FFP and RBC's Administered through same line simultaneously

[BB1956]

I am looking for the answer to this question posed by one of our physicians.  Can FFP and RBC's be administered through the same line at the same time in a trauma situation?  This has never been the practice where I have worked however when I checked for standards that might apply I could only find AABB 5.28.9  Addition of Drugs and Solutions which really did not seem to answer the question.  Looking for any input with regard to this question and making the assumption the FFP and the RBC's would have to be  compatible.

[David Saikin]

I don't see why not.  Just like transfusing whole blood.  Modified WB would be the same thing just premixed into the same bag.

[SMILLER]

The nursing references I have seen specify only normal saline for infusing blood.  If we were releasing a FFP and a RBC at the same time (or two RBCs for that matter), we would ask if they have two lines running.

Scott

[gene20354]

I work at a level 1 trauma center. During trauma/MTP the Belmont Rapid Infuser is frequently used.  Up to 3 units at a time (any combination of RBC/FFP) are hooked up to large diameter tubing that drains into a large reservoir. The products mix together in the reservoir rand then are rapidly infused in about 1 minute.  

I also agree with David's comments about making WB. 

[SMILLER]

That makes sense to me, too.  Would you have to be careful with platelets though?  They are often in plasma that's not necessarily ABO compatible. Letting O platelets sit with A RBCs in a reservoir does not seem like a good idea.

Scott

[BB1956]

I appreciate your responses.  Does anyone have any references supporting the protocol to use the same line for administration providing procedure and guidance? 

[gene20354]

1 hour ago, SMILLER said:

That makes sense to me, too.  Would you have to be careful with platelets though?  They are often in plasma that's not necessarily ABO compatible. Letting O platelets sit with A RBCs in a reservoir does not seem like a good idea.

Scott

 Yes.  We do not allow platelets and cryo to be transfused using the Belmont Rapid Infuser.   

[Sonya Martinez]

The Circular of Information (9/22/16) states "no medications or solutions may be added to or infused through the same tubing simultaneously with blood or blood components with the exception of 0.9% sodium chloride."  When you transfusion whole blood or reconstituted whole blood for exchange you are creating a new product or medication.  Since blood and blood products are considered biologic medication our hospital only transfuses one unit at time.  However, if the patient has multiple lines which our traumas usually do then you can infuse multiple products just not through the same line.  The other problem is if the patient has a reaction how are you going to tell which product is being transfused at the time of the reaction?  Of course this is the same problem we see when patient's are placed on ECMO and both the RBC and FFP are placed in the circuit together. 

[Maura]

I am a certified emergency nurse and combat veteran and in my experience, it has been standard protocol to administer PRBCs and FFP in the same tubing during massive transfusions.  We hang PRBCs on one side and FFP on the other and alternate in a 1:1 ratio using the same tubing.  I have done this with both the Belmont Rapid Infuser and Level 1 Infuser.  Platelets, however, are administered in separate, regular y-type blood tubing and free-flowed (hung "wide open), and not given via rapid infuser/warmer because it is contraindicated per manufacturer's guidelines.  I stumbled across this thread because I have also been looking for specific clinical practice guidelines describing this practice and I can't find any.  Yes, tubing is changed between units during routine blood transfusions to ensure there isn't cross contamination and so you may test products and tubing individually if there is a transfusion reaction, but when someone is hemorrhaging and we have implemented the massive transfusion protocol (MTP), we only hope that they live to have a reaction.  The only adverse reaction I have ever seen to blood products is TRALI, which is a delayed reaction, so we don't know which unit would have caused it anyway.  In reality it was probably a combination of all of the units and the inflammatory response the patient's body was going through s/p bilateral above the knee amputations, shock, acute kidney injury, and massive transfusion, resuscitation, and damage control surgery.  If anyone has found any references regarding giving PRBCs and FFP in the same tubing, please share! My email is mauraleo@gmail.com

Thanks,

Maura Leo BSN, RN, CEN

 

[David Saikin]

The AABB Tech Manual states that only 0.9% saline may be added when transfusing blood or blood components.  I

do not see a problem running plasma and rbcs together - see my comment above.

[David Saikin]

On ‎08‎/‎08‎/‎2017 at 1:42 PM, Sonya Martinez said:

The Circular of Information (9/22/16) states "no medications or solutions may be added to or infused through the same tubing simultaneously with blood or blood components with the exception of 0.9% sodium chloride."  When you transfusion whole blood or reconstituted whole blood for exchange you are creating a new product or medication.  Since blood and blood products are considered biologic medication our hospital only transfuses one unit at time.  However, if the patient has multiple lines which our traumas usually do then you can infuse multiple products just not through the same line.  The other problem is if the patient has a reaction how are you going to tell which product is being transfused at the time of the reaction?  Of course this is the same problem we see when patient's are placed on ECMO and both the RBC and FFP are placed in the circuit together. 

since your institution considers blood/components "medication"  do you get paid what a pharmacist gets paid?  If u are using 2  or more lines for transfusion how would u know which product causes a reaction?  Rhetorical questions.

[Neil Blumberg]

Both Plasma-Lyte A and Normosol are FDA approved in addition to saline.  They are almost certainly better for the patient. The circular of information and AABB guidances need to be changed to reflect this old information (FDA label approval) and new information (normal saline is more toxic than other crystalloids--see the early March 2018 issue of NEJM for example; first authors Semler and Self, respectively).