TPN and PRBC

PostOpPrincess, BSN, RN · Dec 25, 2009

Try for a peripheral IV.

If you can't, you have to stop the TPN, check sugars and treat as needed with glucose protocols.

Think of this as a learning situation.

cherrybreeze, ADN, RN · Dec 25, 2009

My understanding from your post is that you ran the TPN and blood in through the same port, and likely also the same tubing?? In all honesty, be glad it was only a write-up! That is EXTREMELY dangerous practice. I'm actually pretty speechless, here.

How did you even manage to do that, or think it was OK? Did another nurse check off the blood with you (that's our policy, and I imagine it's universal) and see that set up? If you're administering blood in the first place, then you've been checked off/certified to do so, meaning that in a blood administration class (again, that's our system, and maybe other places do things differently), you would have learned in no uncertain terms that NOTHING but normal saline is run through the same line as blood. Ditto with TPN, that's something you learn in nursing school. You can't even give a med through a line that's actively infusing TPN, so what would make you think that blood is ok?

Yea, yea, I understand the posts about it being a learning experience and all that. This is a little much for me, though. I hope the patient doesn't have any adverse effects from this.

RedhairedNurse, BSN, RN · Dec 25, 2009

You should also be very careful in the future with other IV piggy backs, if you ran blood with TPN then I'm afraid you may run antibiotics together or with something that may have incompatibility issues. You need to be very careful, these are peoples lives and if you would only just ask a question, you could save yourself and your patient. Always always ask or call pharmacy, do something, don't just think it will be okay!! Be super careful with these people!!!!

RedCell · Dec 25, 2009

i had a patient today with no peripheral iv access (he was very edematous) and a tlc sc with one lumen clogged, the surgeon ordered 2 units prbc i had carrier and and tpn, i plugged the blood in and the tpn into the blood so i could still have carrier fluid.i was written up. anyone have any feedback?
thanks!
jc

look dude, tpn is hypertonic and when you mix a hypertonic solution with red cells you get crenation. basically you make the blood even more useless than it already was sitting in some refrigerator degrading (you know, building up extracellular k+, diminishing 2,3-dpg, increasing your leftward shift on the dissociation curve...and all the other garbage you deal with in the banked blood business).

i've got a cuppla questions. 1) why did you want to run tpn during an anesthetic. i normally turn that crap off, you just do not need it. 2) why didn't you just use the prbcs as your carrier fluid? 3) if you were concerned about iv access why didn't you or someone else just throw in an ij or femoral line?

sorry you got written up.

from

merrywidow46

yesterday, 06:37 pm

re: tpn and prbc

nothing other than 0.9nss ever is infused with bloo!!!!! you are lucky all that happened was a write up.

did the patient have a reaction?

tpn also should not be run with other things.

do some research.

if in doubt check with the charge nurse, look at hospital/facility policies and procedures, contact the physician.

please educate yourself about iv compatability and admixtures.

good luck.

i'd like to throw a small wrench in the old nursing wheel here and state that this nursing dogma of not being able to run anything with blood is completely wrong. for the record, i hardly ever run nss with blood, but instead dilute my prbcs with plasmalyte. seriously fellas, do some research and prove your nursing instructors and policy writers wrong on this one. there are a number of meds that can be given with blood products. also, look into the quality of prbcs that you are transfusing into the gomer. do you really think you are increasing tissue oxygenation all that much or just simply giving the patient a wad of colloid that is providing volume expansion to improve your hemodynamics. just something to think about in between formulating our next nursing diagnosis and applying ole' lady watson's "brilliant" caring theory.

Zookeeper3 · Dec 25, 2009

Not everyone understands that a physician isn't always available to insert lines, and there are times no one can get another IV, I feel you here and think this is what happened.

I work with attendings, this is common at night, even in the ICU's. But I do have to call the MD and get an order to hold the TPN until the blood infused and because I can't hang D10, I get the thrill of Q2 hour accuchecks.

I'm sorry to say that you did have the choice to refuse to do both and call the MD and have them state their preference. If it's against your policy, no MD order will protect you.

Some people have come down pretty hard on you here and thats not my intentions. I swear, you always will have a choice, an informed one starts with reviewing the policy, no matter how many hours you are behind unfortunately.

You know now, and when your an expert and training new staff... pass that new pearl of wisdom on, and don't let anyone make you feel stupid.

Zookeeper3 · Dec 25, 2009

I had forgotten to mention, check if you have an Activase policy to unclot TLC ports. Usually this works (higher dose used for clot busters in MI's)... so there is some science behind it. Even if you have to get a certified nurse from another area, this may be a future alternative or suggest it to your nurse councel.

glasgow3 · Dec 25, 2009

re: tpn and prbc
nothing other than 0.9nss ever is infused with bloo!!!!! you are lucky all that happened was a write up.
did the patient have a reaction?
tpn also should not be run with other things.
do some research.
if in doubt check with the charge nurse, look at hospital/facility policies and procedures, contact the physician.
please educate yourself about iv compatability and admixtures.
good luck.
i’d like to throw a small wrench in the old nursing wheel here and state that this nursing dogma of not being able to run anything with blood is completely wrong. for the record, i hardly ever run nss with blood, but instead dilute my prbcs with plasmalyte. seriously fellas, do some research and prove your nursing instructors and policy writers wrong on this one. there are a number of meds that can be given with blood products. also, look into the quality of prbcs that you are transfusing into the gomer. do you really think you are increasing tissue oxygenation all that much or just simply giving the patient a wad of colloid that is providing volume expansion to improve your hemodynamics. just something to think about in between formulating our next nursing diagnosis and applying ole’ lady watson’s “brilliant” caring theory.

naw, no "wrench" here at all when you're absolutely correct. even something as common as morphine can be given with blood without one "hurting" the other if absolutely need be however: this original poster no doubt violated his/her facility's blood administration (and tpn) administration policies. a couple years ago i had to rewrite/modify our facilty's blood administration policy and related documentation form and no way did i even consider making note of the exceptions to the rule (no adds to blood). geeezzzz, the op's action is exhibit a of what crazy stuff can happen on a nursing floor these days even with no exceptions permitted by policy.

on balance, however, i think learning that such exceptions do exist would be a much better use of precious nursing school time than studying watson's caring theory (or any other nursing theory for that matter).

ChicagoPeds · Dec 25, 2009

I think the other important thing to note is that it is ultimately the individual nurse's responsibility to be aware of and remain updated on their hospital's/agency's policies & procedures. One of the biggest discussions I get into is that MDs need to write up how to give blood products in a certain way....all i's dotted & t's crossed....if it's not written that way then I can't give the blood. Period. Need to call them & have it fixed.

Furthermore, we as educated & licensed nursing professionals have a duty to do no harm to the patient. When in doubt, ask. When you think that something doesn't seem right about orders, question. I have had to argue with residents, a pharmacist (whom the resident had them call me!)...and even the attending about the rate at which a solution of D5 0.45NS was being given to a toddler. They wanted to give a bolus...you NEVER EVER NEVER EVER give a bolus of anything except 0.9ns & LR...that's it. And all the MDs & pharmacist were saying it's okay. (Eventually I had a conversation with the attending who finally got it...). :-).

So with the situation (as you explained it), there were only 2 lumens available to do a three--lumen job. Okay...ask the MD about the priorities...if the "carrier" was what is commonly referred to as maintenance fluid, then it's not a necessity or priority because you are already going to be giving a lot of volume through PRBCs. If they had said need all 3, then it's a great way to segway into asking about how to fix the original problem (TPA, new/additional line, etc).

Forgot to say...there are medications that can be run/are compatible with TPN, you just need to talk to the pharmacist or look it up...since TPN has some elements to it that have not been "officiallly tested"

My favorite quote in RN school was "Don't be a monkey nurse". 'Nuff said.

scootertrash nurse · Dec 25, 2009

According to your AllNurses profile, you are in nursing education and have a MSN. Have you practiced as a bedside nurse? My question has to do with basic patient safety and basic bedside nursing, standards which have not changed over time.

What are you thinking? You are going to kill someone someday!

STOP AND THINK! ASK QUESTIONS!

MERRYWIDOW46 · Dec 25, 2009

Just a question.....What was your initial education that qualified you for NCLEX? Are you a second Bachelors Nurse or Direct entry MSN???????? Just curious.

sethmctenn · Dec 25, 2009

Here's a good article for review http://findarticles.com/p/articles/mi_m0FSS/is_3_12/ai_n18615883/

Home Health Columnist / Guide · Dec 25, 2009

good info from our friends @ icufaqs: blood products and transfusions

transfusion reactions are scary, and at least part of the problem is that you can’t be sure right away whether the patient is having a “minor” reaction – these are usually called the “febrile, non-hemolytic” reactions – or a major one: “hemolytic”. either kind of reaction will almost always occur during the first few minutes of the transfusion, which is why policy requires a set of vital signs recorded before, and a few minutes after the start of any transfusion.
minor, febrile reactions: these are actually not so rare. the patient usually spikes a fever, probably has rigors, may break out in hives.
major, hemolytic reactions: these are the bad ones. a partial list of the unpleasant things that can occur: hypotension, renal failure, bronchospasm, dic…not a pleasant scenario

blood administration - clinlabnavigator.com

[color=#333333][color=#333333]iv solutions and medications
[color=#333333]normal saline (0.9% sodium chloride) can be added to blood, but drugs and medications must never be added. compatible fresh frozen plasma, 5% albumin, and plasma protein fraction can be added to blood following approval by the patient's physician. isotonic electrolyte solutions that do not contain calcium may mix with blood if the fda approves the solution for such use or if there is adequate documentation of safety. some solutions should not contact blood in the bag or tubing. solutions containing glucose (e.g. 5% dextrose) may cause red cells to aggregate and lyse and those containing calcium (e.g. ringer's lactate) may cause blood to clot.

[color=#333333]clinical guidelines (hospital)

compatible fluids and medications

in general, no medications or solutions should be added to or infused through the same tubing as blood products except for sodium chloride 0.9%, abo compatible plasma or 4% albumin.
co-administration of morphine (1mg/ml in sodium chloride 0.9%), pethidine (10mg/ml in sodium chloride 0.9%) and ketamine (1mg/ml in sodium chloride 0.9%) has been shown to not adversely affect red blood cells or these medications. where co-administration is required the blood product and medication should be administered via separate iv lines, with the blood product being connected closest to the patient to minimise mixing.
if other medications are required during a blood transfusion the transfusion must be stopped and the line flushed with sodium chloride 0.9% before and after administration of the medication, the blood transfusion can then recommence.
fluids containing glucose are not compatible with red blood cells, they cause clumping of the red blood cells.
crystalloid or colloid solutions that contain calcium should never be added to or administered concurrently with any blood product. calcium reverses the anticoagulant citrate, causing red blood cells to clot.

blood simultaneously with other meds in the same iv - nursing for ...

blood transfusions and the immune system -- blood groups and red ...

transfusion reactions: emedicine emergency medicine

transfusion reactions: emedicine hematology

jcaho: issue 10: blood transfusion errors: preventing future occurrences ...

you can only interrupt tpn for 30 minutes or hypoglycemia will occur; it can not be abruptly stoped but needs to be tappered at rate of 1/2 rate over 1-2 hours. total parenteral nutrition.

this situation needed to have been discussed with doc ordering blood or attending. if unsure how to proceed always best to ask those in charge or bump up to nursing supervisor. may others reading this learn from your situation and prevent patients from future harm.