Running PRBC concurrently with NS?!

Okami_CCRN, BSN, RN · Feb 21, 2013

Did this patient only have 1 IV Port? I would have inserted a second IV and given the fluids through a separate site. I am under the impression that blood should always be run by itself.

cjcalimer · Feb 21, 2013

The best thing to do it to check your hospitals policy on blood administration. It doesn't matter what the nurses on your floor say is correct or incorrect, it all comes down to the policy. You are responsible for knowing it and adhereing to it, especially for something like blood administration. I would look it up and see what it says so you know for the future. If it doesn't specify, it should say who wrote the policy or is otherwise responsible for it and you should contact that person and ask them to update it. Always look it up and ask questions is you need to, because the policy should always be the right answer and what you would be held to legally.

VANurse2010 · Feb 21, 2013

You should have started a second IV site and ran the NS and blood though each site separately. Of course, consulting the facility P/P is a good start too.

jadelpn, LPN, EMT-B · Feb 21, 2013

Running them concurrently and at in the same site is different than 2 seperate sites. I know, seems confusing. First, always get a clarification of an order like that. Second, make sure you know the policy, so you can say "our policy is not to mix anything with blood, so I am going to start a second site to run the blood through". This seems like a multi step process, as you would have to hang a bag of NS for the blood --to run through the blood line after the blood in that line is complete, per your policy---- However, I am perplexed as to why your preceptor did not direct you correctly. Last, be sure you read your order yourself before you do anything. It is good practice to do so. But seems like you could run NS at 70 while the blood is going, stop that, let the NS in the blood line run through until clear, then start the NS infusion again at 125. BUT be sure to ask (again, not medical advice per TOS, just a thought) if--depending on the condition of your patient, you are going to throw the patient in fluid overload with all of that. LOTS of questions, and starts with a careful clarification of your order.

iluvivt, BSN, RN · Feb 21, 2013

First. you did not do anything that will harm the patient but use the opportunity to learn something or add to what you know. There are slight variations in policy from institution to institution but there are some universal principles that you should know. The AABB technical manual also provides guidelines that provide for the safe administration of blood as well has the FDA.

1. Wear gloves when handling all blood products

2. Blood once out of controlled refrigeration must be hung no later than 30 min after that event.

3. Do not store any blood products in non-blood refrigerators due to fluctuations in temperature.

4. No IV fluid other than 0.9 % sodium chloride should be added to or administered simultaneously with blood

5. Do not piggyback blood into a main line that that has been used for any other IV solution other than 0.9 % sodium chloride

6. Blood products should be filtered ( use an in line or add on filter ) There are various products available.

7. A new filter should be used for each transfusion and should by used for no more than 4 hours.

So you DID NOT to anything that violated the standard of care. You can add a double T ext or extension set with two ports right at the site (into the cannula) and hook up the primary of NS at 70 cc per hour and then set up a standard Y blood tubing with an in line filter and hook that up to the other port on the double extension. The way you set it up was OK too by using the lowest port.

Most MD's and LP's will order what they want and just leave the nurses to figure out the best way to do it. The MD did not want to risk fluid overload so ordered the lower rate during the transfusion. Another option would have been to start another PIV and administer the blood through that new line. I usually go for this option but starting a new line may be difficult at times. Did you all think of this as an option? With all this said you do need to check the exact wording of your policy..did you do that? What does it say? You should follow it if it makes sense.I think that many nurses would be surprised that you can administer 0.9 % sodium chloride simultaneously with blood other than as in the Y type set up. Many nurses also just hold their IVFs if the patient can handle the interruption but I would get an order to cover for that.

There are many more principles of administration you need to know but I just listed the universal ones.

edmia, BSN, RN · Feb 21, 2013

Hi,
I'm a new RN working on a medical oncology unit and went off of orientation last week. Today a Dr came in and told me she'd like me to administer 2 units of PRBC's. She added that she'd like the patient's fluids, normal saline, to be reduced to 70 ml/hr during the infusion and returned to 125 ml/hr (the current running rate) after the transfusion was complete. I know you're typically not supposed to mix anything with blood, but being that it was normal saline and that's what we prime the transfusion line with I went to ask my trusted past preceptor what he thought. Together we agreed that I would get a second pump to run the blood through using the Y-port tubing, which is standard on our unit, and then connect it to the line running the NS. I connected the blood line to the lowest port, closest to the insertion site, on the fluids line. When the night shift came on I got reamed for making such a mistake. I don't know if what I did was truly wrong or if I was just being bullied. The RN II on nights is very mean to new nurses, but my colleagues have stated she's especially rough on me. Spending my ride home in tears is pretty commonplace. Anyway, I've spent the last 3 hours googling and haven't found a concrete answer. Though some sites indicate it's ok to run PRBCs concurrently with NS. My old preceptor pulled me aside before he left and told me it was fine and that they're compatible. The RN II said I read the order wrong. The Dr had not written the words run concurrently. The order just read reduce rate to 70 and then return to 125. But when she verbalized it to me I took it to mean run together. I'm exhausted with anxiety. Besides answering regarding this issue, can you also tell me if things get better... Right now I feel like a failure, because no matter how many times I'm told I'm doing well, this woman (RN II) makes sure I go home feeling incompetent nightly. :/
Thanks in advance fellow nurses!

Well, if you only have one IV site, then it meant concurrently. It's not ideal, but it's not wrong (in my experience, but could be wrong).

A better way to do it would be to stop the NS and run the blood in at 125.

Sent from my iPhone using allnurses.com

IVRUS, BSN, RN · Feb 21, 2013

I am so sorry that you spend your ride home berating yourself for any, and all mistakes made. You are a NEW nurse, and confidence will come, and the tears will stop in time. Interpreting this order to mean that it should run concurrently with the NS, is a matter of interpretation, so your best bet, IMO, would have been to call this MD back and get clarification of the order. Then, rewrite the order so it is not ambiguous.

Older nurses who have the propensity to "eat" their younger counterparts, should not be preceptors.

It takes a great deal of patience to help nurture and guide a new nurse, and while your experience seeminly is lacking this, you must remember that your allegenance must be to that patient, and therefore do not freak-out about something as minor as this. Get clarification and then, take care of your patient. You didn't become a RN, because you were stupid. You became one through hard work, sweat, and tears. So disregard petty indifferances and always pull for your patient. After all, that is why you are employed... To take care of the patient. If conflicts continue, I would speak to your nurse manager about getting a different preceptor.

EHNurse19 · Feb 21, 2013

As far as the blood administration goes you did nothing that could HARM the patient but next time just clarify with the provider exactly what they wanted done. If you are unsure always double-check and then take the time to compare it to your organizations policy. As far as this night nurse that is being a bully I went through the same situation when I graduated and got my first job. My advice to you is to be confident in yourself and stand up to her. This nurse has no right to treat you in such a manner and maybe if you let her know it is unacceptable behavior she will realize what she is doing. You are both equal in your roles at work. She has no authority over you just because she has been working there longer. If that doesn't work definitely go to your manager regarding this because it is absolutely unacceptable. In my case I finally had enough of the "bullying" from a certain RN so I just said, in a polite way, that I wasn't going to allow her to talk to me like this anymore and instead of telling me that I am wrong or didn't do it right show me or tell me how to do it correctly. Being a new nurse is a learning experience because there is no way that we can be prepared for the "real life" nursing straight out of college. Don't beat yourself up :)

turnforthenurse, MSN, NP · Feb 21, 2013

I don't think you did anything wrong because NS is okay to run with blood (and should be the ONLY OTHER fluid you run with it) but I never run it concurrently...I take out my Y-type tubing and prime the line with saline, then run it at KVO until I can get the blood. I close off the port to the NS, spike the blood and open that port and start running it. When the bag of blood is done, I close the clamp to the blood and reopen the NS to "flush" the tubing so that the patient gets everything in the line, too.

If a patient has IV fluids, I typically just stop them until the blood is finished, then resume them. If the MD wants them continued along with the blood and I don't have a central line, I start another peripheral somewhere so that I can have both running at the same time.

nurseap · Feb 21, 2013

Hi, I'm a new RN working on a medical oncology unit and went off of orientation last week. Today a Dr came in and told me she'd like me to administer 2 units of PRBC's. She added that she'd like the patient's fluids, normal saline, to be reduced to 70 ml/hr during the infusion and returned to 125 ml/hr (the current running rate) after the transfusion was complete. I know you're typically not supposed to mix anything with blood, but being that it was normal saline and that's what we prime the transfusion line with I went to ask my trusted past preceptor what he thought. Together we agreed that I would get a second pump to run the blood through using the Y-port tubing, which is standard on our unit, and then connect it to the line running the NS. I connected the blood line to the lowest port, closest to the insertion site, on the fluids line. When the night shift came on I got reamed for making such a mistake. I don't know if what I did was truly wrong or if I was just being bullied. The RN II on nights is very mean to new nurses, but my colleagues have stated she's especially rough on me. Spending my ride home in tears is pretty commonplace. Anyway, I've spent the last 3 hours googling and haven't found a concrete answer. Though some sites indicate it's ok to run PRBC's concurrently with NS. My old preceptor pulled me aside before he left and told me it was fine and that they're compatible. The RN II said I read the order wrong. The Dr had not written the words "run concurrently". The order just read reduce rate to 70 and then return to 125. But when she verbalized it to me I took it to mean run together. I'm exhausted with anxiety. Besides answering regarding this issue, can you also tell me if things get better... Right now I feel like a failure, because no matter how many times I'm told I'm doing well, this woman (RN II) makes sure I go home feeling incompetent nightly. :/ Thanks in advance fellow nurses!

Thank you all very much for your replies. I'm going in early to check the hospitals policy, which I should have done rather than ask someone else.

nurseprnRN, BSN, RN · Feb 21, 2013

It's perfectly acceptable to do what you did. As a matter of fact, it is perfectly acceptable to backprime NS into a unit of PRBCs to make them thin enough to run better prn.

The people who are getting in a fluff about it don't know the physiology involved (including the ones with the idea that you just stop the IV fluids and give the blood at 125) and are ritualistically relying on inappropriate transfer of incomplete information that no IV fluids may run c blood products.

If the AABB says you can run NS with blood products, then you can, um, take it to the bank. You should print out their statement and post it in the break room. If I were you I'd make extra copies, because you-know-who will probably take it down as soon as she sees it. Give extras to your manager and charge nurse. Yay, evidence-based practice!!!!

Don't waste another tear over this one. You're not really being bullied, anyway; you're just finding out how dumb some of your coworkers are. Let them bluster, they're still wrong. I'm betting your blood bank will back you 100%.