Question: Give blood AND heparin?

[TangoLima]

I have just about 3 months experience in the MICU, and have a question about giving blood and heparin.

I had a patient who had a Rt. IJ blood clot and was on a heparin gtt. I received report from the day nurse that the patient's H&H had dropped and she was supposed to receive 2 units of blood on my shift. So, I go in and do my assessment, notice that the heparin gtt is about to run out and called the pharmacy for a new bag. In the meantime, I start thinking, "why are we giving heparin gtt to a patient we're about to give blood to because of low H&H?" In all my previous experience (20 months on Telemetry floor), this has always been a red flag for me. I should have asked the day nurse about it, but I didn't think about it at the time.

So, I start doing a little research. The patient had a history of anemia, but the most recent H&P stated that it had been stable. At noon the previous day, the Hgb was 10.1, now it was 7.7, quite a drop in 24 hours to me. The heparin gtt had been started the previous night based on the blood clot findings, but was not ordered by the attending physician, rather the on call hospitalist. There were no comments in the progress notes about continuing the heparin gtt while giving blood.

Since I'm new to the MICU, I usually talk to a more experienced nurse before calling the physician, but this particular time I felt like I had thoroughly researched the situation, and that it was a legitimate, cut-and-dry question. In addition, the previous week I received a patient in the ICU who was on a heparin gtt and had developed a retro-peritoneal bleed. So, I call the hospitalist and get the on-call PA, explain the situation, including the fact she has a history of anemia and a blood clot, and ask whether or not to continue the heparin gtt. The PA gave me an order to hold the heparin gtt, do a U/A, guiac stools, etc.

So, I inform the same nurse the next morning that he heparin gtt was on hold, she gave me a funny look but didn't really say anything about it. When I came in the next night, she basically chewed my butt saying the patient could have lost her arm or had a stroke, and I should have called her at home if I had a question about it. I told her that I just didn't feel comfortable running blood and heparin at the same time, and needed someone with more authority to tell me it was OK to continue the heparin.

I have just felt really bad about this ever since. I know I have a lot to learn, but I felt this was a legitimate question. I have never continued heparin on a patient with low H&H receiving blood before. I talked to my former preceptor about this and she stated she probably wouldn't have stopped the heparin unless she saw obvious bleeding.

Im just wondering if anyone else has any other thoughts on this. What should I have done differently? Do you routinely give heparin to patients with low H&H? Any input would be appreciated as I know I lack experience.

[APNgonnabe]

I think you were right to question it. If there was no clear cut answer then yes you need to go up the "food" chain to someone with more letters behind their name. Personally I think the RN was mad she didnt think of it. good job

[Bumashes, MSN, APRN, NP]

Yeah, she was just mad she didn't come up with that. Sometimes it takes a fresh pair of eyes to find possible problems. I'd have definitely wondered about that, too. Granted, I work med-surg, but still, we do heparin gtts on my floor, and I can see the same situation possibly coming up. I would have questioned it for sure with such a big drop in H&H. I mean, 1 point drop would have made me think and then ask in the am when the nurse returned, but 2.4 pts total... I'd have definitely called cuz even if they didn't stop the gtt, the pt probably still needed to have those tests run just in case.

[suanna]

What purpose would have been served by calling another nurse at home. Even if you are new, you have an obligation to follow your critical thinking skills to safely care for the patient. In this case- ? should the patient be on a heparin drip when there may be an active bleed? There are good reasons for the use of heparin even with a dropping hemoglobin. That isn't the point. You still had an obligation to voice your concern to the doc on call. The doc on call made the decision to stop the heparin- not you . What would a phone conversation between nurses have done to countermand the change in medical orders? Your co-worker needs to get a grip on the limits of the role of an RN. If she had discussed the heparin drip with the attending or her doc on call, and the decision was to continue the heparin despite the dropping blood count, then she needed to write the order "continue heparin, and parameters of hgb/hct/vs that would have prompted a repeat call to the docs, or a change in treatment. At the very least she needed to pass on in report that the issue was discussed and the decision to continue the heparin was made by "...". Without this input you have no way of knowing if the doc that was called with the H&H knew and approved the continued use of heparin.THIS IS NOT A NURSING DECISION! We don't pick and choose what doctors we are going to listen to and what docs we are going to over rule by another nurses decision?!?! If the attending doc wants to "clairify" the rational for the continued heparin with the on call doc- that is there business. Don't let an old timer (like me) push you around. You have an obligation to care for your paients to the best of YOUR ability- no one can relieve you of thay role. You were acting as a professional nurse- that is your job. Don't let a cranky old timer make you doubt yourself.

[meandragonbrett]

When I came in the next night, she basically chewed my butt saying the patient could have lost her arm or had a stroke, and I should have called her at home if I had a question about it.

Since when do we call other nurses at home to obtain medication orders? You are new and had a concern and you did what was appropriate for the patient.......you sought clarification.

I probably wouldn't have blinked about the change in the H/H and being on heparin gtt. H/H changes on what seems like to be a never ending basis. So many different variables that can affect it that's not necessarily bleeding related.

Also, keep in mind that MANY of the things we do in the unit come down to a risk vs. benefit for the patient.

[CNL2B]

I didn't see you post what his PTT was. This would be a piece of relevant data.

Without knowing that, yes, I would be concerned if my patient had an almost 3 gm unexplained drop in Hgb over the last 24 hours. (You also didn't say if you had noted any bleeding anywhere I don't think.) I think it would be appropriate to call the doc and ask to hold the heparin (at least mention it), especially if his PTT was therapeutic or supratherapeutic.

This butt chewing thing -- ? Makes no sense. Who cares. Blow it off?

And "lost her arm"? Give me a break. How about dies from a GI bleed?

[TangoLima]

Thank you all for your replies.

A few more pieces of relevant info:

* No, I did not see any obvious signs of bleeding.

* The patient's vitals did not indicate hypovolemic shock.

* I don't remember what the PTT was. I don't even think I checked since I wasn't concerned with adjusting the gtt, but rather concerned with whether or not to continue it. I do see now how knowing the PTT would indicate whether the gtt was therapeutic or too high as to increase the chance of bleeding.

Meandragon,

Thanks for your comment about "risk vs. benefit". This is something I have to consciously work on. I tend to be a black-and-white kind of girl, when much of medicine is in the "gray area".

One thing I find myself struggling with is knowing my boundaries in the ICU. On the tele floor, our hands are tied, and we don't do much of anything without first calling the doctor. In the ICU however, the nurses have much more autonomy, and do a lot of treating before calling the doctor, especially on the night shift. So, I'm having to learn to adjust my thinking and actions because of this. (By the way, hospital-wide we have been discouraged from calling docs in the middle of the night, so we often wait to call abnormal labs, results, etc. until in the morning unless it's something critical. We are going to be getting intensivists soon, so I think it will be better to always have a point of contact during the night.)