blood warmers during traumas

[Antrita]

I found out that during traumas they are using blood warmers on all blood products. I told the surgery supervisor that they can't give platelets and cryo through a warmer. What I have found on FFP seems to be a little iffy. The blood warmers go to 40 C. I understand why they don't want to give these patients cold blood products. What do all of you do?

Antrita

[adiescast]

Perhaps I am missing something...what is the problem with giving components through a warmer? As far as I know, although I have not asked about actual practice, all components may go through the blood warmers. It does not seem necessary for platelets or cryo, but refrigerated plasma is just as hard on the patient as refrigerated blood.

[Antrita]

They are putting everything thru a blood warmer. I do understand the FFP going thru the warmer but the platelets and cryo arn't cold. The manufacturer of the blood warmer says not to put platelets and cryo thru but doesn't say anything about FFP. We just want to make sure that the coag factors are not destroyed by the 40 C blood warmer.

[NedB]

The temperature of the blood warmer is 40C, but the blood does not get that hot. It is only in contact long enough to bring the tmperature above 30C. Some work better than others. Any way, the exposure above 39C can't be long enough to degrade the labile coag factors. We recommend the Nurses not put platelets through because the kind we use has a mesh filling that I worry will trap too many platelets. I probably wouldn't worry about cryo, but in truth, that hasn't come up.

[tbostock]

We recommend that platelets do not go through a blood warmer, although the warmer we use here is FDA approved for platelets. They are room temp, so usually not an issue. Everything else is warmed for traumas.

[jcdayaz]

They are putting everything thru a blood warmer. I do understand the FFP going thru the warmer but the platelets and cryo arn't cold. The manufacturer of the blood warmer says not to put platelets and cryo thru but doesn't say anything about FFP. We just want to make sure that the coag factors are not destroyed by the 40 C blood warmer.

WOW! I would never ever allow platelets and/or cryo to be transfused through a blood warmer. FFP? No problem in my mind.

[Antrita]

My problem was I never considered the fact that during a trauma they might be using a blood warmer for all blood products. My lab manager found out at a trauma meeting and freaked out. Hopefully we have convinced them of the error of their ways. Though, since they have adopted a policy of using "packs" of products during a massive transfusion and only half of the staff know about it I doubt if this is they last we will hear the about the misuse of blood warmers.

[adiescast]

I should say that we do have a policy that non-rbc products are run through a separate line. This may prevent them from running through the blood warmer. I don't think it is a good idea to run platelets or cryo simultaneously through the same line as red cells.

[Malcolm Needs ☆]

I think it is down right dangerous.

:mad::mad:

[jcdayaz]

Sorry to be "slow" everyone. Why is the need for a blood warmer during a massive transfusion necessary? We use a blood warmer for transfusion only when we detect a cold auto antibody >2+ in strength.

Any thoughts?

[Malcolm Needs ☆]

I think that it is to do with the volume of cold blood and blood components that are transfused over a very short space of time bringing down the core temperature of the patient.

This, in turn, leads to less efficient enzyme kinetics in things such as the clotting cascade (apart from other systems relying on enzymes) and the patient going into, effectively, hypothermia, on top of their trauma.

I stress, I think!

:confused:

[adiescast]

Malcolm, you are absolutely correct. One of the biggest problems in trauma patients is that you can't get them to stop bleeding. The traumatic coagulopathy is caused in part by the rapid infusion of cold blood products that brings the body temperature (already low from shock and blood loss) to a level that cuts out the coagulation cascade and deactivates any decent platelets the patient may have had left (in addition to any you give during the resuscitation). Cold blood also contributes to the pH shift to acidosis, which affects coagulation. It is absolutely imperative to keep the patient warm enough and pH neutral enough for coagulation to occur. If the patient is coagulopathic, even the blood components you give to replace what they lost will not function properly. It is also important to remember that the patient's body has to be able to combat the anticoagulant in the blood products in order to produce decent coagulation at the site of the injury. A cold body cannot do that either.

Edited December 23, 2009 by adiescast
spelling

[Antrita]

Adiescast is right. A trauma patient that is hypothermic, acidodic and has abnormal coag results has a 50% decrease in surviving the trauma. The company manufacturing our blood warmers says they have FDA approval for running plasma. These patients have multiple lines so they don't need to run the platelets and cryo thru the same lines that are being used for the packed cells. I heard from one hospital that doesn't use blood warmers for their FFP they wrap them in warmed blankets before transfusing them in a trauma. Does anyone do this?

Antrita

[huntilla]

Malcolm, you are absolutely correct. One of the biggest problems in trauma patients is that you can't get them to stop bleeding. The traumatic coagulopathy is caused in part by the rapid infusion of cold blood products that brings the body temperature (already low from shock and blood loss) to a level that cuts out the coagulation cascade and deactivates any decent platelets the patient may have had left (in addition to any you give during the resuscitation). Cold blood also contributes to the pH shift to acidosis, which affects coagulation. It is absolutely imperative to keep the patient warm enough and pH neutral enough for coagulation to occur. If the patient is coagulopathic, even the blood components you give to replace what they lost will not function properly. It is also important to remember that the patient's body has to be able to combat the anticoagulant in the blood products in order to produce decent coagulation at the site of the injury. A cold body cannot do that either.

So let us assume that the ER does not have ready access to a blood warming device, would it not be prudent to slip two units of blood into overwraps and let them equlibrate in a plasma bath for about ten minutes or so? I would proposition that this method would be preferable to running units through a warmer, you could then infuse the units through a large bore IV in a rapid fashion.

[Antrita]

That does sound like a good idea. It would be more controled than a blanket. I don't think they are lacking in blood warmers. We no longer have anything to do with them, they are monitored by bio-med. Were we still monitoring them we would have found out about how they were using them. I guess out of sight out of mind.

Antrita

[adiescast]

The main thing with alternate methods of warming is to ensure that the blood is not exposed to a temperature that causes hemolysis. A waterbath in blood bank would be much better controlled than warmed blankets. The thing is that neither of those methods are as fast as an in-line blood warmer. Some of the rapid infusers are simply amazing. So as long as the infuser or blood warmer is available, I would use that in preference over warming the blood in a plasma bath.

[Antrita]

I agree, and our as it turns out our blood warmers are ok for FFP. The waterbath would be better than the blankets if you can't use a blood warmer. One of our sister hospitals is using blankets, so I was going to suggest the waterbath to them.

I have stayed out of the loop when it comes to blood warmer technology since we no longer monitor them. It was a good wake-up call. Even though I don't monitor them doesn't mean I can ignore them.

Antrita