Blood Transfusion during Dialysis

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Specializes in Med/Surg/Tele, Neuro, IMU.

I am employed in the Quality department of an LTAC. We use contract dialysis nurses to come in and perform dialysis on our patients. I am reading through a chart today and I find out that she infused 2 units of blood in less than a half hour on a patient with a BNP of 1555! Clearly the patient was in CHF. The patient's H&H was 8/25 so there was no need to rush the transfusion. The patient also had 4+ pitting edema of the bilat lower extremities. I am researching the standard for transfusions during dialysis because I don't know what they are. I know as a floor nurse, the standard minimum time for a single unit to infuse is 2 hours but could go as long as 4 hours based on the patients' status. The reason Lasix is ordered between units is to prevent fluid overload. Because this patient is on dialysis, I am not sure how effective the loop diuretic was. . .the nurse did not document her outputs via dialysis or foley! Needless to say, the patient ended up in respiratory failure and fortunately made it through the code. Now she's sucking on a vent. Does anyone have legit info that I can further research? I would like to prevent this from happening in the future. Part of my job is to identify what went wrong and put processes in place that will correct this and keep it from happening again. Thanks. . .

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Specializes in Critical Care- Medical ICU.

How was the pts blood pressure? I know I have had pts in the ICU who were severely fluid overloaded and needed dialysis but had a low BP and somewhat low H&H and were given blood products during dialysis to help keep the pressure up. Not under 30 min. though.

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Specializes in ICU.

Did they take fluid off? How much? or was it just for clearance? If she put in 700cc of PRBC but took off 4 liters of fluid total ...

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Specializes in Med/Surg/Tele, Neuro, IMU.

Funny you all should ask these questions. . .the dialysis nurse's note is absent from the chart so there is zero information about what was taken off during dialysis, vital signs, etc. This whole case is seriously lacking complete (or even incomplete) documentation.

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Specializes in Emergency, Telemetry, Transplant.

First, I am not sure of how reliable BNP is for a renal failure pt...also, I lost some respect for this post with the "sucking on a vent" comment.

What happened to the documentation during the dialysis? Did the facility lose it or the did the nurse just not document (I'm doubtful of the latter explanation)?

I would think you would need a dialysis nurse's answer....or better yet, you could contact the company that provides the dialysis nurses.

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Specializes in ICU.

"Sucking on a vent" stated like a veteran nurse!

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Specializes in Critical Care- Medical ICU.

I agree that you need to contact a dialysis nurse, particularly the actual nurse who performed the dialysis in this case, to inquire about the missing documentation.

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I am employed in the Quality department of an LTAC. We use contract dialysis nurses to come in and perform dialysis on our patients. I am reading through a chart today and I find out that she infused 2 units of blood in less than a half hour on a patient with a BNP of 1555! Clearly the patient was in CHF. The patient's H&H was 8/25 so there was no need to rush the transfusion. The patient also had 4+ pitting edema of the bilat lower extremities. I am researching the standard for transfusions during dialysis because I don't know what they are. I know as a floor nurse, the standard minimum time for a single unit to infuse is 2 hours but could go as long as 4 hours based on the patients' status. The reason Lasix is ordered between units is to prevent fluid overload. Because this patient is on dialysis, I am not sure how effective the loop diuretic was. . .the nurse did not document her outputs via dialysis or foley! Needless to say, the patient ended up in respiratory failure and fortunately made it through the code. Now she's sucking on a vent. Does anyone have legit info that I can further research? I would like to prevent this from happening in the future. Part of my job is to identify what went wrong and put processes in place that will correct this and keep it from happening again. Thanks. . .

If you are doing a root cause analysis you have to look at the communication here:

1. What were the dialysis orders? Even if the nurse notes are missing there should be a dialysis orders which state what the goal dialysis was. Are these consistent with someone in heart failure?

2. Did the providers at the LTAC communicate the worsening volume overload in the patient? or did the nephrology providers examine the patient before the dialysis run and appreciate the volume overload?

3. Was the patient on EPO or something similar which would have alleviated the need for blood (i'm assuming someone was shooting for the standard Hgb> 11 for dialysis patients.

4. What was the indication for dialysis? What stage renal failure? Was this an inability to concentrate or complete renal failure with an inability to maintain electrolytes?

Basically its perfectly reasonable to run in two units of blood in half an hour on dialysis. If you look at it in terms of blood flow on HD (350-500 ccs/min) two units of blood are really a drop in the bucket and will be rapidly diluted (for disclosure purposes I work in an ICU an we usually do CVVH or CVVHD). If you look at it another way a dialysis run is usually three hours. At two hours for a unit you could at best get in one unit. For that matter I don't even know if you could run it in that slow. Dialysate runs at 500-800 ccs per minute and the HD runs a little slower. You are moving huge volumes of fluid, it doesn't really lend itself to running things in slow. In the ICU We will frequently run a liter in over 1-2 minutes off the CRRT when we are short on access when someone is in shock. Works great.

The real issue is how much were they supposed to take off and was that target achieved? Also was the blood ordered by the LTAC team and nephrology didn't account for it? Usually when we give blood during dialysis we add that amount to the target so the total run is dialysis target + Blood. It would be unusual for someone that brittle to be outside an ICU but it happens.

Bottom line you should have the nurses notes. Not having them in the chart is not acceptable. On the other hand its unlikely that the sole reason your patient is on the vent is because of the blood (or whether its even a factor). What probably happened is that the patients volume status worsened and this wasn't communicated to nephrology or nephrology failed to appreciate the volume overload when they examined the patient. There are lots of reason that patient could have worsening volume status including worsening/poorly treated CHF, poor fluid restriction in PO patients, worsening renal failure not appreciated by nephrology etc.

Your focusing on the two units of blood and the time which is irrelevant. You need to look at the global picture and figure out why the patients CHF worsened and whether it was adequately treated.

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Specializes in Nephrology, Cardiology, ER, ICU.

A BNP of 1555 is normal for an ESRD on hemodialysis.

To infuse two units in this time frame provided they are removing fluid as they push the blood in is accepted practice.

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Specializes in Critical Care.

When a dialysis patient needs blood, during dialysis is the best time to give it so that the fluid shifts the transfusion causes can be corrected with the dialysis, and it can actually make dialysis more effective as the blood pulls third-spaced fluid. You probably aren't going to get a very impressive response with lasix in a chronic HD patient.

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with ESRD , a BNP that elevated, and the +4 edema who's to say the patient wasn't heading towards respiratory failure secondary to the CHF anyway. The interventions easily could of had nothing to do with it, and I doubt the volume of 2 units set her into it. This sounds like a chronic problem, that if anything has been undermanaged over a long period of time.

As for the missing documentation, I would document that it is indeed missing from the chart, and make every effort to locate the notes, and/or the person responsible for it. I hope that is a regular thing :(

Sounds like a sick patient, and she can thankful she survived the failure if it was her wish to do so. Off the cuff remarks like the one in your post, detour actually qualified from wanting to contribute to your research if that is your intention. Lets keep it professional and respectful.

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I'm also a former dialysis nurse. As pp have said, blood can be given much faster on dialysis than via peripheral IV; however, I would try to give it over 30-45 min per unit, as a typical dialysis tx lasts at least 3 hours (it may be less in acutes, but rarely

Lasix is usually not given to ESRD pts as the dialysis machine will take off excess fluid as programmed. In acutes (i.e., your setting) the nephrologist often determines the fluid removal goal, which will be part of the dialysis orders in the chart (or it may be something like "as tolerated"). Dialysis nurses (should) know to account for the fluid of the blood product by adding it to this goal; of course, if the pt is highly unstable during tx then no fluid may be removed and sometimes more has to be given (as NS) than can be removed; the tx sheet (which is apparently missing) should state this.

There should be a tx sheet; the acute/contract nurse has to provide a copy to his/her employer, and the original stays in the pt's chart. If you don't have it, you should be able to obtain it from the dialysis company.

DeLana

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