Running PRBC concurrently with NS?! - page 4

Hi, I'm a new RN working on a medical oncology unit and went off of orientation last week. Today a Dr came in and told me she'd like me to administer 2 units of PRBC's. She added that she'd like... Read More

  1. Visit  qaqueen profile page
    0
    I am not a new grad, and I was recently in a "sort of" similar situation. My pt had 2 IVs, one running a cardiac med that could not be stopped, y-ed into NS running at 100. Because there had been a suspected problem with a previous PRBC transfusion (nurse stopped after 90ml), the doctor told me to run one unit of PRBC over 8 hours. Now clearly, that was not an acceptable order. I told her I would run it over 4, she agreed. As the pt was in hospital, for dehydration and anemia, I did not want to stop the NS for 4 hours. I ran the blood into one IV at 75ml hour, ran the NS with the cardiac med at 100 in the other IV. Monitored the pt very closely for fluid overload, no problem.
    My shift manager leaves for the day, and the oncoming shift manager calls me into the office to tell me that we "never" run fluids during a transfusion, even in another IV.

    I have tried to find documentation that I screwed up, I havent found it yet.

    Dear OP, things will get better, and somedays things will be worse. Keep learning and improving your skills. Do the best you can for your patients. Dont let the bad days trip you up too much. Nursing is an adventure.
    Last edit by qaqueen on Jun 3, '13 : Reason: grammar
  2. Get the hottest topics every week!

    Subscribe to our free Nursing Insights newsletter.

  3. Visit  OCNRN63 profile page
    0
    I would have started a second site for the NS. Don't keep beating yourself up over this. It's not something that harmed the patient, and you have learned for the next time.
  4. Visit  SwansonRN profile page
    3
    Quote from qaqueen
    I am not a new grad, and I was recently in a "sort of" similar situation. My pt had 2 IVs, one running a cardiac med that could not be stopped, y-ed into NS running at 100. Because there had been a suspected problem with a previous PRBC transfusion (nurse stopped after 90ml), the doctor told me to run one unit of PRBC over 8 hours. Now clearly, that was not an acceptable order. I told her I would run it over 4, she agreed. As the pt was in hospital, for dehydration and anemia, I did not want to stop the NS for 4 hours. I ran the blood into one IV at 75ml hour, ran the NS with the cardiac med at 100 in the other IV. Monitored the pt very closely for fluid overload, no problem.
    My shift manager leaves for the day, and the oncoming shift manager calls me into the office to tell me that we "never" run fluids during a transfusion, even in another IV.

    I have tried to find documentation that I screwed up, I havent found it yet.

    Dear OP, things will get better, and somedays things will be worse. Keep learning and improving your skills. Do the best you can for your patients. Dont let the bad days trip you up too much. Nursing is an adventure.
    Really? I work in an ICU. The other day I had a patient who was crashing and was about to get a central line and intubated, so I had fluid blousing in one IV, blood products going into another, peripheral dopamine running into the third, and the other the anesthesiologists were using to push meds during the intubation all at the same time.

    I do see their rationale, but I don't think "never" is necessarily a good rule. I think it's better to use your clinical judgement or clarify with the ordering provider.
  5. Visit  qaqueen profile page
    0
    Sarakjp,

    Thank you! I appreciate your comments.
  6. Visit  carolinapooh profile page
    1
    Quote from qaqueen
    Sarakjp,

    Thank you! I appreciate your comments.
    The only reason I can think of to NOT do this is if the other medication is something that could cause a reaction - because then you don't know if the blood or the other med is the cause.

    Example: I would never, ever run Rituxan and blood at the same time. Rituxan, even if the pt's been fine with it before, can cause serious adverse reactions. If it happens while I'm running blood, I don't really know the source.

    Vanc's another one. There are many, many more.

    But there are plenty of meds without that propensity that are perfectly fine to run at the same time as blood in another line.
    canoehead likes this.
  7. Visit  GrnTea profile page
    8
    Quote from IVRUS
    I am so sorry that you spend your ride home berating yourself for any, and all mistakes made. You are a NEW nurse, and confidence will come, and the tears will stop in time. Interpreting this order to mean that it should run concurrently with the NS, is a matter of interpretation, so your best bet, IMO, would have been to call this MD back and get clarification of the order. Then, rewrite the order so it is not ambiguous.
    Oh, horsepucky. NS can be run with blood products of all kinds, be they platelets, packed red cells, or even whole blood (not that you ever see that around anymore, but hey).

    Asking for a clarification from a physician on this prescription is like asking whether a pill that's labeled "may be taken with food" has to specify that it's ok to take with your morning oatmeal. There is no "matter of interpretation" here. The physician's plan of care was to give less NS while the PRBCs were running to prevent fluid overload, which I am assuming the crank one didn't understand either. It had nothing whatsoever to do with compatibility.

    OP, whoever cranked on you is revealing her vast ignorance. You did nothing wrong AT ALL, nothing whatsoever needs to be clarified, you made an appropriate nursing judgment which was proper and completely within your scope of practice, and you can start sleeping properly again.

    Grrrrrr.
    canoehead, applewhitern, NRSKarenRN, and 5 others like this.
  8. Visit  squatmunkie_RN profile page
    0
    If you have a large catheter line I'm not sure what you did wrong...NS is ran with blood all the time. But assuming that the blood is ran at 125ml/hr and the NS at 70, that's a lot of fluid for 1 line..it might not hold up.

    Outside of that I can't think of anything you did wrong...and even then, its not a big deal.
  9. Visit  Altra profile page
    1
    Quote from squatmunkie_RN
    If you have a large catheter line I'm not sure what you did wrong...NS is ran with blood all the time. But assuming that the blood is ran at 125ml/hr and the NS at 70, that's a lot of fluid for 1 line..it might not hold up.
    What kind of line are you thinking of that won't "hold up" to an administration rate of 195/hour?
    carolinapooh likes this.
  10. Visit  squatmunkie_RN profile page
    1
    Quote from Altra
    What kind of line are you thinking of that won't "hold up" to an administration rate of 195/hour?

    I doubt a 22g would last very long if I had to run blood/NS at 195ml/hr for the time it take for 2 units to infuse. That would be about 6 hours.
    NurseKitten likes this.
  11. Visit  Altra profile page
    4
    Quote from squatmunkie_RN
    I doubt a 22g would last very long if I had to run blood/NS at 195ml/hr for the time it take for 2 units to infuse.
    Have you ever given a patient a fluid bolus? One liter in an hour or less? What's the administration rate then?

    Here's a link to one brand of IV catheter. Note that the flow rate for a 22# catheter is 35mL/min. (2,100mL per hour)

    https://www.bd.com/infusion/pdfs/D16128.pdf

    If there are other links to information I can pass on please let me know. I'm not sure where you got the idea that the catheters themselves were so fragile.
    canoehead, applewhitern, NRSKarenRN, and 1 other like this.
  12. Visit  squatmunkie_RN profile page
    1
    Quote from Altra
    Have you ever given a patient a fluid bolus? One liter in an hour or less? What's the administration rate then?

    If there are other links to information I can pass on please let me know. I'm not sure where you got the idea that the catheters themselves were so fragile.
    Experience...sure I've given boluses. Ive bloused (sp??) a unit of blood on a regular floor. The IVs don't last long after that. They leak...and infiltrate all the time.

    Maybe it's the type that my hospital uses, but that's just my personal experience working.
    NurseKitten likes this.
  13. Visit  Altra profile page
    1
    Leaking & infiltration are related to the vein in which the catheter is in ... not the IV itself.
    carolinapooh likes this.
  14. Visit  NurseKitten profile page
    1
    The size of the IV speaks to the resistance to flow overall. According to Pouseille's Law, decreasing the diameter of a flow tract by 50% will increase resistance by a factor of 16x's. Resistance in an IV also contributes to turbulent flow, (as opposed to laminar). If trying to infuse quickly through a smaller IV, it increases your chances of infiltration.

    So you're correct when you say it's not related to the IV itself...directly. But it could be argued that there is an indirect correlation.
    squatmunkie_RN likes this.


Nursing Jobs in every specialty and state. Visit today and Create Job Alerts, Manage Your Resume, and Apply for Jobs.

Top