Chapter 8



Give the right blood product to the right patient at the right time. Failure to correctly check the patient or the pack can be fatal.

At the bedside: 

  • correctly identify the patient and the blood components to be transfused, and
  • observe the patient throughout the transfusion.

All transfusions should be completed within 4 hours.

A typical erythrocyte transfusion is 2 hours.

Medications and IV fluids (apart from normal saline) should not be given through the same cannula during a transfusion.

Routine administration of calcium after a transfusion is not required.


8.1.1 Collecting the pack from the Transfusion Laboratory

Written documentation should be taken to collect the blood from transfusion service that includes patient’s first name, surname, and hospital reference number /date of birth or age.

Collect the pack only when you are ready to start the transfusion.

If blood needs to travel significant distance or may not be transfused within 4 hours, then the blood should be transported and stored short term in a validated insulated container called a “shipper”. 

8.1.2 Delivery to the ward

When the selected and compatibility tested unit(s) of blood arrive at the ward, Operating Room or Intensive Care Unit, the label and the bag must be inspected for:

  • Integrity and any signs of deterioration, clots, leaks or discoloration.
  • Cross-match information and compatibility label information.
  • Patient identification details matches the patient for whom the blood was requested.

If any checks fail, contact or return the pack to the hospital transfusion service.

Blood transfusion should be started within 30 minutes of leaving the transfusion service unless it is stored in a validated shipper.

Return blood not being used promptly to the hospital transfusion laboratory.


8.2.1 Equipment for blood administration

Cannulas for infusing blood products:

  • Must be sterile and never be reused.
  • Use flexible plastic cannulas, if possible, as they are safer and preserve the patient’s veins.
  • A doubling of the diameter of the cannula increases the flow rate of most fluids by a factor of 16.

Administration sets for whole blood, erythrocyte, plasma, platelets and cryoprecipitate transfusions must be:

  • new and sterile for each patient with an integral 170–200 micron filter and a preferably a Y-set connection port,
  • changed at least 12–hourly (or more frequently in very warm climates) during blood component transfusion or earlier if the filter is blocked or flow rate is slowed, and
  • discarded after use according to standard hospital protective precaution policy.

A new IV line should ideally be used for each blood product. In cases where limited IV administration lines are available platelets and plasma should be administered before erythrocytes and whole blood (Yellow blood products before Red products). If platelets are administered after erythrocytes or whole blood they will become trapped by the debris accumulated in the blood filter.

Paediatric patients should have a special paediatric IV set if possible. These allow the blood or other infusion fluid to flow into a graduated container built into the infusion set. This permits the volume given, and the rate of infusion, to be controlled simply and accurately and reduces the risk of over transfusion.

8.2.2 Pre-medication

Routine administration of pre-medication is not required.

  • Recurrent febrile reactions: Consider pre-medication with paracetamol. Prestorage leucodepletion, within 24 hours of collection, is more effective in reducing recurrent febrile reactions.
  • Recurrent allergic reactions: Consider pre-medication with an antihistamine and/or corticosteroid.
If a premedication is ordered ensure it is given with sufficient time to have effect.

8.2.3 Pre transfusion checks

The blood should be checked at the patient’s side by two staff members at the same time. The staff should be registered nurses or doctors.

See Annex 4 “Transfusion Administration Checklist” for additional information.The staff should check the details:

  • Blood product type is the same as the prescription.
  • Blood pack label, compatibility paperwork and the patient details are identical and correct.
  • Ask the patient to say their name and confirm the patient identification band details are identical and correct.
  • Expiry date of blood pack.
  • Integrity and any signs of deterioration, clots, leaks or discoloration.

If any checks fail contact or return the pack to the hospital transfusion service.


One of the staff members who checked the blood product must then spike or start the transfusion.

The patient should be in a setting where he or she can be directly observed and resuscitation equipment is available.

Ideally only transfuse during business hours when the largest number of senior staff are available. Transfusion after hours should take place if the patient is unstable and there is sufficient staff to monitor the patient. Transfuse one blood component at a time. Any reaction can then be attributed to a certain product.

Each unit of blood or blood component should be completed within four hours of the bag being punctured or less in high ambient temperatures. Typically a unit of erythrocytes is infused in 1–2 hours while platelets and plasma are infused over 20-30 minutes. In emergency situations all blood components can be administered faster. If a unit is not completed within four hours, discontinue its use and dispose of the remainder through the clinical waste system.


8.4.1 Observations

Monitoring and evaluating the transfused patient is an important part of the bedside transfusion process. This will allow any adverse event or alteration in the patient’s state to be detected as early as possible. This will ensure that potentially lifesaving action can be taken quickly. It will also determine if any action needs to be taken before the blood transfusion starts.

Severe reactions often present during the first 15–30 minutes of a transfusion. All patients, in particular unconscious patients, should be monitored during this period and for the first 15–30 minutes of each subsequent unit. For each unit of blood transfused, monitor the patient:

  • before starting the transfusion,
  • as soon as the transfusion is started,
  • 15–30 minutes after starting the transfusion,
  • at least every hour during transfusion, and
  • on completion of the transfusion.

At each of these stages, record the following information on the patient’s chart:

  • patient’s general appearance,
  • vital signs: temperature, pulse, blood pressure, respiratory rate, and
  • fluid balance:
    - oral and IV fluid intake, and 
    - urinary output.

The patient should be educated to notify a nurse or doctor immediately if he or she becomes aware of any reactions such as shivering, flushing, pain or shortness of breath or begins to feel anxious. 

8.4.2 Recording the transfusion

The following information should be recorded in the patient file:

  • Whether the patient and/or relatives have been informed about the proposed transfusion treatment and consent should be documented.
  • The reason for transfusion.
  • Signature of the prescribing clinician.
  • Pre-transfusion checks:
    - patient’s identity,
    - blood pack,
    - compatibility label, and
    - signatures of the staff performing the pre- transfusion identity check.
  • The transfusion:
     - type and volume of each product transfused,
    - unique donation number of each unit transfused,
    - blood group of each unit transfused,
    - time at which the transfusion of each unit commenced,
    - signature of the person administering the blood component, and
    - monitoring of the patient before, during and after the transfusion.
    - date and time the transfusion is completed,
    - volume and type of all products transfused,
    - unique donation numbers of all products transfused, and
    - any adverse effects.

8.4.3 Medication during a transfusion

Do not add any medicines or any infusion solutions other than 0.9% sodium chloride to any blood component.

Never add calcium or calcium containing fluids to a transfusion. Never add dextrose solutions as these may cause haemolysis.

If an intermittent medication has to be given either insert another IV cannula or:

  1. stop the transfusion,
  2. flush the IV line with 0.9% sodium chloride through the IV access port closest to the patient to clear the blood component from the line and cannula,
  3. administer the medication as required,
  4. flush the line with similar volume required to clear the line initially and then
  5. recommence the transfusion and complete within required timeframe. 

Use a separate IV line if an intravenous fluid other than 0.9% sodium chloride has to be given at the same time as blood components or in major blood loss to rapidly infuse replacement fluids (volume).

8.4.4 Medication after a transfusion

Routine use of IV or PO calcium after a transfusion is not required. Consider when the patient is symptomatic or a large volume has been transfused in a short time such as a massive transfusion.

  • Whole Blood and erythrocyte concentrates are stored in solutions that contain approximately 1.2 g of citrate. A healthy liver can metabolise 3 g citrate every 5 minutes. Transfusion rates higher than 1 unit per 5 minutes or transfusion in patients with severe liver impairment may develop hypocalcaemia due to citrate toxicity.

8.4.5 Warming of blood

Keeping the patient warm is more important than warming the infused blood.

There is no evidence that warming blood is beneficial to the patient when the infusion is slow. A 70 kg patient with a temperature of 37° C will tolerate a 400 g blood pack at 15°C and the patient’s temperature will readjust quickly.

At infusion rates greater than 100 mL/minute, cold blood may be a contributing factor in cardiac arrest for adults.

Warmed blood is most commonly required in:

  • large volume rapid transfusions e.g. greater than 50 mL/kg/hour for adults,
  • exchange transfusion in neonates, and
  • patients with clinically significant cold agglutinins.

Blood should be warmed in a dedicated blood warmer. Blood warmers should have a visible thermometer and an audible warning alarm and should be properly maintained. Red cells must not be warmed above the set point temperature of the approved device, commonly 41°C. Older types of blood warmer may slow the infusion rate of fluids.

Dry heat blood warming equipment is preferable due to the risk of contamination from infected water bath warmers. If a water bath warmer is used it must be emptied and cleaned, as per hospital equipment cleaning policy, after use and stored dry.

Body heat can be used to warm a blood pack if required and a blood warmer is unavailable. The pack should be wrapped to avoid cross infection and the ports protected.

Blood should never be warmed in a bowl of hot water or on a radiator as this could lead to haemolysis of the red cells which could harm the patient and be life-threatening.

8.4.6 External Pressure Devices

These devices make it possible to administer whole blood or erythrocytes within a few minutes and should only be used in an emergency situation and with a large gauge venous access needle.

The external pressure device should:

  • exert pressure evenly over the entire bag,
  • have a gauge to measure the pressure,
  • never exceed 300mm Hg of pressure, and
  • be monitored at all times when in use.

8.4.7 Equipment used in transfusion

Any equipment used to administer blood products needs to:

  • be validated by the manufacturer to not damage blood cells by the action of the equipment,
  • have clear instructions for staff to use the equipment,
  • be used as specified by the manufacturer, and
  • have a regular maintenance program. 


There is a risk of bacterial proliferation or loss of function in blood products once they have been removed from the correct storage conditions. This is particularly true in warm climates. All blood components must be infused within 4 hours of start of transfusion. See table 8.1.

Table 8.1 Time limits for infusion.

  Start Infusion Complete Infusion

Whole Blood Erythrocytes

Within 30 minutes of removing unit from refrigerator

Within 4 hours.
Typically within 1–2 hours.



Within 4 hours.
Typically within 20–30 minutes.

FFP Cyroprecipitate

Immediately after thawing

Within 4 hours.
Typically within 20–30 minutes.

8.5.1 Calculation Guide for Administration of Whole Blood in drops per minute

Whole blood contains 350 mL blood plus 49 mL of additive solution. Administration sets can either provide 15 or 20 drops per mL blood. The following tables (8.2 and 8.3) provide the number of drops per minute to complete a 400 mL transfusion in a given time.

Table 8.2 Administration set as 15 drops per mL administration times

Volume 1 hour 2 hours 3 hours 4 hours

400 mL

100 drops per minute

50 drops per minute

35 drops per minute

25 drops per minute

Table 8.3 Administration set as 20 drops per mL administration times

Volume 1 hour 2 hours 3 hours 4 hours

400 mL

135 drops per minute

66 drops per minute

45 drops per minute

33 drops per minute


To ensure the patient receives all of the blood product administer IV 0.9% Sodium Chloride, in a volume approximating the “line prime” volume, in order to clear the blood component from the line. This additional fluid should only be given if the patient is at low risk of fluid overload.

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