Blood Transfusion Guide | GCC Nursing Reference

Blood Product Types & Specifications

🔴 Packed Red Blood Cells (PRBC)

Volume: 250–350 mL per unit
Expected Hb rise: ~1 g/dL per unit
Shelf life: 42 days at 2–6°C
Hct: ~55–80%
Indication: Symptomatic anaemia, haemorrhage

💌 Fresh Frozen Plasma (FFP)

Volume: 200–300 mL per unit
Contents: All clotting factors (I–XIII)
Shelf life: 1 year frozen; 4 h after thaw
Indication: INR >1.5–2.0 with active bleeding
Dose: 10–15 mL/kg

💥 Platelets

Pool unit: 50–60 mL (4–6 donor pool)
Apheresis: 200–300 mL (single donor)
Shelf life: 5 days at 20–24°C with agitation
Indication: Plt <10 (prophylaxis), <50 (bleeding)

❄️ Cryoprecipitate

Volume: 10–20 units pooled (~200 mL)
Rich in: Fibrinogen, Factor VIII, vWF, XIII
Indication: Fibrinogen <1.5 g/L with bleeding
Shelf life: 4 hours after thaw

💦 Whole Blood

Volume: ~450–500 mL per unit
Use: Damage control resuscitation (rarely used)
Context: Military trauma, mass casualty
Shelf life: 21–35 days at 2–6°C

💧 Albumin

4% solution: Volume expansion (burns, sepsis)
20–25%: Oncotic pressure (hepatic failure)
Not a blood substitute: No O2-carrying capacity

🦠 Granulocytes

Indication: Severe neutropenic sepsis not responding to antibiotics
Shelf life: 24 hours maximum
Note: Rarely used; irradiate before transfusion

Transfusion Thresholds — When to Transfuse

Product	Trigger Threshold	Clinical Context	Target
PRBC	Hb <7 g/dL	Critical care / ICU (non-cardiac)	7–9 g/dL
PRBC	Hb <8 g/dL	Post-cardiac surgery / symptomatic anaemia	8–10 g/dL
PRBC	Hb <8 g/dL	ACS, symptomatic heart disease	8–10 g/dL
Platelets	Plt <10 × 10⁹/L	No active bleeding (prophylactic)	>10 × 10⁹/L
Platelets	Plt <50 × 10⁹/L	Active bleeding or invasive procedure	>50 × 10⁹/L
Platelets	Plt <100 × 10⁹/L	Major surgery, CNS procedure	>100 × 10⁹/L
FFP	INR >1.5–2.0	Active bleeding or pre-procedure	INR <1.5
Cryoprecipitate	Fibrinogen <1.5 g/L	Bleeding (DIC, trauma, PPH)	Fibrinogen >2.0 g/L

Restrictive Transfusion Strategy

Single-unit transfusion is recommended for stable, non-bleeding patients. Re-assess after each unit before transfusing again. Over-transfusion increases risk of TACO, infection, and immune sensitisation.

Pre-Transfusion Safety Checklist

0 of 10 checks completed

Valid consent obtained (verbal / written per hospital policy)
Blood group and type & screen OR crossmatch result verified and valid
Correct blood product matches prescription / transfusion request form
3-point Patient ID check: Full name, Date of Birth, MRN — wristband vs blood bag label vs request form
Blood bag expiry date checked — not expired
Unit donation number matches blood bank request form exactly
Two-nurse independent check completed and both nurses signed documentation
IV access confirmed — minimum 20G cannula (18G preferred for rapid transfusion)
Baseline vital signs documented: BP, HR, Temperature, RR, SpO2
15-minute observation plan communicated to team and nursing documentation ready

Blood Bag Integrity — Visual Inspection

Check bag for leaks, tears, or cracks
Inspect for unusual colour (purple / black tinge may indicate bacterial contamination)
Check for visible clots or aggregates — do not use if present
Confirm bag has been stored correctly prior to issue
Never warm blood in a microwave — use only approved blood warmers (hypothermia / neonates)

Religious & Cultural Considerations — GCC Context

Jehovah's Witnesses

Jehovah's Witnesses may refuse blood transfusion based on religious belief. Always check for an advance directive (advance refusal of treatment) on admission. Document clearly. Explore bloodless surgery alternatives: cell salvage, erythropoietin, iron infusion, surgical haemostasis. Respect autonomy — competent adults have the legal right to refuse treatment in most GCC jurisdictions. Involve the clinical ethics team for paediatric cases or emergencies.

Islamic Scholarly Position on Blood Transfusion

The majority of contemporary Islamic scholars consider blood transfusion permissible (halal) under the principle of darurah (necessity/medical need). The ruling that blood is impure applies to consumption but not to medical treatment when life is at risk. Patients and families should be reassured by hospital Islamic affairs advisors if concerned. Document any discussion regarding religious beliefs and treatment decisions.

General Cultural Sensitivity

Some patients may express concern about receiving blood from a donor of different ethnicity or gender. Explain that blood banks follow strict ABO and Rh compatibility matching. Where available and clinically appropriate, autologous (own-blood) collection may be offered pre-operatively. Involve interpreter services and patient relations for informed consent discussions.

Administration Guidelines by Product

Product	Giving Set	Infusion Time	Max Time from Issue	Special Notes
PRBC	Blood giving set (170–200 μm filter)	90–120 min (usual); up to 4 h	Start within 30 min	Complete within 4 h of issue
FFP	Standard blood giving set	15–30 min per unit	4 h after thaw	Thaw takes ~30 min; give promptly
Platelets	Platelet giving set (no filter / 170 μm)	20–30 min per unit	Use immediately	Do NOT refrigerate; agitate gently
Cryoprecipitate	Blood giving set	Rapid infusion (10–20 min)	4 h after thaw	Often given as pooled pack
Albumin 4%	Standard IV set	Rate per prescription	Per product label	No blood giving set required

Observation Schedule

Baseline

BP, HR, Temperature, RR, SpO2 — document before hanging bag

15 Minutes

Critical window — most acute reactions occur in first 15 min. Remain with patient, repeat full observations. Do not leave bedside until this check is complete.

Hourly

Repeat BP, HR, Temp, RR, SpO2 every hour throughout transfusion

Completion

Final set of observations at transfusion completion. Document exact finish time, volume infused, patient response, any adverse events.

Vital Signs — Alert Thresholds (Compared to Baseline)

>1°C

Temperature rise from baseline — investigate for FNHTR or haemolytic reaction

>20 bpm

Heart rate increase from baseline — consider allergic or haemolytic reaction

>20 mmHg

Systolic BP fall — consider anaphylaxis, haemolysis, or TACO (with hypertension)

>2%

SpO2 drop — consider TACO or TRALI — apply supplemental O2, assess urgently

⚠️ If ANY Alert Threshold Is Triggered

STOP the transfusion immediately. Keep IV line open with normal saline. Perform full assessment. Notify medical officer. Refer to Reactions tab for management. Do not restart without medical authorisation.

IV Access & Compatibility

Minimum 20G cannula; 18G or larger for rapid infusion or emergency
Do NOT infuse blood through same line as dextrose solutions — can cause haemolysis
Compatible flush: 0.9% Sodium Chloride only
Do NOT add medications to blood products
Use dedicated blood giving set — change set after each unit if multiple units given over different sessions
In-line blood warmers: use only for hypothermia risk, neonates, rapid massive transfusion — approved device only

Reaction Types — Recognition & Management

FNHTR Febrile Non-Haemolytic Transfusion Reaction COMMON

Clinical Features

Fever (>1°C rise), rigors, chills, malaise — typically 15–30 min after start; no haemolysis

Management

Stop transfusion temporarily; give paracetamol 1g; monitor; if fever resolves and mild, restart slowly with medical approval; report

AHR Acute Haemolytic Reaction (ABO Incompatibility) EMERGENCY

Clinical Features

Fever, rigors, loin/flank pain, haemoglobinuria (red-brown urine), hypotension, disseminated intravascular coagulation (DIC), acute renal failure

Management

STOP immediately; keep IV patent with normal saline; urgent bloods (FBC, crossmatch, DAT, haemoglobin); fluid resuscitation; supportive care; return bag to blood bank; ICU review; incident report

ALLERGIC Mild Allergic Reaction MANAGEABLE

Clinical Features

Urticaria (hives), pruritis (itching), flushing — no systemic features; can occur any time during transfusion

Management

Stop transfusion; administer antihistamine (e.g., chlorphenamine 10mg IV/IM); wait for symptoms to resolve; restart slowly with medical approval; document and report

ANAPHYLAXIS Anaphylactic Reaction EMERGENCY

Clinical Features

Bronchospasm, stridor, severe hypotension, angioedema, urticaria, loss of consciousness — rapid onset

Management

STOP transfusion; call emergency team; Adrenaline (Epinephrine) 0.5 mg IM (anterolateral thigh); ABC support; O2; IV fluid bolus; antihistamine + corticosteroid after adrenaline; ICU review

TACO Transfusion-Associated Circulatory Overload SERIOUS

Clinical Features

Dyspnoea, orthopnoea, pulmonary oedema, hypertension, tachycardia — especially in elderly/cardiac/renal patients and those with slow infusion over hours

Management

STOP transfusion; sit upright; O2; IV frusemide (furosemide) 20–40 mg; chest X-ray; BNP/NT-proBNP; escalate; may restart at slower rate after diuresis with medical review

TRALI Transfusion-Related Acute Lung Injury SERIOUS

Clinical Features

Bilateral pulmonary infiltrates, severe hypoxia (PaO2/FiO2 <300), non-cardiogenic pulmonary oedema within 6 hours of transfusion; no fluid overload

Management

STOP transfusion; high-flow O2; supportive care; ICU for ventilation if needed; NO diuretics (not volume overload); report to blood bank urgently; haemovigilance report

SEPTIC Bacterial Contamination (Septic Transfusion Reaction) EMERGENCY

Clinical Features

Severe rigors, high fever or hypothermia, rapid-onset shock, hypotension — most common with platelets (room temperature storage); rare with PRBCs

Management

STOP transfusion; return bag to blood bank immediately for culture; blood cultures × 2 sets from patient; broad-spectrum IV antibiotics; fluid resuscitation; ICU; sepsis protocol activation

Reaction Management Flowchart

Patient reports symptoms OR vital sign alert threshold triggered

STOP TRANSFUSION IMMEDIATELY — clamp blood line

Keep IV patent — flush with 0.9% NaCl via new administration set

Assess patient: A–B–C, full vital signs, symptoms history

Notify medical officer — urgent if systemic / life-threatening

Collect bloods if indicated: FBC, crossmatch, DAT, cultures; return blood bag to blood bank with completed reaction form

Treat per reaction type (see above) — complete haemovigilance incident report

🔎 Symptom-Based Reaction Identifier

Select all symptoms present — tool will suggest likely reaction type

Fever / Temp rise

Rigors / Chills

Loin / Back pain

Red/brown urine

Urticaria / Rash

Pruritis / Itch

Bronchospasm / Wheeze

Hypotension

Hypertension

Dyspnoea

Pulmonary oedema

Severe hypoxia

Shock (rapid onset)

Select symptoms above to identify likely reaction type.

Massive Transfusion Protocol (MTP)

MTP Activation Triggers

Criterion	Definition
Volume criterion	>10 units PRBC transfused in 24 hours, or >4 units in 1 hour
Haemodynamic	Ongoing haemorrhage with systolic BP <90 mmHg despite initial resuscitation
Clinical assessment	Surgeon/anaesthetist anticipates massive ongoing haemorrhage (trauma, PPH, GI bleed, surgical)
ABC Score	Assessment of Blood Consumption score ≥2 (commonly used in trauma)

Damage Control Resuscitation — 1:1:1 Ratio

PRBC

FFP

Platelets

Damage control resuscitation for haemorrhagic shock — evidence-based for trauma contexts

Hypocalcaemia During Massive Transfusion

Blood products are preserved with citrate, which chelates (binds) ionised calcium. During rapid or massive transfusion, citrate load can cause symptomatic hypocalcaemia. Monitor ionised calcium. Treat with: Calcium Chloride 1g IV (10 mL of 10%) — preferred in cardiac arrest; or Calcium Gluconate 10 mL of 10% IV — preferred for peripheral access (less irritant). Repeat as required guided by ionised calcium levels.

The Lethal Triad — Recognise and Prevent

In massive haemorrhage: Hypothermia + Acidosis + Coagulopathy = lethal triad. Use blood warmers, correct metabolic acidosis (treat source of bleeding), transfuse FFP and platelets early. Avoid dilutional coagulopathy from excessive crystalloid use.

Autologous Transfusion Options

Alternatives to Allogeneic Blood

Cell Salvage (Intra-op)

Blood lost during surgery is collected, washed, and reinfused. Used in cardiac, vascular, orthopaedic surgery. Reduces allogeneic blood exposure.

Pre-op Autologous Donation

Patient donates own blood weeks before elective surgery. Stored and returned if needed. Less common now due to logistics.

Erythropoietin (EPO)

Pre-operative EPO + iron supplementation to stimulate RBC production. Used for Jehovah's Witnesses and anaemia optimisation pre-surgery.

Acute Normovolaemic Haemodilution

Blood drawn immediately pre-op, replaced with crystalloid/colloid; own blood re-transfused if needed during/after surgery.

Documentation Requirements

Mandatory Transfusion Records

Blood product type (PRBC / FFP / Platelets etc.)
Donation unit number (from blood bag label)
Volume transfused (mL)
Date and exact start time
Date and exact finish time
All vital sign observations (baseline, 15 min, hourly, post)
Patient response to transfusion
Any adverse reactions and actions taken
Names and signatures of administering nurse and second-check nurse
Medical officer who authorised / was notified
Cumulative units received in this admission (for MTP tracking)

GCC Blood Bank — Key Contact Information

Service	Expected Timeframe	Notes
Routine type & screen	30–60 minutes	Non-urgent, advance planning
Standard crossmatch	45–60 minutes	For elective transfusions
Emergency crossmatch	15–20 minutes	Urgent — call blood bank directly, provide patient ID
Emergency uncrossmatched blood	Immediate (stock)	O-negative PRBC; for life-threatening haemorrhage pending crossmatch
MTP Pack activation	10–15 minutes (first pack)	Contact blood bank to activate MTP; specify PRBC:FFP:Platelets ratio required
Platelets	30–60 minutes	May need to order from national blood services if not in stock

Note: Post blood bank number for your unit prominently at the nursing station. In many GCC hospitals the blood bank is available 24/7 for emergency requests. Confirm local extension numbers during orientation.

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