Blood Transfusion during Dialysis

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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. . .

Specializes in Critical Care and ED.

I've been an Acute Dialysis Nurse for 5 years, and also work in Critical Care. We do it all the time. I've given 2 units in about that timeframe, but only if the Hct is low, the lungs are clear, and I know the pt is going to tolerate a decent ultrafiltration. Lasix isn't going to do squat with ESRD, and is not a predictable outcome anyway. UF is far more fast and effective and is controlable by the RN. I'm concerned about the lack of documentation, but acute charting is a little crazy. Maybe it's all there but you don't know how to interpret the chart. Call them and ask. Acute dialysis nurses generalyl have a diverse autonomy and our nephrologists tend to give us a wide parameter within which to use our judgement.

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

Thank you so much for the information! I appreciate all of you!

Just to clarify a few things. . .

There are MANY discrepancies in the charting (I do know how to interpret the chart with the exception of the dialysis information I asked for in this forum). The patient was admitted and on day 3 received a Quinten cath and PICC line. It appears from the chart that the patient was dialized daily (for 2-3 hours) x4 days then it was ordered every other day. I agree that the Lasix wouldn't be expected to do much for an ESRD patient but if there is NO documentation on output after a foley was placed. This patient's diagnosis was ARF. My question was directed at dialysis nurses and whether they are comfortable giving what is essentially a blood bolus of 2 units in about 30 minutes. What I am reading is that during dialysis is the time to do it. I can accept that. I just needed clarification so I could wrap my mind around the situation. Again, I am NOT a dialysis nurse and I needed the standards from someone who specializes in dialysis. I thought about the BNP and whether it would be accurate in someone suffering ARF. I will have to further research those numbers.

I received a call last night from the nurse manager that this particular dialysis nurse came back to dialize another patient the same night and they ended up coding the second patient as well. That is another chart I will have to research and I HOPE the documentation is there and complete. I don't have documentation of an assessment to tell me if the patient's lungs were clear or not. Her chest x-ray from the day before states there was "consolidation" in bilat lower lobes. I intend to dig deeper today and I intend to contact the dialysis agency to gather some information there as well. One of the things I will ask for is their P&P on transfusing during dialysis.

My comment "sucking on a vent" was not intended to offend anyone, it was meant to stress that if in fact this patient is on a vent related to poor nursing judgement, then my researching these charts MUST be done thoroughly and fully. I am sorry if I offended anyone.

My concern is, I found NO documentation from the dialysis nurse for any of the previous dialysis sessions. I have to investigate if her protocol states that their documentation goes back to their agency or stays with us. There are NO records accounting for the time spent with the dialysis nurse. I will again go thru the chart today to confirm that they are not there.

I am NOT interested in taking anyone down or making a nurse stand trial. What I am interested in is changing processes that could possibly prevent this from happening in the future. . .if possible. I am not even sure if there was any wrong-doing.

I agree that there is no way to tell if this patient wouldn't have coded regardless of dialysis and that is why I am here asking questions. I really appreciate everyone's time and attention. I will check back often to consider everyone's input.

Have a wonderful day and thank you all!

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Hemodialysis is where the blood of the patient is circulated or flow through a dialysis machine. The patient needs some sessions per week for the dialysis to be adequate. The filter removes the toxic chemical and extra water that usually accumulates in a patient with kidney failure. The blood must be easily taken out from the body and given back to the patient for this technique to be successful.

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Specializes in ER.

It seems that you shouldn't be reviewing a chart where the main point of interest is the dialysis, seeing as you are not familiar with the procedure. Can you pass it off to someone that is familiar?

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Thank you so much for the information! I appreciate all of you!

Just to clarify a few things. . .

There are MANY discrepancies in the charting (I do know how to interpret the chart with the exception of the dialysis information I asked for in this forum).

...

I received a call last night from the nurse manager that this particular dialysis nurse came back to dialize another patient the same night and they ended up coding the second patient as well. That is another chart I will have to research and I HOPE the documentation is there and complete.

I think you will know a lot more once you review the second chart. And if there is no documentation there as well, something strange is going on. Since these were your hospital's pts, at least a copy (in our case, it was always the original) of the tx sheet should be in your chart (we filed under "nurses' notes").

As with anything else, not every nurse doing acute dialysis is competent to do so (the outpt clinic I used to work at once forced the RNs to take acute call, which is not something some of them felt comfortable doing; but they had to, or risk losing their jobs); I'm not implying that this is the case here, but it has me concerned that both pts coded after tx. Acute pts can be unstable, of course, and it could be a coincidence, but....

Even if you're not a dialysis nurse, some things are pretty basic here and should raise concern, including that there is no documentation for a medical procedure prerformed, which is really strange for any specialty area (in house it might be on the computer, but contractors should provide a paper copy if they don't use your computer system).

DeLana

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

OK, I am happy to report that the dialysis notes were located by medical records and I am so happy the nurse was meticulous in her documentation. The report from the day the pt. coded, the nurse documented that the physician gave an order to infuse the blood "wide open" to bring the blood pressure up from 50/30. I agree that this pt.'s condition was precarious prior to dialysis and the code could have happened regardless of dialysis. The second patient she took care of was NOT coded but sent out emergently related to SOB. All vital signs except the O2 sat (88%) were stable. The physician ordered a STAT CT to r/o PE and our facility could not complete that fast enough so the pt. was sent to a facility that could perform the CT STAT as ordered. The pt. did in fact have a PE and stayed in the hospital for 7 days to resolve the issue. The nurse did nothing wrong and as a matter of fact, followed all protocols and procedures. Thank you all for your time and attention to my questions/concerns. All of you got me thinking outside of my usual ways. These incidents just go to show that situations are not always as they first appear, I am happy to report! Thank you again and I will bring future concerns here as they arise.

Sincerely,

Biggirl71

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

I forgot to add that this Quality gig is new for me. I have spent my career in Management/Supervisory positions and I have dealt with nursing issues all along. However, working in the Quality department is a different animal all together. Out of this investigation, I yielded information on how to better design the nurse's notes. There is a section (basically a check-off) that addresses "edema." This section does not allow the nurse to indicate where the edema is but all of the nurses documented 4+. So I took my concern to the Director of Clinical Services and she is going to redesign the nurse's note. Another positive result of this investigation is that the DCS will do teaching to the nurses about the importance of accurately documenting I&O on renal patients (actually every patient) but especially real patients.

Thank you all again! Have a great day!

Biggirl71

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Better indicator for dialysis patients + those with CHF rather than Intake/Output is daily weight looking for wt gain over 2 lbs/day or 5lb/wk.

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I'm a HD Nurse. Regarding your problem about BT during HD, PRBC can be given as fast as 15 min each bag (approx. 250- 350 mL). So no problem with transfusing 2 bags within 30 mins. Regarding the case of your Pt. w/c is CHF. There's no problem either coz during HD we are removing excess fluid from the Pts including the amount of BT that are given. Lasix is useless if your patient is doing Dialysis coz it will be dialyzed. And if you would like to give it after HD, Think about it. Your Pt is ESRD, meaning they probably don't pass urine anymore. So it's common sense my dear. /and besides lasix can cause Hypotension to the patient who just undergone HD. I hope this would help you solve your problem. Take it from me who is 8 yrs as Hemodialysis (HD) Nurse.

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Specializes in Med/Surg.

so it's common sense my dear.

no need to be snotty or demeaning.

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Specializes in Oncology; medical specialty website.
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. . .

How did she manage to wrangle 2 units of blood from the blood bank so quickly? You'd think that would have been a red flag. Did this happen in a hospital? I wasn't aware LTCs had blood available.

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Specializes in Oncology; medical specialty website.

Interesting comments from experienced HD nurses. Thanks for sharing your knowledge.

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