Quote from 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. . .
If you are doing a root cause analysis you have to look at the communication here:
1. What were the dialysis orders? Even if the nurse notes are missing there should be a dialysis orders which state what the goal dialysis was. Are these consistent with someone in heart failure?
2. Did the providers at the LTAC communicate the worsening volume overload in the patient? or did the nephrology providers examine the patient before the dialysis run and appreciate the volume overload?
3. Was the patient on EPO or something similar which would have alleviated the need for blood (i'm assuming someone was shooting for the standard Hgb> 11 for dialysis patients.
4. What was the indication for dialysis? What stage renal failure? Was this an inability to concentrate or complete renal failure with an inability to maintain electrolytes?
Basically its perfectly reasonable to run in two units of blood in half an hour on dialysis. If you look at it in terms of blood flow on HD (350-500 ccs/min) two units of blood are really a drop in the bucket and will be rapidly diluted (for disclosure purposes I work in an ICU an we usually do CVVH or CVVHD). If you look at it another way a dialysis run is usually three hours. At two hours for a unit you could at best get in one unit. For that matter I don't even know if you could run it in that slow. Dialysate runs at 500-800 ccs per minute and the HD runs a little slower. You are moving huge volumes of fluid, it doesn't really lend itself to running things in slow. In the ICU We will frequently run a liter in over 1-2 minutes off the CRRT when we are short on access when someone is in shock. Works great.
The real issue is how much were they supposed to take off and was that target achieved? Also was the blood ordered by the LTAC team and nephrology didn't account for it? Usually when we give blood during dialysis we add that amount to the target so the total run is dialysis target + Blood. It would be unusual for someone that brittle to be outside an ICU but it happens.
Bottom line you should have the nurses notes. Not having them in the chart is not acceptable. On the other hand its unlikely that the sole reason your patient is on the vent is because of the blood (or whether its even a factor). What probably happened is that the patients volume status worsened and this wasn't communicated to nephrology or nephrology failed to appreciate the volume overload when they examined the patient. There are lots of reason that patient could have worsening volume status including worsening/poorly treated CHF, poor fluid restriction in PO patients, worsening renal failure not appreciated by nephrology etc.
Your focusing on the two units of blood and the time which is irrelevant. You need to look at the global picture and figure out why the patients CHF worsened and whether it was adequately treated.