Administration

Transfusing an unidentified patient

Monitoring for adverse events or reactions during transfusions

Transferring blood with a patient

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		Consensus	Grade
19.1	The use of blood and blood products should be directed by established protocols.	Yes	B
19.2	The use of blood and blood products should be subjected to gatekeeping controls.	Yes	C

Administering the wrong blood type in error (with the risk of ABO incompatibility) is the most serious outcome of blood transfusion. Most of these incidents are due to the failure of the final identity checks carried out between the patient (at the patient’s side) and the blood to be transfused. All members of staff involved in the administration of a blood component must be trained and competency-assessed as per local policy. Local policy will also stipulate if this is a one- or two-person bedside check, with each person performing the check independently.⁷⁸ RCC transfusions should start within 60 minutes of removal from a controlled temperature container. Thereafter, one can infuse RCCs at 1 to 2 ml/minute (60–120ml/hour) for first 15 minutes and then as rapidly as tolerated thereafter. The total infusion time should not exceed four hours.

All prescriptions for transfusion must be documented in the patient record, either on the anaesthetic chart or on the drug/fluid prescription chart. Local policy for confirmation of the transfusion must be followed as it is a legal requirement that 100% of blood components must be traceable.⁷⁹ Where blood transfusion is anticipated, this should be discussed with the patient before surgery and valid consent to receive transfusion should be documented.⁸⁰ Patients should be informed that they have received blood or blood components before discharge from hospital, as they will otherwise be unaware; they should also be informed that this removes them from the donor pool for a period of six months. It is also important that the patient’s general practitioner/clinical team is informed if possible.

The following guidance is for a manual checking process at the bedside (the preferred system is an electronic transfusion management system, but is not currently widely available in South Africa):

• The patient must be positively identified. All patients receiving blood components should ideally be wearing an identification wristband (or hospital identifier) containing four core identifiers: first name, last name, date of birth and patient identification number.
• Immediately before the transfusion, check the component next to the patient, against the prescription.
• Check the four core identifiers on the compatibility label attached to the blood component with the identification attached to the patient. If there are any discrepancies, do not proceed and call the transfusion laboratory.
• Check that the compatibility label attached to the blood component has the same blood group and numerical component donation number (or batch number for coagulation factors) as the sticker on the blood component.
• Visually check the blood component for any leakage, discolouration or presence of any clots or clumps.
• Check the expiry date and time

Transfusing an unidentified patient

All hospitals should have a clear local policy for transfusion of patients whose identity is unknown. In emergency situations or where the patient cannot immediately be identified, the patient should still have identification attached stating unknown male or female and a unique identification number. The blood sample sent to the transfusion laboratory should contain these exact details. In the event that the patient’s identity becomes known, new identification must be attached to the patient and a new transfusion sample collected and fully labelled with the known patient’s details.

Monitoring for adverse events or reactions during transfusions

Clinical observations should include heart rate, blood pressure, temperature and respiratory rate, as per local guidelines (national guidelines define a minimum of pre-transfusion, and close observation for the first 30 minutes after transfusion). In cases of major blood loss, ideally pulse, blood pressure, respiratory rate and urinary output should be monitored every 15 minutes throughout the transfusion. In less severe cases the recipient’s vital signs should be checked every half hour after the initial 30-minute observation. Patients at risk for circulatory overload should be observed for 12–24 hours after transfusion.⁷³ If there are any signs of a transfusion reaction, such as tachycardia, rash, breathlessness, hypotension or fever, stop the transfusion and contact the laboratory immediately.⁸¹ Management may include the administration of antihistamine or steroid drugs, or intramuscular/IV adrenaline if life-threatening.⁸² Diagnosis of a transfusion reaction during ongoing haemorrhage may be difficult, but if concern arises, the documentation should be double-checked for administration errors and further analyses performed as per local protocols.

Transferring blood with a patient

Blood components should be transferred with patients at high risk of requiring transfusion en route or immediately on arrival. There should be effective communication between the blood transfusion laboratories involved, according to regional policy. Blood components must be transported in a storage box suitable to maintain their integrity, along with accompanying paperwork, and careful handover is required. When the patient arrives at their destination, the receiving transfusion laboratory should be immediately informed that blood was transported. The patient should be issued with a new identity wristband (or hospital identifier), a new sample taken for cross-match and more blood issued; until this is available, blood transferred with the patient may be administered if required.

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South African Society of Anaesthesiologists (SASA) Guidelines for Patient Blood Management 2020,  Confirmed as current version on the SASA website as of November 2024.