My mother's hemoglobin was down to eight again, which is confirmation of severe anemia, so her primary care physician sent her over to a hematologist to receive a blood transfusion. It was all well intended to avoid another hospitalization. This blood specialist has her practice in a cancer center where they provide all kinds of intravenous therapy including blood transfusion, so it seemed that an out patient administration of packed cells made sense. Well, they infused two units over five hours and sent her home after a two-hour observation.

For the first two days, Mom was fine. Then she started to become more talkative than usual and grew progressively more excited over the next 24 hours. By the end of the third day, she was completely confused and agitated; with a mindset that we had not seen for about thirty years (she is 97). She had no connection to the present and did not recognize her live-in caretaker who had been with her for six years. The situation had become dangerous, hence we called 911 and the paramedics took her to the hospital emergency room. The initial diagnosis was trans-ischemic attack (TIA) which is a series of tiny hemorrhages (small strokes) in the brain that usually produces sudden temporary mental aberrations.

After a series of tests, i.e. CAT scan, x-rays, labs, etc., the gerontologist ruled out TIA and said it was a delayed transfusion reaction. This was surprising because in my experience as a nurse I have always believed that blood reactions are usually immediate and if the patient does not react after 2 hours of observation, we don't have to worry about it. However, I have come to learn that this standard only pertains to compatibility issues. Apparently, there is another issue regarding sudden increases in hematocrit, which alludes to the viscosity (thickness) of the blood. In my mother's case her hematocrit went up post infusion from 26 to 33. This is a problem for the elderly because the thicker blood builds up more pressure in the capillaries (tiny peripheral blood vessels) and with the loss of elasticity in the elderly, pressure can build up in the sensitive brain areas and cause deleterious changes in mental status.

In conclusion, it is clear that the hematologist (blood specialist) was unaware of this risk factor in the elderly with the infusion of two units of packed red blood cells (PRBC) over only five hours. The gerontologist, however, stated that the standard of care is to infuse no more than one unit per day and take a complete blood count in between to check the results to determine if a second unit is even necessary.