Blood Order and Administration

Minimum Time Needed Before RBCs are Available

Turnaround Time Testing Performed Risk for Hemolysis
5 minutes – extreme emergency
None;
O Neg RBC issued STAT
Low*; life threatening hemolysis rare
15 minutes - emergency
ABO, Rh type.
RBC antibody screen not performed.
Low*
60-90 minutes
 
For patients who lack RBC antibodies.
ABO, Rh type.
RBC antibody screen negative; electronic crossmatch performed.
Negligible
Up to 48 hours
 
For patients with RBC antibodies, including autoantibodies.
ABO, Rh type.
RBC antibody screen positive; manual crossmatch performed.
Negligible
Subsequent units for patients with a current type and screen and who quality for an electronic crossmatch
10-15 minutes Electronic crossmatch performed. Negligible

* Red cell antibodies are found in approximately 0.5% of patients
(0.04% of persons who have never been transfused or pregnant, 1% of those previously transfused or pregnant, 3% of multiparous females).

Maximal Surgical Blood Order Schedule (MSBOS)

The type and screen must be collected 1-30 days prior to surgery or within 1-3 days if the patient has a history of RBC antibodies, pregnant within 3 months, or transfused within 3 months.

Surgical Procedure Units/Order Surgical Procedure Units/Order
Arthroplasty, total shoulder
TS
Hysterectomy, vaginal             
TS
Arthroplasty, total knee
TS
Ileal loop
TS
Arthroplasty, total hip
2
Lymph node dissection, axillary/inguina
TS
Amputation
TS
Lymph node dissection, retroperitoneal
2
Aneurysm, abdominal aortic
6
Mastectomy
TS
Aneurysm, peripheral vascular
2
Neck dissection
2
Appendectomy
TS
Nephrectomy, radical
2
Aneurysm, thoracic aortic
6
Nephrectomy, simple
TS
Biopsy, liver
TS
ORIF of fracture
TS
Biopsy, lung
TS
Ovarian malignancy debulking
2
Bone graft
TS
Pacemaker change/insertion
TS
Biopsy, heart
TS
PDA repair
2
Bone marrow harvest, allo
1
Peripheral vascular bypass, aorto bifemoral
5
Bone marrow harvest, auto
1
Peripheral vascular bypass, femoral popliteal
2
Bowel resection
TS
Pneumonectomy
2
Bronchoscopy & ediastinoscopy,
lymph node biopsy
TS
Prostatectomy, radical
2
C section
TS
Prostatectomy, transurethral
TS
CABG, initial
4
Shunt, ventriculo-arterial
TS
CABG, reoperation
6
Shunt, ventriculo-peritoneal
TS
Craniotomy, tumor
2
Spinal decompression
TS
Craniotomy, posterior fossa
2
Spinal fusion
2
Cystectomy
2
Spinal, laminectomy
TS
Debridement
TS
Splenectomy
TS
Esophageal resection
2
Tetrad repair
4
Exploratory laparotomy
TS
Thoracotomy/open lung biopsy
TS
Colostomy/ileostomy/gastrotomy
TS
Transplant, adult liver
15
Carotid endarteretomy
TS
Transplant, heart
4
Cholecystectomy
TS
Transplant, heart/lung
4
Cleft palate repair
TS
Transplant, kidney
2
Coarctation of aorta repair
3
Transplant, kidney donor
TS
Colectomy
TS
Transplant, kidney/pancreas
2
Cranioplasty
1
Transplant, lung
6
Craniotomy, aneurysm
2
Transplant, pancreas
2
Contracture release
TS
Transplant, pediatric liver
10
Facial reconstruction
4
Ureteral implant
TS
Gastrectomy
2
Urethroplasty
TS
Hypophysectomy
TS
Vaginectomy
TS
Gastric bypass
TS
Valve replacement, aortic
5
Hernia repair
TS
Valve replacement, mitral
6
Hysterectomy, TAH/BSO
TS
Vulvectomy, radical
1
Hysterectomy, total abdominal
TS
Vulvectomy, simple
TS

Informed Consent

Prior to non-urgent transfusions, it is the provider’s responsibility to obtain informed consent from the patient or the patient’s authorized surrogate decision maker (if the patient does not have decision making capacity). This responsibility includes explaining the risks, benefits, and alternatives and answering any questions the patient may have. Also, the patient should be asked if he/she had any prior transfusion reactions.

The hospital has informational pamphlets, available for patients, which describe the general nature of, risks from, and alternatives to allogeneic blood transfusion. Quantitative estimates of transfusion risks are included in these guidelines.

Consent obtained for the administration of blood components is valid for an entire hospital stay or for one year after the signature date for an outpatient course of treatment UNLESS:

1. There has been a significant deviation from the treatment plan to which the patient originally consented, in which case the provider will inform the patient of the change and obtain consent to the change in plans; or

2. Risk factors have changed since the provider’s discussion with the patient such that it would be reasonable for the patient to be informed of the risks and asked to consent again in light of the changed facts. In this case the patient will be informed of the new risks and asked for consent; or

3. The patient has revoked consent, in which case the blood component may not be administered.

Provider’s Order

Blood component administration begins with a provider order based upon a clinical assessment that a transfusion is indicated. A written order in the patient’s medical record should include the following elements:

1. Order for type and screen within the last 3 days

2. Type of component(s) and number of units to transfuse

3. Special requirements, if any, such as irradiation, volume reduction, washing

4. Time component is to be started

5. Rate of infusion

Premedications

Order premedications ONLY if indicated. If the patient has a repeated history of transfusion reactions with signs and symptoms such as fever, chills, shortness of breath, hives, or pruritus, premedications should be considered. (See page 34 for a complete list.) Antipyretics such as acetaminophen (Tylenol®) and antihistamines such as diphenhydramine (Benadryl®) may be ordered.

Blood Warmer

The routine use of blood warmers is not needed for patients receiving transfusions. Blood warmers may be used for red cell and plasma transfusions to prevent hypothermia in patients receiving massive transfusions, in children receiving blood at a rate greater than 10 mL per kg per hour, and for patients with clinically significant cold agglutinins.

Platelets are stored at room temperature and not transfused through a blood warmer.

Basic Principles of Blood Transfusion*

  • Informed consent for transfusion should be obtained prior to transfusion.
  • Prescribing decisions should be based on national guidelines as well as hospital-developed guidelines approved by the medical staff (Transfusion Committee).
  • During acute blood loss, volume replacement should not be achieved with blood components but by IV replacement fluids while assessing the need for transfusions.
  • A patient’s hemoglobin level, while important, should not be the sole deciding factor in starting transfusion. The decision to transfuse should be supported by the need to relieve clinical signs and symptoms and to prevent morbidity and mortality.
  • The clinician should be aware of the risks of transfusion-transmitted infection and acute reactions to the blood component given to the patient.
  • Transfusion should be prescribed only when the benefit is greater than the risk.
  • The clinician should record the reason for the transfusion 
  • A trained heath care worker should monitor the patient during the transfusion and respond immediately if an adverse event occurs.
  • The clinician should report all acute (reactions) and delayed (transfusion-transmitted HIV, hepatitis) adverse outcomes.
* Loosely based on Callum JL, Pinkerton PH. Bloody Easy. A guide to transfusion medicine. 2003:7.