Medical Errors Alert: The Risk of Delayed Reactions to Blood Transfusion in the Elderly

My mother's hemoglobin was down to eight again,the gerontologist ruled out TIA and said it was a
which is confirmation of severe anemia, so her primarydelayed transfusion reaction. This was surprising
care physician sent her over to a hematologist tobecause in my experience as a nurse I have always
receive a blood transfusion. It was all well intended tobelieved that blood reactions are usually immediate and
avoid another hospitalization. This blood specialist hasif the patient does not react after 2 hours of
her practice in a cancer center where they provide allobservation, we don't have to worry about it.
kinds of intravenous therapy including blood transfusion,However, I have come to learn that this standard only
so it seemed that an out patient administration ofpertains to compatibility issues. Apparently, there is
packed cells made sense. Well, they infused two unitsanother issue regarding sudden increases in hematocrit,
over five hours and sent her home after a two-hourwhich alludes to the viscosity (thickness) of the blood.
observation.In my mother's case her hematocrit went up post
For the first two days, Mom was fine. Then sheinfusion from 26 to 33. This is a problem for the elderly
started to become more talkative than usual and grewbecause the thicker blood builds up more pressure in
progressively more excited over the next 24 hours. Bythe capillaries (tiny peripheral blood vessels) and with
the end of the third day, she was completely confusedthe loss of elasticity in the elderly, pressure can build up
and agitated; with a mindset that we had not seen forin the sensitive brain areas and cause deleterious
about thirty years (she is 97). She had no connectionchanges in mental status.
to the present and did not recognize her live-inIn conclusion, it is clear that the hematologist (blood
caretaker who had been with her for six years. Thespecialist) was unaware of this risk factor in the elderly
situation had become dangerous, hence we called 911with the infusion of two units of packed red blood cells
and the paramedics took her to the hospital(PRBC) over only five hours. The gerontologist,
emergency room. The initial diagnosis washowever, stated that the standard of care is to infuse
trans-ischemic attack (TIA) which is a series of tinyno more than one unit per day and take a complete
hemorrhages (small strokes) in the brain that usuallyblood count in between to check the results to
produces sudden temporary mental aberrations.determine if a second unit is even necessary.
After a series of tests, i.e. CAT scan, x-rays, labs, etc.,