blood transfusion and first 15 minutes

schnookimz · Jan 20, 2014

Not our policy to stay in the room and no one does. It's usually the CNA that takes the second set of vitals. I've seen one bad blood reaction and patient did die from it.

RainMom · Jan 20, 2014

Interesting. I wasn't aware that VS q5 x 3 and staying with the pt when initiating the transfusion was not standard anymore. For those of you that don't, do you at least start at a low rate or do you just start transfusing at 125-150/hr?

annie.rn · Jan 20, 2014

I always stay in the room the first fifteen minutes, without exception. Even if the patient is monitored, most of the first signs of transfusion reaction would not be immediately reflected in the vital signs (rash, back pain, itching, feeling of impending doom, pain at IV site, etc.) Every minute counts during a reaction and I certainly wouldn't want to walk in and find my patient in anaphylaxis. I also make sure to prime the blood all the way to the end if the tubing before hooking the IV up. Otherwise, in the first 15 mins. you could end up administering nothing but NS as you wait for the blood to make its way down. Lastly, I was taught to run the blood at a very slow rate during the first 15mins. (15-20ml/hr) then bump up if pt. Is tolerating.

Here.I.Stand, BSN, RN · Jan 22, 2014

We check VS pre, 15 min in, and 1 hr post. Of course being in the ICU we're checking VS from continuously (art line, cardiac monitor, esophageal or bladder temp probe) to q 1 hr anyway; just talking for blood transfusion purposes.

That said, I do stay with them for the first 15 min and observe.

Bananachiki17 · Mar 7, 2014

in our ICU all of our patients are monitored and we hang up the blood and run it wide open. We do not necessarily stay IN the room, but we sit just outside the room charting, etc and typically only have one patient.

Catchall_RN · Mar 7, 2014

Places I have worked have similar VS policies as is listed here so I won't go into that, none of the places I have worked specifically say we have to stay in the room

Places I have worked have had different blood infusion rates for ICU in particular, and a couple have given us another set of rates we can use in emergencies (specifically wide open). I have found bigger ICUs that have higher acuity pts have more liberal policies for us for obvious reasons (if a pt is bleeding out and I'm getting the level 1, that policy is useless anyways)

Generally speaking, what I usually see in the ICU and what I also do with starting transfusions: if it's a pt's very first transfusion and they're stable, I'll start at a slower speed and turn it up 10-15 mins after. I try to stay near the room, or at least in eye and ear shot. There are situations where I cannot do this, but I will still listen up for it. I will tell the pt and/or family (if pt is unconscious for example) some of the signs to call for me, like itchiness, rash, back pain etc. If it's a pt's 3rd or 4th, I'm usually more liberal with the speeds.

I'm happy to say I have NEVER witnessed, or heard of my units, having blood transfusion reactions. A very very small # of pts got pre-medicated with benadryl. On at least 3 occasions I can think of off the top of my head, blood bank did send us the WRONG BLOOD .. one of which was a few weeks ago where that error was terrible, as we were using the level 1 ... We caught it immediately on double check, but still, that time is precious :\

calivianya, BSN, RN · Mar 7, 2014

We do stay in the room and assess/check vitals after the first 10 minutes, but we start it at 120/hr so if a reaction is going to happen, it's going to show up fast. After the first 10 minutes we do every 30 minute checks until the blood is finished, and of course do one last set of vitals/assessment when it finishes. I don't see why anyone would walk out during that initial period. It's not a hassle, especially if you've already checked the blood off with another nurse, done your vitals, and hung it before you started the 0 minute charting. If you're standing at the bedside doing the 0 minute charting, by the time you're finished entering all of the information in it's already time for the 10 minute check anyway, so it's not like it actually takes any time away from patient care to stand there with your patient. Even if you had to wait 15 minutes instead of 10, what's five minutes of conversation with the patient or family if it makes the difference between you catching a reaction at "I feel weird" vs. when the patient's throat swells closed.... it's going to really screw up your time management if you have to call the code team up to intubate your patient. Just saying.

MunoRN, RN · Mar 7, 2014

I've actually never heard of having to stay in the room as an established rule. I would assume that these Nurses also stay in the room during the first portion of an antibiotic infusion?

annie.rn · Mar 8, 2014

I've actually never heard of having to stay in the room as an established rule. I would assume that these Nurses also stay in the room during the first portion of an antibiotic infusion?

Every place where I have worked has had staying in the room for the first 15 minutes written into the policy and procedure for blood transfusion. I was assigned to be the unit trainer on blood transfusion in one of the ICU's I worked in so I got pretty familiar with the policy :-)

As for why we don't do the same with abx., I'm not sure. When I administered Amphotericin B way back in the day, we had to stay with the pt. during the first 3O mins. of the infusion and do frequent vital signs throughout. If a nurse has the time (ha!) it probably would be prudent to lag around during the beginning of an abx. infusion if the pt. has never had it before.

Here is a link I found from the University of Michigan:

https://www.pathology.med.umich.edu/bloodbank/faqs.html

Here's an excerpt:

"Transfusion policy dictates that the nurse must stay in the room of a patient receiving blood for the first 15 minutes of the transfusion. Give the blood very slowly infusing no more than approximately 25ml (proportionately smaller volumes for pediatric patients) in this first 15 minutes. This reaction is dose and rate related. The more of the incompatible blood that the patient gets, and the faster they receive it, the worse will be the outcome."

I was once indirectly involved in a very bad patient situation where the wrong blood type was given. I won't go into specifics of how this logistically happened for privacy's sake.

During the first 15 minutes of the transfusion, the pt. complained of back pain and mild itching. The nurse stopped the transfusion, ran NS and called the resident. He told her to give Benadryl and resume infusion. The nurse didn't feel right about it and called the attending. The attending backed up the resident. The blood was resumed. This was night shift. When I came in the next AM, the pt. was majorly crumping. No UOP, fluid overload, resp. distress. Transferred to ICU. The docs all huddled around trying to figure out what could be wrong. Nurse brought up the blood transfusion. They would not consider this as a possibility. Pt. received a second unit of the wrong blood type in the ICU. Pt. did not survive.

Had the transfusion been stopped and a work up been done when the symptoms presented, the outcome could have been avoided.

The nurse was a very good nurse but she took the fall for this situation. No, she didn't lose her license but it took a tole on her professionally.

I have seen a handful of blood transfusion reactions in my career...mostly when working in oncology where the pt.'s often had multiple antibodies built up from prior transfusions. All have been more subtle than one might think. Even in the above scenario when the pt. was given the wrong blood type, the symptoms were not as obvious as one would expect.

This, to me, illustrates the importance of being on the ball during a transfusion and listening to your gut if you think something is not quite right. I know the nurse involved in the above scenario wished she had taken the ridicule/anger/whatever of the doctors and done a transfusion reaction work up. I don't know that I would have done differently than she did if I was receiving that much resistance from the doctors but I have never forgotten it and it is always in the back of my mind when I give blood or when something just doesn't seem quite right.

Thanks for bearing with me. Sorry so long.

calivianya, BSN, RN · Mar 8, 2014

I've actually never heard of having to stay in the room as an established rule. I would assume that these Nurses also stay in the room during the first portion of an antibiotic infusion?

Not really sure why antibiotics would matter - patients can be allergic to anything. I had a patient who was allergic to Benadryl once. I always wondered if there was something else to give her besides just epi if she had a reaction to something else... but I digress.

I think the biggest problem with blood, and the reason patients have to be watched, is that blood is not standard in the slightest. I don't know how thorough a crossmatch really is but reactions happen because of foreign leukocytes, plasma proteins, etc. too. I know even a unit of leukocyte-reduced, irradiated PRBCs could potentially still have a few donor leukocytes in it, which can cause a reaction in the patient receiving that unit. I know crossmatches involve samples of both the donor blood and the recipient blood, but what if there are only a few leukocytes from the donor in the whole bag and the little sample they draw up from the unit doesn't have any of those leukocytes in it? It seems like something that could cause a reaction could get missed quite easily.

However, I've never worked in the lab so I honestly don't know how thorough a crossmatch really is. Does anyone know?

NPOaftermidnight, MSN, RN, NP · Mar 12, 2014

I don't think anyone actually stays in the patient's room for the whole 15min where I work, but we definitely keep a close eye on the patient. I generally am in the room for about 5 minutes, and then I'm in and out and at least laying eyes on the patient every few minutes until the blood is done. I usually just set the monitors to q15 for the whole transfusion, which is generally not that long since we almost always run it wide open on bolus tubing, sometimes with a pressure bag depending on the situation. The only exception is in a patient with a cards history and then we'll run it on the pump over a couple hours.

I have never seen a blood transfusion reaction, and have been told how rare they are. I have to say that after hearing your stories, I will be a little more careful next time I hang blood.

sugarmagnolia3 · Mar 12, 2014

I prime with saline, and run wide open until the blood almost reaches the patient. Then I start at 75mL/hr for 15 minutes. I stay close by. Then I turn up to 120-150/hr. To the poster that said they run all blood wide open: Why would you run it so fast, unless your patient was bleeding out?