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Blood Administration
Reference: http://rnbob.tripod.com/blood.htm

1.   Only two units per filter.
2.   Verify units.
3.   Use within four hours after removal from blood bank.
4.   Use 20 ga. or larger catheter.
5.   Obtain Informed consent.
6.   PRBC replaces RBCs only.
7.   If more than 6-8 units of PRBC are given then give FFP with every other unit.
8.   Give platelets one for every unit of PRBC after eight units.

ESSENTIAL INFORMATION:

1. Clinical Pathology and Transfusion Medicine Guide
2. Nursing Department Policy: Infusion of Blood and Blood Components.
3. Department of Transfusion Medicine (DTM) Procedure: Infusion of Non-cryopreserved Cellular
   Components.
4. Circular of Information For the Use of Human Blood and Blood Components, American Association of
   Blood Banks. July 1998 (Distributed by DTM)

EQUIPMENT:


                       STEPS                                            KEY POINTS

Verify physician order for type and crossmatch


Draw blood sample for crossmatching

                       Place patient labels on large red top tube
                       Patient label includes patient name and
                       hospital ID#.

                       Use a ballpoint pen and press hard when       Blood samples, which are missing any
                       writing: patient name, ID#, date              of this information, are rejected. A
                       specimen collected, and initials of person    new sample will then need to be
                       collecting specimen.                          drawn and properly labeled.

                       Identify the patient using at least 2 forms   The major cause of acute transfusion-
                       of identification, ex., hospital              related death is error in identification.
                       identification bracelet, MAS data, asking     Patient identification is the most
                       the patient to state his/her name. Or the     important step in the transfusion
                       new picture hospital card. Sign blood         procedure.
                       product request form indicating you
                       verified patient Identification.

                       Collect blood specimen in large red top       To prevent hemolysis of the blood
                       tube. If venipuncture required, use 20        sample, a 22 gauge needle or larger
                       gauge needle or larger for adults and a       should be used to obtain the blood
                       22 or 23 gauge needle for children.           sample. The minimum sample volume
                                                                     needed is 8 ml. Will have to draw one
                                                                     tube for each two units.

                       Keep in mind the expiration dates of          The crossmatch sample expires on
crosmatches for most hospitals.                 11:59 p.m. on the third day after the
                                                                    day it is drawn, i.e. a sample drawn
                                                                    anytime Tuesday the 23rd, will expire
                                                                    at 11:59 p.m. on Friday the 26th.

Blood Transfusion Preparation – Verify Order for Blood Product, Identification & Consent

                    Check physician’s order to determine:           Allow 30 – 60 minutes for oral
                       a. product to be administered                medications, 10 minutes for IV
                       b. number of units or volume to be           medications to become effective.
                          administered
                       c. date to be administered
                       d. special processing
                       e. duration of infusion
                       f. pre-medication orders, if indicated

                    For whole blood, red blood cells or
                    granulocytes, verify in the computer or
                    with the blood bank.results of:
                        a. blood grouping
                        b. Rh type
                        c. number of units crossmatched
                        d. number of units set up

                    Verify informed consent has been                Consent required for ALL blood
                    obtained and signed in the past year,           products.
                    except for emergency transfusions.

                    Ensure the inpatient is wearing hospital        Required for ALL blood products.
                    ID bracelet. Ask lucid patients to state full
                    name and date of birth. If not lucid, ask
                    responsible visitor.

Establish Line & Check Client’s VS

                    Establish or verify patency of peripheral       When infusion pump is used, 20
                    or central venous access device.                gauge needle or larger is
                                                                    recommended to prevent lysis of red
                                                                    blood cells. 23-gauge needle can be
                                                                    used for transfusing pediatric
                                                                    patients.

                    Obtain and record patient’s baseline            Febrile patients destroy cells
                    vital signs. Conduct patient teaching and       rapidly. If febrile, notify physician to
                    alert staff to the following symptoms:          decide if transfusion can wait or if
                       • Chest pain.                                patient should receive acetaminophen
                       • Flushing.                                  as a pre- medication.
                       • Shivering.
                       • Abdominal discomfort.
                       • Rashes.
                       • Shortness of breath.
                       • Pain in the loins or extremities.
                       • Blood in urine.
                       • A feeling of restlessness or anxiety.
                       • Feeling generally unwell

Pick up Blood from Blood Bank
When the patient is ready to be               There should be a four hour time
transfused, take pick up slip to blood        lapse between completing infusion of
bank to obtain blood.                         Amphotericin and beginning
                                              transfusion of granulocytes or vice
                                              versa. It is advisable that all other
                                              blood products be separated from
                                              Amphotericin by two hours. Blood
                                              products must be hung within 30
                                              minutes of leaving the Blood Bank
                                              refrigerator. The Blood Bank will
                                              usually only release one blood
                                              product at a time. However, with
                                              physician phone call multiple units
                                              may be issued during an emergency.
                                              Blood products MUST NEVER be
                                              placed in the refrigerator on the
                                              patient care unit.

Check the appearance of unit for              If appearance is suspicious, return it
presence of clots, brown discoloration,       to Blood Bank, as it may not be
clumps or abnormal cloudiness, and            appropriate for infusion.
integrity of seals.
                                              Warming is not normally necessary
                                              and blood components should never
                                              be put in a bowl of warm water, on a
                                              radiator or in a microwave oven: this
                                              is dangerous, as it will damage the
                                              cells.


Two qualified health professionals trained    All three records must correspond
in blood administration procedures            exactly.
compare:                                      All identification attached to the
    a. Blood product received on the unit     container must remain attached until
       to product requested in the            the transfusion has been terminated.
       medical order.
    b. Blood type and Rh type recorded
       in computer with the container
       bag and container label ensuring
       that they are either identical or
       compatible.
    c. The blood product number on the
       blood container with the product
       number on the blood container
       tag.
    d. Compare the expiration date and
       time, if present, on the blood
       container label to the current date
       and time.

Immediately before the transfusion,           The major cause of acute transfusion-
in the presence of the recipient, two         related death is error in identification.
qualified health professionals identify the   Proper patient and unit identification
patient using at least 2 forms of             is one of the most important steps in
identification:                               the transfusion process. If any
    a. Verify the patient’s name and          discrepancy is noted, notify Blood
        medical record number on the          Bank at once and return the blood
        blood unit with the information on    product until the discrepancy is
the recipient’s identification        resolved.
                            bracelet and the information
                            recorded in the patient record.       Identify patients with patient hospital
                         b. Ask the patient to state his/her      ID band or hospital label and ask the
                            name.                                 patient to state their name. Correlate
                         c. Verify the information on the         this information with blood
                            patient wristband and blood unit.     component’s tag.

Start the Infusion Set

                     Prime the administration set with the        Use of other IV solutions damages
                     blood product or 0.9% Sodium Chloride.       blood components.
                         a. Add a three-way stopcock onto the     During a reaction, 0.9% Sodium
                            end of the blood administration       Chloride may be administered
                            set. Have 0.9% Sodium Chloride        through the stopcock without infusing
                            solution and IV tubing unopened       the additional blood product in the
                            and available in room for             tubing
                            emergency use or attached to          Leukocyte depletion filter may be
                            stopcock.                             used to prevent repeat febrile
                         b. If a leukocyte-depletion filter is    reactions, decrease the risk of CMV
                            indicated, follow the                 transmission, and decrease the risk
                            manufacturer’s and blood Bank         of alloimmunization. Do not flush
                            instructions for set up.              filter with saline. Leukocyte
                                                                  depletion filters are not to be
                                                                  used when administering
                                                                  granulocytes.

                     Connect the blood administration set to      During a blood transfusion, it is
                     the IV extension set either directly or      recommended that no intravenous
                     through the intermittent infusion cap via    drugs are added to the same cannula
                     needleless system.                           or giving set, because of the risk of
                                                                  interactions


                     Adjust the rate of flow for first few            .
                     minutes                                      A volumetric infusion pump may be
                     For adults:                                  used to administer blood products.
                         • Platelets or plasma - 2-5              Symptoms of an immediate adverse
                            cc/min for 5 minutes                  reaction are usually manifested
                         • Whole blood, RBC or                    during infusion of the initial 50 cc. If
                            granulocytes - 2cc/min for 15         an incompatible transfusion is
                            minutes                               terminated early, acute renal necrosis
                     Patient should be observed closely for the   and death may be prevented.
                     first 15 minutes.
                                                                  For pediatric patients, volume of
                     For pediatric patients:                      blood products (excluding
                        • transfuse 5% of the total volume        granulocytes) to be transfused should
                           ordered in the first five minutes      be ordered based on the child’s
                           of platelet or plasma infusion         weight, i.e. 10 - 15 ml/kg.
                        • first 15 minutes of whole blood,
                           RBC’s or granulocyte infusion.

                     Remain with the patient for the first 15
                     minutes after the start of the infusion.

Monitoring for Adverse Reaction

                     At the end of the first 15 minutes,          The desirable rate of infusion
obtain and record TPR and BP. If vital       depends upon patient’s blood volume,
                    signs are within normal range and the        cardiac status, and hemodynamic
                    patient has no signs/symptoms of an          condition. Suggested rates for adults
                    adverse reaction, change the rate to         are:
                    infuse the unit within the time period       PRBCs: 100-230 cc/hr
                    specified in the physician’s order.          Granulocytes: 75-100 cc/hr
                                                                 Plasma/platelets: 200 – 300 cc/hr
                                                                 The volume of a plateletpheresis bag
                                                                 varies from 120 cc to 400 cc. The
                                                                 entire platelet product should be
                                                                 given within one hour, if possible.

                    Continue to monitor the patient for signs        .
                    and symptoms of adverse reaction during      Adverse transfusion reactions can
                    transfusion and 1 hour post- transfusion.    occur anytime during or after the
                    If patient experiences a transfusion         transfusion.
                    reaction while transfusion is in progress,   For treatment of adverse transfusion
                    immediately stop the transfusion.            reactions: see Clinical Pathology and
                    Maintain patency of line with normal         Transfusion Medicine Guide quot;Adverse
                    saline and notify MD.                        Reactions to Transfusionsquot;.

                    Complete transfusion as ordered not to       Increased possibility of contamination
                    exceed four hours.                           and decreased viability of cells if
                                                                 prolonged.
                    Tubing sets can be used for second
                    unit of blood if used within four hours.     As there is a possibility of delayed
                                                                 transfusion reactions, some hospitals
                                                                 require empty transfusion packs to be
                                                                 kept to enable testing if required.
                                                                 Packs should only be stored for the
                                                                 required time as they are a source of
                                                                 infection in themselves if left for
                                                                 extended periods.

                    At the conclusion of a blood product         Do not flush leukocyte filters with
                    transfusion in which no adverse reaction     saline.
                    occurred:
                        a. Obtain 10 - 60 minute post
                           transfusion CBC for post-count as
                           indicated.
                        b. Flush the blood administration set
                           with 0.9% Sodium Chloride until
                           the tubing is clear.
                        c. Obtain and record vital signs.
                        d. Disconnect and discard the empty
                           blood product container in a
                           contamination red bag.




Adverse Reactions

Pyrexia A temperature of more than 38 C might be due to:
   • n Pyrogens resulting from bacterial contamination.
   • n Reaction to white cells or platelets which can
   • also be accompanied by chills or rigors.
   • n Haemolytic blood reaction (see below).
The appropriate action is to stop the transfusion and to seek medical advice.
Allergic reaction Allergic reactions can present as an urticarial rash or a mild pyrexia. This can also
develop into oedema around the eyes or larynx and cause dyspnoea. Full anaphylaxis is uncommon. The
appropriate action is to stop the
transfusion and to seek medical advice. (Subsequent transfusions might require pre-medication with a
prescription for an antihistamine and paracetamol.)

Infection Although donated blood is screened for major viruses and bacteria (including HIV, hepatitis B,
hepatitis C and syphilis), infections, although very rare, do occasionally occur. Much more common,
however, is local phlebitis which
occurs if a cannula remains in situ for too long: the most commonly isolated bacteria are staphylococci
or corynebacteria. Platelets are stored at room temperature and so can act as an ideal medium for
bacterial growth. The appropriate action is to check cannula insertion sites regularly for inflammation and
infection, and to change the insertion site routinely every 72 hours. When using platelets, bags should be
checked for discolouration, which may indicate the presence of bacteria.

Haemolytic reaction A haemolytic reaction is caused by destruction of the donor red blood cells by
antibodies in the recipient’s plasma. It can occur after only a few millilitres of blood are transfused,
although a delayed reaction can occur up to two hours later. Haemolytic reactions can be fatal and as
such, a suspected haemolytic reaction must always be responded to as a medical emergency. A
haemolytic reaction is indicated by:
    • Breathlessness.
    • Collapse.
    • Tachycardia.
    • Hypertension followed by hypotension.
    • Chest or loin pain.
    • Subsequently, the patient might develop:
    • Disseminated intravascular coagulation (DIC).
    • Circulatory and respiratory failure.
    • Renal failure.

The appropriate actions are:
   1. stop the transfusion
   2. disconnect the pack and giving set
   3. maintain the intravenous line with normal saline
   4. seek urgent medical advice.

This is an emergency, life-threatening situation. Haemolytic reaction is most likely to be due to a patient
receiving the wrong blood from one or more errors in the chain of events from taking a cross-match
sample, the laboratory processes, the collection of blood for transfusion and administration into the
recipient. All blood must be returned to the blood bank and an investigation must be carried out to
ascertain the source(s) of the error.

Circulatory overload Circulatory overload causes less of a problem now that concentrated red cells are
used more frequently than whole blood. Problems can occur with older people, neonates or patients with
megaloblastic anaemia.
The action to take is to give diuretic therapy as prescribed, slow the rate of transfusion and observe
closely for pulmonary and peripheral oedema.

Iron overload Patients who receive multiple transfusions have an increased serum ferritin. At a level
greater than 1,000mg per litre, the iron infiltrates organs such as the liver, heart and kidneys, which can
lead to organ failure or even
be fatal. In patients on multiple transfusion programmes, an iron chelater such as desferrioxamine can be
prescribed to regulate the level of serum ferritin.

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Blood Administration

  • 1. Blood Administration Reference: http://rnbob.tripod.com/blood.htm 1. Only two units per filter. 2. Verify units. 3. Use within four hours after removal from blood bank. 4. Use 20 ga. or larger catheter. 5. Obtain Informed consent. 6. PRBC replaces RBCs only. 7. If more than 6-8 units of PRBC are given then give FFP with every other unit. 8. Give platelets one for every unit of PRBC after eight units. ESSENTIAL INFORMATION: 1. Clinical Pathology and Transfusion Medicine Guide 2. Nursing Department Policy: Infusion of Blood and Blood Components. 3. Department of Transfusion Medicine (DTM) Procedure: Infusion of Non-cryopreserved Cellular Components. 4. Circular of Information For the Use of Human Blood and Blood Components, American Association of Blood Banks. July 1998 (Distributed by DTM) EQUIPMENT: STEPS KEY POINTS Verify physician order for type and crossmatch Draw blood sample for crossmatching Place patient labels on large red top tube Patient label includes patient name and hospital ID#. Use a ballpoint pen and press hard when Blood samples, which are missing any writing: patient name, ID#, date of this information, are rejected. A specimen collected, and initials of person new sample will then need to be collecting specimen. drawn and properly labeled. Identify the patient using at least 2 forms The major cause of acute transfusion- of identification, ex., hospital related death is error in identification. identification bracelet, MAS data, asking Patient identification is the most the patient to state his/her name. Or the important step in the transfusion new picture hospital card. Sign blood procedure. product request form indicating you verified patient Identification. Collect blood specimen in large red top To prevent hemolysis of the blood tube. If venipuncture required, use 20 sample, a 22 gauge needle or larger gauge needle or larger for adults and a should be used to obtain the blood 22 or 23 gauge needle for children. sample. The minimum sample volume needed is 8 ml. Will have to draw one tube for each two units. Keep in mind the expiration dates of The crossmatch sample expires on
  • 2. crosmatches for most hospitals. 11:59 p.m. on the third day after the day it is drawn, i.e. a sample drawn anytime Tuesday the 23rd, will expire at 11:59 p.m. on Friday the 26th. Blood Transfusion Preparation – Verify Order for Blood Product, Identification & Consent Check physician’s order to determine: Allow 30 – 60 minutes for oral a. product to be administered medications, 10 minutes for IV b. number of units or volume to be medications to become effective. administered c. date to be administered d. special processing e. duration of infusion f. pre-medication orders, if indicated For whole blood, red blood cells or granulocytes, verify in the computer or with the blood bank.results of: a. blood grouping b. Rh type c. number of units crossmatched d. number of units set up Verify informed consent has been Consent required for ALL blood obtained and signed in the past year, products. except for emergency transfusions. Ensure the inpatient is wearing hospital Required for ALL blood products. ID bracelet. Ask lucid patients to state full name and date of birth. If not lucid, ask responsible visitor. Establish Line & Check Client’s VS Establish or verify patency of peripheral When infusion pump is used, 20 or central venous access device. gauge needle or larger is recommended to prevent lysis of red blood cells. 23-gauge needle can be used for transfusing pediatric patients. Obtain and record patient’s baseline Febrile patients destroy cells vital signs. Conduct patient teaching and rapidly. If febrile, notify physician to alert staff to the following symptoms: decide if transfusion can wait or if • Chest pain. patient should receive acetaminophen • Flushing. as a pre- medication. • Shivering. • Abdominal discomfort. • Rashes. • Shortness of breath. • Pain in the loins or extremities. • Blood in urine. • A feeling of restlessness or anxiety. • Feeling generally unwell Pick up Blood from Blood Bank
  • 3. When the patient is ready to be There should be a four hour time transfused, take pick up slip to blood lapse between completing infusion of bank to obtain blood. Amphotericin and beginning transfusion of granulocytes or vice versa. It is advisable that all other blood products be separated from Amphotericin by two hours. Blood products must be hung within 30 minutes of leaving the Blood Bank refrigerator. The Blood Bank will usually only release one blood product at a time. However, with physician phone call multiple units may be issued during an emergency. Blood products MUST NEVER be placed in the refrigerator on the patient care unit. Check the appearance of unit for If appearance is suspicious, return it presence of clots, brown discoloration, to Blood Bank, as it may not be clumps or abnormal cloudiness, and appropriate for infusion. integrity of seals. Warming is not normally necessary and blood components should never be put in a bowl of warm water, on a radiator or in a microwave oven: this is dangerous, as it will damage the cells. Two qualified health professionals trained All three records must correspond in blood administration procedures exactly. compare: All identification attached to the a. Blood product received on the unit container must remain attached until to product requested in the the transfusion has been terminated. medical order. b. Blood type and Rh type recorded in computer with the container bag and container label ensuring that they are either identical or compatible. c. The blood product number on the blood container with the product number on the blood container tag. d. Compare the expiration date and time, if present, on the blood container label to the current date and time. Immediately before the transfusion, The major cause of acute transfusion- in the presence of the recipient, two related death is error in identification. qualified health professionals identify the Proper patient and unit identification patient using at least 2 forms of is one of the most important steps in identification: the transfusion process. If any a. Verify the patient’s name and discrepancy is noted, notify Blood medical record number on the Bank at once and return the blood blood unit with the information on product until the discrepancy is
  • 4. the recipient’s identification resolved. bracelet and the information recorded in the patient record. Identify patients with patient hospital b. Ask the patient to state his/her ID band or hospital label and ask the name. patient to state their name. Correlate c. Verify the information on the this information with blood patient wristband and blood unit. component’s tag. Start the Infusion Set Prime the administration set with the Use of other IV solutions damages blood product or 0.9% Sodium Chloride. blood components. a. Add a three-way stopcock onto the During a reaction, 0.9% Sodium end of the blood administration Chloride may be administered set. Have 0.9% Sodium Chloride through the stopcock without infusing solution and IV tubing unopened the additional blood product in the and available in room for tubing emergency use or attached to Leukocyte depletion filter may be stopcock. used to prevent repeat febrile b. If a leukocyte-depletion filter is reactions, decrease the risk of CMV indicated, follow the transmission, and decrease the risk manufacturer’s and blood Bank of alloimmunization. Do not flush instructions for set up. filter with saline. Leukocyte depletion filters are not to be used when administering granulocytes. Connect the blood administration set to During a blood transfusion, it is the IV extension set either directly or recommended that no intravenous through the intermittent infusion cap via drugs are added to the same cannula needleless system. or giving set, because of the risk of interactions Adjust the rate of flow for first few . minutes A volumetric infusion pump may be For adults: used to administer blood products. • Platelets or plasma - 2-5 Symptoms of an immediate adverse cc/min for 5 minutes reaction are usually manifested • Whole blood, RBC or during infusion of the initial 50 cc. If granulocytes - 2cc/min for 15 an incompatible transfusion is minutes terminated early, acute renal necrosis Patient should be observed closely for the and death may be prevented. first 15 minutes. For pediatric patients, volume of For pediatric patients: blood products (excluding • transfuse 5% of the total volume granulocytes) to be transfused should ordered in the first five minutes be ordered based on the child’s of platelet or plasma infusion weight, i.e. 10 - 15 ml/kg. • first 15 minutes of whole blood, RBC’s or granulocyte infusion. Remain with the patient for the first 15 minutes after the start of the infusion. Monitoring for Adverse Reaction At the end of the first 15 minutes, The desirable rate of infusion
  • 5. obtain and record TPR and BP. If vital depends upon patient’s blood volume, signs are within normal range and the cardiac status, and hemodynamic patient has no signs/symptoms of an condition. Suggested rates for adults adverse reaction, change the rate to are: infuse the unit within the time period PRBCs: 100-230 cc/hr specified in the physician’s order. Granulocytes: 75-100 cc/hr Plasma/platelets: 200 – 300 cc/hr The volume of a plateletpheresis bag varies from 120 cc to 400 cc. The entire platelet product should be given within one hour, if possible. Continue to monitor the patient for signs . and symptoms of adverse reaction during Adverse transfusion reactions can transfusion and 1 hour post- transfusion. occur anytime during or after the If patient experiences a transfusion transfusion. reaction while transfusion is in progress, For treatment of adverse transfusion immediately stop the transfusion. reactions: see Clinical Pathology and Maintain patency of line with normal Transfusion Medicine Guide quot;Adverse saline and notify MD. Reactions to Transfusionsquot;. Complete transfusion as ordered not to Increased possibility of contamination exceed four hours. and decreased viability of cells if prolonged. Tubing sets can be used for second unit of blood if used within four hours. As there is a possibility of delayed transfusion reactions, some hospitals require empty transfusion packs to be kept to enable testing if required. Packs should only be stored for the required time as they are a source of infection in themselves if left for extended periods. At the conclusion of a blood product Do not flush leukocyte filters with transfusion in which no adverse reaction saline. occurred: a. Obtain 10 - 60 minute post transfusion CBC for post-count as indicated. b. Flush the blood administration set with 0.9% Sodium Chloride until the tubing is clear. c. Obtain and record vital signs. d. Disconnect and discard the empty blood product container in a contamination red bag. Adverse Reactions Pyrexia A temperature of more than 38 C might be due to: • n Pyrogens resulting from bacterial contamination. • n Reaction to white cells or platelets which can • also be accompanied by chills or rigors. • n Haemolytic blood reaction (see below). The appropriate action is to stop the transfusion and to seek medical advice.
  • 6. Allergic reaction Allergic reactions can present as an urticarial rash or a mild pyrexia. This can also develop into oedema around the eyes or larynx and cause dyspnoea. Full anaphylaxis is uncommon. The appropriate action is to stop the transfusion and to seek medical advice. (Subsequent transfusions might require pre-medication with a prescription for an antihistamine and paracetamol.) Infection Although donated blood is screened for major viruses and bacteria (including HIV, hepatitis B, hepatitis C and syphilis), infections, although very rare, do occasionally occur. Much more common, however, is local phlebitis which occurs if a cannula remains in situ for too long: the most commonly isolated bacteria are staphylococci or corynebacteria. Platelets are stored at room temperature and so can act as an ideal medium for bacterial growth. The appropriate action is to check cannula insertion sites regularly for inflammation and infection, and to change the insertion site routinely every 72 hours. When using platelets, bags should be checked for discolouration, which may indicate the presence of bacteria. Haemolytic reaction A haemolytic reaction is caused by destruction of the donor red blood cells by antibodies in the recipient’s plasma. It can occur after only a few millilitres of blood are transfused, although a delayed reaction can occur up to two hours later. Haemolytic reactions can be fatal and as such, a suspected haemolytic reaction must always be responded to as a medical emergency. A haemolytic reaction is indicated by: • Breathlessness. • Collapse. • Tachycardia. • Hypertension followed by hypotension. • Chest or loin pain. • Subsequently, the patient might develop: • Disseminated intravascular coagulation (DIC). • Circulatory and respiratory failure. • Renal failure. The appropriate actions are: 1. stop the transfusion 2. disconnect the pack and giving set 3. maintain the intravenous line with normal saline 4. seek urgent medical advice. This is an emergency, life-threatening situation. Haemolytic reaction is most likely to be due to a patient receiving the wrong blood from one or more errors in the chain of events from taking a cross-match sample, the laboratory processes, the collection of blood for transfusion and administration into the recipient. All blood must be returned to the blood bank and an investigation must be carried out to ascertain the source(s) of the error. Circulatory overload Circulatory overload causes less of a problem now that concentrated red cells are used more frequently than whole blood. Problems can occur with older people, neonates or patients with megaloblastic anaemia. The action to take is to give diuretic therapy as prescribed, slow the rate of transfusion and observe closely for pulmonary and peripheral oedema. Iron overload Patients who receive multiple transfusions have an increased serum ferritin. At a level greater than 1,000mg per litre, the iron infiltrates organs such as the liver, heart and kidneys, which can lead to organ failure or even be fatal. In patients on multiple transfusion programmes, an iron chelater such as desferrioxamine can be prescribed to regulate the level of serum ferritin.