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Transfusion Time


khalidm3

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Rarely we would have a physician write an order to transfuse a unit over "X hours" with X > 4. This usually occurred with a patient in congestive heart failure or some other problem where a rapid increase in blood volume would be a bad thing. The solution is simple. Divide the unit in half and issue each half individually. Each half then has the 4 hour time limit. Of course this only works when you have advanced notice. If the 4 hours is exceeded consider it an opportunity for education and let them know that splitting the unit is an option next time.

:boogie:

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Are you saying that the unit was infused over more than four hours? Was it an oversight on the nurse's part, or a lack of education?

Yes, It is a quarry from a head nurse that some time the transfusion could not be completed with in four hour. She want to know in this case what she will do to remaining blood.

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John, splitting units under ISBT is not so easy since you need to be able to print labels with the right split product code on them or you need to have pre-printed barcoded aliquot labels of every possible aliquot. Small places on ISBT probably can't offer to split units anymore. My prior blood supplier called that a "boutique" service anyway. The label printers and software are quite expensive for something you would do very rarely. Although, if memory serves, our old friend Dave Pollock had created some ISBT labels on his website (just as he did the codabar labels before) that might solve the problem for small places that don't have the printers. I don't see him on here much these days.

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Khalidm3, in our place, at the end of the four hours, the remainder of the unit must be discarded.

Yes, It is a quarry from a head nurse that some time the transfusion could not be completed with in four hour. She want to know in this case what she will do to remaining blood.
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We strike this occasionally. Since new EU regulations, remainder of the pack must be discarded at the four hour mark. We use packed red cells, so it is a rare patient that cannot tolerate a pack over four hours, especially if diuretics are co-administered.

Anything outside this will generate a non-conformance. Had some physicians calling early on when new rule was enforced, but they accept it now and we rarely waste any leftovers in the pack.

Cheers

Eoin

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I have heard of places where continuing the transfusion after 4 hours is considered a medical decision to be made by the patient's physician. That was some years back and starting to dim a bit in my memory.

Not allowed under AABB, CA state must follow AABB standards. Discard of unit is mandatory. And ISBT really does change some old practices..... which were sound and useful for the occassional patient, imo, but alas these improvisitions can't be done anymore unless you are properly prepared in advance with a policy that complies with regulations, approved by necessary powers that be in advance.

I HAVE put in place a "Deviation of Procedure" Policy complete with form to be approved by the BB Medical Director. This must be done PRIOR to the event. We are hoping this would stand up to an inspection. What are people's thoughts on this?

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As long as you can justify deviations and have medical director approval that should fly. If we use all of our plts but have one that expired 2 hours ago we are going to get permission to give it to a patient that is in dire need of plts. Getting permission to give blood beyond 4 hrs would probably not justify that unless the patient had a jillion antibodies.

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John, splitting units under ISBT is not so easy since you need to be able to print labels with the right split product code on them or you need to have pre-printed barcoded aliquot labels of every possible aliquot. Small places on ISBT probably can't offer to split units anymore. My prior blood supplier called that a "boutique" service anyway. The label printers and software are quite expensive for something you would do very rarely. Although, if memory serves, our old friend Dave Pollock had created some ISBT labels on his website (just as he did the codabar labels before) that might solve the problem for small places that don't have the printers. I don't see him on here much these days.

Years ago we had a rash of transfusions exceeding four hours. I campaigned to make sure all nursing areas and physicians understood that the preferred and accepted alternative was to order a split unit. I took care to make sure every tech was familiar with the procedure and the equipment used to split a unit. At least ten years later, ISBT came into our lives and, since a split unit had NEVER been ordered in all that time, we abandoned the practice rather than deal with printing labels. As a small facility, we don't pool or irradiate any products so we were not willing to invest in a label printer for the hypothetical split unit.

The occasional transfusion which exceeds 4 hours is written up as an incident. In reality I suspect that the nurses are delayed in getting back into the room and when they do, they find the bag empty and document the time that they found it - it had probably finished within the proper time frame since the infusion rate is set on a pump which should result in completion within the limit, but no one wants to do the math or to guess at when it was finished.

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I bet this is what happened. Good call!

Years ago we had a rash of transfusions exceeding four hours. I The occasional transfusion which exceeds 4 hours is written up as an incident. In reality I suspect that the nurses are delayed in getting back into the room and when they do, they find the bag empty and document the time that they found it - it had probably finished within the proper time frame since the infusion rate is set on a pump which should result in completion within the limit, but no one wants to do the math or to guess at when it was finished.
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Bottom line; it should NOT exceed 4 hours. To my knowledge, there is no "out" for a Physician to approve transfusion over a longer period of time. In some places I have worked, that has been 1 of the documents we have audited; completed Transfusion Forms that show when the transfusion was completed. But we would also look in our computer system to see when the unit was Issued; as the 4-hour clock (per my understanding; and I think there is at least 1 previous Thread on this), starts when the unit leaves the Transfusion Service; not when the Nurse decides to start the transfusion (i.e. if it sits on the floor for 30 mins. before they start the transfusion, they now have 3 1/2 hours to transfuse the unit).

So, what I recommend if a transfusion was > 4 hours is that you document it on your Facilitie's Occurrence/Error/Quality Improvement Form (whatever you call them) and let them know that was against Policy and Regulations.

Brenda Hutson, CLS(ASCP)SBB

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I read something recently, I think in the Tech Manual, that said it was ok to give the blood 4 hours after it was spiked (not issued). I was kind of surprised.

AABB Technical Manual page 622 17th Edition

If a unit has been entered (spiked for transfusion), it may not be returned to the transfusion service for reissue. It must either

be infused within 4 hours of the time it was spiked, or it must be discarded.

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I think 4 hours is the time for room temp storage of an open system. You could argue that the system is closed until the unit is spiked. That said, we don't have a storage time defined for RBCs for room temp storage otherwise so nothing to compare to. I will have to try to find the quote in the Tech Manual; I was surprised too.

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AABB Technical Manual page 622 17th Edition

If a unit has been entered (spiked for transfusion), it may not be returned to the transfusion service for reissue. It must either

be infused within 4 hours of the time it was spiked, or it must be discarded.

This is the regulation. Not room temp open system. If unit issued from Blood bank at 1PM, then transfusion needs to be concluded no later than 5PM.

HOWEVEDR, cooler situation is different because the COOLER is now considered storage (1-6 degrees C). So issuing from the cooler (from whatever dept) is considered the same as when you take it out of refrigerator... Spike time for practicle purposes... Take out of cooler, spike, ok for 4 hours. Just write a note in training and procedures this is how the time is documented.

Problems I HAVE found is in OR units being removed from cooler, laid on counter, and then put back into cooler.. OR transfused (not spike time). This requires training. And only reason I found out this practice occurred was on RETURNED units. They put the units back in the cooler, units came back cool. We would not have been wiser... except for the SAVE T VUE on the back of the unit was RED. Why I instituted all units being dispensed to coolers MUST have safe t vues. OR They cannot be returned to be reissued.

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Unless something has changed in the past couple of years (probably has) the AABB Technical Manual is NOT regulations. AABB Stds and FDA CFR however are regulations/rules/mandates etc.., at least in the USA. Just something to keep in mind during discussions. The Tech Manual is an excellent resource on the "how" of things but not the end all, do all of practice.

:raincloud

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This came up in another Thread sometime within the past 2-4 years (sorry, previous job; don't recall at what point it was discussed). But I think I had either e-mailed my AABB contact, or spoken to her by phone; and that she told me it was from the time it left the Blood Bank. I also know that at one place I worked at years ago, we audited those Forms when they came back form the floor; making sure the time from Issue to completion of Transfusion, was not >4 hours. Those audits were viewed by AABB and FDA Inspectors.

Brenda

I think 4 hours is the time for room temp storage of an open system. You could argue that the system is closed until the unit is spiked. That said, we don't have a storage time defined for RBCs for room temp storage otherwise so nothing to compare to. I will have to try to find the quote in the Tech Manual; I was surprised too.
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John. I do not have my standards book handy BUT even though the technical manual was quoted that is consistent to the actual standards. 4 hours is not a recommendation but a requirement.

Thanks Barbarakym, I am aware of this. I felt it was a good time to remind folks that the Tech Manual is just that, a tech manual to be used as a reference not a place to consult for regulations and rules. :peaceman:

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Thanks Barbarakym, I am aware of this. I felt it was a good time to remind folks that the Tech Manual is just that, a tech manual to be used as a reference not a place to consult for regulations and rules. :peaceman:

I actually use my Tech manual to also explain the darn rules from the standards. Some are just not written clearly, IMO.

In the tech manual a regulation is often referred to as MUST do this.... Whereas an option (idea) is referred to as SHOULD do or MAY do. These terms are defined in the standards but as of the date of the Tech manual printing are usually pretty accurately described this way also in the tech manual. I use my Tech manual constantly and then refer to the standards to be sure policy I wrote is addressed. Usually they agree.

When REALLY in doubt I pose question here.... did I say I LOVE THIS SITE...... So many people with so many other takes on things.... Really has improved my procedure writing.

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