Transfusing Blood

[Honeybun1206]

I'm just curious.. let's say a patient came in with a Hemoglobin/Hematocrit of 6 & 21. PRBC's 2 units were given. H&H re-checked an hour later, to be 8 & 23. Ordered to transfuse 1 more.

My question is, after the last unit of transfusion.... without checking H & H, someone mistakenly gave another unit for a total of 4 units that day instead of 3. Would it do a lot of harm to the patient?

This came up when a co-worker got really confused by the I&O's from the last shift; the intake for blood transfusion didn't quite match up. I left work early so I didn't find out what happened (whether or not the blood should have been given or not).

But can giving one unit of PRBC's with a H&H that low be really harmful?

Please answer, thanks. I'm about 6 months experience as an RN, and would really loooove to know.

[oMerMero]

In short, no, the extra unit of prbcs should not harm the patient. The same transfusion risks apply as with the previous units (reactions). If the patient has CHF the amount of fluid given might cause some trouble if lasix was not given during the transfusions. If you figure one unit of prbcs brings up the hgb 1 point, then the patient would end up with a hgb of around 10 after all the units...assuming the patient is not actively bleeding.

I would be more concerned about how the extra unit of blood made it through the system and was given to the patient without an order.

[deeDawntee, RN]

I would say that there would be no possibility of harm to the patient other than the usual risks associated with any blood transfusion. As long as your protocol was followed to assure it was the right patient with the right blood type and right product etc...

Any good manager would look to where the breakdown in the system occurred. There must have been a communication breakdown somewhere in the system...that should obviously be addressed and corrections made.

If anything, I'll bet the patient looks a little pinker today than anticipated!!!!

[Tweety, BSN, RN]

I doubt it because their HH probably rose only to 10 after the four units. Other than the risk of a reaction, no harm more than likely occurred.

Still it's a major error and the process of how it occurred needs to be thoroughly investigated.

[Tweety, BSN, RN]

I would say that there would be no possibility of harm to the patient other than the usual risks associated with any blood transfusion. As long as your protocol was followed to assure it was the right patient with the right blood type and right product etc...

Any good manager would look to where the breakdown in the system occurred. There must have been a communication breakdown somewhere in the system...that should obviously be addressed and corrections made.

If anything, I'll bet the patient looks a little pinker today than anticipated!!!!

Basically we were typing and saying the same thing. I agree. :monkeydance:

[DutchgirlRN, ASN, RN]

If 3 units total were ordered the blood bank would only have 3 units typed & crossed for that patient.

I don't see how a 4th could have been given unless it was another patients blood which also seems pretty far fetched since two nurses have to check the armband against the blood and the paperwork.

[BBFRN, BSN, PhD]

If 3 units total were ordered the blood bank would only have 3 units typed & crossed for that patient.

I don't see how a 4th could have been given unless it was another patients blood which also seems pretty far fetched since two nurses have to check the armband against the blood and the paperwork.

That's what I was thinking, too.

[sister--*]

If 3 units total were ordered the blood bank would only have 3 units typed & crossed for that patient.

I don't see how a 4th could have been given unless it was another patients blood which also seems pretty far fetched since two nurses have to check the armband against the blood and the paperwork.

Sometimes our orders read: Type and crossmatch 4 units packed red cells. Infuse two units packed red cells.

[BBFRN, BSN, PhD]

Sometimes our orders read: Type and crossmatch 4 units packed red cells. Infuse two units packed red cells.

But wouldn't you still have to have another order to infuse the other 2 units?

[Tweety, BSN, RN]

But wouldn't you still have to have another order to infuse the other 2 units?

Of course.

Maybe this is a part of the process that can be improved, but the blood bank I work at would take our word for it that we needed it if we went down to get them. They don't check the docs orders. They release the blood when the RN says they need it, no questions asked. In other words if they had four units available and the MD prescribed three, if I went down and got all four they would give it to me.

[Tweety, BSN, RN]

If 3 units total were ordered the blood bank would only have 3 units typed & crossed for that patient.

I don't see how a 4th could have been given unless it was another patients blood which also seems pretty far fetched since two nurses have to check the armband against the blood and the paperwork.

Not necessarily. It wouldn't be a stretch that they typed and crossed several units when the patient was initially typed and crossed, especially if they had such a low HH. Often they set up more units of blood than are ordered. Often there are units of blood available and never used.

[Daytonite, BSN, RN]

katrn28. . .essentially, what you are asking about is the complications that can occur as a result of blood transfusion. the ones that might apply in the case of too much blood being given would be:

• circulatory overload - this is congestive heart failure brought on by too much volume, either the ns or whole blood being given to a patient who already has some cardiac or pulmonary decompensation - you would assess for signs and symptoms of chf (dyspnea, non-productive cough, crackles in lungs, hemoptysis, tachycardia, development of s3 and s4 heart sounds and cool, pale skin)
  
• hypothermia - usually only occurs when there has been rapid infusion of large volumes of refrigerated blood over a short period of time - again, you would assess for signs and symptoms of hypothermia (drop in temperature, tachycardia, tachypnea, impaired speech, disorientation and a generalized lethargy)
  
• hypocalcemia due to citrate overload - citric acid is often added to whole blood, blood products or plasma to prevent the blood cells from clotting during storage; when multiple units are transfused, the citric acid ends up in the patient's circulation and will bind with their free calcium ions, thus causing hypocalcemia - assess a serum calcium level drawn after the transfusion(s) and watch for physical symptoms such as muscle spasms, carpopedal spasms (i saw this in a patient once during my career and i will never forget what it looks like), facial grimacing, possible convulsions, irritability, depression and psychosis.
  
• hyperkalemia - the longer a unit of blood is stored in refrigeration or freezing conditions, some cellular disintegration occurs resulting in the release of potassium from those cells. i have one resource that says the plasma potassium level goes from 5.1 mmol/l to 78.5 mmol/l in one unit of blood after a storage period of 35 days (intravenous therapy: clinical principles and practice). that would increase if multiple units are transfused. this resource is saying that potassium increases need to be considered only when the patient already has an elevated potassium level. still, you would want to assess a serum potassium level after the transfusion(s) and watch for any development of irregular heart beats or arrhythmias (which you would see if the patient is on telemetry).

hope that answers your question for you. the above information was put together from these resources:

• intravenous therapy: clinical principles and practice, edited by judy terry, leslie baranowski, rose anne lonsway and carolyn hedrick, published by the intravenous nurses society, 1995, page177.
  
• portable rn: the all-in-one nursing reference, third edition, published by lippicott, williams & wilkins, 2007, page 383
  
• taber's cyclopedic medical dictionary, 18th edition, published in 1997 by f.a. davis company