perform this verification with a second qualified healthcare professional when institutional policy requires 1
• Visually inspect the blood component for leakage, discoloration, clots, or clumps before administration—do not transfuse if any abnormalities are present 1, 2
• Establish baseline vital signs: heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 1
• Ensure patent IV access with normal saline—never use dextrose solutions with blood products 1
• When administering blood products to patients on vasopressors (e.g., noradrenaline), use separate IV access sites whenever possible 2

Initiation and Monitoring Protocol

Monitor vital signs pre-transfusion, at 15 minutes after starting (the most critical period), at completion, and 15 minutes post-transfusion as the minimum standard. 3

• Start the transfusion slowly and remain at the bedside for the first 10-15 minutes, as immediate reactions typically occur within the first minute 3
• Check vital signs every 15 minutes during the transfusion when administering blood products with vasopressors simultaneously 2
• Transfuse red blood cells unit-by-unit with interval reassessment in non-bleeding patients 4
• Use slow transfusion rates in high-risk patients: those over 70 years old, patients with heart failure, renal failure, low body weight, or hypoalbuminemia 4, 2
• Consider prophylactic diuretics in patients at high risk for transfusion-associated circulatory overload (TACO) 4

Recognition of Transfusion Reactions

Stop the transfusion immediately at the first sign of any suspected reaction—do not wait to confirm the reaction type. 1

Critical signs requiring immediate action include:

• Tachycardia (>110 beats/min) 3
• Hypotension or hypertension 1
• Fever (temperature rise >1°C) 4
• Rash, urticaria, or flushing 1, 3
• Breathlessness or respiratory distress 1, 3
• Back pain or chest tightness 3
• Behavioral changes or altered consciousness 3

Immediate Management of Suspected Reactions

Maintain IV access with normal saline for medication administration and fluid resuscitation after stopping the blood product. 1

Step-by-step reaction management:

1. Stop the transfusion immediately and disconnect the blood tubing 1
2. Keep the IV line open with normal saline using new tubing 1
3. Call for medical assistance immediately 1
4. Assess ABCs (Airway, Breathing, Circulation) and level of consciousness 1
5. Position the patient appropriately: Trendelenburg for hypotension, sitting upright for respiratory distress, or recovery position if unconscious 1
6. Administer high-flow oxygen to address potential hypoxemia 3
7. Monitor vital signs every 5-15 minutes until resolution 1

For anaphylaxis or severe allergic reactions:

• Administer epinephrine 0.3-0.5 mg (1 mg/mL) IM into the anterolateral mid-thigh, repeating every 5-15 minutes as needed 1, 3
• Provide fluid resuscitation with normal saline 1-2 L IV at 5-10 mL/kg in the first 5 minutes 1
• Give diphenhydramine 50 mg IV plus ranitidine 50 mg IV 1
• Administer corticosteroids equivalent to 1-2 mg/kg IV methylprednisolone every 6 hours 1

For mild to moderate reactions (febrile or mild allergic):

• For febrile reactions: administer only IV paracetamol—avoid indiscriminate use of steroids and antihistamines 4
• For allergic reactions: administer only an antihistamine 4
• Slow the infusion rate for Grade 1 reactions; temporarily stop for Grade 2 reactions 1

For suspected TACO (fluid overload):

• Administer diuretics immediately 3
• Position patient upright 1
• Monitor for pulmonary edema, jugular venous distension, and cardiovascular changes 3

For suspected TRALI (acute lung injury):

• Do NOT give diuretics—they are ineffective and potentially harmful 3
• Provide critical care supportive measures and oxygen therapy 3
• Prepare for potential intubation 3

Laboratory Investigation and Reporting

Contact the transfusion laboratory immediately when any reaction is suspected and send the blood unit with administration set for investigation. 1

Required laboratory workup:

• Complete blood count 3
• Direct antiglobulin test (Coombs test) 3
• Repeat crossmatch 3
• PT, aPTT, fibrinogen 3
• Visual inspection of plasma for hemolysis 3
• Brain natriuretic peptide if TACO suspected 4

Critical reporting requirements:

• Report ABO-incompatible transfusions to the transfusion service without delay—this is a mandatory investigation with statutory requirements 3
• Notify the blood bank for all reactions, as TRALI and other serious reactions are underdiagnosed and underreported despite being leading causes of transfusion-related mortality 3
• Document all transfusions in the patient record—100% traceability is a legal requirement maintained for 30 years 1, 3
• Report to the hospital transfusion committee for audit and protocol refinement 1
• Inform the patient's general practitioner, as this may remove implicated donors from the donor pool 3

Special Considerations and Common Pitfalls

Avoid rapid transfusion in patients on vasopressors due to increased risk of TACO. 2

• Do not delay blood transfusion in critically ill patients due to concerns about concurrent vasopressor use 2
• Remember that signs of hemolytic reactions may be masked in anesthetized patients or erroneously attributed to other causes 1
• Never transfer blood between hospitals without coordination with the transfusion laboratory to maintain the cold chain 4
• Do not assume behavioral changes are purely psychiatric—they can indicate life-threatening complications such as TACO, TRALI, or acute hemolytic reaction 3
• Avoid using electronic transfusion management systems as a substitute for bedside verification—both are required 3
• Never administer blood products without visual inspection, even if the unit appears properly labeled 1, 2

Post-Transfusion Care

• Monitor vital signs until complete resolution of symptoms 1
• For severe reactions, provide close observation for 24 hours 1
• Assess urine output and color to monitor for hemolytic reactions 1
• Document the reaction for future reference to guide prevention strategies (e.g., washed blood products for allergic reactions, slower rates for TACO risk) 1
• Inform patients they received blood products before discharge 3