If the implementation of normal saline results in dilution of serum electrolyte concentrations, overhydration, congested states, or pulmonary edema, then its use is strongly discouraged.[1]. Mayo Clinic does not endorse companies or products. endobj Saline is not physiological Despite its name, saline is neither normal nor physiological. Can you use normal saline in a blood transfusion? Ahmed Elsayed on LinkedIn: Must know information about Blood Blood donors urgently needed in Rochester. 2 0 obj Make sure the medicine bag is higher than your IV line. /StructTreeRoot 4 0 R Rowell SE, Fair KA, Barbosa RR, Watters JM, Bulger EM, Holcomb JB, Cohen MJ, Rahbar MH, Fox EE, Schreiber MA. What is a blood transfusion? Signs and symptoms of fluid overload can undergo an evaluation with a comprehensive physical exam. Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions. So far, no good replacement for human blood is available. Both adults and children can receive lactated Ringers solution. Review appropriate monitoring parameters for normal saline. https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/blood-transfusion-and-donation/how-blood-transfusions-are-done.html. Bhaskaran K, Arumugam G, Vinay Kumar PV. Make a donation. A transfusion provides the part or parts of blood you need, with red blood cells being the most commonly transfused. bone marrow can result in a low red blood cell count - called anaemia. Patients should undergo assessment for signs and symptoms of dehydration and fluid overload. Mar 16, 2007 The main reason you cannot utilize LR because the calcium in the LR will bind to the citrate in the blood and cause clumping of the RBCs this is also why you give 1gram of calcium after every 4 transfusions, becuase the citrate that is infused will bind to calcium in the body. A comparison of LR and NS with rapid infusion rates of blood showed no significant difference between infusion time, filter weight and clot formation. IV Fluids (Intravenous Fluids): The 4 Most - NCLEX Practice Tests The treatment of hemolysis includes the administration of normal saline after the transfusion is stopped and all the tubing is changed to . Clinicians, including nurses, must recognize the indications on when to implement this IV solution and when there is a potential for untoward side effects from over-hydration. An intravenous (IV) line with a needle is inserted into one of your blood vessels. 4 Intravenous immunoglobulin (IVIG) is only compatible with D5W. Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid. This effect usually isnt a concern unless a person gets a large amount of normal saline solution. 16.6B: Plasma and Blood Volume Expanders - Medicine LibreTexts Patientswho are fluid-overloaded should not receive crystalloid fluids. Why is normal saline used for blood transfusions? First resuscitation of critical burn patients: progresses and problems. Therefore, we prefer balanced salt solutions for most intraoperative uses. Sometimes Ringers solution also has more glucose (sugar) in it than lactated Ringers. In addition to fluid overload, too much lactated Ringers solution could affect your electrolyte levels. The Impact of Pre-Hospital Administration of Lactated Ringer's Solution versus Normal Saline in Patients with Traumatic Brain Injury. After completing an assessment, the nurse learns that the patient has a . Flush the Y-type blood administration set or appropriate administration set with 0.9% normal saline after the unit of blood has infused. { N7:&`J>9-9%\M* g:{7_r" x\YoH~7/H},cHb}Ycc/v "U_-B{{c/|&/C{B \Cg/v?_&K }/-~}v5 -y4oy8FW%||.h|]?_{'@/{\ \h There is no physiologic rationale for its use as a resuscitative fluid. Which fluid is used to flush IV line after blood transfusion? (2016). Describe the contraindications to normal saline. . /Font RIij-C.tvNKh%rMCYmI 78HKkt ^'M?C z\ ?$<93b%ef9j%d@F9D#%cc)>p/7Cca)$M-mc@/m>/JIt4Bg64Oy iyQ`+ /pyu-j )##|s`X;,+sHB kFG,-#R?#[ "zPBawM:yHs3/s@1u d:O+ 74 y ')]\XLol.v[aX<84O.,("^P 8]4\q)qhx G, LFG"5'n2J]g@0%e1\J~A9(~Gj _`e- kjk%%thu]]zNX%ee%U#i9ye5eRKX\QU]KJa5}R Before Patients receiving large volumes of crystalloid fluids shouldbe monitored for electrolyte imbalances caused by crystalloid fluid administration.[10]. 6 0 obj The donated blood that's been stored in a plastic bag enters your bloodstream through the IV. Do a google search and you'll likely come up with your information. Use of Ringer's Lactate with Emergency Blood Transfusion /F4 17 0 R Ringers solution usually has sodium bicarbonate instead of sodium lactate in it. 2022 Apr;36(4):1040-1046. doi: 10.1053/j.jvca.2021.07.006. Hypertonic solutions such as 3% saline solutions contain higher concentrations of solutesthan thosefound in human serum. << However, there are few studies either evaluating or quantifying increased coagulation during rapid infusion of LR and blood. Delivery of fluid should be administered through large-bore peripheral lines or via central-line access. If you have to have an IV, you may see that your IV bag reads lactated Ringers. This is a time-tested option for fluid replacement that doctors commonly prescribe. <> Crystalloid solutions for intravascular volume replenishment are typically isotonic (eg, 0.9% saline or Ringer's lactate). Schumann R, Zaimi I, Shebaclo K, Gupta A. J Cardiothorac Vasc Anesth. <> The following are primary indications for the use of normal saline infusion that have been approved by the FDA: Additionally, it has a use as a priming solution for various procedures (e.g., hemodialysis procedures) and to initiate and terminate blood transfusions. These fluids approximate concentrations of various solutes found in plasma anddo not exert an osmotic effect in vivo. The blood typically comes from donors. Epub 2018 Feb 21. When complications do occur, they're typically mild. 3 What are the disadvantages of normal saline? Ideally, the solution helps to maintain or achieve fluid balance in your body. Trials. It is vital for the clinician to monitor these patients carefully and administer the minimum required volume to maintain volume homeostasis. n = 25) and packed red blood cells (PRBC, n = 26) were rapidly admixed with normal saline (NS), Lactate solution and LR with 1 g (LR-1), 2 g (LR-2), and 5 g (LR . When the white blood cell count becomes too low, it is . Background: Blood bank recommendations specify that Ringers lactate solution (LR) should be avoided while transfusing blood. Can you mix isotonic saline with red blood cells? endobj Blood Transfusion: What is it, Benefits, Risks & Reactions, Time 6 When to use IV fluid and blood transfusion? There are many potential problems related to saline. << http://creativecommons.org/licenses/by-nc-nd/4.0/ There is no physiologic rationale for its use as a resuscitative fluid. If youre very dehydrated, a doctor may order fluids infused at a very fast rate, such as 1,000 milliliters (1 liter). %PDF-1.5 Saline versus balanced crystalloids for intravenous fluid therapy in the emergency department: study protocol for a cluster-randomized, multiple-crossover trial. Further clinical applications include acting as a solution for intravenous medication delivery, delivering maintenance fluid in patients with limited or no enteral nutrition, blood pressure management, and increasing diuresis to avoid nephrotoxic drug or toxin-mediated end-organ damage. Ringer's lactate is compatible with the rapid infusion of AS-3 preserved packed red blood cells. J Neurotrauma. Science Nursing The physician has ordered one liter of Normal Saline to run at 125ml/hour for a MedSurg patient. Certainly normal saline can be used to flush the line after blood transfusion finishes. Tell your health care provider if you've had a reaction to a blood transfusion in the past. Crystalloid fluids are the first choice for fluid resuscitation in the presence of hypovolemia, hemorrhage, sepsis, and dehydration. Patients require evaluation for signs and symptoms of dehydration and fluid overload. The saline priming of blood transfusion tubing is one such nursing practice that has long been guided by tradition. Excessive renal bicarbonate excretion can occur, resulting in metabolic acidosis. << Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid. Access free multiple choice questions on this topic. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Approximately 15 million blood and blood component transfusions occur annually within the United States, making it a common lifesaving and life-sustaining intervention, especially within intensive care, surgical, and trauma units. This activity also highlights the mechanism of action, adverse event profile, and other key factors (e.g., administration, monitoring, relevant interactions) pertinent for members of the interprofessional team in the management of critically ill patients. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Neyra JA, Canepa-Escaro F, Li X, Manllo J, Adams-Huet B, Yee J, Yessayan L., Acute Kidney Injury in Critical Illness Study Group. Under normal testing conditions, red blood cells have a negative surface charge, and sodium ions (Na +) in saline solutions aggregate around the red cell surface. Our website services, content, and products are for informational purposes only. sharing sensitive information, make sure youre on a federal To monitor for fluid overload, patients at high risk of developing this complication shouldreceive frequent re-evaluation. #A(sl JeO}J7Op=}8Dc 4d`DLh-#3s*}::`FG(-,)|RVkt/!1-+#7Xar&g U~i \\0)&G&&bM White blood cells White Blood Cells help fight infection, bacteria and other substances that enter the body. Osmotic pressure is a measurement of the balance of solutes (such as sodium, calcium, and chloride) to solvents (for example, water). Normal saline is the IV fluid used alongside the administration of blood products. Semler MW, Self WH, Wang L, Byrne DW, Wanderer JP, Ehrenfeld JM, Stollings JL, Kumar AB, Hernandez A, Guillamondegui OD, May AK, Siew ED, Shaw AD, Bernard GR, Rice TW., Isotonic Solutions and Major Adverse Renal Events Trial (SMART) Investigators. Giving large amounts of pure water directly into a vein would cause your blood cells to become hypotonic, possibly leading to death. Normal saline solution can be administered only via intravenous access. Some people have medical conditions that mean their body cant handle the extra fluid well. There are many potential problems related to saline. If you continue to use this site we will assume that you are happy with it. 2021 Mar 31;8:639848. doi: 10.3389/fvets.2021.639848. Effect of hydroxyethyl starch on blood glucose levels. The .gov means its official. % Hypertonic saline is contraindicated in all clinical settings except in patients with severe hyponatremiaand neurologic sequelae. The implementation of normal saline is standard during resuscitation, and administration can be at various concentrations. Ordering basic metabolic laboratory values, specifically identifying any elevations in electrolytes (e.g., sodium, chloride, bicarbonate), Urinary output (keep output over 0.5 mL/kg/hr), Physical examination findings that may indicate fluid status (e.g., peripheral edema, lung crackles, dry or moist oral mucosa), Patient composition (e.g., body weight, mass), Continuous assessment of the patient and their requirements for normal saline. There are many potential problems related to saline. Why normal saline is used in blood transfusion - knowledgeburrow.com << When to use IV fluid and blood transfusion? A blood transfusion is a routine medical procedure in which donated blood is provided to you through a narrow tube placed within a vein in your arm. Three Reasons Not to Use Normal Saline or Crystalloids in Trauma Normal salineis a crystalloid fluid. Lactated Ringers doesnt mix well with some IV solutions. Most commercially available crystalloid solutions are isotonic to human plasma. Getting a blood transfusion. This is a detailed article about almonds and their health benefits. When the solution goes into the vein, it goes inside cells as well as outside. Accessed Feb. 7, 2017. . Other commercially available crystalloid fluids include: A crystalloid fluid is an aqueous solution of mineral salts and other small, water-soluble molecules. The dose for lactated Ringer's depends on the circumstances. Ringer's lactate is largely used in aggressive volume resuscitation from blood loss or burn injuries; however, Ringer's lactate is a great fluid for aggressive fluid replacement in many clinical situations, including sepsis and acute pancreatitis. Chapter 30 Blood transfusions.docx - Chapter 30 Blood Safety considerations: 1 No medications may be added to blood units or through IV tubing. Epub 2021 Jul 9. Prime the line with saline and attach to IV pump before you even pick up the blood from blood bank. Doctors use IV saline to replenish lost fluids, flush wounds, deliver medications, and sustain patients through surgery, dialysis, and chemotherapy. Broadly,intravenous fluids can fall into two separate categories: crystalloids and colloids. Its indications include both adult and pediatric populations as sources of hydration and electrolyte disturbances. The SMART and SMART-SURG trials demonstrated a decreasedrate of AKI but not overall survivalamong critically ill patients who received Ringer's lactate, a balanced, lactate-buffered crystalloid over normal saline. What are the disadvantages of normal saline? Its also sometimes called Ringers lactate or sodium lactate solution. Hence, excessive administration of lactated crystalloids may be of concern in patients with diabetes.[6]. To minimize the risk of possiblecontaminations,the final solution should be inspected for ambiguity or precipitation immediately after mixing, before administration, and periodically during administration. Fluid resuscitation after severe trauma injury : U-shaped associations between tetrastarch dose and survival time or frequency of acute kidney failure. /Kids [5 0 R 6 0 R 7 0 R 8 0 R 9 0 R] Eisenhut M. Causes and effects of hyperchloremic acidosis. /ExtGState 1 Why is normal saline used for blood transfusions? There are many potential problems related to saline. Water is a necessary ingredient of the body and comprises more than two-thirds of total body weight. Answered: The physician has ordered one liter of | bartleby The 2018 sepsis guidelines from the Surviving Sepsis Campaign havesuggested the initiation of treatment with crystalloid fluids. Christine Kessler; Priming Blood Transfusion Tubing: A Critical Review of the Blood Transfusion Process. This potentially life-saving procedure can help replace blood lost due to surgery or injury. Overall, this decreases the number of bicarbonate ions available for buffering. Hypotonic concentrations of sodium chloride (0.45%) are best for parenteral maintenance fluids rather than aggressive intravascular volume repletion. A blood transfusion is a routine medical procedure in which donated blood is provided to you through a narrow tube placed within a vein in your arm. PDF Transfusion Blood Administration - Children's Minnesota Mane AS. Normal saline functions to expand intravascular volume without disturbing ion concentration or causing large fluid shifts between intracellular, intravascular, and interstitial spaces.[2]. to restore fluid balance after significant blood loss or burns. 1991 Jul;173(1):9-12. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. <>>> Enter a Melbet promo code and get a generous bonus, An Insight into Coupons and a Secret Bonus, Organic Hacks to Tweak Audio Recording for Videos Production, Bring Back Life to Your Graphic Images- Used Best Graphic Design Software, New Google Update and Future of Interstitial Ads. Why is normal saline the only solution used for blood transfusions? Researchers are working on developing artificial blood. Contraindications for the use of normal saline are evaluated clinically from patient to patient. All rights reserved. No significant difference in clot formation between NS and LR with WB or PRBC was found, but the presence of visible clot was increased in the LR-5 group (P = 0.013, WB, and P = 0.002, PRBC). We use cookies to ensure that we give you the best experience on our website. Q: Should blood tubing be primed with or without normal saline before administration of blood products? This route is normally used in the acute care setting when a rapid infusion of fluids is necessary (e.g., hypovolemia). Manufacturers dont intend for people to drink lactated Ringers solution. Has 28 years experience. endobj Adverse effects of normal saline may occur secondary to solution or technique of administration. /Type /Page Crystalloid solutions and medications may cause agglutination and/or hemolysis of the blood or blood components. Lactated Ringers solution, or LR, is an intravenous (IV) fluid you may receive if youre dehydrated, having surgery, or receiving IV medications. We also use the saline to flush through the blood in the tubing before changing tubings betweeen blood units. Healthline Media does not provide medical advice, diagnosis, or treatment. For this reason, some doctors use lactated Ringers when treating medical conditions such as sepsis, in which the body becomes very acidic. Within these compartments,sodium plays a significant role in sustaining homeostatic concentrations and the distribution of water. It may also be used to treat metabolic acidosis in cases other than those caused by lactic acidosis 3. 2 Which IV fluid is compatible with blood products? 5 0 obj /Marked true government site. /Group Saline is more likely to cause severe hypotension in renal transplant patients. Food and water consumption are essential components to life. The maintenance need for water in parenteral fluid therapy, by Malcolm A. Holliday, MD, and William E. Segar, MD, Pediatrics, 1957;19:823-832. and transmitted securely. ), and these patients should, therefore, receive treatment withjudicious useof intravenous fluids. This serves the dual purpose of administering to the patient any residual blood left in the administration set (up to 40 mL), and it flushes the line for later use. [11], Despite its ubiquity in clinical scenarios, normal saline requires an interprofessional approach to dosing and administration among physicians, specialists, nurses, and pharmacists, all working collaboratively as an interprofessional team to optimize patient outcomes. Blood bank recommendations specify that Ringer's lactate solution (LR) should be avoided while transfusing blood. However, there are few studies either evaluating or quantifying increased coagulation during rapid infusion of LR and blood. /Pages 3 0 R You're curious, because the patient is. This activity describes the indications, action, and contraindications for normal saline as a valuable agent in the use of fluid and electrolyte resuscitation. Advertising revenue supports our not-for-profit mission. Must know information about Blood Transfusions! Treasure Island (FL): StatPearls Publishing; 2022 Jan-. When a person receives fluids intravenously (through an IV bag, for example), a saline solution is sometime used. Studies performed on dogs have shown that even small volumes of acetate-containingcrystalloids cansignificantly increase the serum concentration of acetate to 10to 40 times the physiologic level. Their primary indication is for emergent replacement of serum solutes, such as in hyponatremia with neurologic symptoms. Can Ringer's lactate be used safely with blood transfusions? 6 When to use saline to flush the tubing? In 2012, the Surviving Sepsis Campaign guidelines recommended Early Goal-directed Therapy (EGDT) as the standard of care in managing patients in septic shock. This activity reviews the mechanism of action, adverse event profile, toxicity, dosing, pharmacodynamics, and monitoring of crystalloid fluids pertinent for interprofessional team members for treating hypovolemia and other indications. /S /Transparency Special care is prudent when administering fluids to patients with congestive heart failure or those with significant renal impairment (e.g., CKD-V dialysis-dependent patients). Various estimates indicate that between 15% and 45% of patients require transfusions during their intensive care unit (ICU) stay, depending on their length of stay.1,2 The Joint Commission mandates that hospitals have Christine Kessler is a nurse practitioner in the department of endocrinology at Fort Belvoir Community Hospital in Fort Belvoir, Virginia. This helps to wash away bacteria or make a surgical site easier to see. In some cases, you can donate blood for yourself before elective surgery, but most transfusions involve blood donated by strangers. 1998 Apr . A single copy of these materials may be reprinted for noncommercial personal use only. 7 What are the safety considerations for blood transfusions? << Is lactated Ringers compatible with blood products? There are many potential problems related to saline. Other clinical applications include acting as a solution for intravenous medication delivery, delivering maintenance fluid in patients with limited or no enteral nutrition, blood pressure management, and increasing diuresis to avoid nephrotoxic drug or toxin-mediated end-organ damage. There is no physiologic rationale for its use as a resuscitative fluid. The revised guidelines now state that fluid provision should be in a 1-hour bundle by administering 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. People receive blood transfusions for many reasons such as surgery, injury, disease and bleeding disorders. Normal saline infusion is used for extracellular fluid replacement (e.g., dehydration, hypovolemia, hemorrhage, sepsis), treatment of metabolic alkalosis in the presence of fluid loss, and for mild sodium depletion. Saline can be used to increase blood volume when a blood transfusion is not possible. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW., SMART Investigators and the Pragmatic Critical Care Research Group. Background: It is standard practice at many hospitals to follow blood component transfusions with a normal saline (0.9% NaCl) flush. Accessed Feb. 7, 2017. Other commonly used intravenous solutions will cause varying degrees of difficulty when mixed with red cells. Normal saline (0.9% Saline) Normal saline has a higher concentration of chloride ions (154 mmol/L) than in human serum (98 to 106 mmol/L). stream Normal saline is compatible with blood; ringer's lactate, dextrose, hyperalimentation and other intravenous solutions with incompatible medications are not compatible with blood and blood products. Also, lactated Ringers contains the additive sodium lactate. ( In these patients, fluid overload is a considerable concern; this can lead to life-threatening pulmonary edema and the worsening of diastolic or systolic heart failure, leading to end-organ damage or evendeath. These include causing hyperchloremic acidosis, hyperkalemia, hemodynamic instability, renal malperfusion, systemic inflammation, and hypotension. [2]Since this time,their initial formula has been modified to provide clinicians with guidelines for administering maintenance crystalloid fluids. Compared to human serum, saline has a nearly 10% higher Na concentration and 50% higher Cl concentration. Lactated Ringers solution has a lot of the same electrolytes that blood naturally does. The differences in particles mean that lactated Ringers doesnt last as long in the body as normal saline does. rBn= Ringer's lactate solution contains calcium ions. "Normal" saline is a hypertonic, acidotic fluid. Drinking hot water is a great way to stay hydrated, and it might have extra health benefits. This content does not have an Arabic version. In patients receiving hypertonic saline for severe hyponatremia with neurologic sequelae, frequent neurologic checks are necessary to assess clinical improvement. endobj in patients with hyperglycemia. >> [1]However, revised guidelines in 2018 have called into question the efficacy ofEGDT. Hang the bag on the IV pole, and prime the tubing. SPlR@ 7R$ KQY$BY$'{J~EuC"U]5* It is a crystalloid fluid administered via an intravenous solution. It has high levels of sodium and chloride, levels that are higher than the blood. Learn what this procedure involves. It is used to push any residual medication or fluid through the IV line and into your vein. Monitoring. In: StatPearls [Internet]. Sodium ions are the main electrolytes of extracellular fluid, integral in the distribution of fluids and other electrolytes. /Filter /FlateDecode Our members represent more than 60 professional nursing specialties. The extra calcium could bind with the preservatives added to blood by blood banks for storage. >> "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. 2017 Apr 13;18(1):178. doi: 10.1186/s13063-017-1923-6. Lactated Ringer's/Hartman's solution (lactate buffered solution). This influx of hyperchlorhydria causes an intracellular shift of bicarbonate ions to allow for equilibria. Clipboard, Search History, and several other advanced features are temporarily unavailable. This article reviews all you need to. Choice of Fluid Therapy in the Initial Management of Sepsis, Severe Sepsis, and Septic Shock. /F1 13 0 R Crystalloid fluids are a subset of intravenous solutions that are frequently used in the clinical setting. We use cookies to ensure that we give you the best experience on our website. Because there is less sodium in lactated Ringers than there is in the blood, your sodium levels could become too low if you get too much. While saline and lactated Ringers solution have a few similarities, they also have differences. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure. There are a variety of signs and symptoms of blood transfusion reaction for both hemolytic and non-hemolytic reactions. Saline can be used to increase blood volume when a blood transfusion is not possible. <>/XObject<>/Pattern<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Rapid correction of hyponatremiamay cause central pontine myelinolysis, a devastating neurologic condition. The procedure typically takes one to four hours, depending on which parts of the blood you receive and how much blood you need. [10]Although additional prospective studies are still needed. PDF FLUID AND BLOOD THERAPY - adph.org /Length 4456 You may be hungry all the time for several reasons, including diet, stress, or medical conditions. /F6 15 0 R This site uses cookies. Patients with congestive heart failure are at anincreasedrisk for detrimental effects of normal saline administration. [1], An isotonic concentration of sodium chloride is best suited for the parenteral replacement of chloride losses that exceed or equal the sodium loss. /F2 12 0 R /ProcSet [/PDF /Text /ImageB /ImageC /ImageI] Therefore, monitoring should focus on laboratory results and clinical evaluation (see Monitoring section). Paediatric blood administration sets are appropriate for small volume transfusions. 5 Can you use normal saline in a blood transfusion? No significant differences in infusion time or filter weight using WB or PRBC with NS or LR were seen. We hang the saline in case a reaction occurs, then we can maintain the line after stopping the blood. A nurse will monitor you throughout the procedure and take measures of your blood pressure, temperature and heart rate. A: Christine Kessler, RN, MN, CNS, ANP, BC-ADM, replies: Many hospital transfusion protocols and related nursing practices have been based more on tradition and assumptions than on scientific evidence.