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temp of returned units stored in continuously monitored coolers


suhu

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We have permanent OR coolers with continuous temp monitoring (temptrak). Units are sent to and returned from the OR via pneumatic tubes. We are taking the temps of returned units (tempcheck) and discard units over 10 degrees. Way too many units are recording temps slightly over 10 and being wasted.I believe that the whole transporting process (taking units out of the coolers, placing in the tubes, traveling thru the tube system, removal of units from pneumatic tube and finally taking the temps) is causing otherwise fine units to go over 10 degrees during the transporting process.  Is it necessary to check the temps of returned units that have been stored in continuously monitored coolers?  It seems so silly, as we accept units back from the regular floors within 30 minutes of issue without any refrigeration or temperature checking. 

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  • Couple of questions:

Have you validated that units are ALWAYS within the accaptable temperature range and can thus use the 30 minute rule.  When we checked this the best we could come up with was about 18 minutes out of the refrigerator before the temperature was exceeding 10 degrees.

I understand the frustration of units wasted because they are slightly over temp.  Is there any other possible means to retrieve the units from OR?  The first thing that comes to mind is a transport cooler to move the units to for return to the blood bank.  I realize this is probably not convienent, but to save a unit from discard in the scenario you describe it may be worth the effort.  Let us know what you decide.

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There is an article titled "Debunking the 30-Minute Rule" in the May 2010 edition of the AABB News.  The 30-minute rule ignores the laws of thermodynamics and is unacceptable today.  The temperature must be taken on all units returned unused to determine if the unit can be re-issued for transfusion. 

 

You didn't mention the pneumatic tube transit time.  It is likely the reason why units are exceeding 10C as Deny Morlino mentioned.

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There's an interesting study in the June 2013 Transfusion (Thomas, Hancock and Cardigan, The 30 minute rule for red blood cells: in vitro quality assessment after repeated exposure to 30°C (pages 1169–1177)) http://onlinelibrary.wiley.com/doi/10.1111/j.1537-2995.2012.03890.x/pdf

 

 

I'm not sure if the NHS formalized the 30 minute rule (FDA and AABB haven't, as noted above,) but the authors write like it's a rule, and for their study they tested some temperature excursions: core temp to 10°C and multiple 30°C excursions for 30 or 60 minutes.

From the abstract:

CONCLUSIONS: There was no evidence of significant damage to RBC after exposure to 30°C for three
periods of 30 minutes. Multiple exposures of 60 minutes caused limited damage but this was within current regulatory limits if there were three or fewer exposures, suggesting that a 60-minute rule may be feasible.

 

Hopefully we see a few more studies like this, because as the original poster noted we as an industry are (likely) wasting a lot of acceptable units.

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Eman,

Not  aving read the full study, did they look at anything other than hemolysis/potassium levels and ATP?  It seems like there have to be a few other parameters looked at in a unit of red cells before one can say that it acceptable for transfusion when studying something like exposure to room temps.

 

Thanks, Scott

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I would encourage you to validate "your" process.  Another place I worked at sent blood through the pneumatic tube all the time.  They put Safe-T-Vue Monitors on them; then the OR removed them from the tube and placed them in coolers stored in the OR.  What wasn't used, was returned through the tube.  Most of the time the units were fine.  I suspect any problems were due to a number of possibilities:

 

1.  Lab taking too long to put monitors on (i.e. units already warming up) such that by the time they got up to OR, they were too warm.  However, OR was instructed to check the temp. monitors prior to placing them in coolers.

 

2.  The coolers in OR may be keeping temp., but if OR is not keeping the units in the coolers, you will have problems.  At another place I worked, if someone neglected to put a temp. monitor on a unit before placing it in a cooler (which was kept in the Blood Bank); then sent it to OR.....when returned from OR, they would take it out and say "oh, it's still cold; we can accept it back."  That was before I took over and pointed out that the OR could have done anything with those units the hours they were up there and then put them back in the cooler long enough for them to cool back down.

 

Just a couple of thoughts... :) 

 

Brenda Hutson, CLS(ASCP)SBB

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Unless something has changed recently which I am not aware of, (the amount of info that changes daily that I am not aware of is truly staggering) a FDA inspector would be very unlikely to consider your use of coolers as transport.  They would be more likely to consider them storage and therefore insist on a storage temp range of 1 - 6 oC.  Especially since the blood is not packed by you and does not leave the blood bank in the coolers.  :faint:

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 I dont know how to solve this. We have 15 OR suites 2 floors away and send blood back/forth via the pneumatic tubes.  The blood is either used on demand for some surgeries, or stored in the TempTraked coolers for other bigger surgeries. Biggest concern is If we start to use the Safe T Vues, I'm afraid they'll see red during transit. Other minor concerns are the logisitics of preparing a stock of tagged units and activating them carefully enough prior to sending... I'm interested in hearing what other large centers are doing. All ideas are appreciated, we are re-visiting our 30 minute floor rule also, but this topic concerns our OR units. Thanks everyone.. 

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Considering the speed of transport, we stopped sending coolers to the OR when we started sending blood in the pneumatic tube.  There is really no good reason to have blood setting in a cooler in the OR when the time lapse between request and arrival can be measured in seconds.  The problem is convincing the docs to give up their security blanket.  Our tube system was rated for upto 7 lbs which meant we could send upto 4 units of PRBCs in one tube.  I failed to mention this to nurses.  They didn't need to know!    :bonk:

Edited by John C. Staley
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Eman,

Not  aving read the full study, did they look at anything other than hemolysis/potassium levels and ATP?  It seems like there have to be a few other parameters looked at in a unit of red cells before one can say that it acceptable for transfusion when studying something like exposure to room temps.

 

Thanks, Scott

 

Those were their primary indicators, but they also looked at ATP, 2,3-DPG, glucose and lactate. For ATP and glucose the only signifcant difference was between the positive and negative controls. The authors also pointed out that their study ignored concerns about bacterial proliferation (which some people suggest was one of the original concerns regarding temperature excursions).

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 I dont know how to solve this. We have 15 OR suites 2 floors away and send blood back/forth via the pneumatic tubes.  The blood is either used on demand for some surgeries, or stored in the TempTraked coolers for other bigger surgeries. Biggest concern is If we start to use the Safe T Vues, I'm afraid they'll see red during transit. Other minor concerns are the logisitics of preparing a stock of tagged units and activating them carefully enough prior to sending... I'm interested in hearing what other large centers are doing. All ideas are appreciated, we are re-visiting our 30 minute floor rule also, but this topic concerns our OR units. Thanks everyone.. 

 

At the Institution I referred to in my post above, they did not have problems with Safe-T-Vue Monitors changing just because of transport in the pneumatic tube (and they had 25 OR suites).  One thing though....the pneumatic tube for the OR was not in an OR Room, so as soon as we hit SEND at the Tube Station, we called the OR so they would know to go get the blood out of the tube station right away.

Brenda Hutson

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 I dont know how to solve this. We have 15 OR suites 2 floors away and send blood back/forth via the pneumatic tubes.  The blood is either used on demand for some surgeries, or stored in the TempTraked coolers for other bigger surgeries. Biggest concern is If we start to use the Safe T Vues, I'm afraid they'll see red during transit. Other minor concerns are the logisitics of preparing a stock of tagged units and activating them carefully enough prior to sending... I'm interested in hearing what other large centers are doing. All ideas are appreciated, we are re-visiting our 30 minute floor rule also, but this topic concerns our OR units. Thanks everyone.. 

 

At the Institution I referred to in my post above, they did not have problems with Safe-T-Vue Monitors changing just because of transport in the pneumatic tube (and they had 25 OR suites).  One thing though....the pneumatic tube for the OR was not in an OR Room, so as soon as we hit SEND at the Tube Station, we called the OR so they would know to go get the blood out of the tube station right away.

Sorry, just had one more thought....is the tube station you use to send blood to the OR, used to send blood elsewhere in the Hospital also?  Because that "traffic" could slow down the transport also.  We had a tube station just dedicated to the OR (then 2 more for the Adult Hospital and the Children's Hospital).

Brenda Hutson

 

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  • 3 weeks later...

Brenda,

  Looks like I need to do a pilot using the Safe T Vue's. Most of what I've read about the Safe T Vue is that application and activation is tricky to avoid color change. Did you keep a supply of blood stored with the monitors already attached for OR use so all that was needed was the activation prior to sending? Or did the techs apply the monitors to each unit at time of request?  If the latter, did this significantly slow down the time to issue units? This also just seems like overkill and an unnecessary additonal expense since the temp of the returned units is so close to acceptable (11-12 degrees) and the Twinbirds/TempTrak continuous monitoring was so costly. And yes, we do have dedicated routes between blood bank and the OR rooms. 

 

Does anyone have an acceptable return temp using a SD deviation of +1 or 2 degrees for this type of situation?

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We initially saw the Safe T Views center turning pink right out of the frige when applied to units. When I called the company they recommended we apply them while units are still in the frige. Since we tried that we haven't had issues. Perhaps if blood is set up ahead of time, kept in frige for some time, then the temp applicators are put on right prior to issue, you will see less issues. We use the 1-6, only for cooler issuance, and require units be started or returned within 4 hours of issue. Although our coolers maintain temp longer than that, we decided to keep it as 4 hours because everyone is used to our "transfuse within 4 hour of issue" policy. Our overall RBC wastage is less than 1%.

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