Blood transfusion: troubleshooting

[Aneri J.]

Hi! I'm a novice RN in the hospital. This month, I have handled two patients undergoing blood transfusions (my first time... and both patients needed packed RBCs) and at both instances I wasn't able to successfully transfuse 1 whole unit of PRBCs (the first patient got half of the blood in the bag, the other got

I know that blood products should be transfused within 4-6 hours. What are the things that I could do when a blood transfusion slows down (so slow that the whole bag may not be transfused within the 4-hour time frame)? I tried to raise the level of the blood bag and PNSS (we transfuse PRBCs with normal saline ran at KVO), and reposition the client's arm, but none of those measures worked.

I don't want to waste any blood products again. I look forward to your replies. Thank you very much!

[Karou]

Are you not using a pump?

[blackribbon]

Are you able to transfuse on a pump? Then you have control over the rate. We start at about 100ml/hr and after 30 minutes, if they are tolerating it well, up the rate to 150ml/hr. My bags are usually infused in 2.5 to 3 hours.

Why is it running so slow?

Are you using large enough IV catheters? 20 gauge or larger?

Where is the catheter? If it is in the AC, is the patient using that arm or bending it? (a pump will alarm if this is happening)

I know when we run ours, we prime the line with normal saline and flush the line with normal saline at the end, but we do not dilute the PRBC in anyway while infuse. Diluting it will slow down the rate that is actually getting in because the volume infusing is part saline and not blood. I don't know what your KVO rate is but if it is 20ml and you are only transfusing at 100ml hour, the patient is only getting 80ml of blood per hour. For an older patient, you risk fluid overloading them before they get the full unit of blood.

Others may have better advice since I have only been an RN for a year but I do hang blood products on a relatively regular basis. The only time I ever have trouble with anything IV running slow is when someone else set it up to run on gravity. I always switch to a pump because I want to know exactly what got into my patients. Now, that doesn't mean I don't fight with the pump always alarming but at least I know there have been occlusion issues.

For badly located IVs, the conservative thing to do is to wrap a folded pillow case or towel around the site (usually the elbow) and tape it in a soft split to remind the arm and the patient to keep it straight. This works some of the time. You could also be starting a new IV on the other arm in a better location (forearm where there is nothing to bend) with a larger IV catheter while infusing and switch administration sites if nothing else works.

In the worse case scenerio, can you blood bank bag the blood in 1/2 bags so that half the unit is sitting safely in the blood bank without the clock ticking and then just extend the time you have to infuse (4 hours for each 1/2 bag)? I've never needed this but I know we were told this was an option in nursing school, especially for older clients who couldn't tolerate the faster infusing rates.

[KatieMI, BSN, MSN, RN]

I assume you use Y-type tubing. Then you can dilute the PRBC with saline before transfusion to decrease viscosity. Here is how:

1. Prime the whole thing with saline. Close both upper clamps.

2. Hung both bags on pole. Make 100% sure the clamp below drip chamber is closed.

3. Take only blood bag from the pole, keep it below the saline bag. Make sure all tubes are free from twists.

4. Open upper clamp on blood bag.

5. Open upper clamp on saline bag and start to gently agitate blood bag as saline flows in it. Let about third of saline to move into blood.

6. Close both clamps, hung the blood bag and proceed with your transfusion.

Do not keep blood and saline running at the same time, even at KVO. Saline is much less viscous and less heavy, and by the law of physics will make blood flow slower.

Use IV cath at least 22g, and better yet 20 or 18.