How closely should the actual transfusion volume match physician's order in pediatric patients?

Dr. David Friedman, Associate Medical Director of the Blood Bank at Children's Hospital of Philadelphia (attribution used with permission) is developing a nursing policy regarding what to do if the volume of a blood product transfused comes up short of the volume ordered by the physician. For example, if 250 ml of RBC is ordered and 230 ml has been infused but the blood bag is empty, is it within nursing practice to flush the tubing with 20 ml of saline to push the remaining RBC into the patient? More generally, what is an acceptable range of tolerance for inaccuracy in transfusion volume? Plus or minus 10% seems reasonable, but is there a benchmark, especially for pediatric patients? What degree of shortfall should trigger a call to the provider to make a decision about whether to make up the deficit with another transfusion?

The following comments have been received.

ADDENDA March 26, 2012

1. A Blood Bank supervisor at a children’s hospital in the Southwest responds that in her facility, when physicians enter orders for transfusion in the computer system, a drop down list allows the physician to set the volume tolerance. This drop down list is user-defined. Their choices include:
   • transfuse exact volume
   • round up to nearest whole unit
   • round down to nearest whole unit.

   The supervisor states that using this system, the blood bank rarely needs to contact physicians for additional instructions.

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