Running PRBC concurrently with NS?!

[nurseap]

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 the patient's fluids, normal saline, to be reduced to 70 ml/hr during the infusion and returned to 125 ml/hr (the current running rate) after the transfusion was complete. I know you're typically not supposed to mix anything with blood, but being that it was normal saline and that's what we prime the transfusion line with I went to ask my trusted past preceptor what he thought. Together we agreed that I would get a second pump to run the blood through using the Y-port tubing, which is standard on our unit, and then connect it to the line running the NS. I connected the blood line to the lowest port, closest to the insertion site, on the fluids line. When the night shift came on I got reamed for making such a mistake. I don't know if what I did was truly wrong or if I was just being bullied. The RN II on nights is very mean to new nurses, but my colleagues have stated she's especially rough on me. Spending my ride home in tears is pretty commonplace. Anyway, I've spent the last 3 hours googling and haven't found a concrete answer. Though some sites indicate it's ok to run PRBC's concurrently with NS. My old preceptor pulled me aside before he left and told me it was fine and that they're compatible. The RN II said I read the order wrong. The Dr had not written the words "run concurrently". The order just read reduce rate to 70 and then return to 125. But when she verbalized it to me I took it to mean run together. I'm exhausted with anxiety. Besides answering regarding this issue, can you also tell me if things get better... Right now I feel like a failure, because no matter how many times I'm told I'm doing well, this woman (RN II) makes sure I go home feeling incompetent nightly. :/

Thanks in advance fellow nurses!

[anonymurse]

Not arguing with anyone else's ideas, just describing me and my buds and our policies. Figured I'd mention them to present alternate POVs and stimulate more conversation.

I use an IV pump (by policy). I use the transfusion set made specifically for the IV pump. Policy limit is 125 ml/H. Rationale is that the pump works by "massaging" the fluid downstream. Over 150 ml/H and the pump starts to crush RBCs, increasing risk of hemolytic reaction and rhabdo.

I give no fluids at all during transfusion except PRBCs (policy). Besides the bag of PRBCs, there is a bag of NS attached to the transfusion set that is there to prime and flush the set, but just a tiny bit, and not concurrently given.

Fluid overload can come fast. I don't want it to come any faster than it does. It was hard for me to understand just how fast until my patient went from asymptomatic to horribly dyspneic (flash pulmonary edema) in 5 minutes running PRBCs at 125 ml/H, and we had to call a rapid response.

I assess before transfusion, and not just breath sounds, BNP, vss, whether they feel even slightly SOB, etc. Whatever's in the chart and in report, I get a fresh transfusion history from them and family with details of adverse reactions. I ask if they ever have swelling, get SOB, were ever told they have or might have CHF, or have renal issues. And I ask if they have ever been treated with Lasix.

If it even vaguely smells like they're prone to fluid overload, I call that history in along with my request for a PRN order for IV Lasix between multiple units, maybe even with one unit if they've been on fluids. Sometimes the cardio will say to just give it, or to give a higher than normal dose.

And then, of course, I give pt ed about adverse reactions and what to report, and repeat with each set of vss.

Just my two cents.

[WoosahRN, MSN, RN]

OP, I read most of the responses but I'm not sure if anyone addressed this..... it does get better. You will get more confident, even in situations you might not be familiar. Even just learning where to look for answers or trusting your gut even if you aren't sure why. And when you do get more experience and confidence you will remember this feeling and treat other new people and coworkers with respect. Every person we come across teaches us how we want to be and you don't want to be that person that sends someone else home crying and doubting their ability to be a nurse. Remember how she made you feel and promise not to do it to someone else. Even in the face of errors you can speak to someone in a way that helps them learn versus belittles them. Once you get that experience and confidence you will be able to see where their comments are coming from. Maybe they got yelled at in their beginnigs and it forever put them on the defensive, finding mistakes in others. There are a few people that I know when they get report they always question things. Usually it's their personality or they are just voicing things they wonder out loud but really don't mean they are questioning me (though it can feel like that sometimes). I hope you are feeling better since your experience. Hang in there and good luck!

[healthstar, BSN, RN]

Where I worked our policy was to ALWAYS run the blood by itself.

[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.

[OCNRN63, RN]

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.

[SwansonRN]

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.

[qaqueen]

Sarakjp,

Thank you! I appreciate your comments.

[carolinapooh, BSN, RN]

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.

[nurseprnRN, BSN, RN]

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.

[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.

Outside of that I can't think of anything you did wrong...and even then, its not a big deal.

[Altra, BSN, 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?

[squatmunkie_RN]

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.