Do bleeding patients increase your blood pressure? Do you love a transfusion, or do you feel a little unsure what you should be looking for when monitoring haematology patients?

If you’re nodding along at your screen right now, don’t worry - I’ve been there too. In general practice, I very rarely did transfusions. I had enough to get my nursing portfolio done as a student VN, but I didn’t do enough to feel like I REALLY knew what I was looking out for.

So if you’ve ever felt this way, let’s change that with today’s case study.

Last month, I introduced David - a terrier with immune-mediated haemolytic anaemia - to my VIP list as part of the Up Your Medical Nursing Skills Challenge. And today, we’re going to chat through exactly how we’d nurse him.

Need a refresher on his case? Here you go 👇🏼

Meet David

David is a 4-year-old MN Jack Russell Terrier.

He presents as an emergency with a 3-day history of initial hindlimb weakness, hyporexia and diarrhoea, progressing to lethargy, pyrexia and pallor.

You’re asked to triage him on his arrival, so you head to reception and begin examining him.

Examination:

On your initial assessment, you find that David:

• Is quiet, but alert and responsive

• Is normal-to-slightly tachycardic at 124 beats/minute

• Has hyperdynamic (slightly bounding) pulses

• Has a grade 2/6 systolic heart murmur

• Is mildly pyrexic at 39.0*C

Initial Results:

You pass your examination findings on to the vet who asks you to place an IV catheter, and collect samples for a PCV, total solids, blood type, in-saline agglutination test, and tick-borne disease panel, alongside submitting an external biochemistry and haematology for analysis. These results show:

• A mildly regenerative anaemia (PCV 20% with some spherocytosis and anisocytosis)

• Hyperbilirubinaemia (TBil 45umol/L, normal 0-16)

• A mild neutrophilia

• A mildly increased ALT

Based on these results, the vet suspects that he has immune-mediated haemolytic anaemia (IMHA). You’re asked to stabilise David with a packed RBC transfusion, prior to performing a sedation for chest X-rays and abdominal ultrasound later that day. These are unremarkable, leading to a diagnosis of non-associative (primary) IMHA.

David’s Treatment

You begin David on the following prescribed treatment plan:

• A DEA 1 negative packed RBC transfusion (to administer a total of 150ml pRBCs starting at 0.5ml/kg/hour for the first 30 minutes, then increasing to deliver the total volume over 4-6 hours)

• Dexamethasone 0.3mg/kg IV q24 hours (immunosuppressant)

• Clopidogrel 2mg/kg PO q24 hours (anti-thrombotic)

• Rivaroxaban 1.5mg/kg PO q24 hours (anti-thrombotic)

• Capromorelin 3mg/kg PO q24 hours (appetite stimulant) depending on appetite

• Maropitant 1mg/kg IV q24 hours

• Prokolin PO q8 hours

You also place a naso-oesophageal feeding tube due to David’s hyporexia history, and begin refeeding at 1/3rd RER with a high-energy gastrointestinal diet.

David’s PCV improves to 27% after his initial transfusion, but this improvement is not sustained, and he requires 3 further transfusions over the next week. After beginning a second immunosuppressant (ciclosporin) he begins showing sustained improvement and is discharged.

David’s Nursing Care

So you have David hospitalised, and it’s time to start thinking about his nursing! How would you manage him in the hospital? Here are some prompts for you to think about:

• Nutritional status and appetite support

• Hydration status and fluid balance

• Cardiovascular status, anaemia and transfusion-dependence

• Transfusion monitoring and reactions

• Toileting/eliminations and diarrhoea management

• Monitoring for complications of IMHA

• Vascular access

So how will we nurse him?

Nutrition and Appetite Support

Nutrition is an important consideration for any hospitalised patient, and David is no exception. We often find that our anaemic patients are hyporexic, or anorexic at presentation - and the lethargy they feel due to their reduced oxygen-carrying capacity can impact their appetite. David is no exception to this, with a reduced appetite before presentation at the clinic.

He’s currently receiving appetite stimulants, and on top of this, we want to calculate his resting energy requirements, tempt him to eat, and assess his voluntary food intake.

After 24 hours, we placed a naso-oesophgeal feeding tube, as he had eaten only around 20% of his RER, and had been hyporexic at home. Unfortunately David was a terrier by name and a terror by nature, and he made short work of removing his tube. Thankfully, with some TLC and chicken, we were able to get David’s intake up and he began eating >80% of his RER consistently.

We were not worried about a specific diet in David’s case, as he had no concurrent diseases and his disease process did not require specific dietary management. Our goal was to tempt him with whatever he’d like, prioritising getting food in, rather than the type of food he was offered.

Hydration and Fluid Balance

With David’s hypovolaemia (due to his anaemia) and his hyporexia, fluid balance is a vital consideration for David. We need to be managing his signs of transfusion-dependence - and although we know he needs a transfusion, we need to provide short-term circulatory support whilst we’re preparing his transfusion.

We did this by administering a 10ml/kg crystalloid bolus, which temporarily improved his perfusion parameters.

After this, he received no crystalloids whilst his packed RBC transfusion was administered (which we’ll chat more about in a minute), and then received LRS at 4ml/kg/hour (due to his diarrhoea).

His hydration status was reassessed regularly, and his fluid rate was decreased to 2ml/kg/hour as his diarrhoea and appetite both improved.

Cardiovascular Status and Transfusion Monitoring

Our initial priority with David is getting his cardiovascular status stabilised. As I mentioned, we administered a 10ml/kg bolus of a balanced crystalloid (LRS) initially, whilst we processed his samples, and got his blood type and PCV result.

Once we had these results, we could select an appropriate blood product, and calculate his requirements.

We administered a total of 150ml of packed RBCs to David, beginning at a low rate of 0.5ml/kg/hour for the first 30 minutes. As we are more likely to see acute immunologic transfusion reactions shortly after a transfusion begins, we monitored David especially closely for the first 30-60 minutes of his transfusion.

We maintained a continual nursing presence in his ward throughout the entire transfusion, recording vital parameters before the transfusion, and as follows:

• TPR, MM/CRT, demeanour and non-invasive BP every 10 minutes for the first 30 minutes;

• Every 15 minutes for the next 30 minutes;

• Then every 30 minutes for the remainder of the transfusion.

We also noted David’s plasma colour on his initial samples, and his urine colour whenever he urinated - because if a haemolytic transfusion reaction occurs, we can see changes to both of these.

We handled his blood product and line with careful aseptic technique, avoiding disconnecting and reconnecting it from his IV catheter - since blood products contain no preservative agents, and we wanted to avoid introducing any contamination.

Another important consideration was the timing of food and medications around David’s transfusion. Because medication reactions can be hard to differentiate from transfusion reactions, and vomiting could be seen both due to a recent meal or due to a transfusion reaction, we avoided feeding David, and administering any non-critical medications until his transfusion was complete.

Thankfully, no transfusion reactions were seen in his case; if one was to occur, we would follow the appropriate algorithm in the AVHTM consensus guidelines.

David’s PCV was rechecked 6 hours after his transfusion finished, and then every 24 hours thereafter. Due to progressive deterioration in his PCV whilst his immunosuppressive medications were taking effect, he received a further 3 transfusions during hospitalisation - each carried out in the same way as the first. Because they were administered in quick succession, we did not need to crossmatch David prior to any of these - but, had they been >5 days after his initial transfusion, we would have done. This is an important consideration as antibodies to foreign/donated RBCs will develop after this time, causing transfusion reactions to some donors (even if they are the same blood type).

Toileting, Eliminations and Diarrhoea Management

Managing eliminations is an important nursing consideration for most medical patients, since they often have conditions or are receiving treatments affecting their urine output or faecal consistency.

David was no exception, with a history of diarrhoea, and given that he was being treated with steroids.

We know that his dexamethasone will make him PU/PD, so after this treatment begins, regularly walking him (and checking his water bowl to ensure it is topped up regularly) is an important treatment to add to his nursing plan.

We also gave him plenty more opportunities to toilet with his diarrhoea history, and noted his faecal appearance (using the purina faecal chart).

His fluid rate was adjusted based on his diarrhoea, and he was bathed regularly to avoid faecal scolding. Thankfully, after a few days of supportive care, his diarrhoea improved.

Monitoring for Complications of IMHA

IMHA can be a really tough disease to manage. We know it has a high mortality rate - and we see several complications of the disease. Looking out for these is, therefore, an important consideration when nursing IMHA patients. Of these complications, the biggest one we monitored for in David’s case was thromboembolic disease.

IMHA patients are predisposed to thromboembolism, as they are hypercoagulable. We manage IMHA with anti-thrombotic drugs (like clopidogrel and rivaroxaban, like we did in David’s case), but we also need to watch out for signs of thromboembolic disease.

Pulmonary thromboembolism is the big one here - if a patient gets a thrombus lodged in a pulmonary vessel, life-threatening hypoxaemia results. So careful monitoring of David’s respiratory pattern, effort, rate, demeanour and SpO2 were all important nursing actions.

Vascular access

David was in hospital for several days, requiring mulitple transfusions and medications alongside regular sampling. But he’s also hypercoagulable - meaning we don’t want to place a central venous catheter in his case, as he’s at an increased risk of thromboembolism.

In his case, we elected to place a sampling catheter, which sat in his saphenous vein, but allowed us to collect daily samples from it without venipuncture, This gave us the benefit of preserving his vessels for other IV catheters as needed, AND meant he was getting less needle sticks - much nicer for him!

PLUS, placing these sampling catheters is a great skill for nurses to perform - it’s quick, easy, and tends to give us more reliable IV access for longer periods than a standard IV.

We monitored his catheter closely for signs of phlebitis, flushing it regularly and aseptically redressing it every 12 hours (or sooner if there were concerns).

Other Considerations

There were a few other things to consider in David’s case. Firstly, once he’d started on treatment for his IMHA, he was receiving immunosuppressive doses of steroid (and ultimately ciclosporin too, a second immunosuppressive agent). This meant that he was potentially at an increased risk for picking up a hospital-acquired infection, so we needed to bear that in mind when nursing him.

We wore gloves and an apron when handling him, and nurses who were dealing with potentially infectious patients were not assiged to his care, to minimise cross-contamination.

Keeping David rested and calm was also an important consideration. Any anaemic patient has a reduction in oxygen-carrying capacity, since they have less RBCs and therefore less haemoglobin. This means he will tire more easily, and the ‘normal’ level of activity or exercise for a hospitalised patient may be too much for him.

To begin with, we carried him outside to the toilet - our walking area is quite far from where he was hospitalised - to allow him to conserve his energy (and oxygen demand!) as much as possible.

And then on top of all of that, there was general nursing care to think about too - and interaction, TLC and reducing anxiety and fear. David was not the calmest of patients in hospital, so we used anxiolytics (trazodone) where needed - and kept nurses who he had bonded with assigned to him as much as possible, giving him a familiar face, and us continuity of care.

As you can see, there were quite a few things to think about with David! IMHA patients provide us with LOTS of opportunities to use our skills - from blood smear exams to transfusion administration and monitoring, sampling line placement, general day-to-day care and beyond, the things we can do to support patients like David make such a difference.