1. Blood Administration
Safety Protocols and Recognition of Adverse Effects
By:
Brian Bosworth, BSN
Student

2. Basic Pathophysiology of
Hematological System
Bone marrow is the blood-forming organ
Stem cell production within the marrow ultimately
differentiates into red blood cells, white blood cells,
and platelets
Growth factor and cytokines secreted from the kidneys
are responsible for the differentiation of these
unspecialized cells
•Erythropoietin is growth factor that potentiates the
differentiation of stem cells into RBCs (erythropoiesis)
(Ignatavicius & Workman, 2010).

3. Blood Components
Cellular Components
Erythrocytes or red blood cells (RBCs)
•Largest proportion of blood cells
•Enucleate, biconcave, and connective tissue
•Perfuse oxygen to all body cells
•O2 binds to hemoglobin
Leukocytes or white blood cells (WBCs)
• Neutrophils, eosinophil, basophil, monocytes, and
macrophages
•Immunological/inflammatory function
Platelets
•Fragments of precursor megakaryocyte
•Responsible for blood clotting (Ignatavicius &
Workman, 2010)

4. Blood Components (cont.)
Plasma
•Is an extracellular fluid (ECF) which contains vital
proteins
•Albumin, globulins, and fibrinogen are the primary
plasma proteins found in the CV system
Albumin
•Increases osmotic pressure, which prevents capillary
leakage into the interstitial spaces
Globulins
•Responsible for transportation
•Protection against infection, main protein of antibodies
Fibrin
•Create the mesh scaffolding to allow for platelet
aggregation (Ignatavicius & Workman, 2010)

5. Laboratory Reference Ranges
Lab Reference range
RBC Female: 4.2 to 5.4 million/mm^3
Male: 4.7 to 6.1 million/mm^3
Hemoglobin Females: 12 to 16 g/dL
Males: 14 to 18 g/dL
Hematocrit Females: 37 to 47%
Males: 42 to 52 %
WBC 5,000 – 10,000/mm^3
Platelet 150,000 – 400,000/mm^3
Fibrinogen 1.5 – 2.77 g/dL
Globulin 2.2 – 3.9 d/dL
Albumin 3.5- 5.0 g/dL
Note: lab values are indicated in adult s, children will have different
values

6. Key Definitions
Antibody: immune protein that neutralizes a threat to the
host i.e. Infectious organism, chemical, or foreign body
Antigen: substance which is capable of inducing an immune
response and triggering production of antibodies
Apheresis: process which separates blood into its constituent
components
Autologous: originating from the organism itself i.e. blood
which the host has banked for their own use
Cryoprecipitate: insoluble concentrate of coagulation factors
Hematocrit: the percentage of blood which is RBCs

7. Key Definitions (cont.)
Refractory: resistance to treatment; recipient immune
response which develops in response to frequent blood
transfusion
Serum: the clear, liquid component of blood that remains
after coagulation has occurred
Thrombocytopenia: a condition characterized by low
platelet count

8. Blood Typing and Recipient/Donor

9. RH System
When combined with the 4 blood types, this concept
can be a difficult one to understand, and lack of
understanding can contribute to fatal flaws in blood
administration
RF factors are classified based on the presence or
absence of major D antigen on the surface of RBCs
•Presence of antigen = RH +
•Lack of Antigen = RH –
The lack of antigen D, or RH-, is able to donate to RH+
individuals; however, RH+ individuals may only donate
to other RH+ recipients.
•This is because the presence of Antigen D would trigger an antibody
response in the RH- individual (ATI, 2012)

10. Benefits of Blood Component Therapy
The use of blood components rather than whole blood
transfusion has marked advantages, and is a more
efficient use of the blood supply
•Patients whom only need a specific component of the blood
for their therapy will only get the constituent which is indicated
for their condition i.e. anemic patient would only need RBCs
•One donor’s blood is able to treat multiple patients
•Blood components will be less likely to trigger an antibody
response
•More efficient use of supply (ATI, 2012)
Whole Blood
•Indicated for use in patients who have undergone significant
trauma and blood loss, need to restore blood volume

11. Adverse Effects
Immediate Adverse Reactions:
•Febrile
•Urticarial reaction
•Anaphylaxis
•Acute hemolytic reactions
•Bacterial contamination
•Acute lung injury
•Volume overload
•Hypothermia
•Citrate toxicity (blood preservative)
•Potassium imbalance (ATI, 2012)

12. Adverse Effects
Delayed and Long-term Adverse Reactions:
•Delayed heamolysis
•Alloimunity
•Graft versus host
•Iron accumulation
•Infectious disease transmission
•Immunomodulatory effects (ATI, 2012)

13. Sentara Procedural Guidelines for Safe
Blood Administration
1. Verify physicians order
2. Ensure informed consent has been obtained
3. Hand hygiene
4. Use two patient identifiers, verify that arm band is
correct before administration
5. Baseline vitals no older than 30 minutes, prior to blood
administration
6. Establish IV: large gauge IV catheter is preferred i.e. 18 or
20 gauge
7. Explain procedure, and articulate adverse reactions client
should notify nurse about
8. Pre-medication if ordered by physician
9. Position patient for optimal comfort
10. Assemble equipment: 100 or 250 mL NS to prime tube

14. Sentara Procedural Guidelines for Safe
Blood Administration
11. Verify availability of blood products with transfusion services
prior to administration of blood or components
12. Transfusion services will require patient identifiers, physician’s
name whom ordered treatment, date and time, reason for
transfusion, will release one unit at a time.
13. Inspect blood for integrity and evidence of contamination
14. Verify two patient identifiers at the bedside, and second check
performed by licensed clinical associate
15. Agitate blood or blood components gently prior to
administration
16. Hand hygiene and don gloves
17. Prime blood administration set tubing with NS, infuse with
standard Y-type IV adaptor or straight filter (170-260 micron
filter). Flush IV with 10 mL of NS prior to administration
18. Stop infusion of NS and insert administration set and spike into
unit of blood.

15. Sentara Procedural Guidelines for Safe
Blood Administration
19. Attach the administration set to the patients IV access device
using aseptic technique
20. Regulate the flow to 60 mL/hour via infusion pump or at
prescribed rate for first 15 minutes (as little as 30 mL of blood
can cause extreme adverse reactions)
21. Direct observation of patient for first 15 minutes
22. Adjust flow rate according to order or patient tolerance
23. Discard equipment in appropriate biohazard containers
24. Remove gloves and wash hands
25. Monitor and assess the patient’s VS throughout procedure, 15
minutes by 2, 30 minutes by 1, and 60 minutes by 3 for adverse
reactions
26. Document findings and VS on the blood transfusion flow sheet
27. Wash hands and don gloves at completion of infusion
28. Purge and discard blood transfusion set appropriately
29. Reassess IV patency

16. Sentara Procedural Guidelines for Safe
Blood Administration
30. Document post-procedure information on blood transfusion
flow sheet
31. Place transfusion tag and flow sheet in the patient’s medical
record at conclusion of therapy
32. Provide the patient with post-transfusion reaction education
and document in EMR with DAR note (Sentara, 2012)
Note: ER department has additional protocols not discussed here

17. Additional Infusion Information
Blood products are an exceptionally good growth medium
for bacteria; therefore, must be fully administered within 4
hours to reduce risk of bacteremia
Blood must be spiked and infusing within 30 minutes of
release from transfusion services, or must be returned
Blood can be left uninfused for extended periods in
approved cooler (thermo sticker affixed), but typically only
used ER. Return unused blood to infusion services
Two pre-serotype tests must be conducted to ensure
appropriate match to blood being infused (Sentara, 2012)

18. Additional Information
Shelf life of blood products
•Whole blood: within 24 hours
•RBCs “packed red blood cells”: 42 days or 10 years
when frozen
•Plasma proteins: 1-7 years frozen, must be used within
24 hours when thawed
•Immune globulin can withstand 10 hours at 140
degrees F – sterilization technique
•Cryoprecipitate: 1 year when frozen
•Platelets: 5 days at room temperature
•Highly susceptible to contamination
•Granulocytes: must be transfused within 24 hours (ATI,
2012)

19. Transfusion Related Infections
In the United States, transfusion related infections are
rare, and all blood units are ran through the gamut of
STD tests to ensure the safety of blood transfusion
However, there are other non-traditional risks which
many health care workers may fail to disclose because
of lack of knowledge or belief that it is too rare to
acknowledge
•Subclinical cancer cells can be transmitted through blood,
and metastasize in the recipient
•Atypical pathogens, helminthes, bacteria, fungus, protozoa,
and non-STD viruses, i.e. dengue fever or malaria.
Full disclosure is essential, and these topics should be
broached with the recipients of blood products.

20. References
ATI. (2012). Skills module: Blood administration. Assessment
Technologies Institute LLC. Retrieved from http://www.ati.com
Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed.). St. Louis, MO:
Saunders Elsevier.
Sentara. (2012). Blood and blood component administration for inpatient
and outpatient (Adult). Norfolk, Va: Sentara Health Care System.