How fast to you run a unit of blood?

Long Term Care Columnist / Guide · Sep 30, 2004

Unless otherwise ordered, I generally start blood at 75ml/hr, then check pt's VS & lungs and assess for reactions in 15 minutes (or less) . If all is going well, I'll increase it to 100-150ml/hr depending on the age and general health of the pt.; our units are usually 350-400ml, and our protocol calls for the entire volume to be infused within 4 hours from the time we take it from the blood bank.

Beyond that, I think it's mostly a matter of judgment and experience on the part of the individual nurse, and the condition of the patient. I've given a lot of transfusions to a wide variety of pts, so I'm pretty confident in my assessment skills; however, I would recommend you ask a more experienced nurse to walk you through the procedure a few times if you're new or you haven't done a bunch of them. The mechanics of it are simple; but it takes time to learn what can go wrong and what to do when it does. I've seen little elderly people go into full-blown CHF in a matter of minutes despite going slow and giving Lasix in between doses; I've also seen people tolerate three units without the slightest indication of trouble and then have a massive reaction in the middle of the fourth unit.

Most of the time, of course, transfusions go well, and they are lifesaving.....it's just when things go bad, they tend to go bad very quickly, and you've got to be prepared to act FAST if they do. :)

talaxandra · Sep 30, 2004

In Australia there's only one source of blood products, so unit size is universal. A unit of packed cells is 260 - 300ml. At my hospital we run blood in over 3 - 4 hours/unit unless the patient is actively bleeding - when I was in theatre and we had a patient with a ruptured aorta we ran in a unit a minute (sadly to no avail). The bag has to be hung within thirty minutes of release from blood bank, but I'm not aware of any end-time limit for transfusion. Given Lasix between units used to be standard unless the patient was dry, but that isn't always the case any more. Hmm - I mean that some patients don't have a Lasix prescription, not that it's ordered on dry patients as well! I've looked after a few patients with low Hb's, but they're usually that way because of a long-standing issue (like renal dysfunction), so there isn't so much urgency, and we run it at the usual rate.

TraumaQueen · Sep 30, 2004

Our hospital has a protocol on running blood..... -however-.....I work in a trauma unit, and on patients that are bleeding out, sometimes a unit of blood goes in over less than 2 minutes.....

Patients that are just getting a routine transfusion, usually get their blood over a few hours.

It's purely situational. :)

Tweety, BSN, RN · Sep 30, 2004

RN1976Nurse said:
Thanks that's how I run blood. You do have to take in consideration the age and condition of the patient and I think that's most important. Our hospital does only allow 3 hours for the blood to infuse once it's been spiked. With 360cc of blood in a unit it makes it kinda rough sometimes when you have a little frail patient especially with CHF. Of course then lasix is in order. Alittle off subject here, I once saw a nurse push the lasix in the line with the blood towards the end of the infusion. I told her no! I learned nothing but NS mixes with blood. Correct?

Correct. Blood is to be run separately from all medications and IV fluids, except normal saline.

eph432girl · Sep 30, 2004

I have worked in the Blood bank for 12 years now (start nursing school in spring) and I want to clarify some points that I have read in response to the original post.

#1 Once you spike the unit of blood, it becomes an OPEN SYSTEM. The American Association of Blood Banks (AABB) and the Technical Manual (blood bank Bible) state than an open system has an expiration time of 4 hours... SO, once you spike the bag, you have 4 hours to infuse the product. The reason is because of microbial contamination and the log growth rate of microorganisms (Yersinia and Staph are the most frequent culprits of bacterial contamination. Yersinia because it is one of the few microbes that can live at 1-6C and Staph because it is everywhere and hard to kill -- as you know).

** this is also why when we pool platelets or FFP for ya, you have to have it in by 4 hours... The pooled product is an open system and there is a risk of contamination when we pool it.... especially with PLTS because those are always stored (and rocked) at room temp.

#2 NEVER, NEVER, NEVER, NEVER, NEVER run any meds in the same line as blood products. You might luck out and not cause harm, but you also might cause the red cells to hemolyze with a hypotonic solution and KILL your patient. NEVER, NEVER, NEVER...

#3 the expiration date of the unit does depend on the anticoagulant used during collection. The outdate is either 35 days 42 days (from the date of collection) depending on whether or not it was collected in ACD or another preservative. This affects the unit outdate which is in written on the bag usually in the top right hand corner. When you sign out the unit does not affect this date.

#4 - if you are giving PRBCs that have been irradiated, that WILL change the original outdate (from 35 days or 42 days) to 28 days. Reason: Irradiation causes the red cell membrane to become more fragile and risk of hemolysis increases (and K+ can do a number on your patient if this happens)

#5 - once you sign out a PRBC, generally you have 30 minutes to return it to the blood bank if you don't spike it. Reason: blood must be kept at 1-6C to prevent microbial growth. AABB and the technical manual both state that 30 minutes is the limit that a unit can sit at Room Temp and still be in temp range. So, remember this in case your patient spikes a temp, you cannot find the consent, he blows his IV, etc.... and take it back to Blood bank before your 30 minute window. You can always check it back out once you get things under control and also that way a unit of blood does not go to waste (ouch - they collect units with either 18g or 16g needles - it is precious, painful to get, and it's expensive - let's not waste it)

#6 - regarding trauma patients: I have given blood to OR for dissected AAA or horrible GSW when they infused them in literally minutes. I have taken 4-5 units to the OR at a time and then ran back to BB to get more.... I am not aware of procedures (from the blood bank side) that says how fast a unit should be infused... most of the time it is as the patient tolerates it. Most of the time on relatively stable patients you can still give it over 2 hours.. and think about this: Your young female patient who had the 5gm Hgb... she did not get that way over night.... or over the last week (or else she would have bled out and had more acute symptoms). Many patients (menstrating females and the elderly) have been chronically anemic, have inadequate intake of Fe, and have a gradual drop of HH over time. They compensate for this slow drop. They feel tired, weak, etc... but generally they are functional in their lives and they are the people who WALK into the Dr office or ER complaining of fatigue... point is... they WALK. Now, if you go and stuff 3 units in them in 6 hours - when they have compensated and adjusted to their low levels -- that will shock their systems. So, I say slower is better...JMHO.

Hope this helps.... and when in doubt...... call the blood bank

Chrisine BS(MT), MT(ASCP)

flaerman · Oct 5, 2004

I usually run blood in over 2 hours unless the patient is a cardiac/CHF, then I run over 4 hours. In the ER with critically hypovolemic pt's we run just open it and run it in ASAP.

Haunted · Oct 5, 2004

Orange County we get our units in about 240-250cc packs, protocol for that amount is to hang no longer then 3 hours. often we give lasix inbetween if we are giving another unit. ER you have an infusion bag that looks like a bp cuff to literally blow blood and fluid in, deal with the other issues later. Cool question!

teeituptom, BSN, RN · Oct 5, 2004

In the ER, the only times Ive hung blood, is usually associated with trauma and each unit goes in about 3 minutes on the Level One infuser.

Didnt know you could hang blood over 2 to 4 hours, we never do it.

mattsmom81 · Oct 6, 2004

If you don't know 'how fast' yourself, best to ask the prescribing doc for guidelines. Don't just assume. In ICU with a 'dry' patient who is postop, fluid shifting and/or hemmorhaging, I may run multiple units together. But I cannot blindly make this decision...which is one of the judgment skills in nursing.

If this is a multi system patient I will prioritize with the nephrologist's advice as he knows the most about his patient. This can be tricky with multiple specialists who may ALL be trying to run things and, again, it takes a nurses' skill and judgment to balance all the physician's input, whose authority overrides whose, etc.

RedBait · Oct 6, 2004

eph432girl said:
I have worked in the Blood bank for 12 years now (start nursing school in Spring) and I want to clarify some points that I have read in response to the original post.
#1 Once you spike the unit of blood, it becomes an OPEN SYSTEM. The American Association of Blood Banks (AABB) and the Technical Manual (blood bank Bible) state than an open system has an expiration time of 4 hours... SO, once you spike the bag, you have 4 hours to infuse the product. The reason is because of microbial contamination and the log growth rate of microorganisms (Yersinia and Staph are the most frequent culprits of bacterial contamination. Yersinia because it is one of the few microbes that can live at 1-6C and Staph because it is everywhere and hard to kill -- as you know).
** this is also why when we pool platelets or FFP for ya, you have to have it in by 4 hours... The pooled product is an open system and there is a risk of contamination when we pool it.... especially with PLTS because those are always stored (and rocked) at room temp.
#2 NEVER, NEVER, NEVER, NEVER, NEVER run any meds in the same line as blood products. You might luck out and not cause harm, but you also might cause the red cells to hemolyze with a hypotonic solution and KILL your patient. NEVER, NEVER, NEVER...
#3 the expiration date of the unit does depend on the anticoagulant used during collection. The outdate is either 35 days 42 days (from the date of collection) depending on whether or not it was collected in ACD or another preservative. This affects the unit outdate which is in written on the bag usually in the top right hand corner. When you sign out the unit does not affect this date.
#4 - if you are giving PRBCs that have been irradiated, that WILL change the original outdate (from 35 days or 42 days) to 28 days. Reason: Irradiation causes the red cell membrane to become more fragile and risk of hemolysis increases (and K+ can do a number on your patient if this happens)
#5 - once you sign out a PRBC, generally you have 30 minutes to return it to the blood bank if you don't spike it. Reason: blood must be kept at 1-6C to prevent microbial growth. AABB and the technical manual both state that 30 minutes is the limit that a unit can sit at Room Temp and still be in temp range. So, remember this in case your patient spikes a temp, you cannot find the consent, he blows his IV, etc.... and take it back to Blood bank before your 30 minute window. You can always check it back out once you get things under control and also that way a unit of blood does not go to waste (ouch - they collect units with either 18g or 16g needles - it is precious, painful to get, and it's expensive - let's not waste it)
#6 - regarding trauma patients: I have given blood to OR for dissected AAA or horrible GSW when they infused them in literally minutes. I have taken 4-5 units to the OR at a time and then ran back to BB to get more.... I am not aware of procedures (from the blood bank side) that says how fast a unit should be infused... most of the time it is as the patient tolerates it. Most of the time on relatively stable patients you can still give it over 2 hours.. and think about this: Your young female patient who had the 5gm Hgb... she did not get that way over night.... or over the last week (or else she would have bled out and had more acute symptoms). Many patients (menstrating females and the elderly) have been chronically anemic, have inadequate intake of Fe, and have a gradual drop of HH over time. They compensate for this slow drop. They feel tired, weak, etc... but generally they are functional in their lives and they are the people who WALK into the Dr office or ER complaining of fatigue... point is... they WALK. Now, if you go and stuff 3 units in them in 6 hours - when they have compensated and adjusted to their low levels -- that will shock their systems. So, I say slower is better...JMHO.
Hope this helps.... and when in doubt...... call the blood bank
Chrisine BS(MT), MT(ASCP)

Thanks so much for the complete and concise review of blood and blood products administration. I would only add, that when you have a particularly fragile patient, one with a history of flash pulmonary edema, for example; get an order for the blood bank to split the unit which will buy you a little more time. You could give the first half in two hours and then wait to pick up the second half until diuresis can be accomplished. The blood itself cannot go in slower, because opening the unit to repackage it reduces it's "safe" life, just like pooling units does, but you can space out the delivery times and minimize the risk of overload. In theory, it could be divided into three or four aliquots, but I have only seen two.