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Blood Transfusion during Hemodialysis: An Evidence-Based Procedure

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Copyright 2014 American Nephrology Nurses’ Association (ANNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the American Nephrology Nurses' Association.

Clinical Consult Charlotte Szromba, Department Editor

Blood Transfusion during Hemodialysis:

An Evidence-Based Procedure
Deborah Ashton

Q:
We are seeing an increase in transfusion rates for Copyright 2014 American Nephrology Nurses’ Association
our patients on hemodialysis. What actions will
help us deliver the blood transfusion in a safe Ashton, D. (2014). Blood transfusion during hemodialysis: An
manner? evidence-based procedure. Nephrology Nursing Journal, 41(4),
424-428.

A:
Patients with acute and chronic kidney disease
Key Words: Hemodialysis, blood transfusion, chronic kid-
(CKD) become anemic due to inadequate ery-
ney disease, erythoropoietic stimulating agents,
thropoietin generation and a myriad of other anemia.
co-morbid conditions. The anemia of CKD is
treated with supplemental iron infusions and the adminis-
tration of erythropoietic stimulating agents (ESAs), but cate a decrease in Hgb levels correlating to the FDA-
blood transfusion may also be required, and the need for decreased dosing recommendations and payment and
transfusion is on the rise (U.S. Renal Data System regulatory changes in the United States in 2011 (see Figure
[USRDS], 2013). 1). Data show a decrease in Hgb levels of 12 to 12.9 g/dL
and above from 31.8% in August 2010 to 15.0% in
December 2013 (Arbor Research Collaborative for
Introduction Health, 2014).
In 2007, the United States Food and Drug Admini- The USRDS 2013 Annual Data Report notes that
stration (FDA) reported an increased rate of adverse between July 2010 and July 2013, the overall percentage of
events, including non-fatal heart attacks, strokes, heart fail- patients with at least one transfusion event has increased
ure, blood clots, and death, in patients with CKD when 40% (USRDS, 2013). A five-year study by Lawler,
ESAs were adjusted to achieve and maintain a hemoglo- Bradbury, Fonda, Gaziano, and Gagnon (2010) involved
bin (Hgb) level greater than 12 g/dL. Prescribers were patients at the Veterans Administration (VA) with Stage 3
advised to utilize the lowest doses of ESAs to steadily CKD or higher who had decreased Hgb levels less than
improve the Hgb concentration to a level adequate 11 g/dL. The purpose of the study was to look at transfu-
enough to avoid the need for transfusion. Additionally, sion events in this population. Some participants had
prescribers were counseled to avoid a target Hgb greater received treatment for anemia with ESAs and iron sup-
than 12 g/dL to prevent cardiovascular events (FDA, plementation. The results indicated that among 97,636
2007). A black box warning label (a label added to drug patients with CKD and anemia, there were 68,556 trans-
package inserts to warn that the drug carries significant fusion events. Additionally, the researchers observed that
risk of serious or even life-threatening adverse effects) was for patients whose Hgb levels ranged from 10.0 to 10.9
added to ESA packaging calling attention to these adverse g/dL, the transfusion rate was 2% for those receiving ESAs
effects. In 2011, the FDA issued a safety announcement and iron, compared to 22% for those not receiving treat-
recommending an even more conservative dosing of ment. At lower Hbg levels (7.0 to 7.9 g/dL), the transfusion
ESAs, stating that in controlled trials with patients with rate for the population treated for anemia was 10% to 12%
CKD, the same adverse events occurred when a Hgb of and as high as 58% for untreated patients (Lawler et al.,
greater than 11 g/dL was targeted (FDA, 2011). ESA man- 2010).
ufacturers changed their prescribing warnings at that time,
and they remain the same as of April 2014 (Amgen, 2014).
The Clinical Consult department is designed to provide answers to
The Dialysis Outcomes Practice Patterns Study questions concerning clinical problems and to report innovative clinical
(DOPPS) data from August 2010 to December 2013 indi- practices. Readers are invited to submit questions to be answered by a
guest consultant. Questions should provide background information
and state specific information requested. Answers will be referenced.
Deborah Ashton, BSN, RN, CNN, is Clinical Nurse II, Acute Hemodialysis Manuscripts that address clinical problems or present innovative ideas
Program at the University California, San Diego, San Diego, CA and a member are also invited. These should be between 400 and 600 words and
of ANNA’s Nephros South Chapter. She may be contacted directly via email at contain one to three references. Address correspondence to: Charlotte
[email protected]
Szromba, Clinical Consult Department Editor, through the ANNA
Acknowledgment: The author would like to thank Mona Jaime, RN, for her expert- National Office; East Holly Avenue/Box 56; Pitman NJ 08071-0056;
ise and input in the development of this evidence-based procedure; and Judy Davidson, (856) 256-2320. The opinions and assertions contained herein are the
PhD, RN, and Laura Dibsie, MSN, RN, of the UCSD Nursing Education private views of the contributors and do not necessarily reflect the
Development and Research Department, for their guidance and encouragement. views of the American Nephrology Nurses’ Association.

424 Nephrology Nursing Journal July-August 2014 Vol. 41, No. 4

Copyright 2014 American Nephrology Nurses’ Association (ANNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the American Nephrology Nurses' Association.

Figure 1
DOPPS Hemoglobin Data

Hemoglobin (most recent)

National Sample

< 9.0 g/dl 9.0-9.9 g/dl 10.0-10.9 g/dl 11.0-11.9 g/dl 12.0-12.9 g/dl > =13.0 g/dl

Overall
100% 5% 4% 5% 5% 4% 4% 5% 3% 4% 4% 5% 5%
8% 8% 7% 7% 7% 6% 6%
9% 10%
9% 9%
10% 10% 11% 10% 9% 10% 10%
11% 12% 11%
14%
16% 15%
21% 20% 21% 21%
80% 23% 24%

28% 32% 34%

33% 33% 31% 29% 29%
34% 34% 34% 32%

33% 34%
60%
39%
Percent

40% 39% 40% 40%

40% 37%

40% 37%
37% 38% 38%
34% 36% 39%
37% 36% 33% 36%
30% 33%
31%
27%
23% 22%
20% 19%
20% 22% 22%

17%
12% 14% 14% 13% 13% 14%
11% 11% 11% 13% 14% 12% 12%
6% 7% 8% 7% 7% 6% 8%
3% 3% 3% 3% 3% 3% 3% 4% 5% 5% 5% 4% 4% 4% 5% 5% 5% 5% 4% 5% 5%
0%
AUG 10 DEC 10 APR 11 AUG 11 DEC 11 APR 12 AUG 12 DEC 12 APR 13 AUG 13 DEC 13

N Patients: 3208 3548 3595 3842 3596 1790 2620 2834 2628 2867 2717

Most recent (single) monthly value

Facility sample transitioned from DOPPS 4 to 5 in Jan-Apr 2012 (see “Study Sample and Methods)
Source: US-DOPPS Practice Monitor, April 2014; http://www.dopps.org/DPM

Source: Arbor Research Collaborative for Health. (2014). Used with permission.

The risks of blood transfusions are numerous, population. Intradialytic blood transfusions is given differ-
including iron overload, transfusion reactions, transmis- ently than at other times. Time constraints frequently
sion of infectious agents, acute lung injury, and the require blood products to be given rapidly, which can
development of alloantibodies, which can affect a increase risk of transfusion reaction and volume overload.
patient’s ability to receive organ transplants (Lawler et A survey conducted and a review of web-based nursing
al., 2010; University of California – San Diego [UCSD] blogs by the author found that there is a wide variety of
Medical Center, 2007). practices used for transfusing blood products during
hemodialysis (AllNurses.com, 2011; ANNAnurse.org,
2011). Input from nursing practices outside our organiza-
Transfusion Administration during Dialysis
tion was extracted from practice specialty nurses’ blogs (n
The concurrent fluid removal (ultrafiltration) and = 10 responses). When nephrology nurses at UCSD were
electrolyte correction during hemodialysis make surveyed regarding current blood transfusion techniques,
hemodialysis the first choice for transfusing blood in this we found many different practices.

Nephrology Nursing Journal July-August 2014 Vol. 41, No. 4 425

Copyright 2014 American Nephrology Nurses’ Association (ANNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the American Nephrology Nurses' Association.

Blood Transfusion During Hemodialysis: An Evidence-Based Procedure

Evidence-Based Practice in Nursing (see Figure 2) (Brown & Ecoff, 2007). Other resources
used include a literature review that revealed no publica-
Nephrology nurses are committed to providing safe, tions written on the specific subject. Nephrology nursing
effective patient care resulting in improved patient out- blogs showed no consensus concerning intradialytic trans-
comes. Best practice level care is driven by evidence, and fusions. Current policies, blood bank manuals, nursing
an evidence-based intradialytic transfusion policy will and medical expert opinion/experience, and literature
help achieve this. pertaining to blood transfusion in the general patient pop-
Nurses are expected to incorporate evidence in the
ulation were also reviewed. An evidence-based intradia-
development of their clinical practice. Newhouse,
lytic transfusion policy was written using existing policy,
Dearholt, Poe, Pugh, and White (2005) describe evidence-
literature, current best practice, and expert nursing and
based practice as “a problem-solving approach to clinical
medical input. The process was guided by following the
decision making within a health care organization that
steps outlined in Brown and Ecoff’s (2007) Evidence-
integrates the best available scientific evidence with the
Based Practice Institute model.
best available experiential (patient and practitioner) evi-
dence. Evidence-based practice considers internal and Evidence-Based Practice Model
external influences on practice and encourages critical Implementation
thinking in the judicious application of evidence to care of
the individual patient, patient population, or system” (pp. Catalyst. The catalyst for the project came from a
3-4). question: How quickly can one safely give an intradialytic
A good portion of nursing practice is based on tradi- blood transfusion?
tion, opinion, and how nurses were originally taught Assessing. This problem is important because giving
(Estabrooks, 1998; Pravikoff, Tanner, & Pierce, 2005). Too blood rapidly can have devastating consequences.
often, there has been a lag between new science and Searching the literature revealed no current, existing stan-
changes in clinical practice (Institute of Medicine [IOM], dard policy for administering intradialytic transfusions.
2001). This lag is evident when reviewing nephrology No national or local standards were found.
nursing blogs and a survey that sought to answer the ques- Asking. A focused question was developed using the
tion about transfusion practices (AllNurses.com, 2011; PICO format (patient problem or population, interven-
ANNAnurse.org, 2011). tion, comparison, and outcomes). Will a standardized, evi-
dence-based procedure operationalized by nephrology
nurses when transfusing blood products during hemodial-
Development of a Project to Improve Patient ysis, compared to no standard method, be used in clinical
Outcomes during Transfusion practice and insure patient safety?
Evidence-based practice is best achieved in a health- Acquiring. The author performed literature review
care culture dedicated to supporting the process (Fineout- and consulted topic experts (personal communication,
Overholt, Melnyk, & Schultz, 2005). Support and expert- Lischer, 2012; personal communication, R. Mehta, 2012).
ise were sought from the author’s manager, Eileen Appraising. How good is the evidence? Is there
Lischer, MA, RN, and Ravindra Mehta, MD, Acute enough reliable evidence to change practice? Works from
Dialysis Medical Director (personal communication, juried journals, current international data, and books were
August 14, 2012). Further guidance and instruction were reviewed. Salient information was extracted and incorpo-
given by Laura Dibsie, MSN, RN, and Judy Davidson rated into procedure development.
PhD, RN, of the UCSD Nursing Education Development Applying. The procedure was written and approved
and Research Department. Ten responses from specialty for implementation.
nursing practice blogs outside of ANNA were obtained Analyzing. A survey will be distributed post-imple-
through a survey. Nephrology nurses working in acute mentation and outcomes measured. How many of the
hemodialysis at UCSD were also surveyed regarding cur- nephrology nurses have changed their practice based on
rent blood transfusion technique, yielding a 21% response the evidence presented?
rate (n = 23, five responses). The informal survey was Advancing and adopting. Work will be shared via
developed by the author and Mona Jaime, RN, a fellow poster presentation and journal article, and possibly by
RN working in acute hemodialysis, who teaches new beginning a thread on the ANNA Specialty Practice
graduate nurses how to administer blood transfusions. Networks (SPN) blog.
Combined, the survey of five questions with 19 possi-
ble answers yielded 12 different practices (see Table 1). Revised Transfusion Protocol Based
The survey results inspired the question, “Is there a way to On Current Evidence
identify the safest and most efficient way to give blood Transfusing red blood cells (RBCs) during hemodial-
during a hemodialysis treatment?” ysis based on current evidence requires several procedur-
To insure systematic, thorough exploration of the al modifications:
problem and to organize policy development, the • Blood will be transfused into the pre-pump chamber
Evidence-Based Practice Institute Model was followed using a volumetric pump for the test dose to prevent

426 Nephrology Nursing Journal July-August 2014 Vol. 41, No. 4

Copyright 2014 American Nephrology Nurses’ Association (ANNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the American Nephrology Nurses' Association.

Table 1
Survey of Blood Transfusion Protocols

UCSD Retrieved
Yes No % from Blogs
We need a written procedure for giving blood during hemodialysis. 5 0 100
Do you use an IV pump when giving blood during hemodialysis? 1 4 80
How much blood do you give as a ‘test dose’ (responses in ‘mL’) 5 1 20
10 0 0
15 4 80
50 1
Over how long do you run the test dose in? (responses in minutes) 5 0 0
10 2 40
15 3 60
How quickly do you give a blood transfusion on dialysis? (responses in minutes) 15 0 0
20 1 20
25 0 0
30 0 0 3
40 2 40
45 2 40 3
60 0 0 2
How often do you check v.s. during transfusion? (responses in minutes) q5 0 0 1
q 10 1 20
q 15 4 80 3
q 30 0 0

Note: UCSD = University of California at San Diego Medical Center.

Figure 2 free-flow of blood. The infusion rate will be set

Evidence-Based Practice Model between 60 to 180 mL/hour to deliver 15 to 45 mL
over 15 minutes. The RN will observe the patient con-
tinuously. Rationale: Nearly 85% of all transfusion
Assisting reactions will occur within the first 15 minutes (Taylor,
Navarette, & Contreras, 2008). Limiting test dose
amount prevents introducing excess antigen into the
Advancing Asking patient.
• Ultrafiltration will either be pre-transfusion or con-
current (i.e., ultrafiltrate in the amount of blood to be
Adopting Acquiring given will be removed prior to transfusing, or ultrafil-
tration will occur concurrently with blood administra-
tion). For example, the hemodialysis treatment will
ultrafilter at least as much as the volume of blood
Analyzing Appraising transfused. Pre-transfusion or concurrent ultrafiltra-
tion during transfusion will help reduce the risk of
Applying
fluid overload in patients who are volume sensitive.
This technique was used in 1994 to perform rapid red
cell transfusion using apheresis, which was subjective-
ly well-tolerated (McLeod, Reed, Viernes &
Source: Brown & Ecoff, 2007. Used with permission.
Valentino; 1994). However, in the case of profound

Nephrology Nursing Journal July-August 2014 Vol. 41, No. 4 427

Copyright 2014 American Nephrology Nurses’ Association (ANNA) All rights reserved. No part of this document may be reproduced or transmitted in any form
without the written permission of the American Nephrology Nurses' Association.

Blood Transfusion During Hemodialysis: An Evidence-Based Procedure

hypotension or exsanguination, blood can be given ANNAnurse.org. (2011, October 18). ANNA Blog. [Web log mes-
free-flow (UCSD Medical Center, 2007) sage]. Retrieved from http://community.annanurse.org/
• After the test dose is completed and tolerated without communities/viewdiscussions/viewthread/?GroupId=151&
reaction, the blood may be given rapidly, the entire unit MID=5471
Arbor Research Collaborative for Health. (2014). DOPPS practice
within 20 minutes, if necessary (McLeod et al., 1994).
monitor: Most recent trends in US hemodialysis practice following
policy changes. Retrieved from http://www.dopps.org/dpm/
Results Default.aspx
Brown, C., & Ecoff, L. (2007). A systematic approach to the
There have been no adverse events since the institu- inclusion of evidence in healthcare design. Health Environ-
tion of this standardized practice. Evaluation of the impact ments Research & Design Journal 4(2), 7-16.
on outcomes is in process. The initial outcome measured Estabrooks, C.A. (1998). Will evidence-based nursing practice
will be the percentage of nurses who have changed their make practice perfect? Canadian Journal of Nursing Research,
practice based on the evidence provided. Another out- 30(1), 15-16.
come measure being considered is to monitor the inci- Fineout-Overholt, E., Melnyk, B.M., & Schultz, A. (2005).
Transforming health care from the inside out: Advancing
dence of transfusion reactions pre- and post-evidence-
evidence-based practice in the 21st century. Journal of
based procedure implementation. Professional Nursing, 21(6), 335-344.
Improved patient outcomes are one goal of nursing Institute of Medicine (IOM). (2001). Crossing the quality chasm: A
practice; evidence-based practice will lead us there. new health system for the 21st Century. Washington, DC:
Creating a standard approach and testing it in an EBP National Academies Press. Retrieved from http://iom.edu/
model is the first step of generating the evidence we need Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-
to optimize outcomes. System-for-the-21st-Century.aspx
Lawler, E.V., Bradbury, B.D., Fonda, J.R., Gaziano, J.M., &
Gagnon, D.R. (2010). Transfusion burden among patients
Implications for Nursing Practice with chronic kidney disease and anemia. Clinical Journal of
the American Society of Nephrology, 5(4), 667-672.
Establishing evidence-based practice is a process that
McCleod, B.C., Reed, S., Viernes, A., & Valentino, L. (1994).
can be approached systematically by primary care nurses Rapid red cell transfusion by apheresis. Journal of Clinical
at the bedside. Frontline care providers are the most like- Apheresis, 9(2), 142-146.
ly practitioners to generate ideas and questions regarding Newhouse, R.P., Dearholt, S., Poe, S., Pugh, L.C., & White, K.
evidence-based care. Advanced academic degrees are not (2005). Evidence based practice: A practical approach to
required; however, an advanced-degree mentor will help implementation. Journal of Nursing Administration, 35(1), 35-
encourage, guide, and move the process along. As nurses 40.
continue to question current practice and traditions, cou- Pravikoff, D.S., Tanner, A.B., & Pierce, S.T. (2005). Readiness of
pled with reviewing literature and expert opinion, our U.S. nurses for evidence-based practice. American Journal of
practice will move from “because we’ve always done it Nursing, 105(9), 40-51.
Taylor, C., Navarrete, C., & Contreras, M. (2008).
this way” to “current evidence supports this intervention.”
Immunological complications of blood transfusion.
We are in an era in which third party payor reimburse- Transfusion Alternatives in Transfusion Medicine 10, 112-126
ment will be based on outcomes. Evidence-based practice University of California – San Diego (UCSD) Medical Center.
is how outcomes have been and will be improved. (2007). Blood bank manual. San Diego, CA: Author.
As nephrology nurses, we are the experts rendering Retrieved from http://pathology.ucsd.edu/assets/pdf/
care to patients living with acute or chronic renal failure. Blood_Bank_Manual.pdf
Our patients trust and look to us to give safe, effective, United States Food and Drug Administration (FDA). (2007).
state-of-the-art, evidence-based care. Nephrology nursing Erythropoiesis-stimulating agents (ESA). Silver Spring, MD:
will build an evidence-based practice one question at a United States Department of Health and Human Services.
time. What will be your contribution? United States Food and Drug Administration (FDA). (2011). FDA
drug safety communication: Modified dosing recommendations to
improve the safe use of erythropoiesis-stimulating agents (ESAs) in
chronic kidney disease. Retrieved from htpp://www.fda.gov/
References drugs/drugsafety/ucm259639.htm
AllNurses.com. (2011, June 23). Blog – Blood transfusion during United States Renal Data System (USRDS). (2013). USRDS 2012
dialysis [Web log message]. Retrieved from http://all annual data report: Atlas of end stage renal disease in the United
nurses.com/general-nursing-discussion/blood-transfusion- States, Bethesda, MD: National Institutes of Diabetes and
during-582754.html Digestive and Kidney Diseases. Retrieved from http://
Amgen (2014). Epogen® (epoetin alfa) injection, for intravenous or sub- www.usrds.org/adr.aspx
cutaneous use. Highlights of prescribing information. Thousand
Oaks, CA: Author. Retrieved from http://pi.amgen.
com/united_states/epogen/epogen_pi_hcp_english.pdf

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