How fast is too fast to transfuse blood?

Nurses General Nursing

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I have been trying to find a clearer answer to my question. I am a new nurse and new to transfusing blood. I know to get the blood in within four hour time period, vitals, priming, etc... My question has to do with rate and size of the patient's IV. I know that preferably we want and 18 or 16 gauge but unfortunately I end up with 22 gauges. I know about watching for first 15 minute blood reactions also. Just safe rate and patient IV size.:confused:

1. Patient IV #18, #20, #22?

2. How fast is too fast?

Specializes in Anesthesia.
"i have never understood the hemolysis issue with 22 ga catheters. has anyone seen the how tiny the hollow fibers are in an artificial kidney??!! much tinier than a 22 ga.

i suppose i should look at the most recent research!"

now, is anyone watching? there's critical thinking for you.

evidence doesn't quite match critical thinking on this one.

the "only use catheters of > xga" is a holdover from the old-wives'-tale school of nursing. thanks for sharing a good bit of reasoning.

transfusion. 2004 mar;44(3):373-81.

transfusions via hand-held syringes and small-gauge needles as risk factors for hyperkalemia.

miller ma, schlueter aj.

source

department of pathology, university of iowa college of medicine, 200 hawkins drive, iowa city, ia 52242, usa.

abstract

background:

pediatric emergency rbc transfusions are often infused rapidly through 22-gauge (ga) or smaller needles or catheters using hand-held syringes. data relating needle size, unit age, and infusion rate are needed to assess the risk of hemolysis and hyperkalemia in this setting.

study design and methods:

multiple simulated transfusions were performed during storage of rbc units. aliquots from five units were rapidly passed through needles (18, 20, 22-25 ga) using a hand-held syringe. resulting plasma hb and k+ concentrations were measured. free hb levels were used as a measure of needle-associated hemolysis (nah).

results:

passage through 18-ga and 20-ga needles caused no hemolysis, but rapid passage through 23-ga, 24-ga, and 25-ga did. rbcs stored less than 7 days showed significant k+ release with 23- to 25-ga needles. the greatest needle-associated k+ release was 10 meq per l, on day 5. due to high k+ concentrations resulting from spontaneous efflux, k+ release from nah was not detectable after 2 or more weeks of storage.

conclusions:

rapidly transfusing rbcs using hand-held syringes through 23-ga or smaller needles can cause hemolysis. in rbcs stored 2 weeks or more, nah does not measurably increase k+ concentrations above that present from storage-related efflux. during rapid transfusions, rbc storage time is the primary risk factor for transfusion-associated hyperkalemia.

pmid: 14996194 [pubmed - indexed for medline]

http://www.ncbi.nlm.nih.gov.lrc1.usuhs.edu/pubmed/11399823 (another study on size, pressure, and hemolysis)

am j perinatol. 1991 jul;8(4):280-3.

impact of venous catheters on packed red blood cells.

oloya ro, feick hj, bozynski me.

source

aultman hospital, canton, ohio.

abstract

this study was designed to test the hypothesis that there would be increased hemolysis, as indicated by an increase in plasma free hemoglobin and potassium, when packed cells were infused through small gauge percutaneous catheters (24 and 28 g, pc) compared with short catheters (24 g; sc). we were unable to study the 28 g pc because after 1 hour, at a flow rate of 10 ml/hr, only 2.4 ml packed cells were infused. there was a significant increase in plasma free hemoglobin when pre- and postinfusion values were compared (sc, p = 0.005; pc, p = 0.009), but a statistically significant increase in potassium only for the sc (p = 0.008). there were no significant differences between the catheters for either potassium or free hemoglobin. for either catheter the quantity of free hemoglobin transfused could potentially cause a significant rise in serum bilirubin and hemoglobinuria.

pmid: 1741874 [pubmed - indexed for medline]

Specializes in ICU, Telemetry.

I've had someone bleeding out from a GI bleed where I had one bag of PRBCs squeezing the life out of it and someone else had another bag in the other arm doing the same thing because our pumps wouldn't go to 999. We got them into the pt in roughly 10 or 15 minutes. Blood was pouring out of her and she went straight to surgery after the OR team got there and had most of her large intestine removed due to diverticulitis. Would I have done that with someone with a BNP of 9000? No, because they'd have probably went into flash edema and died. This woman was losing volume equal to what we were replacing.

Gauge...I try to get the biggest one I can, but the simple truth is, sometimes you are jumping for joy if you get a 24 in a dialysis patient, an IV drug user, or someone who's chronically ill and just doesn't have any veins left. Generally, smaller = slower, bigger = faster, but one of my "tricks" is I run NS thru the IV site at our max (non emergency) infusion rate, which is 150. You can have a good gauge, beautiful vein, you pressurize that vein with a rapid infusion, and it blows. I kick the NS up to 150 and let it run at that rate while I'm getting the consent signed, etc,. before I go get the blood.

Specializes in Pediatrics, ER.

Drawing blood is to gravity, when you've got the added pressure of a pump is when you're really at risk for hemolysis. However, you can get hemolysis when drawing blood out of a 22 gauge, especially if the tourniquet is on too long.

Specializes in Anesthesia.
Drawing blood is to gravity, when you've got the added pressure of a pump is when you're really at risk for hemolysis. However, you can get hemolysis when drawing blood out of a 22 gauge, especially if the tourniquet is on too long.

How do you draw blood from gravity? Isn't either a vacuum tube or a syringe you are getting the sample with?

Specializes in CICU.

A lot of my patients are CHF'ers, so I run it as fast as they tolerate it. Starting slow, maybe 75/hour and increase (probably not faster than150/hour) if they sound good, etc.

Like someone else wrote, if there is concern, the doc will often order Lasix too.

Specializes in Pediatrics, ER.
How do you draw blood from gravity? Isn't either a vacuum tube or string you are getting the sample with?

Gravity was the wrong term, perhaps? Sort of. When performing phlebotomy you're drawing blood out via a vacuum (with a negative pressure, correct?) When you venipuncture with an angiocath, blood flows out to gravity if you don't staunch it, am I right? Neither one creates the same type of pressure as setting a 150-200ml/hour infusion through 20 ml tubing into a #22. Correct me if I'm wrong, please.

Gravity was the wrong term, perhaps? Sort of. When performing phlebotomy you're drawing blood out via a vacuum (with a negative pressure, correct?) When you venipuncture with an angiocath, blood flows out to gravity if you don't staunch it, am I right? Neither one creates the same type of pressure as setting a 150-200ml/hour infusion through 20 ml tubing into a #22. Correct me if I'm wrong, please.

I think the blood flow is due to the difference between venous pressure and atmospheric pressure, which would make the flow of blood through the angiocath pressure-induced, the same as infusing through a pump, but I could be wrong.

Transfusion. 2004 Mar;44(3):373-81.

Transfusions via hand-held syringes and small-gauge needles as risk factors for hyperkalemia.

Miller MA, Schlueter AJ.

Source

Department of Pathology, University of Iowa College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.

Abstract

BACKGROUND:

Pediatric emergency RBC transfusions are often infused rapidly through 22-gauge (ga) or smaller needles or catheters using hand-held syringes. Data relating needle size, unit age, and infusion rate are needed to assess the risk of hemolysis and hyperkalemia in this setting.

STUDY DESIGN AND METHODS:

Multiple simulated transfusions were performed during storage of RBC units. Aliquots from five units were rapidly passed through needles (18, 20, 22-25 ga) using a hand-held syringe. Resulting plasma Hb and K+ concentrations were measured. Free Hb levels were used as a measure of needle-associated hemolysis (NAH).

RESULTS:

Passage through 18-ga and 20-ga needles caused no hemolysis, but rapid passage through 23-ga, 24-ga, and 25-ga did. RBCs stored less than 7 days showed significant K+ release with 23- to 25-ga needles. The greatest needle-associated K+ release was 10 mEq per L, on Day 5. Due to high K+ concentrations resulting from spontaneous efflux, K+ release from NAH was not detectable after 2 or more weeks of storage.

CONCLUSIONS:

Rapidly transfusing RBCs using hand-held syringes through 23-ga or smaller needles can cause hemolysis. In RBCs stored 2 weeks or more, NAH does not measurably increase K+ concentrations above that present from storage-related efflux. During rapid transfusions, RBC storage time is the primary risk factor for transfusion-associated hyperkalemia.

PMID: 14996194 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov.lrc1.usuhs.edu/pubmed/11399823 (another study on size, pressure, and hemolysis)

Am J Perinatol. 1991 Jul;8(4):280-3.

Impact of venous catheters on packed red blood cells.

Oloya RO, Feick HJ, Bozynski ME.

Source

Aultman Hospital, Canton, Ohio.

Abstract

This study was designed to test the hypothesis that there would be increased hemolysis, as indicated by an increase in plasma free hemoglobin and potassium, when packed cells were infused through small gauge percutaneous catheters (24 and 28 g, PC) compared with short catheters (24 g; SC). We were unable to study the 28 g PC because after 1 hour, at a flow rate of 10 ml/hr, only 2.4 ml packed cells were infused. There was a significant increase in plasma free hemoglobin when pre- and postinfusion values were compared (SC, p = 0.005; PC, p = 0.009), but a statistically significant increase in potassium only for the SC (p = 0.008). There were no significant differences between the catheters for either potassium or free hemoglobin. For either catheter the quantity of free hemoglobin transfused could potentially cause a significant rise in serum bilirubin and hemoglobinuria.

PMID: 1741874 [PubMed - indexed for MEDLINE]

In the context of this discussion, the problem with the first study is that they used hand held syringes to push the blood through. The problem with the second study is that they didn't test 22g. catheters.

Specializes in Medsurg/ICU, Mental Health, Home Health.

I just read over my institution's transfusion practice guidelines.

IV Gauge isn't noted at all.

As for rate, the first 15 minutes the blood is to be run at 60 mL/hour, then it can be increased up to 180 mL/hr. MOST of my patients receive their blood at 125 mL/hr. But as many have stated, it depends on the patient. I have only given the blood at the highest rate once. He should not have been on our floor...we were just keeping him until an ICU bed opened.

Obviously, in an emergent situation pressure bags and whatnot can be used, but if I ever am in a situation like that I as a floor nurse won't be making the decision in regards to rate.

Specializes in Anesthesia.
In the context of this discussion, the problem with the first study is that they used hand held syringes to push the blood through. The problem with the second study is that they didn't test 22g. catheters.

There is enough research out that suggests that using smaller gauge IVs in blood transfusions can increase the risk of hemolysis. In my practice I rarely give PRBC or FFP over longer than 5-10 minutes so IV gauge size in my practice is very important.

^^Yes, but in your practice, you're infusing them rapidly. On a typical inpatient unit, over 3-4 hours is the norm.

Specializes in Anesthesia.
^^Yes, but in your practice, you're infusing them rapidly. On a typical inpatient unit, over 3-4 hours is the norm.

There is an old saying "loaded for bear hoping for squirrel". Using a 22g for adults is just the opposite and when you need a larger bore IV or the 22g doesn't work fast enough to transfuse the blood etc. someone will be scrambling for a larger IV, and the patient is the one that suffers in the end. With the problems with aged blood and possible increased risk mortality with blood transfusions using a 22g IV adult patients for blood transfusions just adds another variable that doesn't need to be there IMO.

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