ICU PROCEDURES: Blood Transfusion

ICU PROCEDURES: Blood Transfusion

ICU Procedures: Blood Transfusion – Nursing Management

Blood transfusion is a critical procedure in the ICU setting, often used to restore blood volume, improve oxygen-carrying capacity, and correct clotting disorders in critically ill patients. Nursing management of blood transfusion in the ICU requires meticulous attention to ensure the safety of the patient, prevent complications, and manage any adverse reactions promptly.

Nursing Management of Blood Transfusion in the ICU

1. Pre-transfusion Preparation:

• Verify the Physician’s Order:
  • Confirm the blood product ordered (e.g., packed red blood cells [PRBCs], platelets, plasma) and ensure it matches the patient’s clinical needs.
• Patient Identification:
  • Verify the patient’s identity using two identifiers (e.g., name, date of birth) and check the patient’s blood type against the transfusion requisition.
  • Ensure a valid crossmatch has been performed within the appropriate time frame.
• Obtain Consent:
  • Verify that informed consent has been obtained from the patient or family, explaining the risks, benefits, and alternatives to the transfusion.
• Prepare Equipment:
  • Gather the necessary equipment, including a blood transfusion set (with a filter), normal saline solution (0.9% NaCl), and an infusion pump.
  • Ensure IV access is functioning properly, typically using an 18- or 20-gauge catheter for rapid infusion.
• Baseline Assessment:
  • Take baseline vital signs (temperature, pulse, respiratory rate, blood pressure, and oxygen saturation) before initiating the transfusion.
  • Assess for any pre-existing symptoms that could be confused with transfusion reactions, such as chills or shortness of breath.
• Blood Product Inspection:
  • Inspect the blood product for color, clots, or leaks and check the expiration date.
  • Compare the patient’s identification with the blood unit information (using two licensed personnel) to ensure accuracy.

2. Initiating the Transfusion:

• Start Slowly:
  • Begin the transfusion at a slow rate (e.g., 1-2 mL/min) for the first 15 minutes, as most transfusion reactions occur within this period.
  • Stay with the patient for the first 15 minutes to monitor for signs of a transfusion reaction (fever, chills, itching, shortness of breath).
• Monitor for Reactions:
  • Febrile Non-hemolytic Reaction: Presents as fever and chills without hemolysis; most common reaction.
  • Acute Hemolytic Reaction: Caused by ABO incompatibility; presents as fever, chills, hypotension, and hematuria.
  • Allergic Reaction: Mild reactions include hives, itching, and flushing. Severe reactions include anaphylaxis (bronchospasm, swelling, and hypotension).
  • Transfusion-related Acute Lung Injury (TRALI): Presents as acute respiratory distress, often with fever and hypotension.
  • Transfusion-associated Circulatory Overload (TACO): Presents as dyspnea, hypertension, and pulmonary edema.
• Vital Signs Monitoring:
  • Monitor the patient’s vital signs every 5-15 minutes during the first 15-30 minutes, then every 30 minutes, and post-transfusion as per hospital policy.
  • Assess the patient for early signs of complications, such as changes in heart rate, blood pressure, or oxygen saturation.

3. Managing Adverse Reactions:

• If a Reaction Occurs:
  • Stop the Transfusion Immediately: Disconnect the blood product, and maintain the IV line with normal saline at a slow rate using a new IV set.
  • Notify the Physician: Report the reaction and follow orders for treatment (e.g., antihistamines for allergic reactions, corticosteroids, or diuretics for TACO).
  • Monitor the Patient: Continue to assess vital signs and symptoms closely, providing supportive care as necessary (oxygen therapy, fluids, or vasopressors).
  • Send Blood Samples: Send the remaining blood unit and patient’s blood samples to the lab for analysis (e.g., direct Coombs test, hemolysis tests).
• Documentation: Document the reaction, the steps taken, and the patient’s response in detail.

4. Continuation of Transfusion:

• Rate of Infusion:
  • After the initial 15 minutes, increase the transfusion rate as ordered, ensuring the transfusion is completed within 4 hours to prevent bacterial growth.
• Monitor Hemodynamic Status:
  • Critically ill patients may require continuous hemodynamic monitoring, including heart rate, blood pressure, central venous pressure (CVP), or cardiac output to ensure stability.
• Maintain IV Patency:
  • Keep normal saline (0.9% NaCl) running alongside the blood product to maintain IV patency and flush the line between transfusions of different blood products.

5. Post-transfusion Care:

• Post-transfusion Vital Signs:
  • Take a full set of vital signs and compare them to baseline readings to assess any delayed reactions.
• Monitor for Delayed Reactions:
  • Be alert for signs of delayed hemolytic reactions, which may occur days after transfusion, such as fever, jaundice, or dark urine.
• Lab Monitoring:
  • Repeat lab tests as ordered, including hemoglobin, hematocrit, and coagulation studies to evaluate the effectiveness of the transfusion.
• Document the Transfusion:
  • Record the start and end time, volume infused, patient’s response, and any complications that occurred during the procedure.
• Dispose of Blood Components:
  • Properly dispose of any remaining blood products and sharps, following hospital infection control policies.

Nursing Considerations:

• Patient Education:
  • Explain the transfusion process, possible reactions, and the importance of notifying the nurse if they feel unwell during the procedure.
• Infection Prevention:
  • Follow strict aseptic technique during IV setup and handling of blood products to prevent infection.
• Hemodynamic Support:
  • In hemodynamically unstable patients, continuous monitoring is required to assess the impact of transfusion on cardiac function.
• Fluid Overload Prevention:
  • For patients at risk of fluid overload (e.g., heart failure, kidney injury), administer diuretics as prescribed and monitor for signs of TACO.

Complications of Blood Transfusion:

1. Febrile Non-hemolytic Reaction: Most common; due to cytokine release.
2. Acute Hemolytic Reaction: Caused by ABO incompatibility; potentially life-threatening.
3. Allergic Reaction: Varying from mild (rash, hives) to severe (anaphylaxis).
4. TRALI (Transfusion-Related Acute Lung Injury): Severe respiratory distress following transfusion.
5. TACO (Transfusion-Associated Circulatory Overload): Fluid overload leading to pulmonary edema.
6. Infectious Disease Transmission: Rare due to rigorous blood screening protocols.

Conclusion:

Effective nursing management of blood transfusion in the ICU is vital to ensuring patient safety and optimal outcomes. By thoroughly assessing the patient before, during, and after the transfusion, nurses can prevent and promptly address complications such as transfusion reactions or circulatory overload. Coordination with the healthcare team, diligent monitoring, and patient education are key to the success of blood transfusion therapy in critically ill patients.