Blood Transfusion during Dialysis

[Biggirl71]

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 a half hour on a patient with a BNP of 1555! Clearly the patient was in CHF. The patient's H&H was 8/25 so there was no need to rush the transfusion. The patient also had 4+ pitting edema of the bilat lower extremities. I am researching the standard for transfusions during dialysis because I don't know what they are. I know as a floor nurse, the standard minimum time for a single unit to infuse is 2 hours but could go as long as 4 hours based on the patients' status. The reason Lasix is ordered between units is to prevent fluid overload. Because this patient is on dialysis, I am not sure how effective the loop diuretic was. . .the nurse did not document her outputs via dialysis or foley! Needless to say, the patient ended up in respiratory failure and fortunately made it through the code. Now she's sucking on a vent. Does anyone have legit info that I can further research? I would like to prevent this from happening in the future. Part of my job is to identify what went wrong and put processes in place that will correct this and keep it from happening again. Thanks. . .

[klm49]

I have been reading the excellent post regarding blood administration and dialysis and thought I would add to it. Before becoming an Acute dialysis nurse I worked nights in ICU. Dialysis was something that happened occasionally during the day but wasn't something I knew well. One thing that I didn't understand well enough in those days was what dialysis could and could not do in terms of fluid balance.

The only fluid that can be removed from a patient is that which is in the Intravascular space or within the blood vessel it's self. A patient may have pitting edema up to their waist and still be intravascularly dry. Many times presents as low B/P, low CVP, tachycardia etc. Patient's will shift fluid into the extravascular space or 3rd space fluid for a variety of reasons. Dialysis can not touch that fluid until the patient shifts it back into blood vessels. Sometimes the Dr will order 25% Albumen, PRBC's, Hypertonic saline etc to help shift that fluid from the extravascular back into intravascular space. These are usually very short term fixes and may exacerbate the existing problem. We will occasionally get orders from non Nephrology services wanting us to dialyze a patient with pleural effusions or increasing acites. I will try, but it's not going to work. The real challenge comes in when the patient is septic on multiple pressors, has a serum Albumen of 1.2, and pitting edema up to the arm pits. Everyone wants dialysis to come in take some of the extra fluid off and "fix them". Without a decent B/P fluid removal or ultrafiltration becomes next to impossible. I keep telling them "give me a B/P and I will be happy to take off fluid." Until that patient has a means of shifting the extra fluid from the tissue back into the blood vessel dialysis can't touch it. I hope this helps someone.

[Gmac]

Good explanation KLM49. In addition to that, If patient is edematous and there is a delay in fluid shift, the intravascular space could dry up and result to hypotension. Another reason is if pt has low albumin level, you will have difficulty of removing fluids without hypotension. The fluid in the intravascular space must have strong osmotic pressure to pull in all the excess fluids in extravascular space. That's the reason why they are giving human Albumin during the first hour of HD. And if there is delay in fluid shift probably you will need to remove fluid slowly and gradually. You could ask the doctor to order to do BVM HD for the Pt. I hope this would help solve your problem. P.S. BVM is Blood Volume Monitoring ( I hope you have that in your place)