How fast is too fast to transfuse blood? - page 3

by RNdiva505 21,413 Views | 53 Comments

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... Read More


  1. 1
    When I worked at a large university teaching hospital, they didn't care what size IV you used for blood. The kids always had 24 g or smaller; not all of the children had central lines. (The smallest amount of blood I ever had an order to infuse was 7 cc's! On a baby, of course.) They held the philosophy that the need for a large gauge was a myth, also, because a red blood cell is only 4 microns. Now I work in a hospital that requires a 20g or larger; they expect you to get a doctor's order if you use a 22g. Also, we have to get a doctor's order to give blood in less than one hour. And yes, it really depends on the particular patient and the situation.
    wooh likes this.
  2. 1
    Orange Tree, I was taught that fluids with dextrose was not to be used, because the dextrose will lyse the cells. But in every facility that I have worked, the policy was to always use normal saline.
    DeLanaHarvickWannabe likes this.
  3. 2
    "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.

    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.
    highlandlass1592 and kids like this.
  4. 0
    Quote from applewhitern
    Orange Tree, I was taught that fluids with dextrose was not to be used, because the dextrose will lyse the cells. But in every facility that I have worked, the policy was to always use normal saline.
    Arch Dis Child Fetal Neonatal Ed. 2011 Aug 16. [Epub ahead of print]
    Effect of co-infusion of dextrose-containing solutions on red blood cell haemolysis during packed red cell transfusion.
    Stark MJ, Story C, Andersen C.
    Source
    1Department of Perinatal Medicine, Women's and Children's Hospital, Adelaide, Australia.
    Abstract
    Aim Transfusion guidelines prohibit co-infusion of maintenance intravenous fluid solutions, with significant consequences for neonatal clinical care. This study investigated co-infusion-related haemolysis in an in vitro model closely resembling clinical practice. Methods Packed red blood cells (PRBCs, n=8) were co-infused at 5 and 10 ml/h with dextrose 5%, 10% and intravenous amino acid solution (synthamin). Free haemoglobin (fHb), as a measure of haemolysis, was measured by spectrophotometry and presented as % haemolysis and total fHb content (Ámol/l). Results Following co-infusion, there was no significant increase in PRBC haemolysis with either type of solution co-infused (p=0.82) or infusion rate (p=0.5). Neither macroscopic nor microscopic agglutination was observed during co-infusion for any type of solution co-infused. Conclusions Co-infusion does not result in increased haemolysis, with total fHb significantly lower than currently accepted safe thresholds for fHb. Adherence to current guidelines may place undue restrictions on current transfusion practice in neonatal intensive care.

    PMID: 21849305 [PubMed - as supplied by publisher]
  5. 2
    Quote from grntea
    "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.usu...ubmed/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]
    canoehead and Esme12 like this.
  6. 0
    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.
  7. 0
    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.
  8. 1
    Quote from NeoPediRN
    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?
    Last edit by wtbcrna on Sep 10, '11
    ~*Stargazer*~ likes this.
  9. 0
    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.
  10. 0
    Quote from wtbcrna
    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.


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