Albumin versus Plasma

melisgood · Dec 20, 2010

He also ordered 1 L NS as a bolus. He said if after albuminate (or was it plasma) was given to repeat if HR>130

melisgood · Dec 20, 2010

Also, does it make sense that I hung the NS first? I ran it through a pump because that's i've done it before (at 600cc/hr)...the night shift nurse said I should have just ran it without a pump (young patient not worried about fluid overload) and then I could have hung the albumin (or was it plasma?) at the same time.

The patient had TPN and a dilaudid PCA pump running into her triple lumen PICC line.

I feel so incompitent this morning like I screwed something up. She was upset though because in report I told her plasma needed to be hung not albumin. I called her on my way home and realized it was albumin not plasma. (this is why now i'm worried maybe i was supposed to order plasma?)

please reply to me as i'm really worried i messed this up! TIA....

melisgood · Dec 20, 2010

I ran the NS bolus on the infusion pump also because the patient had edema +3 BLE so I thought it was better to go a bit slower. The patient was transferred to our unit (tele) the day before due to HR of 145 and I called the doctor because i thought it was strange they hadn't done much to slow down the heart rate except for a bolus of NS 500ml the day before. The patient was in her 30s with colon CA with mets/small bowel obstruction caused by a tumor.

classicdame, MSN, EdD · Dec 20, 2010

You are so stressed over this! Perfect example of how we carry work home with us. You cannot fix the order now and I will assume someone would have called you by now to fuss if it were wrong. I recommend doing the JC approved method of telephone order READ BACK. It is imperitive to read it back. Also, you could call the lab or blood bank director and discuss the appropriate products. Worse case - call MD back and say, I was distracted when I talked to you and want to be sure the patient gets what you want.

Hope you find peace soon.

blondy2061h, MSN, RN · Dec 20, 2010

What's this patient's baseline that you're treating a BP of 96/66 on a young lady?

Given the edema, albumin does likely seem to be what the order was suppose to be, but we really have no way of knowing. Take this as a lesson learned- that's why verbal orders should be read back.

melisgood · Dec 20, 2010

I read back the order...but I wrote it on my clipboard i was carrying with me and then copied it to the telephone order. I spoke with another nurse friend of mine this morning and realized why I was confused. Plasmanate is the same thing as albumin. I wrote for Plasmanate and then was thrown off when I saw albumin show up from pharmacy. I then told the night shift to hang "plasma" and she was thinking FFP. This is also why she was upset with me hanging the NS bolus first because she was saying the plasma has clotting factors. I told her we're not giving the plasma for clotting we're giving it for increased volume.

I called the night shift nurse on my way home and told her I knew why she was thrown off on what I had done and told her it was albumin not plasma that was ordered. When I hung up the phone I kept thinking the doctor ordered plasma (but it was plasmanate....same as albumin).

melisgood · Dec 20, 2010

Next question though:

When hanging a 1L NS bolus do you leave it wide open without a pump? On our floor with so many pt's having CHF we usually use a pump to monitor for fluid overload so a bolus is given much slower. I ran it at 600cc/hr. She had a triple pump and a double lumen picc line. In one line she had Dilaudid PCA/Normal Saline and the other was TPN/lipids. So the pump had NS, TPN and lipids taking up all three pumps. I started the 1L NS bolus where her Normal Saline@85cc/hr was infusing. Because there were no more pumps and i've never piggy backed albumin I was saving that for night shift. Should I have done something differently?

melisgood · Dec 20, 2010

Also, we were trying to decrease her HR since it was 130-140. She had been throwing up a lot (before I put the NGT in yesterday and took out 600ccs) and he was treating dehydration and trying to increase her circulating volume and pull fluid from her tissue (edema in legs) into her vascular system. This increase in circulating volume should decrease her HR if I understand correctly. The order was to repeat the plasmanate (albumin) if HR>130 after the first one was given.

highlandlass1592, BSN, RN · Dec 21, 2010

Had this beautiful post to you earlier today, discussing the use of plasma vs. plasmanate...and then my internet promptly went down so I lost all of it. Saw though that someone else posted to you about albumin (plasmanate). So I'll leave that be.

On to your other question re: giving a NS bolus. You asked about running it free flow vs. using an IV pump. I would say there is no set answer, it's going to depend upon the situation. Is your patient crashing? Free flow with a pressure bag on the line will probably get it in quicker than using an IV pump. Is your patient's blood pressure marginal but pt is tolerating? You've got more time, I'd use the pump.

This is the type of situation where you're gonna have to critically think it through. You will also need to know a bit about your patient. You mentioned a part of your patient population having CHF...yes that is a big factor in figuring out how to run things. However, again....if your patient is crashing, you support them anyway you can which would involve a large infusion of fluid to maintain a BP till you can correct whatever is going on.

Side note about albumin: if necessary, you can give albumin IV push. What you need to familarize yourself with is the current policy at your facility regarding it's administration. I work with open heart patients, we use albumin frequently for volume expansion without trying to give them a huge amount of fluids. You will support the BP which gives you time to try to fix things. A challenge but it is doable.

Now in the situation you mentioned, you stated you left the albumin for the night shift and started the NS at 85 cc/hr. Would I have done it that way? No. If you need more "bang for your buck" it's hard to beat albumin...whether it's in a 5% solution (like plasmanate) or giving it straight...you will usually get an immediate response to help support the BP. This is purely antecdotal on my part...there was a study a few years ago that stated there is no difference in using NS vs. albumin. But I've found, when pt's are 3rd spacing, if I give them a lot of NS they just continue to 3rd space.

You spoke of attempting to increase circulating volume which would be correct but to pull fluid out of the tissue and them move it to the vascular space in hopes to decrease edema, you're probably going to need to use a diuretic as well. In the ICU we call that a "push-pull".

Side note: you spoke of giving the fluid in response to an elevated heart rate. You need to make sure there is no other cause of the tachycardia. Is it truly being caused by hypovolemia? If your hemoglobin is 11.8, that corresponds roughly to a HCT of 34...I'm not sure that would be the cause.

Anyway, just some points from my sleep-deprived brain.