Blood transfusion saves lives, but every unit carries a small risk. Most serious transfusion reactions happen in the first 15 minutes, and the most dangerous errors involve giving blood to the wrong patient. Nurses are the last safety check before blood reaches the patient.
The bedside check
- Positively identify the patient: ask their full name and date of birth, and check it against the wristband and the blood unit label
- Check the blood group, unit number, expiry date and any special requirements (such as irradiated) on the unit, prescription and compatibility label
- Inspect the bag for leaks, clots or unusual colour
- Do not transfuse if anything does not match
Observations during a transfusion
| When | What to record |
|---|---|
| Before starting (within 60 minutes) | Temperature, pulse, blood pressure, respiratory rate, saturations |
| 15 minutes after starting each unit | Same set of observations |
| During the transfusion | Visual checks and observations if the patient feels unwell |
| End of each unit (within 60 minutes) | Full set of observations |
Red cells should usually be completed within 4 hours of leaving controlled storage. Ask the patient to tell you straight away if they feel unwell, especially in the first 15 minutes.
Types of acute reaction
| Reaction | Typical signs |
|---|---|
| Febrile non-haemolytic | Fever and chills without other features; common and usually mild |
| Mild allergic | Itchy rash or hives only |
| Anaphylaxis | Sudden airway swelling, wheeze, low blood pressure; treat as anaphylaxis |
| Acute haemolytic (often ABO incompatibility) | Fever, rigors, loin or back pain, chest pain, low blood pressure, dark urine, bleeding; can be fatal |
| TACO (circulatory overload) | Breathlessness, high blood pressure, crackles, raised heart rate, within hours; higher risk in older or small adults and those with heart or kidney disease |
| TRALI (lung injury) | Severe breathlessness and low oxygen within 6 hours, often with low blood pressure and fever |
| Septic (bacterial contamination) | High fever, rigors and rapid collapse; more common with platelets |
What to do immediately
- Stop the transfusion. Do not discard the bag.
- Keep the IV access open with 0.9% sodium chloride through a new giving set.
- Assess ABCDE, take a full set of observations and call for urgent medical review. Call the emergency team if the patient is deteriorating.
- Recheck the patient’s identity against the unit label and compatibility form.
- Treat as directed: for anaphylaxis, follow the anaphylaxis algorithm; for TACO, sit the patient up and give oxygen and diuretics as prescribed.
- Inform the blood bank, and return the unit and giving set as instructed, with samples for investigation.
- Document and report through your hospital incident system and national haemovigilance scheme.
For a mild fever or rash only, the prescriber may decide to restart the transfusion slowly with closer observation, but only after review.
Delayed reactions
A delayed haemolytic reaction can occur days later, with fever, jaundice, falling haemoglobin and dark urine. Tell patients what to look out for after discharge.
Sources: British Society for Haematology, Guideline on the investigation and management of acute transfusion reactions and administration of blood components; Serious Hazards of Transfusion (SHOT) annual reports; World Health Organization, The clinical use of blood handbook.
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