Leaking blood during transfusion

[fiveoclocksomewhere]

So the other day I hung blood for the first time ever, and the charge nurse was in the room with me to walk me through it. Very time consuming but she assured me that it gets easier the more you do it. Anyway, the pt had an 18 gauge iv and my charge nurse told me that they need at least a 20 gauge, but she had given blood through an 18 and that it should be fine. So we started the blood at 90ml/hr and the pt complained of itching at the site. Called the MD and she said to keep it going and see how she does. After about 30mins, blood starts seeping out all around the iv site and around the tape. Stopped the infusion and the charge came in to see it, said it had infiltrated. Is this because of the 18gauge?? Or did some kind of reaction happen?

[sapphire18]

An 18 gauge is bigger than a 20, so no that has nothing to do with it. It sounds like it just infiltrated or wasn't in the vein anymore. Did it flush ok before that?

[wish_me_luck, BSN, RN]

did I miss something? Do you have it backwards? An 18 is larger (and more appropriate for blood) than a 20.

[Sun0408, ASN, RN]

Sounds like the IV went bad, did you flush it before you started the blood? The IV size had nothing to do with it, as others have stated an 18 is larger than a 20.

[fiveoclocksomewhere]

Ah sorry, I meant to say she had a 22 gauge. So very small iv. It was flushing okay but it clotted off easily, after that initial push it would be fine though. She refused another iv after the whole debacle, btw.

[traumaRUs, MSN, APRN]

Can't run a full unit of PRBCs thru a 22g - way too small. Should have placed a new IV or if not an option, central line would have been my second choice.

[wish_me_luck, BSN, RN]

It's possible. Like the others said, did you flush it to check patency before running the blood?

[edmia, BSN, RN]

Was this patient on a heparin drip or anticoagulated in any way?

This happens with larger bore IVs (18g is larger than 20g) after they've been in place for a few days because they make a larger hole into the skin. The IV was leaking and you noticed it when the leaking fluid was red instead of clear. I've had this happen and the site was not infiltrated as there was no swelling of the surrounding tissue, no induration, no redness, no pain, and the site was flushing well. In any case, it is not a good site to continue using, so it's best to place a new IV and d/c that one.

For IVs that will stay the whole 96 hours per protocol, a 20g is fine because you avoid the larger entry into the skin. Even a 22g is perfectly acceptable in a non-emergent situation.

[edmia, BSN, RN]

Can't run a full unit of PRBCs thru a 22g - way too small. Should have placed a new IV or if not an option, central line would have been my second choice.

I disagree. You can definitely run blood through a 22g. In kids and babies we even use 24g.

You may not be able to put a pressure bag on it, but for a normal transfusion to be infused over 3 to 4 hours, as is usually the case in med-surg, 22g is the norm where I work. Coming from the ED, I like to put in at least a 20g, but my colleagues are used to a 22g and Ooh and Aah when I routinely replace my IVs with 20s. An 18g? Gosh, I'd get a party for that ;-)

[Altra, BSN, RN]

You can definitely run blood through a 22, so that was not the problem in and of itself. It does sound like the site was bad, and/or there was a loose connection either between the IV catheter and the cap, or the cap and the tubing.

The patient refused a new IV and so did not get the transfusion? What was the outcome of that?

[wish_me_luck, BSN, RN]

The patient refused a new IV and so did not get the transfusion? What was the outcome of that?

This is the part that I was wondering about, myself....

[IVRUS, BSN, RN]

INS standards of practice say that one should place the smallest gauge and length for the therapy. 99.9% of the time I give blood to my elderly patients with a 22 gauge. Now, If I were in a trauma situation, or I'm needing to push the unit in in a small time frame, then yes, I use a larger bore.

If I can draw labs with a 24 gauge butterfly and not lyse the cells, then why can't I give it using a 22?

Of course I can. What matters is the time frame you need to get in it. Most elderly people can't handle the unit but over a 3-4 hour time frame. A 22g works well.

In this case, It sounds as if there may have been a clot at the end of the lumen which caused a retrograde of the blood. Itching at the site could be from histamine release from the seepage in the SQ tissue.