Leaking blood during transfusion

[fiveoclocksomewhere]

So the other day I hung blood for the first time ever, and the charge nurse was in the room with me to walk me through it. Very time consuming but she assured me that it gets easier the more you do it. Anyway, the pt had an 18 gauge iv and my charge nurse told me that they need at least a 20 gauge, but she had given blood through an 18 and that it should be fine. So we started the blood at 90ml/hr and the pt complained of itching at the site. Called the MD and she said to keep it going and see how she does. After about 30mins, blood starts seeping out all around the iv site and around the tape. Stopped the infusion and the charge came in to see it, said it had infiltrated. Is this because of the 18gauge?? Or did some kind of reaction happen?

[tamadrummer]

What I usually do is get my set up ready, prime the line with NS, start the pump with the NS going at around 30cc/hr then go to lab get my blood check it with another RN and then hang it. That way you know you're IV is good before starting. The pt maybe gets around 10-15 cc of NS before I'm ready to start...but at least it's a constant flow of NS keeping the vein open.

And, you can give blood through a 22g (not the best situation, and it always seems like the hardest sitcks need some type of blood product). When I have a 20g I'm thrilled...an 18g and I'm downright EXCITED!

I will begin to use this idea from now on. I usually go get my blood and run NS at 125 for about 5m while checking and signing and spiking to make sure the site is patent and not leaking but starting before I even go to the blood bank and and being ready to simply spike the bag, knowing full well I am safe to use without delay makes awesome sense.

As far as that patient being d/c in the AM, who knows. If they only needed one unit, they probably were not too far off from their normal h&h and as long as they have decent blood making capacity, they will recover just fine. Not like my active GI bleed lady with an h&h of 6.5/20.7 and such high antibody containing blood that we had to go all over FL to find non-antigen containing blood. Took hours and hours and hours. Was an ugly night Friday night.

[limaRN, BSN, RN]

It seems to me that your IV had just infiltrated. I think it's important to point out, however, that once the patient reports any signs/symptoms of a transfusion reaction such as itching the you should immediately discontinue the transfusion, flush the IV, ad then notify the MD. I find it interested that the doctor wanted to continue the transfusion when the patient was reporting symptoms even if they were only relatively benign such as itching... Always remember to save the blood bag if you ever have a patient that develops s/s of a transfusion reaction (because the blood bank will want it)!! What do you guys think?

[hiddencatRN, BSN, RN]

It seems to me that your IV had just infiltrated. I think it's important to point out, however, that once the patient reports any signs/symptoms of a transfusion reaction such as itching the you should immediately discontinue the transfusion, flush the IV, ad then notify the MD. I find it interested that the doctor wanted to continue the transfusion when the patient was reporting symptoms even if they were only relatively benign such as itching... Always remember to save the blood bag if you ever have a patient that develops s/s of a transfusion reaction (because the blood bank will want it)!! What do you guys think?

I've had patients who receive routine transfusions who are often premedicated with an antihistamine prior to transfusion because they get minor reactions such as itching. They still need the transfusion, so we deal with the itching.

[limaRN, BSN, RN]

I've had patients who receive routine transfusions who are often premedicated with an antihistamine prior to transfusion because they get minor reactions such as itching. They still need the transfusion, so we deal with the itching.

I agree hiddencat- I suppose it depends on how severe the reaction is. If it is just itching this particular patient may need to be pre-treated anti-histamines or corticosteroids with subsequent transfusions. I would just be wary that the reaction did not develop into anything worse! I hope that the patient would at least be monitored more closely for changes in vital signs or any signs of respiratory compromise :)

[decembergrad2011, BSN, RN]

If my patient was itching I would stop transfusion, check site, and assess vitals. If site and VS were ok, I would call the doctor and ask for additional benadryl and continue transfusion. Make sure lines are patent before running anything, but especially blood, antibiotics, and vesicants such as chemo. You can easily check blood return on central lines usually if you're unsure.

[classicdame, MSN, EdD]

Could have been DIC! Talk to the lab medical director for insight. Ours is very accessible and trains the nurses to look for the zebra not the horse

[Anna Flaxis, BSN, RN]

Somehow I doubt this was DIC, but you're right, it's a good thing to keep in mind.

[Jenni811, RN]

18 is bigger than a 20...it's backwards as to what you would think. So the gauge as nothing to do with it.

IV's infiltrate frequently, that is why we assess every shift. It happens...it can happen with saline running. Did you assess it b efore you accessed it? like Flush it? check for blood return? (Although not all peripherals have blood return, and don't force it) Usually an IV in a large vein like the AC will have blood return.

[x4livin, ADN]

I have given blood many times through a 22. No problem. Just stay on it and watch for pump beeping showing you that it needs to be flushed. Flush at the closest port with NS. Let 'er run some more. If the patient is getting multiple units, though, while it is up and going, I would look for that second site, 20 or better will make it easier.

Your site didn't infiltrate because it was a 22 or because it was blood. It infiltrated for one of a couple of hundred reasons they do that. Patient moved it somehow, is generally the primary reason. An older IV site will wallow out and patients with fragile skin will do the same. The vein was exposed to something that caused it to swell or cord off(phenergan undiluted) or swelling to surrounding tissues or patient laying it somewhere that circulation was cut down. Not only will you give blood too many times to count in your career, the IV will infiltrate while you are doing it, blood, infusion, any other IV process, too many times to count. Don't stress it, just be good at IVs and pay closer attention to the stuff that can go bad(always dilute your phenergan, some IV meds are corrosive due too too basic or too acidic, some simply due to chemical composition-these are the one that should scare you enough to watch them very close-hence they are generally unit patients) In a few years, hanging blood will be as routing as hanging NS.

So the other day I hung blood for the first time ever, and the charge nurse was in the room with me to walk me through it. Very time consuming but she assured me that it gets easier the more you do it. Anyway, the pt had an 18 gauge iv and my charge nurse told me that they need at least a 20 gauge, but she had given blood through an 18 and that it should be fine. So we started the blood at 90ml/hr and the pt complained of itching at the site. Called the MD and she said to keep it going and see how she does. After about 30mins, blood starts seeping out all around the iv site and around the tape. Stopped the infusion and the charge came in to see it, said it had infiltrated. Is this because of the 18gauge?? Or did some kind of reaction happen?

[x4livin, ADN]

If itching at the site was the only complaint, I would stop the blood for a sec, flush fast with 10 or 20 of NS..."That hurt?"..if IV bad..new IV and resume. If not, continue and watch, closely. I might even just start a new site at the complaint of itching. Even though the patient may complain a bit, it is much nicer to poke than to infiltrate, and they will complain to the neighbors after they get home that you let an IV infiltrate, and it will be remembered, but if they complain that they got a new IV while in the hosp....and?

: )

[nurseynurse36]

Here is information about IV gauges and permissible transfusions from RN.COM.

Peripheral Access Devices

Practitioners insert more than five million peripheral IV catheters into patients each year.² This catheter is by far the most commonly used peripheral venous access device. In choosing size, a 22-gauge IV catheter is appropriate for the infusion of peripheral IV fluids and medications in adult patients. A small 24-gauge catheter is appropriate for neonates, pediatric patients, geriatric patients, and patients with small-lumen veins.^{1 (Level A)}

IV Catheter Flow Rates

• 18 gauge: 4,000 mL/hr
  
• 20 gauge: 3,500 mL/hr
  
• 22 gauge: 2,000 mL/hr
  
• 24 gauge: 1,500 mL/hr
  

A 20-gauge catheter is the most appropriate size catheter for adult blood transfusions, most pre-op patients and patients in labor. However, a 22-gauge catheter can safely infuse packed red blood cells into adults without damage or hemolysis to the red blood cells.^{1 (Level A), 3} A 24-gauge catheter is the most appropriate size for blood transfusions in neonates.

Gauge Selections

• 18 gauge: massive hemorrhage; major surgery
  
• 20 gauge: adult blood transfusions; preop patients; labor patients
  
• 22 gauge: routine IV therapy in adult patients; permissible for adult blood transfusions
  
• 24 gauge: routine IV therapy and blood transfusions in neonates; infusions in geriatric patients
  

Retrieved from: Avoiding the Pitfalls of IV Therapy | CE94-60 > Content

[x4livin, ADN]

Awesome reference! Thank you!