A member inquired if the e-Network Forum could discuss strategies for providing blood without delay for patients who begin to bleed out while being treated in a cardiovascular OR and/or ICU that is remote (for example, 15 minutes by elevator, even with dedicated key) from a blood bank. The member's institution uses a pneumatic tube system for blood deliveries, but this system is not completely reliable, so they are hesitant to rely on it in a crisis situation. They have considered placing a remote refrigerator containing only group O negative RBC units in the OR and ICU, but they are meeting resistance from nursing and physicians. The member wants to know what other strategies blood banks have found to be effective in providing blood for exsanguinating OR and ICU patients.

EDITOR's NOTE: The e-network forum previously discussed strategies for emergency provision of group O RBCs for patients who are brought to the hospital and seen in the Emergency Room environment, but the forum has not yet discussed the above situation. The current question expands the previous discussions to include patients who are already in the hospital when they begin to bleed out. To see the previous discussions, go to:

• Management of Compatibility Testing When a Patient is Transferred To Another Hospital Sharing the Same Transfusion Service SOPs and Computer System
• Managing Emergency Blood Needs in Hospitals Whose Lab is Not Staffed During the "Graveyard" Shift
• Policies for Ensuring An Adequate Supply of O Rh Negative Blood in Emergencies
• Transporting Blood With Patients
• Quantifying When To Switch from O Rh-negative to O Rh-positive Red Cells in Bleeding O Rh-negative Patients

The following input has been received in response to the above question:

1. The physician who directs an operating room laboratory at a University Hospital in Virginia commented that in his opinion remote refrigerators are a real headache and are never monitored well by personnel other than from the blood bank. Rather than set up a remote refrigerator, his hospital has recently created a satellite blood bank (for dispensing only) to service their operating rooms. This dispensing activity is coordinated with an intra-operative laboratory. The responding member says that this model worked very well at the University of Washington.

2. A blood banker from Philadelphia commented that at his hospital, they have a remote blood storage refrigerator in the Cardiac ICU. It is stocked with 2 Units of group O negative RBCs. The RBC units are rotated weekly. The blood bank does all the QC except for daily temperature checks which are done by someone from nursing up there. It is intended for unanticipated emergencies only. It was originally set up as a way of dealing with the fact that numerous type and crosses were being done for "line pulls" and this blood was almost never used. Once the refrigerator was in place, we stopped doing the T & C and considered bleeding with a line pull to be an unanticipated emergency. Other unanticipated emergencies have been sudden post-op bleeding, STAT institution of ECMO, etc. They were worried about abuse of this unit, and about failure to document the use when it was needed. These issues have arisen but not as a constant problem. In general, it has generally been successful.

3. A blood banker in California says that he is aware of at least one hospital that has a remote (separate building approximate 1 city block away) blood bank that: (i) has a "blood bank" refrigerator in the OR (an complies with all monitoring requirements), and (ii) has "panic" units of O negative in the OR for not only Cardiac work, but for any other time there is a crisis requiring the immediate transfusion of uncrossmatched blood. If the hospital does have the monitored blood bank refrigerator, it must comply with all regulatory requirements including remote monitoring if the OR is not manned 24/7 and the blood is stored during the unmanned times.

4. A blood banker in Texas commented that his hospital has had a system in place which has worked well for several years to deal with this situation. The principle was originally based on the accepted practice used in Emergency Rooms of having an on-site blood refrigerator containing a stock of O neg. blood for trauma and other emergency cases. Their revision of this concept works as follows:

• There is a blood refrigerator in the OR that contains a stock inventory of group O positive, group O negative, group A positive and group A negative RBC's (Other blood types are added as needed following a review of the surgical schedule the night before). The inventory is returned to the Transfusion Service every night after surgeries have finished. The surgical schedule is evaluated, and a new stock prepared for the next day. The blood refrigerator is connected to a central alarm system monitored 24 hours/day, and follows all the same QC requirements imposed on the refrigerators in the Transfusion Service.
• Segments from the units sent to the OR refrigerator are kept in the Transfusion Service, as well as a in-date type and screened specimen for the patients scheduled for surgery that day.
• The OR personnel are trained by the Transfusion Service on the proper dispatch and release SOP's. Also, the crossmatch result is entered into their computer system (CERNER) where the blood type verification is done. If the patient's blood type and the unit type are different (as in the case of Allogeneic Bone Marrow Transplants) the computer system requires a special password to verify the validity of the transaction.
• When a surgeon needs blood for a patient in the OR, they call the Transfusion Service with the pertinent information (Patient's name, medical record number, number of units needed and OR number). The Transfusion Service then uses the patient's sample, the segments from the units kept in the OR blood refrigerator and performs an immediate spin crossmatch. If the units are compatible, labels are printed on a designated printer in the OR, the units are labeled and released for transfusion. The total time involved in the transaction is approximately 5-10 minutes, from receipt of the call to the release of the units.
• According to the responding member, the above method allows them to keep better control of their inventory as they do not set up units for surgery ahead of time, unless the patient has a documented antibody problem, or the type of surgery is known to cause significant blood loss. If they have a specimen on the OR patient, and the T&S is negative, they can guarantee the availability of blood and a fast TAT of the testing.
• The responding member states that they have had no hemolytic transfusion reactions due to the system described above, although after implementing the practice they had an incident where units of the same ABO/Rh had their crossmatch labels switched. The error was caught by the anesthesiologist, and the units were returned to the OR satellite office for correction.

5. A blood banker in Colorado commented that at her facility they rely almost exclusively on a pneumatic tube system for rapid transport of blood; problems have been rare. If very large quantities of blood are needed rapidly, blood bank staff or hospital messengers, if available, will physically run the blood down to the OR/ICU, which is no more than 5 minutes from the blood bank. The responding member comments that they used to have a Stat Lab in their OR, which made it much more convenient (but costly) to store blood in the area, and at that time they did keep two units of group O Rh negative RBCs down in the Lab blood bank refrigerator during the hours it was open (not round-the-clock). They still have a refrigerator in the OR where blood for the day's cases is stored, but they do not store uncrossmatched units of group O Rh negative RBCs. If additional blood is needed, they tube it down. All units sent to OR have temperature monitoring stickers. Their biggest problem has been getting the OR personnel to retrieve the blood from the tube station in a timely fashion! The OR personnel do not like blood storage refrigerators in their area, because they don't like being responsible (blamed!) for mishandled products. Cardiac surgery is their chronic offender. As for the Emergency Department, they put two units of group O Rh negative RBCs in a cooler and transport them to the E.R. by messenger or by blood bank tech in response to the Level I Trauma beeper. This takes less than 10 minutes (usually, more like 5), even though the ER is even a little more distant than OR/ICU.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator