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Problems Spiking Sides of Blood Bags?

The following question was posed on Sun, 23 Apr 2000 to the CBBS e-network.

Is any one having issues with nurses placing spikes through the sides of blood bags with either the Imed spike or the Abbott Hemoset set spike? If yes, please indicate (if possible) the extent and magnitude of the problem.

1. To which there was only one member response. That member reported that his/her institution has been using the IVAC infuser with the IVAC Spec-sets. The institution has noticed an increase in the number of blood bags that were spiked through the sides by the RN staff. In 1999, 12 units were spiked through the sides compared to 7 in 1998. For the first 3 months of 2000, there have been 5 units spiked through the sides. The member did not indicate a denominator for the number of units handled by the nursing staff. When this member spoke to some of the RN's who spiked the units through the sides of the bag, they felt that the bags were more pliable and the ports were not as stable as they had once been.

ADDENDA Nov. 8, 2005

2. An SBB at a Blood Bank and Transfusion Service in Michigan reports that her transfusion service has been experiencing a vexing problem for nearly a year, for which a resolution has been elusive in spite of extensive internal investigations. She comments on a dramatic increase in blood component containers being damaged at the time a transfusionist 'spikes' the container's port with the piercing pin of the blood administration tubing. The container is damaged when the piercing pin goes through the side wall of the container, causing a hole with product leakage. They had only six such "accidents" in 2004, but have seen over 100 incidents to date during 2005. Their blood supplier collects whole blood donations into containers supplied by PALL as a part of a leukocyte-reduction kit. Her hospital uses Alaris pumps for most adult transfusions. She wonders if anyone has seen a similar increase in punctured blood component containers, and if so, is there a resolution?

ADDENDA Nov. 11, 2005

3. Colleen Gilstad CDR, MC, USN, Medical Director, Armed Services Blood Bank Center, National Capital Area (attribution used with permission - the views are her own and not those of the U.S. Navy or Department of Defense) reports a hypothesis that the increased rate in punctured blood component containers observed at the Michigan hospital (which uses Alaris blood component administration sets) might be related to recent changes in the outside diameter and sharpness of the Alaris infusion set spikes. Dr. Gilstad bases her hypothesis on the fact that her facility has also seen a similar increase in blood product container leakage since using a new lot of the Alaris infusion set at her facility (Product reference #72980E, lot #05085473; manufactured August 2005, expires August 2010). The increased rate of spike related product leakage has occurred with different products (FFP, RBCs and Apheresis Platelets) and on different wards. Dr. Gilstad reports that she has compared the 'newer' lot of Alaris infusion set spikes (Product reference #72980E, lot #05085473; manufactured August 2005, expires August 2010) with an older lot of the same product line (Product reference # 72980E, lot # 310792; manufactured October 2003, expires October 2008). The attached photos demonstrate that the newer lot's spike (on the left) has a sharper tip and a thicker wall and wider outside diameter than the older lot's spike (on the right; see table below for measurements). She theorizes that a combination of increased force needed to push the thicker spike into the component container port increases the risk that the sharper spike tip will penetrate the wall of the container. Interestingly, she was able to locate a blood administation set lot that was manufactured in June 2005 (Product reference # 72980E, lot #05065181) and that infusion set's spike has an outside tip diameter measurement, by her measurement with a hand-held manually read caliper, of 0.198 inch which is intermediate between the lot which was manufactured in 2003 (0.195 inch), and the lot which was manufactured in August 2005 (0.199 inch). The outside base diameter of the newest lot is the widest of all three lots at 0.248 inches. The caliper measurements for the three lots of infusion set spikes are shown below, at a scale of thousandths of inches.

Lot#	310792	05065181	05085473
Manufactured	October 2003	June 2005	August 2005
Tip Diameter (inches)	0.195	0.198	0.199
Base Diameter (inches)	0.246	0.246	0.248

Dr. Gilstad wonders if the molds used to make the cannulas might be gradually expanding, accounting for increased wall thickness as well as outer diameters over the course of two years. Finally, Dr. Gilstad is aware of other reports of increased bag punctures when hospitals switch from one blood administration set product to another, but that often those bag punctures are technique related, and as soon as nurses are trained to modify their technique, bag punctures stop happening. She concludes saying that they have alerted their staff to this problem and suggested that they modify their technique to take into account the thicker sharper spikes when beginning a transfusion. She expects they will see a drop in the rate of bag punctures.

4. A transfusion medicine physician in Central California reports that earlier this year (2005) one of the area hospitals experienced an increase in punctured blood containers when its regional blood center switched to a new blood bag. Ultimately, the hospital and the bag manufacturer worked together to identify the cause of the problem as being related to the interaction between the port on the new blood bag and the spike on the administration sets. First, it turned out that the blood bag port was slightly shorter than the port on the bags that had been previously used. Second, the administration set spike was slightly longer and relatively sharper than the spikes on the administration sets that had been used previously. Collectively, these differences led to an increased probability of the spike puncturing the side of the bag near its shoulder. The hospital first attempted to teach the transfusionists not to insert the spike as deeply, and to make certain the spike was directed perpendicular to the membrane within the port (and not at an angle). After this approach proved unsuccessful in fully preventing bag punctures, the hospital ultimately switched to an administration set with a shorter, blunter spike, and has not experienced this problem since. The administration set with which the hospital had problems is made by Alaris--model #72980E. The set to which the hospital switched (and which reportedly has a shorter and blunter spike) is also made by Alaris--model #79980E.
   
   
5. A transfusion service laboratory medical technologist reports that they have seen a distinct and preventable reason for a hole to be punctured near the entry port in a blood bag, and they include training to avoid this problem in their annual nurse training session. They have observed that without adequate training, a nurse will almost always retract the pulled-opened tabs to the side of the blood container port.  Then, holding the port horizontally and allowing the unit to flop over, the nurse pushes the spike through the port, and it inevitably rockets through the seal and punctures the side of the bag on the opposite side, wasting the unit. Saline and medication bags are generally thicker and fuller, keeping the sides away while spiking it, and most have easier-to-open tabs. They therefore train their nurses that 'hanging' the unit from the IV pole (so that the side walls are spread apart by the weight of the blood) before puncturing the seal prevents the occurance.

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