Question

12/2/2019

15:29   80-year-old non-verbal male who presented to ED via EMS c/o abdominal pain, constipation, wheezing and shortness of breath x 1 day per daughters. ED physician evaluated patient

16:19   Upon receiving the blood tube in the Blood Bank Laboratory (no order placed as of yet), blood bank medical technologist placed the tube in an extra rack awaiting possible “Type and cross” order.

17:30   Lasix 40 mg IV administered as ordered by ED physician

17:33   Type & crosshatch and transfuse for 2 units of PRBC ordered by ED physician with repeat H & H between units: 30 minutes post 1st transfusion

17:44   Blood Bank (BB) technologist received order for “Type and Cross” (TC) 1 unit of PRBC. The patient had no previous blood bank history in Meditech. Technologist checked the extra rack to see if a pink top tube was already in the lab. According to the note’s documentation, phlebotomist documented at 17:38 “ok to add to specimen in Lab per RN”. BB technologist did not request a second specimen for confirmation since the original tube was collected with CompiLab. She discovered that the label was missing the barcode, and the Echo (blood bank analyzer) instrument would not be able to read the order information. BB technologist proceeded to print another label containing the TC order and placed it over a tube of blood obstructing the original label which prevented two patient identifier steps.

20:44   Called placed to primary care team for admission for primary impression of severe anemia: Secondary impression: abdominal pain, AKI (acute kidney injury), atrial fibrillation with RVR, bilateral hydronephrosis, coagulopathy, elevated brain natriuretic peptide (BNP) level, elevated troponin, fecal impaction, kidney stones, leukocytosis, pleural effusion, pulmonary edema & wheezing

20:45   ED physician documented: Plan admit, pt was reevaluated and feels better pt.’s labs were reviewed influenza is negative CE were elevated 0.08 BNP 143000 CBC shows WBC 15.0, hgb 6.7, platelets 404 coags shows INR 4.2 BMP shows BUN 38/ creatinine 1.52 lactic acid 1.9 CMP shows no acute findings lipase 173 stool heme occult is negative CT abdomen/pelvis shows bilateral pleural effusion, bilateral hydronephrosis, fecal impaction pt will be admitted to critical care unit.

22:15   Blood consent obtained via phone from daughter

22:19   ED Nurse picked up the unit of blood from the lab, and brought it to ED

22:41   BP 119/72, HR 128, RR 30, Sats 100%, Temp 98.1

22:42   PRBC transfusion started

22:58   BP 100/67, HR 123, RR 36, Sats 100%, Temp 98

00:45   RN documented: "Patient having increased dyspnea although saturation maintains at 100% with 3 LPM nasal cannula. Patient is unable to swallow or take her pill as she does normally according to daughter at home. Had to suction pill out of mouth. Patient seems more fatigued, and distressed. Intensivist notified of patient status; no further orders given at this time. Will continue to monitor patient closely"

01:01   BP 156/72, HR 111, RR 47, Sats 99%

01:42   PRBC transfusion completed

01:43   VS: Temp 97.9, HR 109, RR 46, BP 141/65, Sats 100%

02:12   Post transfusion H&H order not entered into Medi-Tech as indicated in the original transfusion order

02:21   "H & P dictated by primary care physician and documented the following: We will administer Lasix IV. Monitor her output with

strict ins and outs. COVID testing was performed by the ER provider. We will await those results and keep her on isolation until results are finalized. We will get a stat ABG to assess any ongoing deterioration of patient's respiratory status. "

02:25   "ABG on Nasal Cannula 2 LPM: pH 7.14, PCO2 16.70, PO2 107,

BE-21.40, HCO3 5.60, Hgb 8.0. (Per RT who performed the ABG, the results were handed to ordering physician)"

03:00   Patient noted to be in NSR with rate 80, with BP 126/68, RR 42, sats 99%

03:20   Patient transferred from ED to ICU, receiving RN documented that patient is awake, non-verbal, respirations labored with use of accessory muscle while on 3LPM N/C

03:30   Sodium bicarbonate drip order entered by primary physician. Lab notified by ED RN that they needed assistance for blood draw

03:34   BP 92/62, HR 75, RR 43, Sats 99%

03:35   Intensivist notified of respiratory status by ICU RN

03:44   Intensivist at the bedside, documented patient is in respiratory failure and severe metabolic acidosis, preparation for intubation with COVID-19 precautions

03:48   Sodium bicarbonate 2 amps administered by RN (total of 4 given)

04:20 to 04:26 BP ranged from 78/56 to 92/61, HR 112-120…Intensivist notified of hypotension, fluids and vasoactive medication ordered

04:29   Patient intubated emergently by intensivist using glide scope, placed on ventilator

05:00   Sodium bicarbonate drip hung, infusing @ 100 mL/hr

06:10   Hemodynamically unstable in spite of fluids and numerous vasoactive medications

06:30   Central line and arterial line inserted by intensivist: septic shock, respiratory failure, and severe metabolic acidosis

06:32   Blood Bank technologist received an order for 2 units of PRBCs (STAT) ordered by the intensivist. Technologist attempted to validate last Hgb level measured and discovered that there were no post-transfusion Hgb results. Upon further review the technologist recognized that there was an order for CBC to be collected at 04:00 . Technologist also saw that an ABG done at 02:19 had a documented Hgb of 8.0 post transfusion and decided to wait for the pending CBC.

07:10   ABG on vent support pH 7.27, PCO2 19.50, pO2 408, BE -16.40, HCO3 8.8 hgb 7.3

08:47   AM Labs drawn that was scheduled for 0400

08:53   Consulting urologist evaluated patient, spoke with daughters, and obtained consent for emergent placement of ureteral stents

09:04   WBC 15.2, Hgb 5.8, Hct 19.7 called in by the lab to ICU RN

09:14   ICU RN called the blood bank laboratory to find out if units were ready, and to communicate that the patient was going to surgery. Blood Bank technologist pulled the tube from the blood bank storage rack. Upon validating the name on the tube, she could not see the name on the demo label original tube. BB technologist peeled off the label to confirm the patient’s name, and discovered there were 2 different names, different MR# and different Birth Date. The technologist checked the extra rack and found the correct tube with the patient’s name.

09:26   BB technologist reran the type & screen with the actual patient’s tube and determined that there had been a mistake. She asked another technologist to perform a re-type on the CBC tube. The patient typed O on both specimens

09:30   ICU RN documented: "Call received from blood bank, stated we have to run antibody test, it will take about 20 minutes, will call you when blood is ready"

09:32   Lactate 23.7 called in by lab to ICU RN

09:45   BB Technologist notified Laboratory Medical Director that there is a discrepancy with the blood type of a patient. The Medical Director discussed with technologist that another specimen would need to be collected before anything else can be done.

09:54   Medical Director notified Laboratory Administrative Director, about the discrepancy and that the patient received the A positive unit on 4/23/20 at 22:19. Laboratory Administrative Director confirmed that a new type and screen specimen needed to be collected to confirm patient’s blood type. Technologist requested another sample for type and screen and notified ICU RN that there was a discrepancy, and emergency issued units are available if blood is needed while the investigation is underway.

10:03   Intensivist notified of the arterial line BP in low 100's with a MAP of 64, BP via cuff 78/44, patient maxed on Levophed @ 30mcg and Neosynephrine @ 360 mcg

10:06   A new type & screen was ordered

10:08   Critical labs called in by the lab PT 101.5, INR, 8.5,

10:18   Intensivist documented "discussed with surgeon and anesthesia this morning possible operation for large hydro and stone seen on CT causing obstructive uropathy. Patient too unstable for surgery, STAT labs ordered to evaluate hemoglobin and coagulopathy parameters. Called by nurse in serial phone calls that patient hgb 5 after blood products, INR 8.5, and patient increasingly hypotensive, with lactate 24, hypoglycemic to 20s, IV saline 2 liters and D5NS@100 ordered as well as azactam for gram negative coverage. Vitamin K and 4 units of FFP ordered as well as vasopressin, D50 amp given, hypoglycemia protocol as well as stress dose steroids hydrocortisone 100 mg IV q8 ordered".

10:39   New type and screen collected

10:40   Clinical status continues to deteriorate, intensivist is aware of condition

10:43   Type & screen specimen received in the lab

11:15   Progress report given to daughters via phone by the intensivist

11:24   Patient subsequently had large NGT output of blood, began to get bradycardic and dropped MAP into 30s. Intensivist called to bedside for code blue".

11:30   Intensivist and ICU manager on the phone with daughters: DNR activated

11:31   Patient typed O Positive on the new specimen by BB Technologist  

11:52   BB Technologist called the ICU and communicated to the charge nurse of a corrected blood type of A+ to O+. A transfusion reaction protocol was initiated by technologist. Lab Director notified Operations Director about the blood type discrepancy.

11:57   DNR entered in to Medi-Tech by Intensivist

12:03   Medical Director notified VPQ of the blood type discrepancy involving transfusion of wrong blood type given to patient. Lab Director notified COO. and ACOO. of the need to discuss the transfusion issue.

13:05   Patient expired

Questions

1. What do you think about this case?

2. How would you react if your were the RN who administered this transfusion?

Answer 1

(1) Anemia occurs commonly world wide and all ages of lfe , and although frequently overlooked , it affects mortality , morbidity and quality of life , even when a mild . The WHO organizations has established some cut off hemoglobin (Hb) levels , stratified by gender and in pert by age, to define the presence ,of anemia .For adults these levels are less than 12g/dl for women and for ,males  it is less than 13 g/dl , although these cut off points may not be fully appropriately for the elderly.Severe anemis is defined as Hb <8.0 g/dl for both gender . HOwever , several reports have shown that both transfusion and erythropoisis stimulating agents may indeed carry an increased risk of adverse events.

(2) blood should not remain in the client care area for more than 30 minutes so it is important  that the nurse is prepared to begin the transfusion shortly after the blood is delivered to the patient care area . The RN nurse must take a baseline data and the vital signs just prior to the infusion of blood or a blod products and then the nurse should remain with and monitor the client for at least 15 minutes after the transfusion begins at aslow rate since most serious blood reactions and complications occur shortly the transfussion begins . all blood and blood products mmust be administeredcompletly in less than 4 hours .