Blood Transfusion during Dialysis

I am employed in the Quality department of an LTAC. We use contract dialysis nurses to come in and perform dialysis on our patients. I am reading through a chart today and I find out that she infused 2 units of blood in less than a half hour on a patient with a BNP of 1555! Clearly the patient was in CHF. The patient's H&H was 8/25 so there was no need to rush the transfusion. The patient also had 4+ pitting edema of the bilat lower extremities. I am researching the standard for transfusions during dialysis because I don't know what they are. I know as a floor nurse, the standard minimum time for a single unit to infuse is 2 hours but could go as long as 4 hours based on the patients' status. The reason Lasix is ordered between units is to prevent fluid overload. Because this patient is on dialysis, I am not sure how effective the loop diuretic was. . .the nurse did not document her outputs via dialysis or foley! Needless to say, the patient ended up in respiratory failure and fortunately made it through the code. Now she's sucking on a vent. Does anyone have legit info that I can further research? I would like to prevent this from happening in the future. Part of my job is to identify what went wrong and put processes in place that will correct this and keep it from happening again. Thanks. . .
How was the pts blood pressure? I know I have had pts in the ICU who were severely fluid overloaded and needed dialysis but had a low BP and somewhat low H&H and were given blood products during dialysis to help keep the pressure up. Not under 30 min. though.

Did they take fluid off? How much? or was it just for clearance? If she put in 700cc of PRBC but took off 4 liters of fluid total ...

Funny you all should ask these questions. . .the dialysis nurse's note is absent from the chart so there is zero information about what was taken off during dialysis, vital signs, etc. This whole case is seriously lacking complete (or even incomplete) documentation.

First, I am not sure of how reliable BNP is for a renal failure pt...also, I lost some respect for this post with the "sucking on a vent" comment.What happened to the documentation during the dialysis? Did the facility lose it or the did the nurse just not document (I'm doubtful of the latter explanation)?I would think you would need a dialysis nurse's answer....or better yet, you could contact the company that provides the dialysis nurses.

"Sucking on a vent" stated like a veteran nurse!

I agree that you need to contact a dialysis nurse, particularly the actual nurse who performed the dialysis in this case, to inquire about the missing documentation.

Quote from Biggirl71I am employed in the Quality department of an LTAC. We use contract dialysis nurses to come in and perform dialysis on our patients. I am reading through a chart today and I find out that she infused 2 units of blood in less than a half hour on a patient with a BNP of 1555! Clearly the patient was in CHF. The patient's H&H was 8/25 so there was no need to rush the transfusion. The patient also had 4+ pitting edema of the bilat lower extremities. I am researching the standard for transfusions during dialysis because I don't know what they are. I know as a floor nurse, the standard minimum time for a single unit to infuse is 2 hours but could go as long as 4 hours based on the patients' status. The reason Lasix is ordered between units is to prevent fluid overload. Because this patient is on dialysis, I am not sure how effective the loop diuretic was. . .the nurse did not document her outputs via dialysis or foley! Needless to say, the patient ended up in respiratory failure and fortunately made it through the code. Now she's sucking on a vent. Does anyone have legit info that I can further research? I would like to prevent this from happening in the future. Part of my job is to identify what went wrong and put processes in place that will correct this and keep it from happening again. Thanks. . .

A BNP of 1555 is normal for an ESRD on hemodialysis. To infuse two units in this time frame provided they are removing fluid as they push the blood in is accepted practice.

When a dialysis patient needs blood, during dialysis is the best time to give it so that the fluid shifts the transfusion causes can be corrected with the dialysis, and it can actually make dialysis more effective as the blood pulls third-spaced fluid. You probably aren't going to get a very impressive response with lasix in a chronic HD patient.

with ESRD , a BNP that elevated, and the +4 edema who's to say the patient wasn't heading towards respiratory failure secondary to the CHF anyway. The interventions easily could of had nothing to do with it, and I doubt the volume of 2 units set her into it. This sounds like a chronic problem, that if anything has been undermanaged over a long period of time. As for the missing documentation, I would document that it is indeed missing from the chart, and make every effort to locate the notes, and/or the person responsible for it. I hope that is a regular thing Sounds like a sick patient, and she can thankful she survived the failure if it was her wish to do so. Off the cuff remarks like the one in your post, detour actually qualified from wanting to contribute to your research if that is your intention. Lets keep it professional and respectful.

I'm also a former dialysis nurse. As pp have said, blood can be given much faster on dialysis than via peripheral IV; however, I would try to give it over 30-45 min per unit, as a typical dialysis tx lasts at least 3 hours (it may be less in acutes, but rarely < 2 hours); but this doesn't mean it can't be given faster, as per the dialysis provider's protocol.Lasix is usually not given to ESRD pts as the dialysis machine will take off excess fluid as programmed. In acutes (i.e., your setting) the nephrologist often determines the fluid removal goal, which will be part of the dialysis orders in the chart (or it may be something like "as tolerated"). Dialysis nurses (should) know to account for the fluid of the blood product by adding it to this goal; of course, if the pt is highly unstable during tx then no fluid may be removed and sometimes more has to be given (as NS) than can be removed; the tx sheet (which is apparently missing) should state this.There should be a tx sheet; the acute/contract nurse has to provide a copy to his/her employer, and the original stays in the pt's chart. If you don't have it, you should be able to obtain it from the dialysis company.DeLana

I've been an Acute Dialysis Nurse for 5 years, and also work in Critical Care. We do it all the time. I've given 2 units in about that timeframe, but only if the Hct is low, the lungs are clear, and I know the pt is going to tolerate a decent ultrafiltration. Lasix isn't going to do squat with ESRD, and is not a predictable outcome anyway. UF is far more fast and effective and is controlable by the RN. I'm concerned about the lack of documentation, but acute charting is a little crazy. Maybe it's all there but you don't know how to interpret the chart. Call them and ask. Acute dialysis nurses generalyl have a diverse autonomy and our nephrologists tend to give us a wide parameter within which to use our judgement.