A transfusion replaces a specific blood component. It can be lifesaving, but it carries risks of immune reactions, circulatory overload, lung injury, infection, and — most dangerously — ABO-incompatible transfusion, which is almost always caused by misidentification of the client or the sample.

ABO and Rh compatibility (red cells)

• Type O negative red cells = universal donor for emergencies; AB plasma = universal plasma donor
• Plasma compatibility is the reverse of red cell compatibility
• Rh-negative clients should receive Rh-negative red cells (especially people who could become pregnant) to prevent anti-D sensitization

Blood components

Modified products: leukoreduced (fewer febrile reactions, CMV transmission, HLA sensitization), irradiated (prevents transfusion-associated graft-versus-host disease in immunocompromised clients, stem cell transplant recipients, and directed donations from relatives), washed (repeated severe allergic reactions, IgA deficiency).

Transfusion thresholds — for most stable hospitalized adults a restrictive threshold of Hb 7 g/dL (70 g/L) is used; 7.5 g/dL for cardiac surgery; 8 g/dL for orthopedic surgery or preexisting cardiovascular disease; a higher threshold may be chosen in acute myocardial infarction. Symptoms also guide decisions. Transfuse one unit at a time in stable clients, then reassess.

Before transfusion

• Indication, current Hb or platelet count, symptoms (fatigue, dyspnea, tachycardia, chest pain, bleeding)
• Baseline vital signs including temperature — a fever before starting makes a reaction harder to recognize; notify the provider if febrile
• Lung sounds, edema, fluid status, heart and kidney function (TACO risk)
• History of previous transfusion reactions, pregnancies, and religious or personal objections (e.g., Jehovah's Witnesses)
• Patent IV access; informed consent documented

During transfusion — signs of a reaction

Fever or chills, back or flank pain, chest pain, dyspnea, wheeze, hives, itching, flushing, hypotension, tachycardia, anxiety or a feeling of doom, dark or red urine, oozing at IV sites.

• Type and screen / crossmatch — the sample must be labeled at the bedside with two identifiers; many facilities require a sample within 3 days of transfusion when the client has been recently transfused or pregnant
• Suspected reaction workup: send the blood bag and tubing with the attached solutions to the blood bank; repeat type and crossmatch; direct antiglobulin (Coombs) test; CBC, bilirubin, LDH, haptoglobin; urinalysis for hemoglobinuria; blood cultures from the client and product if sepsis suspected; chest X-ray and BNP for TACO vs TRALI
• Post-transfusion Hb or platelet count to evaluate response

Administration standards

Management of reactions (after stopping the transfusion)

Listed in priority order.

1. Identification — the most important safety step
   • Verify the order and consent
   • At the bedside, two qualified people (or one person with an electronic barcode system per policy) confirm: client identity with two identifiers (wristband and client's own statement), blood product label, unit number, ABO/Rh of client and unit, expiration, crossmatch compatibility tag, and the product ordered
   • Inspect the bag: no clots, gas bubbles, discoloration, or leaks
2. Start safely: prime the set with 0.9% saline; take vital signs; begin slowly and stay with the client for the first 15 minutes — most severe reactions start early
3. Monitor: vital signs before, 15 minutes after starting, at completion, and per policy (often hourly); observe breathing, skin, urine
4. If any reaction is suspected
   1. Stop the transfusion immediately
   2. Keep the IV open with 0.9% saline through new tubing (do not flush the blood left in the old line into the client)
   3. Stay with the client; assess airway, breathing, and vital signs; treat emergencies (epinephrine for anaphylaxis)
   4. Notify the provider and the blood bank
   5. Recheck labels and identity at the bedside
   6. Return the bag and tubing to the blood bank; send blood and first-voided urine samples as ordered
   7. Document the reaction, actions, and client response; report per hemovigilance policy
5. Prevent TACO: slow rates, one unit at a time, monitor intake and output and lung sounds; diuretic between units if ordered
6. Documentation: pre-checks and who checked, unit numbers, start and stop times, volume, vital signs, client response
7. Respect refusal: document informed refusal; discuss alternatives (iron, erythropoiesis-stimulating agents, cell salvage, minimizing blood draws)

• Explain the reason, expected duration, and that vital signs will be checked often
• Report immediately: chills, fever, itching, rash, back pain, chest tightness, shortness of breath, or feeling unwell
• Delayed reactions: report jaundice, dark urine, or fever in the days after transfusion
• Tell future providers about any previous reaction
• Options such as preoperative autologous donation or cell salvage may be discussed for planned surgery; autologous blood avoids allergic, alloimmune, and viral risks, but clerical and bacterial risks remain

• Two-person bedside verification; misidentification causes ABO-incompatible transfusion
• 0.9% saline only; no dextrose, no lactated Ringer's, no medications in the line
• Stay with the client the first 15 minutes; start slowly
• Finish each unit within 4 hours
• Any reaction: stop, keep the line open with saline via new tubing, stay, notify provider and blood bank, return bag
• Febrile non-hemolytic is the most common reaction; acute hemolytic is the most dangerous
• TACO = hypertension, crackles → slow/stop, upright, diuretic; TRALI = hypoxemia, hypotension within 6 h, noncardiogenic
• O negative = universal red cell donor; AB = universal red cell recipient
• One PRBC unit raises Hb about 1 g/dL; restrictive threshold Hb 7 g/dL (70 g/L) for most stable adults
• Platelets: room temperature, never refrigerate; FFP = clotting factors; cryoprecipitate = fibrinogen
• Irradiated products prevent transfusion-associated GVHD