Labeling blood pulled into syringes at bedside for transfusion

[Kathy]

I work in a pediatric hospital and have recently learned that during some surgeries, blood/blood products are pulled into syringes from the bags that we send up and are disconnected from the bag and transfused to the patient. Sometimes these syringes are not transfused right away and are sent with the patient label and a 4 hour expiration time to the ICU with no unit number identification or blood type. Obviously, the labeling is not correct at this point and I would like to stop this practice. However, the anesthesiologist says that the units in syringes are "in the process of transfusion". I could understand if the syringes stayed in the same room with the patient, but they are actually being transported and put in the ICU refrigerator and that is where I am concerned. They would like a practical solution to this problem.

My inclination is this: it is okay to do this as long as the blood stays with the patient, but is not transported. As soon as the surgery is finished, they discard any remaining syringes and if they need more blood postoperatively, spike a new unit. The problem with this is that it exposes the patient to more donors. We could pull the blood into a bunch of syringes ourselves and label them properly in the blood bank, but that is a lot of extra work for the techs and it would probably result in wasting blood since the exact blood needs vary according to how the surgery progresses.

One of our nurses said that she worked in a hospital where they have a Y - type filter that has a spike, a syringe, and an IV connection. They were able to pull the blood from the bag into the syringe and transfuse it to the patient without disconnecting the syringe from the setup. Do any of you know about this?

Can anyone here give me some guidance?

[David Saikin]

While I don't condone the practice, I do understand their logic. Once you sign the blood out you lose control. Your Medical Director should get involved since he/she is responsible for blood product utilization . . . once you have a sentinal event you are going to have to explain this practice to folks outside of your institution.

[John C. Staley]

My first question is: is the ICU refrigerator an acceptable devise for the storage of blood products? If not that should stop immediately.

If so, then I suggest that any syringe loaded in the OR be discarded in the OR if not transfused in OR. If the unit goes with the patient to ICU then they could load a fresh syringe on an as needed basis in the ICU. This could still be done with out refrigeration for the 4 hours the unit has for complete transfusion. The problem is training the ICU staff to understand the limitations. While blood is, indeed a precious commodity, the risk it to great to the patients under the circumstances you have described. If there were more than one patient in the ICU with a syringe in the refirgerator..... I'm sure you can imagine all the possibilities. Good Luck. In my experience anesthesiologists can be amoung the most difficult to deal with.

:abduction :abduction

[Bill]

"In my experience anesthesiologists can be amoung the most difficult to deal with." By far the hardest to deal with--in fact they will bluntly state that we will never know what goes on in surgery.

[Kathy]

David, our medical director is involved. He asked me to bring suggestions to the table for alternatives to their current practice.

John, the ICU has a monitered blood bank refrigerator, so it is perfectly safe. If they kept that spiked unit cold, it could theoretically be used for 24 hours, but I don't think I even want to go there. And I definitely agree that anesthesiologists can be difficult.

[John C. Staley]

Kathy, good to hear that the refirgerator in ICU is acceptable for blood storage. I would still be very uncomfortable with syringes being used for long term storage (anything more than 4 hours). I would still recommend that any syringe loaded in OR be discarded in OR and ICU can load their own syringes. Once the unit has been spiked I would guess that most of it ends up discarded anyway.

Are you using the syringes with the built in blood filter in the line? We got ours from Charter Med. They worked great because the filtered the blood going into the syringe and the nurses did not need to use a filter set during the transfusion. It worked very well but then we were loading the syringes and sending them to the bed side. I'm not too sure how they would work in your situation.

We also sterile docked the syringes to the bag so we could maintain the original outdate. That helped minimize donor exposure but then we rarely if ever did surgery on the little pople. Most of our transfusions were for NICU support. If a baby needed surgery they usually went to the local childrens hostital and then returned to us after surgery for the long term support.

Let us know how it works out.

[webersl]

We are not a pediatric hospital, so our pediatric experience is only newborns (born here) in NICU, and not with OR and transfers to NICU. Our blood supplier will sterile dock up to 8, 50mL "daughter" bags to a unit requested for a baby. Each little daughter bag comes completely labeled from the supplier (just like the mother bag). We express off what is needed (or if we don't know, we just do 50mL) into the little daughter bag, seal, and remove the little bag. Now both the "mother" bag and the "daughter" bag have their original outdate still. We issue the daughter bag, and reserve the mother bag for that baby in case they need more blood later. One mother bag may be reserved to more than one baby, at your discretion. Then, at the bedside, the care provider charges the syringe (through a filter) to the amount needed and transfuses. For us at our hospital, it is over then. But for you, the baby may need more than the 50mL in the OR. So, they would place their order for more, you would make another daughter bag from the same mother bag and issue to OR. OR is done and now, they are tranfering to NICU. I would suggest that OR be required to discard (or return) any unused blood in their posession, and NICU be required to request a new daughter bag from the blood bank, if they also need to give blood. If kept in a monitored fridge, the daughter bag maintains the original expiration date until spiked. Once spiked it goes to 24 hrs (if still in fridge). Or, to be safe (never trust a nurse) just tell them if it is spiked, they have 4 hours to give or it must be discarded.

[webersl]

We issue the daughter bag, and reserve the mother bag for that baby in case they need more blood later. QUOTE]

I forgot to say that we, of course, attach all the patient specific identification to the daughter bag before issuing.

[webersl]

Another idea.

When they come to pick up the blood, ask them to bring the syringe they will use. You label the empty syringe in the Blood Bank with the appropriate info. (not best practice)

Another idea:

To whatever product you issue to OR, provide them with an appropriate label that they can transfer to their syringe once they charge it.

[Kathy]

For our own purposes, we sterile dock the Charter Med syringe/filter, pull into the syringe, and label it with an ISBT label and 24 hours exp for the syringe. We give these syringes to our NICU patients, but now our CV unit is asking for them too.

As far as the OR goes, we do not provide them with sets. I assume they spike the bag with a filter, attach a syringe to the set, pull out what they need, detach the syringe, and pull additional syringes. Since they do not have a tube sealer up there and the unit of blood almost certainly gets above 10 degrees, I don't see the wisdom in trying to keep the original expiration date of the unit.

What my medical director and I have agreed upon and will need to discuss with all of the people involved, is that we provide extra ISBT labels for each unit that is likely to be pulled into syringes. That way, they can pull the syringes, label them with the ISBT label and the patient label, and use the unit for 4 hours.

Webersl, I like your quote "never trust a nurse". How I wish that were not true.

[Kashmira patel]

Hello! Kathy,

We sterile dock the syringe (30 mL or 60 mL) to the pediatric aliquot bag and label both the blood bag and syringe with an ISBT lablel and patient/unit identification label.

Blood is pulled in to the syringe by the floor/OR.

Hope this helps.

Kashmira