Switching Blood on Rapid Infuser

[gkerns]

I work as an RN at a busy urban trauma center, and it seems ridiculous that there is no consensus on this issue at our work, and I haven't been able to find any good information in any text or user manual about it, so I figured I would put it out here.

For our rapid blood infusions and massive transfusion protocol (MTP) activations, we use the Level 1 device. When it comes time to switch out the blood bags, I was taught and have made it my practice to do the following:

(FYI, our trauma activation comes with 4 units of uncrossmatched PRBCs - when we elect to activate the MTP, we receive the rest of the products in a 1:1:1 [platelets, FFP, PRBC] ratio)

1. Prime the set with saline

2. Attach the first unit of PRBCs to the second spike, and run that unit

3. While that first unit is running, disconnect the saline, and hang the second unit of PRBCs

4. As soon as the first unit is done, the pressure is turned off, and the clamp is applied to that side.

5. The second unit is immediately put under pressure and infused.

6. This process of switching is continued until the 4th unit has been administered.

7. When the MTP blood arrives, a new Level 1 set has already been primed, and the same process starts again, only the first unit to run is FFP, and then that side is always FFP, and the secondary side is always PRBCs in order to make the ratio easy to remember.

The set is changed whenever the filter seems to be slowing down the infusion

(usually after about 4 units of products).

The problem is that I have recently been approached by some of the newer trauma RNs, who have told me that they are being trained to keep the saline bag up on the first Level 1 channel, and to run a hundred or so mLs of saline through the set after each unit of blood. To me, this seems ridiculous, since the goal is to rapidly replace blood volume in dying trauma patients, and we are starting to realize more and more the perils of instilling crystalloid into these patients (dilution of clotting factors, iatrogenic hyperchloremic acidosis, etc).

Unfortunately, since I haven't been able to locate any hospital policy or national standard... or really anything either way, I don't have much evidence to mount a good argument to change practice. Thankfully, administration seems to be coming down on my side on this one, but I would really appreciate it if anybody could either weigh in on their current practice, or better yet, point me to some national or international standard.

Any comments or links for me?

Thanks in advance!

Geoffrey Kerns, RN, MICN, TCRN

[offlabel]

There is an impulse in all of nursing, everywhere to "flush the line" no matter what....seems like this might be in play here and it is dumb...but...until you can "untrain" these folks, a couple hundred cc's of NS isn't going to hurt anyone (as long as it stays less than a liter or so, including what they got in the field). What will hurt them is raising the blood pressure too much, and you can do that with blood products.

In regard to a hyperchloremic acidosis, I'm always surprised and dismayed to hear of places where NS is still used on trauma patients. Solutions such as Normosol or Plasmalyte are compatible with blood, have pH's of 7.4 (NS is something like 6.9) and there is no risk of causing or worsening acidosis.

[gkerns]

a couple hundred cc's of NS isn't going to hurt anyone (as long as it stays less than a liter or so, including what they got in the field). What will hurt them is raising the blood pressure too much, and you can do that with blood products.

My issue isn't with the small amount of (ab)normal saline that the patient receives as much as it is with the time wasted administering crystalloid instead of utilizing both channels back-to-back in order to deliver blood when dealing with a peri-arrest hypovolemic trauma patient.

Thankfully, most of the new trauma RNs at my shop have been forced to listen to me lecture ad nauseam about permissive hypotension and the horrors of over-resuscitation.

[offlabel]

[quote=gkerns;9094818

Thankfully, most of the new trauma RNs at my shop have been forced to listen to me lecture ad nauseam about permissive hypotension and the horrors of over-resuscitation.

Well... just remember that the "horror of over resuscitation" was the cutting edge of trauma care less than 20 years ago. We might be kicking ourselves 20 years from now because of what we now consider state of the art.

[siegolindoRN]

The practice of flushing the line, or changing blood tubing, in between transfusions comes from the need to monitor for transfusion reactions (policies are created for the broadest applicability). The obvious difference in standard administration vs during hemorrhage is the time frame in which the patient needs the blood product administered. There is data on pubmed regarding transfusion reactions in the trauma population from several studies that did not tie patient death with hemolytic reaction in patients who received uncross matched blood (they did develop the antibodies against the foreign product). The belief is that trauma taxes the immune system thus preventing the reaction traditionally seen in the normal product replacement scenario. You can use this evidence to aid in changing practice. Best of luck!!