How fast is too fast to transfuse blood? - page 4

by RNdiva505 22,103 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. 0
    Quote from NeoPediRN
    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.
  2. 0
    Quote from wtbcrna
    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]
    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.
  3. 0
    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.
  4. 0
    Quote from ~*Stargazer*~
    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.
  5. 0
    ^^Yes, but in your practice, you're infusing them rapidly. On a typical inpatient unit, over 3-4 hours is the norm.
  6. 0
    Quote from ~*Stargazer*~
    ^^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.
  7. 0
    All really good info! Thank you posters!
  8. 1
    "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.
    ~*Stargazer*~ likes this.
  9. 0
    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.
  10. 0
    Quote from wtbcrna
    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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