What are the steps for blood transfusion

Transfusion: who does what?

The handling of foreign blood is comprehensively regulated by law. In everyday life, however, questions often arise: Who starts the transfusion? Who is monitoring the patient? Which tasks can the doctor delegate? Failed transfusions can mean the death of a patient. Nurses therefore need to know exactly what is going on in order to protect the patient, but also themselves.

Blood is a very special juice, ”Mephisto said in Goethe's Faust. But it was not until Karl Landsteiner discovered the blood groups of the AB0 system in 1901 that the prerequisites for many developments in modern medicine were created.

Today a blood transfusion can save lives. But resources for foreign blood are scarce and a transfusion always involves risks. There are now various methods of avoiding foreign blood transfusions, for example through blood-saving measures or preoperative anemia management. However, in certain medical situations, a foreign blood transfusion may be necessary.

Legal Aspects

Binding regulations can be found in the law regulating the transfusion system (transfusion law) and the guideline for the extraction of blood and blood components and for the use of blood products (haemotherapy) (1, 2). In addition, the cross-sectional guidelines of the German Medical Association on therapy with blood components and plasma derivatives play an important role (3). In this respect, it is also important for nursing staff to have knowledge of this area, because some activities may only be carried out by the doctor, while others can be delegated to nursing staff.

According to the Transfusion Act, hospitals must name responsible persons (transfusion officers or officers) and issue transfusion instructions. The people who have to be instructed and then trained regularly include not only doctors and nursing staff, but also, for example, the transport service. The background to this is that incorrect transport of blood components can lead to errors. However, errors can also occur in the preparation, implementation and follow-up of transfusions. And - so much has already been said - many mistakes are based on human error and can be avoided if you stick to the regulations.

Blood type systems

AB0 system: The AB0 system includes blood groups A, B, AB and 0 (zero). It is the most important blood type system. The trait (A, B, AB, or 0) is on the surface of red blood cells (erythrocytes). It is also called an antigen and is innate. There are also antibodies. These are the body's own defense mechanisms against "foreign" blood group properties that everyone has from birth.

The term antigen has nothing to do with genes. It is the abbreviation of “antibody generator” or “antibody-generating”, which means something like antibody generator (7). An antigen is a substance that triggers the formation of antibodies in the organism. Antibodies are protein compounds that neutralize the antigen. They are also called immunoglobulins. The antibodies can be thought of as the catchers with which the bad guys, for example pathogens, are neutralized (7).

Rhesus blood group system: This is the second most important blood type system. As with the AB0 system, the surface features (antigens) of the rhesus system are also located on the erythrocytes (4). The antigen D has a prominent position here. People who have the antigen D are called rhesus-positive, the antibodies are called anti-D. About 85 percent of all people in Europe are Rh-positive. People who do not have antigen D are said to be rhesus negative.

Common questions about transfusions

 

Does the patient need a separate venous line for a transfusion?

In order to avoid undesirable interactions, a specially placed peripheral access or a separate branch of the central venous catheter is ideal. If it is ensured that no other medication or infusion solutions are administered in parallel, an already lying access can be used. In particular, solutions containing calcium or glucose must never run together with a transfusion. There is a risk of coagulation activation or hemolysis. If a can is to be administered quickly, a CVC is usually inferior in terms of flow rate to a large-lumen peripheral venous access, for example in sizes 17 G white, 16 G gray or 14 G orange-brown. This is especially true for multi-lumen central venous catheters.

What is examined in the serological tolerance test (cross match)?

It is carried out before each transfusion of red cell concentrates and is used to test whether the donor red blood cells “get along” with the recipient plasma. This is to rule out any incompatibilities. The cross-match is valid for 72 hours after the time of collection. The duration of the validity can be seen on the preservation slip.

How long can a transfusion set be used?

A maximum of six hours after opening the sterile packaging. The administration of several canned food is possible within this period of time.

How long is a bedside test valid?

For the duration of a series of transfusions. If another doctor takes care of the patient in the meantime, the bedside test must be repeated under his supervision.

Does the doctor have to attach every canned food himself without exception?

No, in intensive care units it is permissible for follow-up products within a transfusion series to be started by qualified nursing staff. The prerequisite is that a doctor is present on the ward and can be reached immediately.


Blood components and transfusions

Blood components are cell-containing blood products such as erythrocyte, thrombocyte and leukocyte concentrates as well as therapeutic plasma (fresh frozen plasma). Their application is called a transfusion (4). The blood components are briefly presented here:

Red cell concentrate (EK): The red cell concentrate is the most important blood product. The aim is always to correct a deficiency in red blood cells. EKs are transfused in the same way as AB0, that is, the transfused concentrate and the recipient have the same blood type. In exceptional cases, AB0-compatible transfusions can also be used. This is possible, for example, with an EK of blood group 0. It can be transfused to patients of all blood types without causing a harmful reaction. The decision on such exceptions is made in the laboratory. An important rule here is: The transfusion of rhesus-positive erythrocyte concentrates should be avoided in rhesus-negative patients, otherwise rhesus antibodies anti c may be formed. This rule applies in particular to girls and women of childbearing age. With them - even years later - these rhesus antibodies can be directed against the unborn child in the event of pregnancy. The prerequisite for this is that the child has inherited property c from the father (5). Exceptions are only made in the event of danger to life, if rhesus-negative red cell concentrates cannot be provided quickly enough and the patient is otherwise at risk of bleeding to death (5).

Red cell concentrates do not need to be warmed up prior to administration. Exceptions are, for example, patients with cold agglutinin disease or those who react to cold stimuli with vasospasm. A standard macro filter with a pore size of 170 to 230 micrometers in accordance with DIN 58360 must be used for the transfusion.

Therapeutic fresh plasma (FFP): The therapeutically active substances are coagulation factors such as the proteins thrombin or fibrinogen. Since this does not contain any erythrocytes, only the blood group identity is decisive. This means that the transfusion is AB0-compatible, the Rhesus factor does not have to be taken into account. Immediately after production, the plasma is shock-frozen; it must be stored below minus 30 degrees Celsius.

Fresh therapeutic plasma is transported frozen to the ward. The cold chain must not be interrupted. It is only used directly before the transfusion in devices approved for this purpose, for example in the Plasmatherm® (Fig. 1) or an approved microwave oven. Under no circumstances may the warming take place in a water bath, for example in a sink or the like, as the preparation could otherwise be changed unpredictably. This can damage the health of the recipient. A standard macro filter must be used for the transfusion. Caution: The foil of the FFP bag can easily break when frozen. Therefore, they should be handled carefully before thawing.

Platelet concentrate (TK): It is used to treat a platelet deficiency. TKs are transfused AB0 and Rhesus compatible. A storage temperature of plus 22 degrees Celsius (± 2 ° C) must be maintained for all platelet concentrates. Platelet concentrates are transported at room temperature.

Once the TC has arrived at the ward, the following applies: The platelets should be administered promptly after delivery. Storage in the refrigerator or heating is prohibited. A standard macro filter can be used for the transfusion. Sometimes, however, a filter is also supplied which must then be used.

Prepare for a transfusion

It is the medical responsibility to inform the patient about the benefits and risks of a transfusion at an early stage. The patient must confirm this in writing; the information becomes part of the patient file. In the case of minors, the consent of the legal guardian must be available. In the case of guardianship or care, the legally appointed person must consent. In emergencies, the information may be given shortly before the planned transfusion; it can only be omitted if life is in danger. In the latter case, it must be made up for.

The blood collection for blood group determination and the request for canned food cannot be delegated, the doctor must do this himself. The blood may only be taken in tubes that are labeled with the patient's label or with the name, first name and date of birth or with the corresponding replacement ID of the patient. Under no circumstances should the patient sticker be affixed until after the blood sample has been taken. Mixing up samples is the most common cause of severe transfusion reactions (6).

Performing a transfusion

Before the transfusion, the doctor needs to check a few things:

  • Does the patient's data match the data on the food receipt? (Name Pre-Name Date of birth)
  • Does the component's blood type match the patient's blood type? Each clinic must determine the patient's blood group itself and must not rely on earlier determination.
  • Is the batch number on the can identical to the batch number on the can accompanying note?
  • Has the canned food not expired?
  • Is the component OK when inspected? In other words, no noticeable discoloration, clot, damage?
  • In the case of an EK transfusion: is the serological tolerance test (crossmatch) still valid?

In addition, the bedside test (bedside = on the bed) is carried out directly on the patient's bed under the supervision of the doctor or by himself. For this purpose, fresh blood is drawn. The bedside test is used to determine the patient's blood group in the AB0 system, and possibly also the rhesus factor. So the patient is tested and not the canned food. The transfusion of autologous blood is an exception. The canned food must also, but not exclusively, be tested here. The bedside test is the last chance to avoid an AB0-incompatible transfusion and must therefore be carried out without exception, even in emergencies (Fig. 2).

The responsibility for monitoring the patient during the transfusion rests with the transfusing physician. The activities that he cannot delegate include establishing the indication for canned food, assigning the canned food to the patient, checking the bedside test and checking papers and findings. After the start of a transfusion, he personally monitors the patient for five to ten minutes (6). After that, monitoring can be delegated to trained nursing staff. If the transfusion of further components is planned, the doctor must restart each one personally. If the nursing staff observes undesirable effects, the transfusion must be interrupted immediately. The access is left and the responsible doctor is informed. He must therefore be available at all times. Clinical signs of transfusion reactions are:

  • Malaise, sweating,
  • Chills, high temperature,
  • Shortness of breath,
  • Itchy skin,
  • Dizziness, nausea, vomiting,
  • Headache, backache,
  • Drop in blood pressure, rapid heartbeat,
  • Collapse, shock,
  • Hemoglobinuria (6).


Aftercare

After the end of a transfusion, the canned food bag should be closed in a sterile manner; the industry offers suitable stoppers for this purpose. The bag (s) must then be stored in a special, vibration-free refrigerator at 2 ° C to 6 ° C for 24 hours so that further examinations can be carried out if necessary. If several cans are administered, the last administered can is stored in the refrigerator together with the transfusion system. Joint storage with medicines or even food is prohibited.

Everyone has to know specific processes

Incorrect transfusions are usually triggered by mix-ups. There is still a high risk of death. Therefore, a transfusion nowadays is embedded in a system of controls that aim to prevent errors at every level. In practical terms, this means that everyone involved knows the steps and must also adhere to them. For this reason, it is important that caregivers also know what the correct processes are - also in order to protect themselves from legal consequences. Avoiding patient harm is a team task, even though the responsibility in connection with a transfusion almost always rests with the doctor.

(1) Law regulating the transfusion system (Transfusionsgesetz-TFG) of July 1, 1998, last amended on July 17. 2009 www.rki.de/DE/Content/Infekt/Blut/Transfusionsmedizin/transfusionsgesetz.pdf?__blob=publicationFile
(2) Guidelines for the collection of blood and blood components and for the use of blood products (haemotherapy). Prepared in accordance with the Transfusion Act by the German Medical Association (BÄK) in agreement with the Paul Ehrlich Institute Cologne: Deutscher Ärzteverlag 2007
(3) Cross-sectional guidelines (BÄK) for therapy with blood components and plasma derivatives. 4th edition Ed. Board of Directors of the German Medical Association on the recommendation of the Scientific Advisory Board Cologne: Deutscher Ärzteverlag 2009
(4) Kretschmer V. et al., Transfusion Medicine - Clinical Haemotherapy, short textbook for clinic and practice, 1st edition 2008, Thieme Verlag, ISBN 978-3-113-145751-6
(5) Website of the University Hospital Würzburg. Institute for Clinical Transfusion Medicine and Hemotherapy. Access on May 23, 2017 www.transfusionsmedizin.ukw.de/studenten/hauptvorlesung/blutgruppen-erythrozyten-ii/die-rh-kompatible-transfusion.html
(6) Dörner R. Handling transfusions correctly. Blood components and their clinical application. CNE Thieme. DOI: 10.1055 / s-0033-1350073
(7) Häcker B. Immunology for Dummies. Wiley-VCH Verlag. 1st edition 2014. ISBN-13: 978–3527706013