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 med/surg.

All really good info! Thank you posters!

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"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)."

the key here is "hand-held." smaller syringes and lumens do develop higher pressures for the same amount of effort-- if you don't believe me, check to see how much easier it is to hit the ceiling from a 5cc syringe than from a 60cc syringe, if you push both as hard as you can. "rapidly passed through needles..." means they pushed as hard as they could on each, and of course they would get higher hemolysis with that. a better experimental design would have been to make sure the pressure was the same in each-- and a gravity feed will not develop the kind of pressure that a good strong thumb does.

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Specializes in Anesthesia.

The question is for all those that use 22g iv on pumps for adult blood transfusions, does the pump manufacture state that it is safe? If the manufacture states that is safe then they should have study that shows giving blood through a 22g at that pressure doesn't cause hemolysis.

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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.

Clearly, the largest bore you can possibly get is the best, not just from a blood transfusion standpoint, but from any practical standpoint. However, it's not always possible to get a 20 or larger, and not every patient is a candidate for a central line.

Now obviously, if you're infusing blood through a 22, you're going to go slowly so you don't blow your site, let alone cause hemolysis from excessive pressure. My understanding, though, is that the 20g. or larger for blood transfusions is a myth, and that 22g. catheters are perfectly acceptable, both by the INS and the AABB.

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Anyway, as far as how fast is too fast, I found a resource that gave some info on infusion rates, and it was something like 40mL/min. was getting dangerous, and 100mL/min. causes cardiac arrest. It also mentioned 200mmHg being max. pressure, and 300mmHg too high. I wish I could find it again! Does any of this sound familiar, wtbcrna?

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Specializes in Anesthesia.
Clearly, the largest bore you can possibly get is the best, not just from a blood transfusion standpoint, but from any practical standpoint. However, it's not always possible to get a 20 or larger, and not every patient is a candidate for a central line.

Now obviously, if you're infusing blood through a 22, you're going to go slowly so you don't blow your site, let alone cause hemolysis from excessive pressure. My understanding, though, is that the 20g. or larger for blood transfusions is a myth, and that 22g. catheters are perfectly acceptable, both by the INS and the AABB.

I have yet to see anything that says it is okay to use a 22g, especially on a pump, for adult blood transfusions, but I could be wrong. A 22g in an adult will not work for my practice when I am doing blood transfusions.

I do realize it is hard to get IVs in some patients, but I also realize it is rare occurrence to only be able to put a 22g in adult patients. Most of the time it is due to inexperience of the person starting the IV. I have went to med-surg on several occasions and started an 18 or 16g where the floor couldn't get an IV or just had one 22g. Normally, if you can get a 22g in a vein you could have got a 20g in instead.

I would like to be proved wrong though and have someone post an article that shows it is safe to use a 22g on a IV pump for adult blood transfusions and still give a unit of blood in the normal 2-4hr time.

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Specializes in Anesthesia.
Anyway, as far as how fast is too fast, I found a resource that gave some info on infusion rates, and it was something like 40mL/min. was getting dangerous, and 100mL/min. causes cardiac arrest. It also mentioned 200mmHg being max. pressure, and 300mmHg too high. I wish I could find it again! Does any of this sound familiar, wtbcrna?

I wish it did, but all my transfusion patients would be dead if that was true. I usually transfuse a unit of PRBCs in about 3min in the OR.

I like the reference to max pressure. That is actually very helpful, and can be verified through the IV pumps information sheet. I am not sure if the max pressure is right since in the ICU and OR we often put blood in a pressure bag with a pressure of 200-300mmhg(at least I think that is the unit of measure).

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Those numbers might not be accurate, since I was trying to remember what it was I read, and couldn't find the reference again.

In my ED, we use a Level 1 rapid infuser. I've never timed it, but the blood infuses in a matter of minutes.

I don't know how much pressure the Level 1 exerts, either. The reference I read was referring to pressure bags.

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.
it's less an issue of iv catheter size (they give blood transfusions to newborns and premies and small kids and you're sure not gonna get a 20ga into some of them) and more an issue of need and baseline physiology.

someone young and otherwise healthy who has recently had an unpleasant encounter with a sharp object and lost a lot of his own blood as a result (remember: surgery is just expensive trauma) needs replacement fast.

the little old lady with chest pain from anemia who acquired her anemia slowly may not do well if you pump her poor old vascular system full of extra volume rapidly (think chf), so more slowly is better for her.

see, it's not just a one-size-fits-all task, it's a nursing intervention that needs a thoughtful assessment before proceeding.

what a great answer and a fantastic example of critical thinking!

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Specializes in Anesthesia.
Those numbers might not be accurate, since I was trying to remember what it was I read, and couldn't find the reference again.

In my ED, we use a Level 1 rapid infuser. I've never timed it, but the blood infuses in a matter of minutes.

Good point...http://www.anesthesia-analgesia.org/content/97/4/1064.full.pdf

They have a maximum infusion rate of around 500ml/min. You can do a unit of blood in under a minute with the level 1 or belmont.

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I infuse as fast as possible. Every patient; every time. No exceptions.

Seriously.

For real.

Good thread, y'all.

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I would like to be proved wrong though and have someone post an article that shows it is safe to use a 22g on a IV pump for adult blood transfusions and still give a unit of blood in the normal 2-4hr time.

Check with the American Association of Blood Banks.

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