An Ohio blood bank physician wrote that several nurses at her facility wish more specific guidance on the length of time a patient must be observed during the start of a transfusion. At her facility a nurse has traditionally spent the first 15 minutes of the transfusion with the patient. Is this generally what others are doing? The Ohio blood banker states that there is no specific number of minutes set by the AABB Standards, which state that "the patient shall be observed during the transfusion and for an appropriate time thereafter for suspected adverse reactions". The e-network membership was asked to share what is their practice with regards to the time frame during which a patient is actually observed at the beginning of transfusion.

The following replies were submitted in response to the above question

1. Both a health system in Nebraska and a health system in Virginia reported that their respective policies called for the transfusionist to continually observe the patient for the first 15 minutes of a transfusion.

2. A blood banker in Michigan reported that their policy booklet does not say specifically that the transfusionist must stay with the patient for the first 15 minutes, although she says that is what they teach. The Michigan blood banker adds that the next edition of their policy booklet will have such a requirement written in it. What their policy booklet currently says is "Fifteen minutes after initiating transfusion of a unit of blood or blood component, document the patient's vital signs including temperature, blood pressure, respirations and pulse, and examine the skin for urticaria. Such monitoring is essential for the prompt recognition of any adverse reaction to transfusion. The rate of flow of the blood should also be noted during these periodic inspections. During the infusion, vital signs should be documented after the first 15 and 30 minutes and hourly until one hour after completion of the transfusion. For outpatient transfusions, the vital signs may be taken at 30 minutes post transfusion."

3. A blood banker in the United Kingdom (UK) reported that in the UK, the practice is similar to that described by the inquiring blood banker, because the majority of severe reactions occur within 15 minutes; this of course applies to each unit being administered. Further observation of the patient is at the discretion of the clinical staff or if the patient becomes unwell. The responding blood banker also added that according to the British Committee for Standards in Haematology (BCSH) Guidelines entitled 'Guidelines for the administration of blood and blood components and the management of transfused patients'), conscious patients should be informed about the possible adverse effects of transfusion and the importance of reporting immediately if they develop one of the symptoms such as shivering, shortness of breath, etc.

4. A second UK blood banker enclosed the full text of the relevant section of the BCSH Guidelines (see below), which were mentioned in reply #3 above. The guideline can be found in full in Transfusion Medicine Guidelines for the administration of blood components and the management of transfused patients. Transfusion Medicine, 1999, 9, 227-238. The relevant section of the BCSH Guidelines are as follows:

E) Care and monitoring of transfused patients. The most basic principle of patient care during transfusion is to ensure the patient's safety. Patients receiving transfusions should be monitored for signs of the potential complications of transfusion and any suspected problems dealt with swiftly and efficiently. There is wide variation in the frequency of nursing observations during transfusion, and it is not clear what the optimum type and frequency of observations should be. Severe reactions are most likely to occur within the first 15 minutes of the start of each unit, and patients should be most closely observed during this period.

Recommendations:

Hospitals should have a policy for the care and monitoring of patients receiving transfusions of blood and blood components. The policy should clearly define the following:

The staff responsible for the care and monitoring of transfused patients.

The information to be given to patient about possible adverse effects of transfusion, and the importance of reporting immediately any adverse effects, including shivering, rashes, flushing, shortness of breath, pain in extremities or in the loins.

Visual observation of the patient is often the best way of assessing patients during transfusion. Transfusions should be given in clinical areas where patients can be readily observed by members of the clinical staff.

The start and finish times of the infusion of each unit should be clearly indicated on observations charts.

Vital signs (temperature, pulse and blood pressure) should be measured and recorded before the start of each unit of blood or blood component, and at the end of each transfusion episode.

Vital signs related to transfusion should be recorded separately from routine observations and clearly dated to enable the information to be retrieved later, if necessary. Routine observations should be continued on unconscious patients in operating theatres and ITU.

Temperature and pulse should be measured 15 minutes after the start of each unit of blood or blood component.

Further observations during the transfusion of each unit of blood or blood component are at the discretion of each clinical area and need only be taken should the patient become unwell or show signs of a transfusion reaction.

Unconscious patients are more difficult to monitor for signs of transfusion reactions. Routine observation patterns should continue. Transfusion reactions should be considered when assessing a change or deterioration in the patient's condition, particularly during the first 15-20 minutes following the start of a unit of blood or blood component. Hypotension, uncontrolled bleeding due to disseminated intravascular coagulation, haemoglobinuria or oliguria may be the first indications of an acute haemolytic transfusion reaction in these patients.

ADDENDUM Feb. 6, 2002

5. Another blood banker from the UK suggested that the e-network consider the guidance offered in a new UK Handbook of Transfusion Medicine (Blood Transfusion Services of the United Kingdom, third edition 2001. Editor: DBL McClelland. The Stationery Office, London. ISBN 0 11 322427-3). There is also a British Society for Haematology Guideline on Blood Administration (Transfusion Medicine 1999;9:227-238). According to the UK blood banker, the referenced handbook makes the following suggestions: All transfusions should be given where the patient can be observed. Serious reactions are usually apparent within first 15 to 30 minutes and are symptomatic. Before starting transfusion record blood pressure, pulse and temperature. Check pulse and temperature 15 minutes after starting each pack. Observe the patient throughout the transfusion. Repeat blood pressure, pulse and temperature when the transfusion is completed. If the patient is conscious further recordings are only needed if the patient becomes unwell or has symptoms or signs of a reaction. An unconscious patient should have pulse and temperature checked at intervals during the transfusion. Each unit is a new transfusion.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator