Question about blood transfusion...

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Specializes in Medicine.

Hello everyone,

I just had a question regarding blood transfusions. I had a patient couple of days ago with a hemoglobin of 76 g/L, the doctor ended up ordering 3 units of RBCs. Initially the patients blood pressure was 118/77 and about 15-20 minutes after beginning at 50cc/hr I took the vitals and her BP dropped to 82/60. No concerns were voiced by the patient and he/she denied any other symptoms when asked. I informed the charge nurse and paged the doctor. The charge nurse said to continue and increase the rate as I normally would have. I waited for the doctor to call back and he told me to do the same but to page him if the systolic dropped below 75.

I increased the rate to 100 (order was received as 100cc for first hr then increase by 50 to max of 200/hr as tolerated) and closely monitored the pt and the BP dropped to 72/60. I once again called the doctor, who took a moment and said to continue as she would benefit from the blood later on.

The BP slowly increased by the end of the second unit and by the end of the third unit, it was up in the 100s/D.

Have any of you nurses seen situations where the blood pressure dropped like this and did you continue to increase the infusion rate? I could just be so new at this but I never seen blood pressure get that low after giving blood. I also should mention I had this pt for 3 nights in a row and her BP was always normal or slightly elevated.

Would this be considered a reaction? How would it be determined if there were no other symptoms indicating a reaction? Would you have done something differently?

Thanks for any feedback!

Maybe I'm just paranoid but I was afraid she was having an allergic reaction.

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Specializes in Critical Care.

Was the patient on an ACE inhibitor and getting leukoreduced blood? Those patients are the most vulnerable to "Acute Hypotensive Transfusion Reaction".

Anaphylaxis often includes hypotension, but it also usually includes many other effects that should have been noticeable. AHTR is usually just hypotension. I think it is only leukoreduced blood that is likely to cause it since it is due to activation of bradykinin by the leukoreducing filter. ACE is responsible for breaking down bradykinin so more of it is left circulating and triggering hypotension with use of an ACE. I would think extra bradykinin would effect anybody's BP, but you mainly only hear about when seen in patients taking ACE inhibitors, making it more obvious.

It may also been unrelated to blood, maybe they had a rebleed of whatever caused their anemia in the first place.

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wow, i never knew that ACE inhibitors could drop BP with blood transfusions. That's good to know.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Was the patient on an ACE inhibitor and getting leukoreduced blood? Those patients are the most vulnerable to "Acute Hypotensive Transfusion Reaction".

Anaphylaxis often includes hypotension, but it also usually includes many other effects that should have been noticeable. AHTR is usually just hypotension. I think it is only leukoreduced blood that is likely to cause it since it is due to activation of bradykinin by the leukoreducing filter. ACE is responsible for breaking down bradykinin so more of it is left circulating and triggering hypotension with use of an ACE. I would think extra bradykinin would effect anybody's BP, but you mainly only hear about when seen in patients taking ACE inhibitors, making it more obvious.

It may also been unrelated to blood, maybe they had a rebleed of whatever caused their anemia in the first place.

My thoughts exactly

:yeah:

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Specializes in Oncology/Hematology, Infusion, clinical.

I have seen BPs drop/rise despite increasing/decreasing rates of transfusion. They have occurred in the presence and absence of a transfusion related reaction. The patient's dx, history, current meds, and the presenting symptoms are key factors in determining the course of action in such situations. Without consideration of these things in conjunction with a change in baseline BP and the fact that a transfusion is in progress, how to respond is just a crapshoot. I suppose that in the absence of such information, and suspicion of a transfusion reaction, it would be ideal to do a tx workup since the degree of severity increases with the amount of blood the patient receives. In your specific situation, with the given information, I would have been willing to continue the tx with close monitoring, and unless in a critical care environment, would have been concerned had the pressure gone much lower despite an increased tx rate. Just my personal thoughts, in which I am very open to consider. :rolleyes:

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Specializes in Developmental Disabilites,.

My hospital considers that a transfusion rxn. You have to stop the blood, call the md, call the blood bank and the house supervisor. Those groups then have a procedure to follow which may include restarting the blood with close supervison.

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Specializes in floor to ICU.
Was the patient on an ACE inhibitor and getting leukoreduced blood? Those patients are the most vulnerable to "Acute Hypotensive Transfusion Reaction".

Anaphylaxis often includes hypotension, but it also usually includes many other effects that should have been noticeable. AHTR is usually just hypotension. I think it is only leukoreduced blood that is likely to cause it since it is due to activation of bradykinin by the leukoreducing filter. ACE is responsible for breaking down bradykinin so more of it is left circulating and triggering hypotension with use of an ACE. I would think extra bradykinin would effect anybody's BP, but you mainly only hear about when seen in patients taking ACE inhibitors, making it more obvious.

It may also been unrelated to blood, maybe they had a rebleed of whatever caused their anemia in the first place.

THAT'S why I love this site. You learn something new all the time. Thanks!

Up Vote Up Vote ×
Was the patient on an ACE inhibitor and getting leukoreduced blood? Those patients are the most vulnerable to "Acute Hypotensive Transfusion Reaction".

Anaphylaxis often includes hypotension, but it also usually includes many other effects that should have been noticeable. AHTR is usually just hypotension. I think it is only leukoreduced blood that is likely to cause it since it is due to activation of bradykinin by the leukoreducing filter. ACE is responsible for breaking down bradykinin so more of it is left circulating and triggering hypotension with use of an ACE. I would think extra bradykinin would effect anybody's BP, but you mainly only hear about when seen in patients taking ACE inhibitors, making it more obvious.

It may also been unrelated to blood, maybe they had a rebleed of whatever caused their anemia in the first place.

Thank you, not only for sharing this important knowledge, but for explaining it so well.

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Specializes in Medicine.
Was the patient on an ACE inhibitor and getting leukoreduced blood? Those patients are the most vulnerable to "Acute Hypotensive Transfusion Reaction".

Anaphylaxis often includes hypotension, but it also usually includes many other effects that should have been noticeable. AHTR is usually just hypotension. I think it is only leukoreduced blood that is likely to cause it since it is due to activation of bradykinin by the leukoreducing filter. ACE is responsible for breaking down bradykinin so more of it is left circulating and triggering hypotension with use of an ACE. I would think extra bradykinin would effect anybody's BP, but you mainly only hear about when seen in patients taking ACE inhibitors, making it more obvious.

It may also been unrelated to blood, maybe they had a rebleed of whatever caused their anemia in the first place.

Thank you so much for this information. She was on Altace and I never knew about the interaction of ACE inhibitors and leukoreduced blood. I looked up some articles on this topic after reading your reply. Thank you again for explaining it so well. It all makes sense now!

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Specializes in Medicine.

Thanks everyone for the feedback! Much appreciated. I love this site so much.

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Having never worked on a cardiac floor or a critical care unit this stuff about pts on ACE inhibitors getting leukoreduced blood is new to me. Gotta say we got some pretty smart cookies here!!! I'm impressed!!! Hope some of you are taking care of me if I am traveling and ever end up in the hospital! and some people think nurses know nothing and do nothing but pass pills, wipe butts and change bedpans all day. They have not met some of the nurses here I tell you!! :nurse: And for the record I may not know my critical care stuff so well but if any of you end up on a psych unit where I am working and need care, I will be sure to provide nothing but the best care--now that's stuff I know about!!! LOL

Thanks for the lesson. I think my brain grew a new cell!!! :D

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Do we hold Ace (Diovan, Cozaar, lisinpril) and B-adrenergic blockers (Coreg, metoprolol) prior to transfusion in clients with low baseline BPs (ie 80/40)?

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