KVO After Blood Transfusion

Lev, MSN, RN, NP · Dec 22, 2015

Hi Everyone! I'm currently a nursing student and we recently just learned about blood transfusions. I kept reading about how after the patient has a blood transfusion reaction, you should "Keep the vein open" with normal saline to maintain IV access in case we need to administer an emergency medication. I don't get how running normal saline at a slow rate will maintain the IV access, can't you just insert the new IV but not have the saline run, or at least just do a saline flush? Does the continuous saline infusion just wash out all the clots?
Thank you for your help in advance!

When your patient has signs of a transfusion reaction, you first stop the infusion, run the normal saline (does not have to be at KVO, can be faster), get vital signs, and then notify the physician. You don't spend time getting a new line. Even if the fluids are infusing at a KVO rate, that is still adequate to keep the current IV open.

MunoRN, RN · Dec 22, 2015

This is an area that could certainly be better defined through more research, but what the research to this point has shown is that using a TKO / KVO rate is not any more effective at keeping the line patent that intermittent flushing, at least when the flushing is done correctly. There are other factors to take into account; is the TKO also being used to infuse and flush IV push medications? How frequently would the line need to be connected and disconnected if not using a TKO rate and what sort of infection risk does that pose? How mobile or confused is the patient, does keeping the tubing constantly connected significantly increase losing the line because you have the IV tethered to something unnecessarily?

There's not really one specific answer that works for all patients, but in general there isn't clear evidence to say that an IV will more likely to remain patent if a TKO infusion is used.

Hope888 · Dec 22, 2015

Thank you for your reply MunoRN! That makes so much sense. That's nursing for you I guess, there is never really a clear-cut answer, as everything can vary depending on the situation and the patient. However, would it be correct to say that the rationale for TKO is to keep the line patent from blood clotting, esp since we just administered blood that caused a reaction would it tend to make the blood clot even more?

iluvivt, BSN, RN · Dec 22, 2015

It never made ANY sense to me to continue to infuse ANY more blood once it had been identified as causing a blood transfusion related reaction. So I do not switch over to saline rather I disconnect it from the catheter hub or needleless connector, then I just flush it.The key point is to keep your line open, whether that be a CVAD or PIV so you can administer diphenhydramine and other medications or fluids.

By all means though, answer on your tests with how they taughtit but the clinical reality is different if you suspect a true hemolytic reaction. With other types of non-hemolytic reactions, you can continue to infuse the blood and treat the symptoms at the same time or even before if there is a high likelihood of a reaction.

Generally speaking, smaller gauge catheters tend to clot off faster, for example if the RN lets the bag run dry.

MunoRN, RN · Dec 23, 2015

Thank you for your reply MunoRN! That makes so much sense. That's nursing for you I guess, there is never really a clear-cut answer, as everything can vary depending on the situation and the patient. However, would it be correct to say that the rationale for TKO is to keep the line patent from blood clotting, esp since we just administered blood that caused a reaction would it tend to make the blood clot even more?

Alterations to normal clotting can occur with transfusion reactions or result from transfusions without reactions to varying degrees, these alterations can be either abnormal clot formation, abnormal failure to clot, or both at the same time.

Obviously, what is being transfused and how much relative to overall circulating volume is a big factor. RBC transfusion do not contain clotting factors, and so can result in a dilution of clotting factors in the patient's whole blood. FFP and platelets can improve the ability to clot, since that is a big part of why they are administered.

With proper technique, the line should be just as well protected for future use with flushing and locking, particularly when a cap intended to prevent reflux of blood into the catheter when disconnecting is not used. It's extremely important to make sure the line is clamped before removing the flush syringe or the tubing, if this isn't done, then a volume equal to what the male end of the tubing or syringe occupied will be pulled into the line, which being stagnant and exposed to a foreign material will predictably clot over time. I'd have to guess that the reason why they've learned they can't trust a saline locked IV is that proper technique was not used, so as a result they've made a TKO infusion their regular practice.

iluvivt, BSN, RN · Dec 23, 2015

When you clamp depends upon the type of needleless connector you are using, whether that be negative.neutral or positive displacement.