How often should blood administration sets be changed while a patient is being transfused?

A blood banker who works at a 300-bed suburban community hospital reports that upon reviewing nursing procedures, it was noticed that the nursing policy requires changing blood administration tubing every 24 hours or after two units of blood, whichever comes first. This concerned the inquiring blood banker because the maximum time allowed for a unit of RBCs to hang is 4 hours. The inquiring blood banker was surprised to learn that at the end of the 4 hours, the blood administration tubing was not changed for new tubing. A second blood banker who works at a highly prestigious academic institution reports that at her institution, questions have come up about the need to change blood tubing approximately every 4 hours. She reports that the package insert for their blood administration sets say to "Change within 24 hours." In addition, the Circular of Information has no direct "shall" or "must" for infusion tubing, but defers to the manufacturer's package insert for specific device information. At the inquiring blood banker's institution, it has always been required that the administration set be changed every 4 hours. The two inquiring blood bankers requested input from the e-network about how often other hospitals change blood administration tubing for patients who are being transfused.

The following replies were received.

1. A blood bank physician who is involved in preparing the 14th edition of the AABB Technical Manual reports that the 13th Edition of the Technical Manual, page 486, states that "Many institutions have a policy of changing sets after every transfusion or of limiting their use to several units or several hours in order to reduce the risks of bacterial contamination. A reasonable time limit is 4 hours. Most standard filters are designed to filter two to four units of blood, but if the first unit required 4 hours for infusion, the filter should not be reused. The filter traps cells, cellular debris, and coagulated protein, resulting in a high protein concentration at the filter surface. The combination of high protein milieu and room temperature conditions promotes growth of any bacteria that might be present. Accumulated material also slows the rate of flow." The responding blood banker adds that since most blood filters are designed to accommodate only 1-2 units of blood after which the filters are usually substantially clogged, that a 24-hour limit seems unreasonable from this regard as most units are administered in less than 4 hours. Looking to the FDA, spiked blood products (i.e., an open system) at room temperature are uniformly limited to 4 hours expiration. It would seem, the use of the tubing set and filter would fall under the same restriction. The responding blood banker also provides the e-network with the pertinent sections from a CDC document which are summarized below:

GUIDELINES FOR PREVENTION OF INTRAVASCULAR DEVICE RELATED INFECTIONS: Intravenous administration set replacement. The optimal interval for routine replacement of IV administration sets has been examined in three well controlled studies. Data from each of these studies show that replacing administration sets 72 hours or more after initiation of use not only is safe but cost beneficial. However, certain fluids (i.e., blood, blood products, and lipid emulsions) are more likely than other parenteral fluids to support microbial growth if contaminated, and more frequent replacement of IV tubing may be required when such fluids are administered. Replacement of administration sets and intravenous fluids A. Administration sets:

1. In general, administration sets include the area from the spike of tubing entering the fluid container to the hub of the vascular device. However, a short extension tube may be connected to the vascular device and may be considered a portion of the device to facilitate aseptic technique when changing administrations sets. Replace extension tubing when the vascular device is replaced.
2. Replace IV tubing, including piggyback tubing and stopcocks, no more frequently than at 72 hour intervals, unless clinically indicated. (Exception: see 4 below)
3. No recommendation for the frequency of replacement of IV tubing used for intermittent infusions. (Unresolved issue)
4. Replace tubing used to administer blood, blood products, or lipid emulsions within 24 hours of initiating the infusion. The responding blood banker concludes with the opinion that in terms of growth curves of bacteria, some organisms such as Bacillus cereus (a frequent contaminant of platelets) can reach concentrations of 10⁸ CFU/mL in 24 hours. Therefore, he believes the current recommendation in the Technical Manual is appropriate.

2. A blood banker in Michigan wrote that the filter used for blood transfusion should be used according to manufacturer's directions. Some are add-on filters and some are integral with the infusion tubing. Some filters may be used for up to 10 units, some are designed to be used for a single units. In filters intended for multiple units, the filter should be changed when there is significant debris build up or according to local policy. If further transfusion is not anticipated, the set should be discarded. If the filter and IV tubing are manufactured together, then then entire sent is discarded. When the filter is added to existing tubing, the filter can be discarded and the tubing can be used for up to 24 hours. 
   
   
3. A Texas blood banker wrote that her hospital has exactly the same procedure in place for changing blood administration tubing as the 300-bed suburban community hospital. When the Texas blood banker inquired about the nursing policy at her hospital, she was told that the nurses run saline through the tubing after the blood transfusion is completed so that no blood is left in the tubing after the infusion. The nurses follow the manufacturer's product insert for how often the blood administration tubing must be changed.
   
   
4. Another Texas blood banker reported that his blood bank reviewed this issue several years ago when a question arose regarding use of blood administration sets for 24 hours. They determined that the majority of facilities in their region change blood administration sets every four hours. Also, they found a statement in the HHS Publication entitled "Transfusion Therapy Guidelines for Nursing" (9/1990) that said "Do Not" use blood filters for more than 4 hours. They promptly changed their policies to that meet that recommendation. More challenging is developing a monitor to ensure compliance. They have not done so.

ADDENDA May 16, 2004

5. A colleague reports that at her community hospital the nurses at work are debating about the principle of why and how often blood product administration tubing should be changed. Their current policy requires them to change blood administration tubing after running two units of blood product through the tubing or after running the blood through the tubing for 4 hours, which ever occurs first. Some of the nurses also change the tubing between the administrations of different kinds of blood products, such as between giving a patient platelets followed by RBCs. Since the inquiring colleague’s hospital stopped using separate administration tubing for platelets, they have wondered if the same tubing can be used for sequential administration of platelets and RBCs. She is aware that one reason for changing the blood administration tubing is avoid cessation of flow that can occur if the in-line filter plugs up, and that a second reason is to prevent bacterial overgrowth that can occur in an open system. She wants to know what policies others use pertaining to why and how often one should change blood administration tubing.

Editor's Note: The following prior e-Network Forum discussions may be germane to these questions.

• Questions about the use of blood component recipient sets
• Does new evidence exist on the safety of using automatic IV infusion pumps for red cell transfusions?
• Is transfusion of platelets contraindicated during dialysis?

ADDENDA May 17, 2004

6. A transfusion medicine physician in Irvine, California reports that at his academic center their policy is to change infusion sets and/or filters after every two units or after four hours, whichever occurs first.

ADDENDA May 18, 2004

7. A colleague in Cantabria, Spain reports that at the hospitals in that location, the common practice is to change infusion sets with every blood component. Apparently the infusion set manufacturers have told them that these sets can be used to infuse two products, but they prefer to limit the use to one product per infusion set.

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