Has anyone ever recommended definitive guidelines on blood pressure changes for nursing to follow for a reported transfusion reaction? Standards indicate that changes, usually acute, either hypertensive or hypotensive should be reported. Sometimes changes occur, but nursing has a difficult time making a subjective decision on whether to call.

If anyone has used definitive criteria, what degree of change triggers the call? 30 mm/40 mm? and is diastolic vs. systolic addressed?

In a recent AABB audioconference "Advanced Transfusion Reactions," one of the physician speakers stated that a 15 mm change in diastolic or systolic pressure would be considered significant.

In Quebec, Canada we have provincial definitions for hypotensive and hypertensive transfusion reactions.

Hypotensive Reaction: Systolic arterial pressure less than or equal to 80 mm Hg not explained by another cause.

Hypertensive Reaction:Increase in systolic arterial pressure more than or equal to 30mm Hg and systolic arterial pressure more than or equal to 180 mm Hg when this is the only clinical sysmptom and there is no explaination by another cause.

Our current SOP indicates that a drop of 15 mm in systolic &/or diastolic pressure is considered significant and should be brought to the medical director's attention.