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Experience in the use of pressure pumps or other rapid infusion techniques for red cell administration |
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A transfusion medicine physician in Pennsylvania would like to know what has been the experience of others regarding the use of pressure pumps (or other rapid infusion techniques) for red cell administration. The Emergency Room physicians, trauma physicians and anesthesiologists at his facility are looking for ways to increase the administration of red cells in critical trauma situations. The following comments have been received. ADDENDA June 5, 2006 1. Anesthesiologists from several medical centers throughout the United States provided feedback regarding experience with the use of pressure pumps or other rapid infusion techniques for rapid red cell administration. Colleagues reported using pressurized systems for RBC administration, including a variety of devices ranging from simple pressurized bags to more elaborate pressurized chambers that can also warm blood, such as the following (list not intended to be exhaustive; if other devices are in use, colleagues are encouraged to provide details):
There was a consensus that systems for rapid administration of red cells, especially those with warmers, have proved invaluable in many clinical situations. These situations include massive hemorrhage due to upper GI bleeding or other medical bleeding episodes, trauma, and surgically controllable hemorrhage that requires rapid restoration of lost blood volume. A note of caution was that pressurized systems need some vigilance to ensure that air does not enter the system (and the patient). Newer devices apparently have air vents that can eliminate small volumes of air in the circuit tubing, and greater safety in this aspect may ultimately include an air detector distal to the final connection between the pump unit and patient. This could be a reusable sensor with a disposable connection built into the tubing similar to those used during cardiopulmonary bypass. Several anesthesiologists commented that they prefer to dilute RBCs with normal saline or some other FDA approved IV solution (such as Plasmalyte A; see prior e-Network forum discussion, Which solutions other than isotonic saline are approved for addition to blood and components?) when using rapid blood administration systems. The practice of diluting RBCs in the rapid blood administration setting extends beyond the use of CPDA-1 RBCs to AS-1, AS-3 and AS-5 RBCs, even though AS-1 RBC, AS-3 RBC and AS-5 RBCs have been pre-diluted by the blood collection center and have a lower hematocrit than CPDA-1 RBCs. No anesthesiologists reported that they would dilute RBCs with 5% Dextrose in water (D5W) or lactated Ringer's (RL) probably because of reports of clumping and hemolysis when RBCs are mixed with D5W and clot formation when RBCs are mixed with RL (see Strautz RL, Nelson JM, Meyer EA, Shulman IA. Compatibility of ADSOL-stored red cells with intravenous solutions. Am J Emerg Med. 1989 Mar;7(2):162-4). Many respondents also favored using a large bore (7-8 French) cannula to reduce the overall resistance to flow, which is a major restriction imposed by the administration system. It was pointed out that for any viscosity, the rate of administration depends upon the length and diameter of the rate-limiting component. Although this is often the IV cannula itself, with the increased use of 8 and 9 French introducer sheaths for resuscitation, the restriction may be in the giving set and/or stopcocks in the connections. |
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Please submit comments to the e-Network Forum. Ira A. Shulman, MD |
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