An inquiring colleague reports that their hospital's policy is to discontinue a transfusion (i.e. not to dimantle the infusion setup) and to maintain IV access-KVO) as soon as nursing (inpatient) is aware of a "suspect transfusion reaction. The hospital policy is to also inform the clinician immediately of a suspect transfusion reaction, but for nursing to complete a Transfusion Reaction form and to send the component bag and patient blood samples to the laboratory. The inquiring colleague has been informed that at a larger regional Hospital in the same 'community' that a Hematology-Oncology physician group insists that nursing calls the responsible attending physician so that the clinician decides whether or not to continue or discontinue the transfusion, and whether or not a transfusion reaction work-up is initiated. The inquiring colleague wonders what others think about the practice of allowing the attending physician to decide whether or not a transfusion reaction investigation should or should not be initiated.

The following comments have been received.

ADDENDA Aug. 17, 2004

1. An officer in the US Navy in San Diego reports that in their practice, it is not necessarily up to the clinician to decide whether or not to pursue a transfusion reaction work-up. In their institution, they contact the patient's physician and explain why this is an important risk reduction strategy that can be initiated by either the Blood Bank or the clinical service. The San Diego colleague reports that their physicians have been very receptive to this.

ADDENDA Aug. 25, 2004

2. A transfusion service medical director in Minnesota who practices at both an academic and a VA institution reports having had success at instituting programs in which nurses are empowered (and required by SOP) to stop transfusions based on temperature rise and symptoms and initiate suspected transfusion reaction evaluations. This must be done regardless of the clinician's desires. Some of the barriers to acceptance have been overcome by answering objections from the nurses and clinicians and developing procedures to meet their needs as well.

• for an objection that a 2F rise in temperature does not always result in clinical fever (e.g., rising from 97F to 99F), they modified their protocol to require that a transfusion is stopped and not restarted when there is both a 2F rise and and the resulting temperature is at least 100F (at one institution it is 101F)
• For the argument that patients who are febrile before the transfusion and that a > 2F rise during a transfusion may actually be from underlying disease and not transfusion, they still have the nurses follow the 2F rise rule. In those cases a blood bank physician assesses the initial laboratory workup of the reaction including the color of the post-transfusion sample, the direct antiglobulin test, and the results of a Gram stain of the returned product). Their clinicians have become cognizant of the risk of bacterially contaminated blood and cooperate with this rule. They've had deaths from bacterially contaminated blood in 1989 and 1999, and reactions from bacterially-contaminated blood at least once a year.
• 75% of their nearly 10,000 platelet transfusions per year are for BMT patients and there was an objection that BMT patients get reactions to platelets all the time and it would waste time and products to enforce a strict reaction workup protocol. To address this objection, they studied 365 consecutive transfusions (all prestorage leukoreduced) to BMT patients and found that only 5 had a 2 F or greater rise in temperature (a rate of 1.4%, and the posttransfusion temperatures were only 100, 101.7, 100.1, 99.9, and 99.5). Thus, their new practice was practical and acceptable.
• They also changed practices so that if the patient has urticaria with no other symptoms, the nurse will stop the transfusion, call the clinician and if treatment is successful (and there were no symptoms other than hives and itching), the nurse and clinician can restart the transfusion. No sample is sent to the blood bank for a reaction evaluation. This is the only type of transfusion that can be stopped and restarted, and the only type not requiring a blood bank evaluation.

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