TPN and PRBC

RedhairedNurse, BSN, RN · Dec 26, 2009

I work with two CRNAs that are petrified of me as I have caught them do some stupid stuff.
They know one more thing I catch them doing wrong, they are out the door.
I have been instructed to do as such by the head anesthesiologist.
My group is realizing that ONE YEAR as a bedside nurse is NOT cutting it and they are no longer hiring "fresh" grads with less than 3 years of experience.
Yes, people, guess what? Your lack of bedside SHOWS.

Aren't these SRNA/CRNA suppose to have 2-3 yrs of ICU exp ?

I wonder how a mistake as this could be made if this person (OP)

had this practical experience. I would love to know if he did his

time in ICU.

sunnycalifRN · Dec 26, 2009

He's a CRNA or SRNA, oh my gosh, that's even worse!
Doesn't a nurse have to have 2-3 years of ICU exp before going into CRNA school?
Wouldn't that have given this OP enough experience to know you don't infuse PRBCs
with TPN?? Geez, for heavens sakes. I still can't get over this situation of his, I know
we all make mistakes, but man, this was a doozy.

to get into CRNA programs, at least 1 year of ICU experience is required. Somehow, I don't think that the OP is going to return to this thread.

MERRYWIDOW46 · Dec 26, 2009

to get into CRNA programs, at least 1 year of ICU experience is required. Somehow, I don't think that the OP is going to return to this thread.

I agree, he's not coming back here.

If you go look at his posting history his creditablity is questionable.

He posts bashing his schooling, and I'm not sure where or what his clinical experience was obtained. He DOES state he finished up a BSN in early 2007, then Fall 2007 he was starting a MSN/CRNA program. No mention of the requisite ICU experience.

I am sorry but knowing about PRBCs and TPN not being hung with other fluids is BASIC NURSING which I learned in my first year nursing school clinicals. What are the schools turning out these days. One of his CRNA buddied who responded said he mixes PRBCs with Plasmalyte......Electrolytes destroy the blood. WHY aren't the people being better supervised????????????????

VERY SCAREY. :crying2: :eek:

Home Health Columnist / Guide · Dec 26, 2009

Mere speculation not helpful.....Closing thread as question answered.

RedCell · Dec 28, 2009

i am sorry but knowing about prbcs and tpn not being hung with other fluids is basic nursing which i learned in my first year nursing school clinicals. what are the schools turning out these days. one of his crna buddied who responded said he mixes prbcs with plasmalyte......electrolytes destroy the blood. why aren't the people being better supervised????????????????
very scarey.

i would like to expand upon this one. one, i am not exactly his buddy. i do not even know of this dude, and know even less concerning what his actual education and certifications are. all we can truly have fun with is responding to his predicament, whether manufactured for entertainment or something that actually took place. also, i am not going to comment on mixing tpn and prbcs as i have already covered that in a previous post. i would love however, to go over this old nursing dogma of not ever ever ever mixing prbcs with anything but .9% nss. ladies and gentlemen….the nursing instructors are wrong on this one (and so are a lot of nursing policy writers). sure hypertonicity and hypotonicity is something that certainly should be avoided with prbcs, however let us just assume that all crytalloids listed below are isotonic. also, there are many drugs that can be pushed with prbcs, but that should be saved for another thread.

merrywidow, you mentioned that electrolytes destroy the blood. don’t forget however, .9%nss is made up of 154meq/l na and 154meq/l cl. these are both electrolytes, and they are not destroying the blood when mixed in this concentration. plasmalyte is not destroying the prbcs either. infact, it is superior to nss in most cases because you do not have to worry about hypernatremia and hyperchloremic acidosis that you can get when pouring in too much nss. it is actually an ideal solution in that plasmalyte is physiologically similar to our own plasma. exceptions to this would be when you need tight regulation of k+ (renal failure, pediatrics, etc). food for thought; what do you think the priming solution is for the bypass machine in open heart procedures….plasmalyte (along with albumin, nahco3 and a few other handfuls of magical concoctions).

if you really push an educator about why you cannot mix various solutions with prbcs a common response will be the citrate. prbcs are diluted in citrate to keep them anticoagulated. the status quo has always been that anything with calcium in it (ringer’s lactate for example) will bind with the citrate resulting in clumping of the prbcs. this has been proven to be false as well. in fact, in big cases in the or where volume loss is an issue, and massive fluid resuscitation is necessary, many providers have been known to reach for rl to mix with the prbcs if that is the only thing laying around (yes there are sources below to support this arrogant and ignorant behavior that i take part in and again yes, my “supervisors” and peers support and take part in this behavior). does this mean that i am going to push a gram of cacl2 through a line infusing prbcs...probably not. it all has to do with the concentrations of various electrolytes.

below are some links from pubmed and a few other sources to back up my statements if you care to read into the subject.

http://www.drugs.com/pro/plasma-lyte-148.html (plasmalyte formulation and indications)

http://linkinghub.elsevier.com/retrieve/pii/s0002961098000117 (looks at infusion time, filter weight and clot formation when using prbcs primed with lr)

http://www.ncbi.nlm.nih.gov/pubmed/1866680?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=2 (compatibility of prbcs with lr)

http://www.ncbi.nlm.nih.gov/pubmed/7404017?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=10 (compatibility of prbcs with solutions containing calcium)

caroladybelle, BSN, RN · Dec 28, 2009

OK, dumb question - I also was taught that we never run TPN with anything but lipids and we don't stop it abruptly. I was also taught that we never run blood with anything but NS.
What I don't remember on these issues is "why". Yeah, I could look it up but am wondering if someone would indulge me being lazy and share what they know about the "why". Hey, it's Christmas. Gift me? I hope you all had great Christmas, even if you had to work like I did. My shift was busy but not bad at all. Everyone seemed determined to be happy and we were.

Most drugs and solutions (other than NS) are not compatible with blood products. And TPN not only contains dextrose, it generally actually containsa very percentage of dextrose, often 2-3x higher percentage if it is central line TPN. It also contains vitamins, minerals, electrolytes, all of which are incompatible. Reactions to this can vary greatly.

Because of the dextrose percentage and electrolyte additives, it is really unwise to push/IVPB drugs into TPN unless the PharmD assures you that everything is compatible, on daily basis. As additives/percentages may change on a daily basis depending the pts lab work, what may be okay one day, may not be the next.

Some places (such as my current unit) that has pts on restricted diets related to chemo regimens, often have set TPN that is mixed to be compatible with some common floor drugs so that we can run some things via the TPN line. But that level of attention by the PharmD is generally not available in most places.

I will tell you that I have seen the results of blood reactions, d/t improper fluid mix. Two of the patients had a full blown hemolytic reactions and nearly died, d/t major cell lysis. And in the case of major lysis, you could end up with serious renal issues, electrolyte issues, not to mention a really sick pt.