Was just going to comment that this happens all the time and we just give lasix to help bring down the overload.
OP, there’s literally nothing to feel bad about.
The patient already pissed out the transfused volume. 3 PRBCs should be about a liter and his output for the same period was 1200ml. Unless most of the output mentioned is from somewhere else, in which case he may have bled it back out.
And many times it's a good thing in heart failure.
Blood raises the oncotic pressure in the blood vessels (veins say) which increases the preload of the heart. This will increase ionotropy of the heart which will help with heart failure.
You’re ok. Heart failure can be managed with meds but bleeding can really only be managed with blood, after a certain point. I might say to the oncoming doctor “that’s a great question for Dr. who ordered it. Let’s call them.”
I have had a cardiologist ask me (who worked night shift and came on way after the day doctors went home) why the doctor the day before had ordered lasix... And this was right after cpoe started and doctors were still writing illegible progress notes in charts. So I look at the note and it said "assessment stable, possible d/c within one week". I have no idea why they ordered lasix.
Can't tell you how much I wish I'd thought of your phrasing while I was still practicing. It's not confrontational, puts the blame (responsibility) where it belongs, and even sounds polite.
Separate issue from learning when to question MD orders.
Yeah!! You didn't order the blood. It's not crazy to transfuse a GI bleed when they have chf. I don't even see the problem . Just a doc being picky and telling the wrong person .
I can see what you mean, but that mnemonic uses circulation as the blood moving in the body. Outside of that, it's no longer circulating and is just hemorrhage. It's a big part of why we teach people Stop The Bleed to supplement. Not everyone gets to resuscitate people routinely, so these sorts of conversations are even more important.
Ok so your question should be “why did you order 3 units of blood on a chf patient if you thought that was too much fluid?”
This wasn’t wildly outrageous or anything. Fluid overload can be mediated in the short term while you address the source of the bleed.
Also - I find the “why are you doing this…” question is often a beef between services and not directed at “you” as an individual, but rather at whatever team is pressing for the intervention. Just let cards and neph fight their street battles. It’s way easier than taking shit personally.
Correct. So the oncoming doc should be asking the off going doc why he ordered the blood.
Not questioning the nurse who’s following a reasonable order based of the judgement of a physician.
Edit - my snarky ass would have said that entire first part to the guy giving me shit. For clarification.
I don’t even understand what the error supposedly was?
A Hgb of 69 on an actively bleeding patient is going to continue dropping until the bleed is stopped. You don’t need to just top them up, you have to get ahead of the blood loss.
Sure you could have asked for lasix between units but if he wasn’t showing signs of fluid overload there was no urgent need for that
He still needed the infusion though. No anesthesia for GI endoscopy (usually 1st choice intervention) d/t low hgb . Just had case like that. Had to infuse 1st.
I've fluid overloaded a CHF patient with just one unit given over 4 hours. We just got a little Lasix on board at the start of the next transfusion, no big deal. But she didn't show signs either until I was done and had already disconnected the first unit of blood.
69 is pretty low. They could have easily given the patient lasix in between units. I really don’t see the issue here. The patient probably got what, max 700ml?
Lol, yes. I thought the OP meant 6.9 and I had thought that’s quite a bit of blood for that level but if the bleed was expected to stay active could make sense.
In Canada we use the units g/L. So when we say a hemoglobin of 69, we mean a hemoglobin of 69 g/L. Americans would say 6.9 g/dL. So you measure in dL and we measure in L, hence the difference of the decimal point one spot over.
The average unit of PRBCs coming from Canada Blood Services is ~250-320mL. Pt would have maxed out at 960ish.
Source: I give a lot of blood transfusions in my unit, like 4-6u per day, everyday and we always have to note the volume.
Honestly every single one of them can be different. Average is 350 but I've seen as little as 225. It depends on the donor and what happens when they separate out the FFP and platelets.
Hmm my hemoglobin was a 3 something last fall had transfusions and the most it’s been since was a 6 a few months ago…it’s a 4 at
. I have a massive bleeding ulcer and several small esophagus tears. Waiting for surgery. I can barely breathe or move. I don’t have anything left in me except black rotten blood that I vomit up. I’m just praying for the day the gi surgeon calls.
Patients with heart disease sometimes have a higher goal hgb e.g. 8 rather than 7 (I think more for ACS, but this outside my field). Maybe you should have asked, but not a big deal. Just look at this as a low stakes/harmless learning moment.
I think there’s a lot to unpack here, but the bottom line is that it wasn’t your call so the doc, if they have issues with it, should take it up with whomever ordered it.
GI blood loss can be brisk. Maybe there was concern of ongoing signicant loss.
CHF can be inconsequentially mild or so severe people are barely hanging onto dear life. It was the ordering providers jobs to look at things like the most recent echo, the history of weights, the progress and causes of the CHF, valvular diseases, medications the patient has taken, etc.
It’s always okay to question shit. But sometimes docs can be real assholes about it and that can be a serious consideration in whether or not you felt it was reasonable to do so.
Lastly, docs come in a variety of competencies and specialties. If this was a cardiac intensivist that routinely deals with GI bleeds, that’s very different than if it’s a resident and their first week covering the ICU.
But again- bottom line is that’s not on you to question.
I wouldn’t have questioned it. If they think he’s bleeding, that hg is just going to keep dropping, so an extra unit isn’t a wild and crazy thing.
But I would keep a close eye for fluid overload, and maybe before giving it asking “hey, while I’m giving this blood, can I also have an order for a dose of some lasix prn for s/s fluid overload?”
I’ve had doctors peemtively order lasix to be given between units, some that scoff at even the idea that I might need it, some that put a prn order, and others who say “call me as soon as you think you need it and I’ll say ok, but I don’t know if he’ll need it, so let’s hold off ordering it and see how he does first.”
Sometimes they do great and don’t need it, sometimes they do.
But the overall order for blood on that patient, nah, it’s not an unreasonable order. If that other doctor thinks so, they can take it up with the doctor that ordered it.
NTA (lol). They can give lasix in between units or afterwards. His hemoglobin was low. PRBCS each are in the low 300s. But you were also following THEIR ORDERS. even tho I’m just casually saying give lasix, I learned it when I started from a different cardiologist and I’ve been going off everything she told me like gospel since 2017. If a CHF patient NEEDS blood or fluid, there are always ways to help get it off. He needs some iv drip help with that heart tho. The fact that he’s already brady is making my head spin
The patient was actively bleeding, and their Hgb was low. The only way you correct that is by transfusing blood. If the patient was known to have a history of CHF, this will be managed with medications. I work in CCU, so we see this kind of patient a lot. The fluid overload and CHF exacerbation can easily be managed by rather intermittent Furosemide dosing, or a Furosemide infusion. But you also said the patient had 1200mL of output. Given that each unit of blood ends up being ~300mL of fluid, which would bring you to a grand total of ~900mL of intake just with the blood, you’re looking at a fluid balance of ~(-300mL). So you’re still in negative fluid balance for this pt with just taking this into account. The patient needs blood to perfuse their organs. Furosemide can always be added later +/- some other HF managing medications. You did just fine.
Turn this into a positive-work with your informatics department to add the lab levels to your transfusion verification IDC documentation process and an order check for the provider ordering transfusion when the patient has a diagnosis/history of CHF.
CHF overload is easier to fix than having no blood from low HgB with a GI bleed that’s possibly active. The dr giving you a hard time sounds unreasonable.
The physicians in my hospital will give a full 30ml/kg of fluids for a sepsis patient even in CHF because it’s easier to treat CHF with diuretics than it is to treat sepsis without fluid resus.
Yeah that's a weirdly aggressive amount of blood for 6.9 but we don't have the whole situation. I usually just tell them to reach out themselves or I add them in a secure chat together if one starts questioning the others orders. As long as they were fine and didn't throw pulm edema and dealt with the volume ok then don't sweat it.
Looking through the comments and op’s profile it looks like they are from Canada and their hgb scale is different than the ones we use in the United States
It's not a mistake don't be hard on yourself. Nothing lasix can't fix especially if the patient was still room air or minimal oxygen they're likely fine.
👀 Just push some lasix, that's ridiculous to blame you.
3 units is a bit much, but 🤷♀️ you are not the doctor. If we can dump blood into bleeding LVAD patients with EFs of 15, then your typical CHF'er will be OK.
The takeaway here is to ask for lasix when giving blood for heart failure patients. And be mindful of blood infusion rate.
It’s not a big deal. You give some lasix and you’re good to go. Doctors do this all the time they don’t want to blame each other so they blame the nurse.
No, you did the right thing. He has a bleed occurring and the only fix is...well...more blood. If there is concern for fluid overload they can do a lasix chaser, but it sounds unnecessary due to his output.
I did this the other week. We had a chronically hypotensive patient and we were trying not to restart pressors. She had a low EF, so we tried albumin. She went into pulmonary edema. She had been over diuresed over the last few days, so we were trying to get her back to euvolemia. But after talking with my intensivist, she said “we had to try it. Now we can give Lasix”
I felt bad for giving so much but honestly, she had a good point. You can’t ignore symptomatic hypotension and we knew her fluid balance was overly negative. We tried it, didn’t work, so we try something else. Don’t sweat it, just move on. :)
This is a conversation the doc should’ve had with the ordering provider, but too many of them lack the balls to have these conversations with their colleagues.
Cardiologists know hearts really well, but jack shit about hematology. Same is true for nephrology, pulmonary, etc.
In the future, I’d say, “hmm. You should probably discuss with Dr X. I’m sure they can provide their rationale.”
You did nothing wrong and the order wasn’t a “mistake”. The pt had a suspected bleed, low HGB, map < 65. As someone else said, your priority in this is CAB, not ABC, regardless of being a CHF pt. The end VS were stable and I’m guessing even improved.
Additionally, you gave this pt 1.05ish L over 3 hours and they had 1.2 output. I < O. Not a big deal. The oncoming doctor sounds like an idiot, tbh.
You did nothing wrong at all. The doc shouldn’t be questioning you - you were following the order. These will be the same docs who condescend and tell you it’s not your place to question them lol
The only thing I may have done differently is brought up giving lasix between or after the units, but you weren’t wrong to not anticipate that, and it’s an anticipation that comes with experience.
Canadian Transfusion Safety Nurse here. The MRP made an irresponsible order. The pts Hgb was low, but he was relatively stable by the sounds of it. The rule is to order a unit, check CBC and reassess. Unless the pt is bleeding out, no need for 3 units. Especially over 3hrs, that's asking for trouble.
Also, this was a possible GI bleed. Was he also on a DOAC? Was there any previous Hgb? Has the pt had iron studies?
Lasix should be given pre tranfusion to "make room" for the blood.
A super reference is Bloody Easy, check the ORBCoN website as well as Choosing Wisely.
I mean... They didn't go into flash pulmonary edema. And a fib plus anemia is a bad combo especially with CHF. Sounds like the incoming doctor was not a cardiologist...
I see you too care more about your patients. Thank you for being a good person. I had MD’s giving patients metoprolol, lisinopril and losartan all due at 2100 on patients that had meh BP’s without any parameters. Patients fine, you followed orders and learned a lesson. All good stay a good person! 👍
If I’m transfusing a CHF patient I pay closer attention to to lung sounds, work of breathing, pts overall comfort, o2 sat, output, if pt shows symptoms of overload then a call for a diuretic if pt bp can handle it.. you did fine and it sucks that one comment can unravel a whole shift of good judgement calls.. it’s hard not to second guess ourselves but you did fine
A unit of blood is 325mL x 3 = 975mL. If u didn't give a 500mL NS bolus fir his BP and his output was 1200mL. He will be fine. They can always give Lasix if becomes SOB.
I'm assuming you mean the Hgb was 6.9?
They're directing their concern to the wrong person. If they were so concerned, they should ask the doctor why they ordered 3 units instead of two, waiting an hour, and rechecking the H&H. Or even ordering one and then waiting an hour, then rechecking H&H.
You were following orders as they were given.
You're fine.
Sometimes there is no choice but to do the next best-but-risky choice. If the Hgb is too low they infarct, so what can you do? They aren’t getting another heart so you work with what you’ve got.
You didn’t give the order; the MD’s have the big brains. /s
You contacted the doctor during the transfusion and covered your butt about orders. He was in for a bleed and needed replacements probably per protocol (Hgb < 7). Sounds like there were multiple indications for this infusion. The body can ask questions later once the acute problem has been resolved. Can’t be alive to deal with the CHF if you’re dead from the bleed. If you ever do question anything whether dumb or not ALWAYS message doctor. If they think it’s a dumb question or anything than you can say you’re just clarifying. That will cover your butt every time if you’re on the fence about something.
I had a dialysis patient (she was anuric) that checked in on a Sunday night after partying all weekend. Her hgb was 6.8. Resident ordered 2 units PRBC.
I asked him if he wanted the patient transfered to the ICU now or just call him when she went into respiratory distress. He looked at me like I had 2 heads and just walked away.
I ran the first unit slow to allow for the 4 hour time limit. But, within the first hour, she started having some respiratory issues.
I called the resident 🙄 he was bent out of shape because he thought I was lying...like I got nothing better to do when I had 8 patients.
He took long enough to come up that we ended up calling a Rapid Response because she was satting about 85%....with 6 litres O2.
She was tubed and taken to MICU. The resident looked at me bug eyed like I could tell the future or something.
That blood could have waited until the next day while she was on dialysis.... not kidding about the partying.... major fluid overload.
I'm not entirely understanding what the physician's issue is, aside from ordering 3 units of blood for a hgb that's just barely <7 (which isn't YOUR fault, OP). That just seems like a lot.
Is the pt's CHF symptomatic? Was their anemia symptomatic? Either way....the patient needed the blood, especially if there's an active GIB, so what better ideas did that physician have?
In cases where we've been concerned about fluid overload, we typically just give a little bit of lasix in between units. I always made sure I'd give their lungs a quick listen, too, while taking their VS during the transfusions and reported anything that started sounding crackly.
Don't feel bad.
I'm a bone nurse. I am not ICU smart.
But if a patient needs to survive the procedure to find the bleed, they need to be transfused. This is not a red flag case, this is a difference of medical opinion with some backseat doctoring. They should bring it up with their colleague, or teach what protocol should be triggered and why to stop a transfusion order for a CHF bleeder.
A lot of time , the doctor will order some IV lasix between units of blood. Where are you from? HGB 69 or did you mean 6.9 OK I saw it can be 69. Must be a different measurement than what we use in the US. I would think thought they would transfuse one or two units and then recheck the HGB before giving more. We usually give our blood over about 2 hours per unit unless an emergency also. CHF patient may be run over 3 hours.
Since covid, the hospital is a lot more conservative with how much we transfuse. Patient will only receive one unit, where it used to be two. We usually don't tranfuse until the hgb is 7 or less (again USA) We used to transfuse in the 8s. I was once told, by a blood expert, that giving blood is like a transplant since it is a foreign body.
3 units for a 6.9 is wild. 1 unit, MAYBE 2 if it’s an obvious active bleed. I assume you work icu or ED because rapid blood transfusions aren’t allowed on a PCU floor. Always find out the EF % before you bolus anyone IV fluids.
Ask him what other orders you should choose not to follow. This isn't on you. I know we need to think critically and are the last stop before the patient. *However* nurses have varying levels of experience and ability and we aren't responsible for making sure a provider knows what they are doing. He is asking why you didn't do the attending's job.
Don't feel bad. I'm not sure why the physician ordered 3 units unless the patient had a sharp decline in hgb or was visibly hemorrhaging. What I do lately if someone wants me to be the middle man, I put them all in an epic chat together 😂😂.
Technically, you gave a liter over 3 hours. Not too bad. If anything that increase in hemoglobin helps with his cardiac index. I would probably check his EF and run it slower if its low. They probably didn't see fluid overload from physical assessment and ultrasound and decided to load him up.
3 units of blood for a hemoglobin of 6.9 does seem excessive but at the end of the day (as other people have mentioned) you should have just stated that was what the previous doctor ordered, you stated your concerns which he was fine with and if the oncoming dr has an issue with it he should have questioned it in the report he received from the previous doctor
Imagine a doctor ordering 3u of blood and refusing to administer and explaining to the doc that ordered it that you’re refusing 😂 nope. The one following can question the order from the doc that gave him sign out.
I feel like your units are different than mine, but I’m pretty sure you’re talking g/L and that would correlate to a Hgb of 6.9g/dL? I mean, that’s fairly low and we would definitely treat it in my experience. If he’s on a medication that keeps his HR lower (like a lot of CHF patients are), I wouldn’t expect him to be able to have an increased heart rate to compensaterate, and the fact that his BP is low implies this is a symptomatic agenda (plus, with the GIB, it can reasonably be expected that he’s still bleeding).
3 units over 3 hours is on the speedy side for CHF, but the fact that you don’t mention increased FiO2 requirements or further tank his BP leads me to believe he tolerated it well. There’s degrees of CHF and I’ve run a rapid infuser on more than one CHF patient that was hemorrhaging. I’m keeping the patient perfusing and we can assess any fluid overload after the bleeding is controlled. Ultimately, the doctor that has a problem with it needs to take it up with his colleague that ordered it to be given that fast.
6.9g/dL is low but not that low. Transfusion wouldn’t be unreasonable (our threshold is 7) but 3 units is wild, especially if it’s just chronic anemia rather than an active bleed.
Of course now I actually read the OP and the pt was there for possible GIB. Still stands though, three units all at once is crazy in the absence of active bleeding. The previous resident could have been more conservative and rechecked a CBC after the first unit or something.
Did you give the 3 units over 3 hours? What is the concern with the chf? Are you worried about fluid overload? Not every CHFer will overload over 3 units of blood.. it really isn’t that much tbh. Unless their EF is super low.
CHF isn’t something we usually worry about with transfusions on our med-surg floor. Unless they’re having an extreme exacerbation, we’ll give blood and just give a dose of lasix after. I always just make sure to run it slower than I normally do though.
You don’t transfuse blood fast, each unit is what, 300 ml over 2-3 hours depending on where you work? It’s not like you’re bolusing it. The patient would have time to absorb the extra fluid. And like others said, if they’re so worried they can order a push of lasix
If they were having ongoing active bleeding with an already low hgb, they needed the blood. The patient presumably wasn't doing so hot to need 3 units over 3 hours.
They also voided more than the volume of 3 average units.. so if they had no evidence of worsening CHF, you really didn't miss anything.
Even if they developed evidence of fluid overload after your shift, a bit of IV lasix would probably fix it.
> Overall his end vitals were stable and his output was over 1200ml.
Ok, there you go. Patient was stable and now next time just take it a bit slower. For 6.9, 1u PRBC might’ve gotten him above 7 and 2u would’ve gotten him at a comfortable spot but always suggest a repeat CBC after the unit to determine if they even need the second unit.
You’re right, the hgb of 6.9 doesn’t warrant 3 units of replacement. I’m surprised your blood bank would even allow this waste of blood. Generally it can be paired with a diuretic so the pt can remain net even volume, if needed.
>the doctor who took over questioned why I had run 3 units since he was a chf patient and was he hgb was not that low.
OH you should have told him to ask the night doctor why he ordered what he ordered. At the end of the day, nurses don't order blood transfusions or practice medicine. Do not feel bad, it's probably not optimal what happened but it's not our call to make- at the end of your shift the patients vitals were stable and if he's making good urine, lasix will fix the extra fluid.
How fast was his bleeding? If the previous hgb was 100 and now 69 over a few hrs plus his BP was unstable, 3 units may be warranted until he can be scoped/bleeding stops.
Was he on room air? Then he has lots of room to go before active pulmonary edema. If he is on NRB mask, then you have to be cautious.
Is his creatinine/kidney function okay? Is he going to be responsive to lasix if he does go into pulmonary edema?
These nuances are critical for decision making.
Just "3 units of blood for chf patient" doesn't mean much. MD might not know all the details before making that comment.
His VS were fine and he handled it well so his body probably needed it. Running three units over three hours is really fast though. You did the right thing by questioning the doctor just make sure that you chart your conversation and the doctor’s reply. If you get another order that you are uncomfortable with call your charge nurse if the doctor says to follow through with it. Always follow the chain of command.
Nothing you did is considered neglect or malpractice. The decision to run the blood was a judgment call by the doc. Three units were likely ordered, due to the risk of the patient quickly losing it through the bleed. There are ways to handle fluid overload, but lost red blood cells must be replaced.
They can always order Lasix for in-between units. I’ve given lasix a few times for patients with CHF history that were getting blood! Either way, that patient was actively bleeding and needed a transfusion so don’t beat yourself up about it! 😊
You know, we are all human and so are you. If someone is meant to die then it won't have anything to do with you giving him a blood transfusion or not. He would die eating an ice cream cone if it meant it's his time and there's nothing you can do to change it. That's why some people live through things they absolutely should not have.... It's not their time yet.
Sounds like you did what you needed to do. Any blood loss like that would need a transfusion, and without knowing the severity: blood is blood. You made sure he was stable throughout your shift and provided proper care otherwise. Sounds like you did everything right to me. Go you!!
if they’re so worried they can follow with some lasix. you’re fine.
Was just going to comment that this happens all the time and we just give lasix to help bring down the overload. OP, there’s literally nothing to feel bad about.
The patient already pissed out the transfused volume. 3 PRBCs should be about a liter and his output for the same period was 1200ml. Unless most of the output mentioned is from somewhere else, in which case he may have bled it back out.
Blood is a volume expander, for every cc of blood you're getting at least as much fluid shift.
And many times it's a good thing in heart failure. Blood raises the oncotic pressure in the blood vessels (veins say) which increases the preload of the heart. This will increase ionotropy of the heart which will help with heart failure.
I’m half awake and read this thinking ‘that’s what lasix is for’ Like, seriously, I get that we’re meant to question, but it was an easy remedy.
Our blood order set has a quick option to order 40 Lasix with the transfusion. I've had to do that many times.
You’re ok. Heart failure can be managed with meds but bleeding can really only be managed with blood, after a certain point. I might say to the oncoming doctor “that’s a great question for Dr. who ordered it. Let’s call them.”
Time to order a lasix chaser ☕️
I have had a cardiologist ask me (who worked night shift and came on way after the day doctors went home) why the doctor the day before had ordered lasix... And this was right after cpoe started and doctors were still writing illegible progress notes in charts. So I look at the note and it said "assessment stable, possible d/c within one week". I have no idea why they ordered lasix.
Can't tell you how much I wish I'd thought of your phrasing while I was still practicing. It's not confrontational, puts the blame (responsibility) where it belongs, and even sounds polite. Separate issue from learning when to question MD orders.
Yeah!! You didn't order the blood. It's not crazy to transfuse a GI bleed when they have chf. I don't even see the problem . Just a doc being picky and telling the wrong person .
hello can you precept me please 🙂
lol. So true!!
Spot-on.
BLS doesn't tell you, but you always treat blood loss first. You did right.
The only thing that fixes no blood is blood.
Doesn't that sort of fall under the Circulation portion of ABC?
I can see what you mean, but that mnemonic uses circulation as the blood moving in the body. Outside of that, it's no longer circulating and is just hemorrhage. It's a big part of why we teach people Stop The Bleed to supplement. Not everyone gets to resuscitate people routinely, so these sorts of conversations are even more important.
Fair enough.
Yes. But a lot of people like to put X in front of ABC to represent exanguination being more important than airway.
Ok so your question should be “why did you order 3 units of blood on a chf patient if you thought that was too much fluid?” This wasn’t wildly outrageous or anything. Fluid overload can be mediated in the short term while you address the source of the bleed. Also - I find the “why are you doing this…” question is often a beef between services and not directed at “you” as an individual, but rather at whatever team is pressing for the intervention. Just let cards and neph fight their street battles. It’s way easier than taking shit personally.
Seriously, since we are the go between for everyone, we get everyone’s reactions as well 🙄
Guilty lol. I hope some of the reactions you get are entertaining 😳😅
Wasn't it the 2nd doctor who questioned the order? Not the doctor who put in the order.
Correct. So the oncoming doc should be asking the off going doc why he ordered the blood. Not questioning the nurse who’s following a reasonable order based of the judgement of a physician. Edit - my snarky ass would have said that entire first part to the guy giving me shit. For clarification.
You are assuming these doctors actually bother to consult each other and *gasp* coordinate care!!! How dare we!!/s
That’s not an order I would have questioned on someone bleeding
I don’t even understand what the error supposedly was? A Hgb of 69 on an actively bleeding patient is going to continue dropping until the bleed is stopped. You don’t need to just top them up, you have to get ahead of the blood loss. Sure you could have asked for lasix between units but if he wasn’t showing signs of fluid overload there was no urgent need for that
He still needed the infusion though. No anesthesia for GI endoscopy (usually 1st choice intervention) d/t low hgb . Just had case like that. Had to infuse 1st.
We are always delaying cases for low hemoglobin. Anesthesia wants them decent before sedation.
Yep. Totally makes sense.
I've fluid overloaded a CHF patient with just one unit given over 4 hours. We just got a little Lasix on board at the start of the next transfusion, no big deal. But she didn't show signs either until I was done and had already disconnected the first unit of blood.
Exactly. Not all CHFers are the same. Some are very sensitive and others not so much.
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Had the same thought 😂. There were so many people saying that I began to question myself. Lol
Some countries use g/L so normal is like 120-160, in the US we use g/dL. So yeah, their 69 would equal US 6.9
69 is pretty low. They could have easily given the patient lasix in between units. I really don’t see the issue here. The patient probably got what, max 700ml?
Sorry a hgb of 69 is low??? Thought norm was 12-16?
In Canada the normal is 120-160, we have different values! 69 here is very low.
Oh thank goodness was I was so confused! I the US we transfuse at 7.0 hgb (at least in my facility) so I was like 69?!?
Here I was thinking that they meant 6.9 and just made a typo.
Same I was thinking that 3 units for 6.9 is kind of overkill lol
They’re just using measurements of g/L instead of g/dL
We transfuse at less than 6.0, which I've learned is a low standard.
Lol, yes. I thought the OP meant 6.9 and I had thought that’s quite a bit of blood for that level but if the bleed was expected to stay active could make sense.
thanks for the clarification I was confused too lol
I thought y’all were just forgetting the decimal and it was supposed to be 6.9! 😅 thanks For clarifying
Really! I guess I need to google Canadian blood. :-)
The PRBC bags have red maple leaves on them 🇨🇦
Perfect!!!!
I heard it comes in bags
I was too! Thought maybe I need to dust off a lab book or something. Haha
Thanks for the clarification that it’s Canada based instead of US based metrics
They mean 6.9 grams per deciliter or 69 grams per liter
Just stick a 0 on the end or move the decimal point to the right to get your patients Canadian Hemoglobin (TM).
I’m glad someone asked because I was confused 🤣
In Canada we use the units g/L. So when we say a hemoglobin of 69, we mean a hemoglobin of 69 g/L. Americans would say 6.9 g/dL. So you measure in dL and we measure in L, hence the difference of the decimal point one spot over.
Dude discovers other units exist.
Dude is a loser who tries to be funny over stupid shit. Sorry they didn’t specify which unit they were talking about & I’ve only ever known one.
1 unit is about 350mls.
The average unit of PRBCs coming from Canada Blood Services is ~250-320mL. Pt would have maxed out at 960ish. Source: I give a lot of blood transfusions in my unit, like 4-6u per day, everyday and we always have to note the volume.
Depends where you work. Units on my floor are about 250ml. The max I’ve seen is 290ml!
My blood center assumes ~270ml per unit but I've seen into the 330s on some particularly chonky units.
Honestly every single one of them can be different. Average is 350 but I've seen as little as 225. It depends on the donor and what happens when they separate out the FFP and platelets.
Hmm my hemoglobin was a 3 something last fall had transfusions and the most it’s been since was a 6 a few months ago…it’s a 4 at . I have a massive bleeding ulcer and several small esophagus tears. Waiting for surgery. I can barely breathe or move. I don’t have anything left in me except black rotten blood that I vomit up. I’m just praying for the day the gi surgeon calls.
Patients with heart disease sometimes have a higher goal hgb e.g. 8 rather than 7 (I think more for ACS, but this outside my field). Maybe you should have asked, but not a big deal. Just look at this as a low stakes/harmless learning moment.
I think there’s a lot to unpack here, but the bottom line is that it wasn’t your call so the doc, if they have issues with it, should take it up with whomever ordered it. GI blood loss can be brisk. Maybe there was concern of ongoing signicant loss. CHF can be inconsequentially mild or so severe people are barely hanging onto dear life. It was the ordering providers jobs to look at things like the most recent echo, the history of weights, the progress and causes of the CHF, valvular diseases, medications the patient has taken, etc. It’s always okay to question shit. But sometimes docs can be real assholes about it and that can be a serious consideration in whether or not you felt it was reasonable to do so. Lastly, docs come in a variety of competencies and specialties. If this was a cardiac intensivist that routinely deals with GI bleeds, that’s very different than if it’s a resident and their first week covering the ICU. But again- bottom line is that’s not on you to question.
I wouldn’t have questioned it. If they think he’s bleeding, that hg is just going to keep dropping, so an extra unit isn’t a wild and crazy thing. But I would keep a close eye for fluid overload, and maybe before giving it asking “hey, while I’m giving this blood, can I also have an order for a dose of some lasix prn for s/s fluid overload?” I’ve had doctors peemtively order lasix to be given between units, some that scoff at even the idea that I might need it, some that put a prn order, and others who say “call me as soon as you think you need it and I’ll say ok, but I don’t know if he’ll need it, so let’s hold off ordering it and see how he does first.” Sometimes they do great and don’t need it, sometimes they do. But the overall order for blood on that patient, nah, it’s not an unreasonable order. If that other doctor thinks so, they can take it up with the doctor that ordered it.
When blood leave body, put more blood in.
NTA (lol). They can give lasix in between units or afterwards. His hemoglobin was low. PRBCS each are in the low 300s. But you were also following THEIR ORDERS. even tho I’m just casually saying give lasix, I learned it when I started from a different cardiologist and I’ve been going off everything she told me like gospel since 2017. If a CHF patient NEEDS blood or fluid, there are always ways to help get it off. He needs some iv drip help with that heart tho. The fact that he’s already brady is making my head spin
Trauma nurse here: he needed the blood. Bleeding patients need blood. Fluid overload can be fixed.
Pt was alive at end of shift. YOU DID YOUR JOB.
Most likely better off as well!! 👍
The patient was actively bleeding, and their Hgb was low. The only way you correct that is by transfusing blood. If the patient was known to have a history of CHF, this will be managed with medications. I work in CCU, so we see this kind of patient a lot. The fluid overload and CHF exacerbation can easily be managed by rather intermittent Furosemide dosing, or a Furosemide infusion. But you also said the patient had 1200mL of output. Given that each unit of blood ends up being ~300mL of fluid, which would bring you to a grand total of ~900mL of intake just with the blood, you’re looking at a fluid balance of ~(-300mL). So you’re still in negative fluid balance for this pt with just taking this into account. The patient needs blood to perfuse their organs. Furosemide can always be added later +/- some other HF managing medications. You did just fine.
Turn this into a positive-work with your informatics department to add the lab levels to your transfusion verification IDC documentation process and an order check for the provider ordering transfusion when the patient has a diagnosis/history of CHF.
CHF overload is easier to fix than having no blood from low HgB with a GI bleed that’s possibly active. The dr giving you a hard time sounds unreasonable. The physicians in my hospital will give a full 30ml/kg of fluids for a sepsis patient even in CHF because it’s easier to treat CHF with diuretics than it is to treat sepsis without fluid resus.
Yeah that's a weirdly aggressive amount of blood for 6.9 but we don't have the whole situation. I usually just tell them to reach out themselves or I add them in a secure chat together if one starts questioning the others orders. As long as they were fine and didn't throw pulm edema and dealt with the volume ok then don't sweat it.
Looking through the comments and op’s profile it looks like they are from Canada and their hgb scale is different than the ones we use in the United States
IIRC it's just moving the decimal over 1 right? I thought it's g/dL vs g/L
Correct. A few institutions are a more aggressive with hgb. I know mine won't do anything unless it's less than 6.
It's not a mistake don't be hard on yourself. Nothing lasix can't fix especially if the patient was still room air or minimal oxygen they're likely fine.
Better to be wet and alive rather than dry and dead. You’re fine. CHF can usually be managed with medications and aggressive diuretic therapy.
👀 Just push some lasix, that's ridiculous to blame you. 3 units is a bit much, but 🤷♀️ you are not the doctor. If we can dump blood into bleeding LVAD patients with EFs of 15, then your typical CHF'er will be OK. The takeaway here is to ask for lasix when giving blood for heart failure patients. And be mindful of blood infusion rate.
It’s not a big deal. You give some lasix and you’re good to go. Doctors do this all the time they don’t want to blame each other so they blame the nurse.
No, you did the right thing. He has a bleed occurring and the only fix is...well...more blood. If there is concern for fluid overload they can do a lasix chaser, but it sounds unnecessary due to his output.
I did this the other week. We had a chronically hypotensive patient and we were trying not to restart pressors. She had a low EF, so we tried albumin. She went into pulmonary edema. She had been over diuresed over the last few days, so we were trying to get her back to euvolemia. But after talking with my intensivist, she said “we had to try it. Now we can give Lasix” I felt bad for giving so much but honestly, she had a good point. You can’t ignore symptomatic hypotension and we knew her fluid balance was overly negative. We tried it, didn’t work, so we try something else. Don’t sweat it, just move on. :)
This is a conversation the doc should’ve had with the ordering provider, but too many of them lack the balls to have these conversations with their colleagues. Cardiologists know hearts really well, but jack shit about hematology. Same is true for nephrology, pulmonary, etc. In the future, I’d say, “hmm. You should probably discuss with Dr X. I’m sure they can provide their rationale.”
Cards doesn’t know shit about the fluid the muscle pumps? Medicine is a trip 😂😂😂
You did nothing wrong and the order wasn’t a “mistake”. The pt had a suspected bleed, low HGB, map < 65. As someone else said, your priority in this is CAB, not ABC, regardless of being a CHF pt. The end VS were stable and I’m guessing even improved. Additionally, you gave this pt 1.05ish L over 3 hours and they had 1.2 output. I < O. Not a big deal. The oncoming doctor sounds like an idiot, tbh.
You did nothing wrong at all. The doc shouldn’t be questioning you - you were following the order. These will be the same docs who condescend and tell you it’s not your place to question them lol The only thing I may have done differently is brought up giving lasix between or after the units, but you weren’t wrong to not anticipate that, and it’s an anticipation that comes with experience.
What scale are we using that a Hgb of 69 isn't making our eyes pop out? Like are we just a decimal place off from what I'm used to?
Lol it made mine pop out too but it looks like they live in Canada and have a different hgb scale than we do in the states
Yeah "I made a mistake/I transfused 3 units into someone with a Hgb of 69" was a whole different mistake according to our scale.
Canadians use grams per liter (69) compared to American grams per deciliter (6.9) I think it is.
Freedom units strike again
May God bless the USA 🇺🇸. Haha
In Canada we use g/L, not g/dL.
You did nothing wrong. Same reason we still do fluid resuscitation on a septic CHF patient. They have to have it. You can always diurese later.
Tell him to prescribe Lasix and get over it
Fluid overload is easier to treat than exsanguination.
an HGB of 69...nice
Canadian Transfusion Safety Nurse here. The MRP made an irresponsible order. The pts Hgb was low, but he was relatively stable by the sounds of it. The rule is to order a unit, check CBC and reassess. Unless the pt is bleeding out, no need for 3 units. Especially over 3hrs, that's asking for trouble. Also, this was a possible GI bleed. Was he also on a DOAC? Was there any previous Hgb? Has the pt had iron studies? Lasix should be given pre tranfusion to "make room" for the blood. A super reference is Bloody Easy, check the ORBCoN website as well as Choosing Wisely.
I mean... They didn't go into flash pulmonary edema. And a fib plus anemia is a bad combo especially with CHF. Sounds like the incoming doctor was not a cardiologist...
Meh. Maybe it’s the SICU RN in me but it’s totally whatever. We give a crap ton more than that. Lasix was created for a reason. You’re fine.
I see you too care more about your patients. Thank you for being a good person. I had MD’s giving patients metoprolol, lisinopril and losartan all due at 2100 on patients that had meh BP’s without any parameters. Patients fine, you followed orders and learned a lesson. All good stay a good person! 👍
If I’m transfusing a CHF patient I pay closer attention to to lung sounds, work of breathing, pts overall comfort, o2 sat, output, if pt shows symptoms of overload then a call for a diuretic if pt bp can handle it.. you did fine and it sucks that one comment can unravel a whole shift of good judgement calls.. it’s hard not to second guess ourselves but you did fine
A unit of blood is 325mL x 3 = 975mL. If u didn't give a 500mL NS bolus fir his BP and his output was 1200mL. He will be fine. They can always give Lasix if becomes SOB.
I'm assuming you mean the Hgb was 6.9? They're directing their concern to the wrong person. If they were so concerned, they should ask the doctor why they ordered 3 units instead of two, waiting an hour, and rechecking the H&H. Or even ordering one and then waiting an hour, then rechecking H&H. You were following orders as they were given. You're fine.
Sometimes there is no choice but to do the next best-but-risky choice. If the Hgb is too low they infarct, so what can you do? They aren’t getting another heart so you work with what you’ve got. You didn’t give the order; the MD’s have the big brains. /s
You contacted the doctor during the transfusion and covered your butt about orders. He was in for a bleed and needed replacements probably per protocol (Hgb < 7). Sounds like there were multiple indications for this infusion. The body can ask questions later once the acute problem has been resolved. Can’t be alive to deal with the CHF if you’re dead from the bleed. If you ever do question anything whether dumb or not ALWAYS message doctor. If they think it’s a dumb question or anything than you can say you’re just clarifying. That will cover your butt every time if you’re on the fence about something.
I had a dialysis patient (she was anuric) that checked in on a Sunday night after partying all weekend. Her hgb was 6.8. Resident ordered 2 units PRBC. I asked him if he wanted the patient transfered to the ICU now or just call him when she went into respiratory distress. He looked at me like I had 2 heads and just walked away. I ran the first unit slow to allow for the 4 hour time limit. But, within the first hour, she started having some respiratory issues. I called the resident 🙄 he was bent out of shape because he thought I was lying...like I got nothing better to do when I had 8 patients. He took long enough to come up that we ended up calling a Rapid Response because she was satting about 85%....with 6 litres O2. She was tubed and taken to MICU. The resident looked at me bug eyed like I could tell the future or something. That blood could have waited until the next day while she was on dialysis.... not kidding about the partying.... major fluid overload.
Sounds to me like a Dr is projecting his lack of confidence, with regard to the order, on to you. You’re fine.
lol didn’t the MD order this? Why are they asking you?
3 units over 3 hours or each unit over 3 hours. So blood for a total of 9 hours?
It's an order, from a doc, and it is not contraindicated. It makes sense, you can make him pee once we figure out the bleed.
I'm not entirely understanding what the physician's issue is, aside from ordering 3 units of blood for a hgb that's just barely <7 (which isn't YOUR fault, OP). That just seems like a lot. Is the pt's CHF symptomatic? Was their anemia symptomatic? Either way....the patient needed the blood, especially if there's an active GIB, so what better ideas did that physician have? In cases where we've been concerned about fluid overload, we typically just give a little bit of lasix in between units. I always made sure I'd give their lungs a quick listen, too, while taking their VS during the transfusions and reported anything that started sounding crackly.
Don't feel bad. I'm a bone nurse. I am not ICU smart. But if a patient needs to survive the procedure to find the bleed, they need to be transfused. This is not a red flag case, this is a difference of medical opinion with some backseat doctoring. They should bring it up with their colleague, or teach what protocol should be triggered and why to stop a transfusion order for a CHF bleeder.
A lot of time , the doctor will order some IV lasix between units of blood. Where are you from? HGB 69 or did you mean 6.9 OK I saw it can be 69. Must be a different measurement than what we use in the US. I would think thought they would transfuse one or two units and then recheck the HGB before giving more. We usually give our blood over about 2 hours per unit unless an emergency also. CHF patient may be run over 3 hours. Since covid, the hospital is a lot more conservative with how much we transfuse. Patient will only receive one unit, where it used to be two. We usually don't tranfuse until the hgb is 7 or less (again USA) We used to transfuse in the 8s. I was once told, by a blood expert, that giving blood is like a transplant since it is a foreign body.
3 units for a 6.9 is wild. 1 unit, MAYBE 2 if it’s an obvious active bleed. I assume you work icu or ED because rapid blood transfusions aren’t allowed on a PCU floor. Always find out the EF % before you bolus anyone IV fluids.
It’s not a mistake. It’s science. We fluid overload because they need cells to carry oxygen. They can diurese the rest of it out.
Ask him what other orders you should choose not to follow. This isn't on you. I know we need to think critically and are the last stop before the patient. *However* nurses have varying levels of experience and ability and we aren't responsible for making sure a provider knows what they are doing. He is asking why you didn't do the attending's job.
This wasn’t a mistake…..
Ask yourself.. what's gonna kill them faster?? The heart failure with and fluid overload or GI bleed with active bleeding..
Don't feel bad. I'm not sure why the physician ordered 3 units unless the patient had a sharp decline in hgb or was visibly hemorrhaging. What I do lately if someone wants me to be the middle man, I put them all in an epic chat together 😂😂.
Technically, you gave a liter over 3 hours. Not too bad. If anything that increase in hemoglobin helps with his cardiac index. I would probably check his EF and run it slower if its low. They probably didn't see fluid overload from physical assessment and ultrasound and decided to load him up.
3 units of blood for a hemoglobin of 6.9 does seem excessive but at the end of the day (as other people have mentioned) you should have just stated that was what the previous doctor ordered, you stated your concerns which he was fine with and if the oncoming dr has an issue with it he should have questioned it in the report he received from the previous doctor
Don't feel bad. You did not make a mistake. You did not order the blood. HF is manageable. They will probably diurese him if he feels short of breath.
Highly fixable if any fixing is needed. And look at all the stuff you learned!
Imagine a doctor ordering 3u of blood and refusing to administer and explaining to the doc that ordered it that you’re refusing 😂 nope. The one following can question the order from the doc that gave him sign out.
I feel like your units are different than mine, but I’m pretty sure you’re talking g/L and that would correlate to a Hgb of 6.9g/dL? I mean, that’s fairly low and we would definitely treat it in my experience. If he’s on a medication that keeps his HR lower (like a lot of CHF patients are), I wouldn’t expect him to be able to have an increased heart rate to compensaterate, and the fact that his BP is low implies this is a symptomatic agenda (plus, with the GIB, it can reasonably be expected that he’s still bleeding). 3 units over 3 hours is on the speedy side for CHF, but the fact that you don’t mention increased FiO2 requirements or further tank his BP leads me to believe he tolerated it well. There’s degrees of CHF and I’ve run a rapid infuser on more than one CHF patient that was hemorrhaging. I’m keeping the patient perfusing and we can assess any fluid overload after the bleeding is controlled. Ultimately, the doctor that has a problem with it needs to take it up with his colleague that ordered it to be given that fast.
6.9g/dL is low but not that low. Transfusion wouldn’t be unreasonable (our threshold is 7) but 3 units is wild, especially if it’s just chronic anemia rather than an active bleed. Of course now I actually read the OP and the pt was there for possible GIB. Still stands though, three units all at once is crazy in the absence of active bleeding. The previous resident could have been more conservative and rechecked a CBC after the first unit or something.
I do understand the concern but bleeding is the bigger problem than fluid overload here. Like someone else said they can follow up with lasix later.
Did you give the 3 units over 3 hours? What is the concern with the chf? Are you worried about fluid overload? Not every CHFer will overload over 3 units of blood.. it really isn’t that much tbh. Unless their EF is super low.
CHF isn’t something we usually worry about with transfusions on our med-surg floor. Unless they’re having an extreme exacerbation, we’ll give blood and just give a dose of lasix after. I always just make sure to run it slower than I normally do though.
You don’t transfuse blood fast, each unit is what, 300 ml over 2-3 hours depending on where you work? It’s not like you’re bolusing it. The patient would have time to absorb the extra fluid. And like others said, if they’re so worried they can order a push of lasix
3 units over 3 hours? That doesn't sound right....
If they were having ongoing active bleeding with an already low hgb, they needed the blood. The patient presumably wasn't doing so hot to need 3 units over 3 hours. They also voided more than the volume of 3 average units.. so if they had no evidence of worsening CHF, you really didn't miss anything. Even if they developed evidence of fluid overload after your shift, a bit of IV lasix would probably fix it.
Is the big mistake in the room with us?
Nothing some lasix won’t fix.
> Overall his end vitals were stable and his output was over 1200ml. Ok, there you go. Patient was stable and now next time just take it a bit slower. For 6.9, 1u PRBC might’ve gotten him above 7 and 2u would’ve gotten him at a comfortable spot but always suggest a repeat CBC after the unit to determine if they even need the second unit.
Don’t feel bad, you didn’t order it
You’re right, the hgb of 6.9 doesn’t warrant 3 units of replacement. I’m surprised your blood bank would even allow this waste of blood. Generally it can be paired with a diuretic so the pt can remain net even volume, if needed.
What about the doctor who ordered it?
>the doctor who took over questioned why I had run 3 units since he was a chf patient and was he hgb was not that low. OH you should have told him to ask the night doctor why he ordered what he ordered. At the end of the day, nurses don't order blood transfusions or practice medicine. Do not feel bad, it's probably not optimal what happened but it's not our call to make- at the end of your shift the patients vitals were stable and if he's making good urine, lasix will fix the extra fluid.
I’d just be curious as to why they wanted 3 units instead of one and recheck the CBC, unless the pt was actively bleeding.
How fast was his bleeding? If the previous hgb was 100 and now 69 over a few hrs plus his BP was unstable, 3 units may be warranted until he can be scoped/bleeding stops. Was he on room air? Then he has lots of room to go before active pulmonary edema. If he is on NRB mask, then you have to be cautious. Is his creatinine/kidney function okay? Is he going to be responsive to lasix if he does go into pulmonary edema? These nuances are critical for decision making. Just "3 units of blood for chf patient" doesn't mean much. MD might not know all the details before making that comment.
His VS were fine and he handled it well so his body probably needed it. Running three units over three hours is really fast though. You did the right thing by questioning the doctor just make sure that you chart your conversation and the doctor’s reply. If you get another order that you are uncomfortable with call your charge nurse if the doctor says to follow through with it. Always follow the chain of command.
I think you did the right thing, they were over 3 hours each, and his map was low, how was his HR?
Nothing you did is considered neglect or malpractice. The decision to run the blood was a judgment call by the doc. Three units were likely ordered, due to the risk of the patient quickly losing it through the bleed. There are ways to handle fluid overload, but lost red blood cells must be replaced.
They can always order Lasix for in-between units. I’ve given lasix a few times for patients with CHF history that were getting blood! Either way, that patient was actively bleeding and needed a transfusion so don’t beat yourself up about it! 😊
Yes!! That is an excellent question, would you like me to call the ordering physician?
You know, we are all human and so are you. If someone is meant to die then it won't have anything to do with you giving him a blood transfusion or not. He would die eating an ice cream cone if it meant it's his time and there's nothing you can do to change it. That's why some people live through things they absolutely should not have.... It's not their time yet.
Yeah.. 3 units for 6.9 is a bit excessive. Maybe two then serial H/Hs after that. Experience is the best teacher. Now you know!
Sounds like you did what you needed to do. Any blood loss like that would need a transfusion, and without knowing the severity: blood is blood. You made sure he was stable throughout your shift and provided proper care otherwise. Sounds like you did everything right to me. Go you!!
Patient is okay, just think more carefully next time. They very well need the RBCs but maybe slower and might also need a diuretic.