19.2 Blood Administration

19.2 Blood Administration

Quick Answer: Transfuse only after informed consent (or a documented emergency exception), baseline vital signs, and two-person bedside identification of the patient and the unit — or a validated electronic identification system. Preferred adult red-cell access is 18–20 gauge; a smaller catheter is acceptable if the infusion is slow. The only fluid that may share the line is 0.9% sodium chloride. Do not use D5W (hypotonic hemolysis) or lactated Ringer’s (calcium; the exam still expects NS only). Hang a 170–260 µm standard blood filter, start promptly, stay for the first 15 minutes, and complete typically within 4 hours. Stop for a suspected reaction (18.1). Rapid infusers and blood warmers must be validated. Do not add medications to the bag. Issue documentation and emergency-release paperwork travel with the unit.

This is June 9, 2026 outline V.E for how a unit is given. Chapter 17 decided whether a unit is indicated. Chapter 18 decides what to do when the patient reacts. This section is the bedside and issue process. If a stem asks two-person ID, NS only, 4 hours, 15 minutes, filter size, needle gauge, warmers, or emergency-release forms, answer it here.

Identify two things: the patient and the unit

Most ABO deaths are still clerical, not serologic. Identification happens at the bedside, not at the nursing station and not from memory. Use two independent identifiers (full name plus medical-record number, or the identifiers your SOP names). A two-person check — the transfusionist plus a second qualified person — compares the patient wristband, the compatibility tag, the unit number, ABO/Rh, expiration, special attributes (irradiated, CMV-safe, HbS-negative, antigen-negative), and the order. A validated electronic positive-patient-ID system (barcode or RFID) may replace the second human if the facility has documented that the system works. Electronic ID is not “we glanced at the pump.”

The same check catches the wrong unit on the right patient and the right unit on the wrong patient. If anything disagrees, do not spike. Return the unit and start over. A historical type in the computer does not replace a wristband that will not scan.

Informed consent is obtained by the authorizing clinician before a non-emergent transfusion. The conversation covers benefits, the major infectious and noninfectious risks, and alternatives — including not transfusing and PBM options (19.3). Consent is not a blood-bank signature on a compatibility tag. In hemorrhage, treat first and document the emergency exception; you do not withhold group O while a family member looks for a pen.

Baseline vital signs (temperature, blood pressure, pulse, respiration, and often oxygen saturation) are recorded before the infusion starts so a later fever or pressure change has a denominator. Inspect the bag for hemolysis, clots, discoloration, or a leaking seal. Do not start a unit that looks wrong.

Access, fluid, and filter

An 18–20 gauge peripheral catheter is preferred for adult red cells because viscosity is high and you may need to increase the rate. A 22–24 gauge catheter is acceptable in children, in adults with poor veins, or when the infusion will be slow. A small needle under pressure is a recipe for mechanical hemolysis (18.2). Platelets and plasma tolerate smaller catheters more easily than packed red cells.

The only solution that may be in the same line is 0.9% sodium chloride, USP. It is isotonic and contains no calcium and no dextrose. D5W is hypotonic relative to red-cell cytoplasm and can hemolyze the unit in the tubing. Lactated Ringer’s contains calcium. Classic teaching — and what BB still expects — is that calcium can overwhelm citrate anticoagulant and clot the bag or the line. Some current literature and later Circular language discuss limited compatibility of LR with certain modern additive-solution red cells in defined conditions. That nuance does not change the exam answer: NS only unless a specifically validated, SOP-approved exception exists. Do not use bacteriostatic saline (benzyl alcohol). Do not piggyback medications, parenteral nutrition, or “just a little” antibiotic into the Y-site while blood is running.

A standard blood-administration set has a 170–260 µm clot screen. That filter is required. It is not a leukoreduction filter (prestorage leukoreduction already happened for most U.S. red cells and platelets) and it is not a 20–40 µm microaggregate filter, which is not routine. Change the set per manufacturer and SOP, typically at least every 4 hours or when it clogs. Do not run five units through a filter full of fibrin and then blame the blood bank for a slow drip.

Time, monitoring, and devices

Issue starts a clock. Begin the transfusion promptly — many facilities use 30 minutes from issue as the “start or return” rule, provided the unit has stayed in a controlled temperature range. Do not park red cells on a windowsill or in an unmonitored ward refrigerator. If the start will be delayed, return the unit while it is still acceptable.

Once spiked, complete the unit typically within 4 hours. The 4-hour window limits bacterial growth in a room-temperature bag. If a patient cannot tolerate the volume that fast, split the unit in the blood bank (aliquots) so each bag still finishes inside 4 hours. Do not “keep it hanging overnight at a keep-open rate.”

Stay with the patient for the first 15 minutes (some SOPs use the first 50 mL) at a slow rate. Most severe hemolytic and anaphylactic reactions declare themselves early. Recheck vitals at 15 minutes, then per SOP, and at completion. Any suspected reaction: stop the transfusion, keep the IV open with 0.9% NaCl through new tubing, and do a bedside clerical check before the blood bank workup starts (18.1).

Blood warmers are indicated for rapid or massive transfusion, exchange transfusion, cold-agglutinin disease, trauma, and many operating-room cases. Use an FDA-cleared, validated warmer. Typical setpoint keeps blood below a device-defined ceiling near 42 °C. Never microwave a unit. Never drop it in an unmonitored sink of hot water. Rapid infusers (Level-1–type pressure/warmer devices, Belmont-type systems) are likewise validated devices, not a pressure cuff cranked on a 22-gauge hand IV. Air embolism and mechanical hemolysis are the device failure modes to respect.

Do not add medications to the bag. No furosemide in the port, no hydrocortisone “to prevent a fever,” no calcium into the red-cell unit. Give drugs in a separate lumen or after the line is flushed with saline. Adding a drug can hemolyze cells, inactivate the drug, contaminate the closed system, and make a reaction investigation uninterpretable.

Issue documentation and emergency release

The issue record is part of the medical and blood-bank record. It includes the unit number and product code, two recipient identifiers, ABO/Rh of unit and patient, compatibility interpretation, special attributes, issue date and time, and who issued and who received the unit. The transfusionist later documents start and stop times, volume infused, vital signs, and whether a reaction occurred. If those fields are blank, you cannot investigate a fatality.

Emergency release is how uncrossmatched group O (or type-specific uncrossmatched, once a current sample has been typed) leaves the refrigerator when delay will harm the patient. The requesting physician accepts responsibility in writing — the signature may be captured as soon as the crisis allows, but the form is not optional. Units are tagged uncrossmatched. The blood bank still performs ABO/Rh, antibody screen, and compatibility testing as soon as a sample exists. If an incompatibility appears, notify immediately. Switch to type-specific after two independent ABO determinations (17.2). Keep O-negative for people with childbearing potential when inventory allows; O-positive is acceptable emergency stock for most men and for women beyond childbearing.

Worked scenario. A floor nurse spikes an AS-RBC unit into a line that still contains D5W “to keep the vein open,” starts the unit 90 minutes after it sat on the counter, and plans to let it run for 6 hours through a 24-gauge catheter with a pressure bag because the patient is a hard stick. Every one of those choices is wrong: flush or change to NS, start promptly or return, finish within 4 hours (aliquot if needed), and do not pressure-infuse through a tiny catheter.

Exam traps. Two-person (or validated electronic) ID is bedside, not at the desk. NS only. D5W hemolyzes; LR is the calcium trap. Filter is 170–260 µm, not a leukocyte filter. 4 hours and first 15 minutes are the timing pair. Warmers are validated, not a microwave. Emergency release still requires paperwork and a completed crossmatch after the fact.