Mass Transfusion Questions

Emergency RN · Dec 12, 2009

i don't know about the or, but in the ed the only time that we ever run multiple blood products together or use the same lines is if the patient's life is at stake (and yes i've done it more times than i care to remember). the idea behind not using the same tubing or running products separately is if the patient has a reaction, it makes it easier to identify and stop the individual product that he reacted to, so that said item can then go back to the blood bank for analysis. (another reason why blood is also given over 3-4 hours is that less potential allergen is rapidly infused, in addition to the traditional fear of artificially inducing heart failure).

that said, if the patient on the gurney is in danger of dying, then all bets (and many safety margins) are off. i remember one horror of a trauma, 19 yo mva; we had three blood bags simultaneously under pressure (along with the routine crystalloids), as we ran with the stretcher from the ed to the or. the blood ran off the stretcher faster than we could pump it into the poor kid and we marked the path we took with a river of blood. the patient eventually died on the table, but not before running our blood bank out of o neg.

the fact that you had "...4-5 units had gone through" of a combination of ffp and prbcs, and a splenectomy, bespeaks volumes as to the clinical precariousness of your patient.

also normosol is saline; normosol-r is essentially ringer's but specifically without the calcium (and with na-acetate replacing na-lactate).

questionsforall · Dec 12, 2009

If we are using a rapid transfuser we will put everything together, except for the platelets because platelets cannot go through the rapid transfuser. I am not sure of the reason platelets can not run through rapid infuser. I love the rapid infusers because you can run 500 ml/min (beats pressure bags).

Also, was the blood results hemolyzed. Because if the blood drawn for labs hemolyzed due to the way they were drawn. If the specimen hemolyzes than the K will be higher than it truly is.

If the specimen was not hemolyzed and is a true specimen than it could be a transfusion reaction. Also, we always give blood from a rapid transfuser through a central line (preferably a cordis).

OutdoorLovinRN · Dec 13, 2009

Thank you Emergency RN and Questionsforall,

You really did a great job of answering my questions. One question that is still unanswered is: do I need to change the filter on the Level 1 even if it still seems to be infusing fine? Do you routinely change it after 4 units?

Our pt's labwork continues to look good. It's a nice feeling to see that his coags, h and h, fibrinogen, and lytes are currently looking adequate.

He got 8 units of blood, 6 of FFP, 1 unit platelets, and 1 "cell saver" which is apparently autotransfusion....I think one of the OR people must have prepared that and the anesthesiologist just shouted to me that he was hanging it. This was all between 7 AM and 0915 AM. Plus I was running fluids and the anesthesiologist had him on phenylephrine at one point-but he was off it before we took him to the unit. I checked on him a little more than an hour later and his systolic blood pressure was in the low 200s (not on any pressors). I didn't get his heart rate from the icu rn. But I'm not sure what mechanism would make post surgery bp that high?

And, someone at work today also suggested the blood might have been hemolyzed to give that K of 7.1. It was done on an I-stat. Anyway, they treated him for high K and follow up lytes looked good--so maybe it was real since K didn't tank with the treatment.

out of curiosity, Do RNs do I-stat at your hospitals?

suanna · Dec 13, 2009

Not a trauma expert, but what I was told MANY years ago: The flow of the fluid has little relationship to the effectiveless of the filter. A filter may have reached its "capacity" of particles and is allowing more debris to pass through to the patient than would be normal with a new filter. That is why you need to change filter/tubing every x units as recommended by each tubings/filters manufacturer.

PostOpPrincess, BSN, RN · Dec 13, 2009

Platelets should run by itself--no pressure bags--open full force--..You can damage the platelets very easily....Otherwise,...agree with above posters....I probably would have been sticking a HUGE gauge needle into the jugular and squeezing the blood in...but...I wasn't there with you so....the filters would've been a non-priority issue since the patient's status was hypercritical.

As for the B/P in the 200's...patient may have a received a pressor bolus as anesthesia tends to IVP NEO/EPI/etc., with a syringe...could've been no time for the drip stuff...did you check after the awhile if the B/Ps remained high?

Jo

OutdoorLovinRN · Dec 13, 2009

Hi JoPACURN,

Thanks for sharing with me your knowledge about platelets. The anesthesiologist took those from me and hung them-without pressure I do believe.

And, I see your point, if in the future there are not enough hands and pt is uber-critical, I probably shouldn't delay hanging blood because "4 units have infused" on the filter-especially if the blood is still infusing fine on the old filter. Fortunately, there was someone who brought the filter to me and changed it while I was checking the additional units of products with someone else.

I didn't get to go back to the unit to see how the pt's vs did later and I don't have close contacts up there.

Thank you so much for your insight. Everyone on here has been so great in answering my questions and sharing their experiences.

PostOpPrincess, BSN, RN · Dec 14, 2009

You should make friends with people in the ICU and even find a mentor there. You could learn a lot.

That's how I end up working all over the hospital. I just loved to learn and it showed.

Made a LOT of friends and cross-trained everywhere.