Infusing a cold spiked unit periodically for 24 hours

[Kathy]

The following is a proposed practice:

We are a pediatric hospital, so frequently only parts of units need to be transfused, by syringe. We are considering letting the OR spike units, change the expiration to 24 hours, and pull off syringe aliquots, so long as the unit is kept cold. There are remote blood bank refrigerators in the OR and the ICU and we will soon be using coolers for transport. All blood that is issued for surgery has a Safe-T-Vue indicator attached. The blood bank would print out several ISBT labels for each unit of blood issued to the OR and attach them with a plastic tie to the unit of blood before it is issued. The perfusionist would change the expiration on the bag to 24 hours and the syringes would only get 4 hours. When the syringes are pulled, the perfusionist would take a label from the bag, put a 4 hour expiration on it, and put it on the syringe along with the patient's identifying information. Syringes would not be transferred with the patient from the OR to the ICU, but the spiked unit of blood would be transported by cooler from the OR to the ICU and put into the ICU refrigerator. The ICU could then pull off more blood into syringes and transfuse as needed until the 24 hours is up, so long as the temperature indicator on the bag is not red. No units of blood spiked outside of the blood bank would be accepted back into blood bank inventory.

I know it is perfectly acceptable for the blood bank to pull off aliquots of a spiked unit of blood into syringes for 24 hours, but is it okay for non-blood bank personnel to do so, outside the blood bank? I know we would be giving up some control, but I can see this potentially being a very good thing in terms of reducing blood wastage, saving tech time, and having blood more immediately available to the patient. We would need to implement some sort of system whereby we could make sure they are putting appropriate expiration times on.

[tcoyle]

How would you handle issuing the blood each time an aliquot is pulled off? If you are printing ISBT labels and they are"dividing" the unit, you are essentially creating a new unit...How can you ensure they are changing the expiration time? You know blood bankers...(from the AABB Smart Brief quote)...We are paranoid hysterics who spend our lives thinking up worse case scenarios and then living as though they happen everyday...

[David Saikin]

Is your safe t vue a 6C or 10C? How will you verify that the blood is transferred from the cooler to the ref and not stay in the cooler? (different allowable temps) - in both the OR and the ICU . . . are you computerized? How will you maintain records of aliquots - both transfused and wasted?

[Kathy]

They already pull the blood out of the blood and put it into syringes. We have no way of controlling or documenting how many syringes they pull (is that really necessary???). The use of syringes for infusion of blood is mentioned in several places of the AABB Technical Manual, and it does mention blood being pulled from the blood bag into syringes at the bedside but does not address labeling. I figure if we can at least provide labels for them, it is better than them using unlabeled syringes. As far as the 6 or 10 degrees, we could err on the side of caution and use the Safe-T-Vue 6. How do I know they are changing the expiration time? Good question. My thinking is doing random checks (don't know how often) or requiring all unused blood to be returned to the blood bank, including spiked units and checking for changed expiration. I also don't know how to handle transfusion documentation in this circumstance.

Edited July 8, 2011 by Kathy

[Mabel Adams]

We got dinged a few years back by FDA because our NICU was pulling the blood from the aliquot bag we sent up into an unlabeled syringe to infuse. We had to develop a system for having the aliquots labeled. We went to filtering it into syringes in the BB and labeling them according to all the barcode etc. requirements of the FDA plus the patient info. This is not surgery so I realize this will not really be the same.

[Kathy]

We do provide syringe aliquots to our NICU that are properly labeled with proper aliquot designations. However, it would not be practical to pull every unit destined for cardiovascular surgery into syringes in the blood bank, give them aliquot designations, etc. Not only would we waste a ton of blood, but we would need to hire an additional tech to deal with the extra work involved.

My real concern is letting them have 24 hours to infuse a cold unit. My medical director is confident that our cardiovascular surgery team will follow the guidelines we give them for changing the expiration and labeling and he would like to move forward with this. Is there any rule anywhere that says that this cannot occur? If there isn't and we do go forward with this, what kind of extra documention should we require?

[David Saikin]

You would have to use the 6C safeTvue's . . . as you are storing the blood.

They already pull the blood out of the blood and put it into syringes. We have no way of controlling or documenting how many syringes they pull (is that really necessary???). The use of syringes for infusion of blood is mentioned in several places of the AABB Technical Manual, and it does mention blood being pulled from the blood bag into syringes at the bedside but does not address labeling. I figure if we can at least provide labels for them, it is better than them using unlabeled syringes. As far as the 6 or 10 degrees, we could err on the side of caution and use the Safe-T-Vue 6. How do I know they are changing the expiration time? Good question. My thinking is doing random checks (don't know how often) or requiring all unused blood to be returned to the blood bank, including spiked units and checking for changed expiration. I also don't know how to handle transfusion documentation in this circumstance.

[Kathy]

I also think I would need to do blood cultures on random units spiked upstairs after the 24 hours is up to ensure that they are using aseptic technique. Aaak.

[tcoyle]

I still think there is an issue with pulling aliquots and labeling and issuing. How will you document these aliquots, who they go to etc. I think the labeling is a huge issue. Not sure if the blood culturing would be required, but could be a QC check if you end up doing this.

[David Saikin]

You could do cultures as a QA monitor but why? If the blood is kept at the proper temperature there should be no sequellae. You or your OR should have a procedure which defines the asceptic technique to be used . . . I wouldn't make more work for myself unless you suspect problems.

I also think I would need to do blood cultures on random units spiked upstairs after the 24 hours is up to ensure that they are using aseptic technique. Aaak.

[Kathy]

David, I am just going based on what we did in the blood bank of the last hospital I worked in. For our NICU babies, we would spike a unit with a filter, attach a stopcock, change the original bag's expiration to 24 hours, and pull syringe aliquots for all babies that needed <50 cc of blood during that 24 hour period. We sent one random bag for culture once a month. For that matter, we send washed cells for culture periodically. I would feel more comfortable at least initially culturing the bags every now and then.

[Avid123]

Why don't you get units from the supplier with pedibags attached, fill them, label them, and issue them in a bunch to the OR. you could do the sizes based on that the OR intends to use or by patient size or by max size of the syringe (Which we found out was 60 ccs). That way it is sterile. and expiration is life of unit. The OR could choose a pedibag and spike it with the syringe attachment. Include a second label for them to use.

[Kathy]

We typically issue 4 units for CV surgery and it would be really a pain to split all 4 units, not to mention the amount of blood we would waste by having a bunch of split units coming back from the OR. I do think it would be safer that way. I will run it by the medical director. It is ultimately his decision.