Blood Transfusion during Dialysis - page 2

I am employed in the Quality department of an LTAC. We use contract dialysis nurses to come in and perform dialysis on our patients. I am reading through a chart today and I find out that she infused 2 units of blood in less than... Read More

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    with ESRD , a BNP that elevated, and the +4 edema who's to say the patient wasn't heading towards respiratory failure secondary to the CHF anyway. The interventions easily could of had nothing to do with it, and I doubt the volume of 2 units set her into it. This sounds like a chronic problem, that if anything has been undermanaged over a long period of time.

    As for the missing documentation, I would document that it is indeed missing from the chart, and make every effort to locate the notes, and/or the person responsible for it. I hope that is a regular thing

    Sounds like a sick patient, and she can thankful she survived the failure if it was her wish to do so. Off the cuff remarks like the one in your post, detour actually qualified from wanting to contribute to your research if that is your intention. Lets keep it professional and respectful.

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    I'm also a former dialysis nurse. As pp have said, blood can be given much faster on dialysis than via peripheral IV; however, I would try to give it over 30-45 min per unit, as a typical dialysis tx lasts at least 3 hours (it may be less in acutes, but rarely < 2 hours); but this doesn't mean it can't be given faster, as per the dialysis provider's protocol.

    Lasix is usually not given to ESRD pts as the dialysis machine will take off excess fluid as programmed. In acutes (i.e., your setting) the nephrologist often determines the fluid removal goal, which will be part of the dialysis orders in the chart (or it may be something like "as tolerated"). Dialysis nurses (should) know to account for the fluid of the blood product by adding it to this goal; of course, if the pt is highly unstable during tx then no fluid may be removed and sometimes more has to be given (as NS) than can be removed; the tx sheet (which is apparently missing) should state this.

    There should be a tx sheet; the acute/contract nurse has to provide a copy to his/her employer, and the original stays in the pt's chart. If you don't have it, you should be able to obtain it from the dialysis company.

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    I've been an Acute Dialysis Nurse for 5 years, and also work in Critical Care. We do it all the time. I've given 2 units in about that timeframe, but only if the Hct is low, the lungs are clear, and I know the pt is going to tolerate a decent ultrafiltration. Lasix isn't going to do squat with ESRD, and is not a predictable outcome anyway. UF is far more fast and effective and is controlable by the RN. I'm concerned about the lack of documentation, but acute charting is a little crazy. Maybe it's all there but you don't know how to interpret the chart. Call them and ask. Acute dialysis nurses generalyl have a diverse autonomy and our nephrologists tend to give us a wide parameter within which to use our judgement.
    Thomas RN likes this.
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    Thank you so much for the information! I appreciate all of you!
    Just to clarify a few things. . .
    There are MANY discrepancies in the charting (I do know how to interpret the chart with the exception of the dialysis information I asked for in this forum). The patient was admitted and on day 3 received a Quinten cath and PICC line. It appears from the chart that the patient was dialized daily (for 2-3 hours) x4 days then it was ordered every other day. I agree that the Lasix wouldn't be expected to do much for an ESRD patient but if there is NO documentation on output after a foley was placed. This patient's diagnosis was ARF. My question was directed at dialysis nurses and whether they are comfortable giving what is essentially a blood bolus of 2 units in about 30 minutes. What I am reading is that during dialysis is the time to do it. I can accept that. I just needed clarification so I could wrap my mind around the situation. Again, I am NOT a dialysis nurse and I needed the standards from someone who specializes in dialysis. I thought about the BNP and whether it would be accurate in someone suffering ARF. I will have to further research those numbers.
    I received a call last night from the nurse manager that this particular dialysis nurse came back to dialize another patient the same night and they ended up coding the second patient as well. That is another chart I will have to research and I HOPE the documentation is there and complete. I don't have documentation of an assessment to tell me if the patient's lungs were clear or not. Her chest x-ray from the day before states there was "consolidation" in bilat lower lobes. I intend to dig deeper today and I intend to contact the dialysis agency to gather some information there as well. One of the things I will ask for is their P&P on transfusing during dialysis.
    My comment "sucking on a vent" was not intended to offend anyone, it was meant to stress that if in fact this patient is on a vent related to poor nursing judgement, then my researching these charts MUST be done thoroughly and fully. I am sorry if I offended anyone.
    My concern is, I found NO documentation from the dialysis nurse for any of the previous dialysis sessions. I have to investigate if her protocol states that their documentation goes back to their agency or stays with us. There are NO records accounting for the time spent with the dialysis nurse. I will again go thru the chart today to confirm that they are not there.
    I am NOT interested in taking anyone down or making a nurse stand trial. What I am interested in is changing processes that could possibly prevent this from happening in the future. . .if possible. I am not even sure if there was any wrong-doing.
    I agree that there is no way to tell if this patient wouldn't have coded regardless of dialysis and that is why I am here asking questions. I really appreciate everyone's time and attention. I will check back often to consider everyone's input.
    Have a wonderful day and thank you all!
    Last edit by Biggirl71 on Jun 24, '11
    DeLana_RN likes this.
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    Hemodialysis is where the blood of the patient is circulated or flow through a dialysis machine. The patient needs some sessions per week for the dialysis to be adequate. The filter removes the toxic chemical and extra water that usually accumulates in a patient with kidney failure. The blood must be easily taken out from the body and given back to the patient for this technique to be successful.
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    It seems that you shouldn't be reviewing a chart where the main point of interest is the dialysis, seeing as you are not familiar with the procedure. Can you pass it off to someone that is familiar?
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    Quote from Biggirl71
    Thank you so much for the information! I appreciate all of you!
    Just to clarify a few things. . .
    There are MANY discrepancies in the charting (I do know how to interpret the chart with the exception of the dialysis information I asked for in this forum).


    I received a call last night from the nurse manager that this particular dialysis nurse came back to dialize another patient the same night and they ended up coding the second patient as well. That is another chart I will have to research and I HOPE the documentation is there and complete.
    I think you will know a lot more once you review the second chart. And if there is no documentation there as well, something strange is going on. Since these were your hospital's pts, at least a copy (in our case, it was always the original) of the tx sheet should be in your chart (we filed under "nurses' notes").

    As with anything else, not every nurse doing acute dialysis is competent to do so (the outpt clinic I used to work at once forced the RNs to take acute call, which is not something some of them felt comfortable doing; but they had to, or risk losing their jobs); I'm not implying that this is the case here, but it has me concerned that both pts coded after tx. Acute pts can be unstable, of course, and it could be a coincidence, but....

    Even if you're not a dialysis nurse, some things are pretty basic here and should raise concern, including that there is no documentation for a medical procedure prerformed, which is really strange for any specialty area (in house it might be on the computer, but contractors should provide a paper copy if they don't use your computer system).

    Last edit by DeLana_RN on Jun 24, '11
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    OK, I am happy to report that the dialysis notes were located by medical records and I am so happy the nurse was meticulous in her documentation. The report from the day the pt. coded, the nurse documented that the physician gave an order to infuse the blood "wide open" to bring the blood pressure up from 50/30. I agree that this pt.'s condition was precarious prior to dialysis and the code could have happened regardless of dialysis. The second patient she took care of was NOT coded but sent out emergently related to SOB. All vital signs except the O2 sat (88%) were stable. The physician ordered a STAT CT to r/o PE and our facility could not complete that fast enough so the pt. was sent to a facility that could perform the CT STAT as ordered. The pt. did in fact have a PE and stayed in the hospital for 7 days to resolve the issue. The nurse did nothing wrong and as a matter of fact, followed all protocols and procedures. Thank you all for your time and attention to my questions/concerns. All of you got me thinking outside of my usual ways. These incidents just go to show that situations are not always as they first appear, I am happy to report! Thank you again and I will bring future concerns here as they arise.
    NRSKarenRN and GrnTea like this.
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    I forgot to add that this Quality gig is new for me. I have spent my career in Management/Supervisory positions and I have dealt with nursing issues all along. However, working in the Quality department is a different animal all together. Out of this investigation, I yielded information on how to better design the nurse's notes. There is a section (basically a check-off) that addresses "edema." This section does not allow the nurse to indicate where the edema is but all of the nurses documented 4+. So I took my concern to the Director of Clinical Services and she is going to redesign the nurse's note. Another positive result of this investigation is that the DCS will do teaching to the nurses about the importance of accurately documenting I&O on renal patients (actually every patient) but especially real patients.
    Thank you all again! Have a great day!
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    Better indicator for dialysis patients + those with CHF rather than Intake/Output is daily weight looking for wt gain over 2 lbs/day or 5lb/wk.
    Last edit by NRSKarenRN on Jul 6, '11
    highlandlass1592 likes this.

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