Blood Infusion

18G

18G

Paramedic
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Had an issue with a blood infusion today. Patient was receiving blood on arrival via IV pump. Nurse would not allow us to keep the blood infusing on their IV pump so blood was taken off to infuse by gravity through central line. Get down to ambulance and blood is no longer infusing. Despite troubleshooting the line, flushing, still couldn't get it to flow. Contacted sending doc who was cool with discontinuing the blood and runnng NSS.

My question is has anyone else had problems with blood running through pump tubing by gravity? Any tips for troubleshooting this problem in the future?
 
Well, considering I have had issues getting normal saline to run through pump tubing because the pump cartridge is so finicky I'm not surprised you had issues with blood. If the pt is running a fluid that they must have, and the hospital won't let me take the pump I'll switch the tubing to the normal stuff.
 
We don't carry regular blood tubing that we could have switched to and never had this situation before so didn't figure there would be a problem. But I'm thinking too that the pressure from gravity alone may not have been enough to get the blood through the cartridge.
 
Maybe a pressure bag? I have exactly zero experience with blood products though. We aren't allowed to transport patients with blood infusing here. Only flight nurses.

Maybe ask the hospital for blood tubing that isn't for a pump?
 
18G said:
Had an issue with a blood infusion today. Patient was receiving blood on arrival via IV pump. Nurse would not allow us to keep the blood infusing on their IV pump so blood was taken off to infuse by gravity through central line. Get down to ambulance and blood is no longer infusing. Despite troubleshooting the line, flushing, still couldn't get it to flow. Contacted sending doc who was cool with discontinuing the blood and runnng NSS.

My question is has anyone else had problems with blood running through pump tubing by gravity? Any tips for troubleshooting this problem in the future?
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Make sure you have a bag of NS running through the same line at the same time.

Also if the blood is clotted in the tubing, you have to change the tubing.

Sometimes the blood clots in the catheter and you have to use a syringe to withdraw the clot out. (obviously don't push it in)

Pressure bag or bp cuff is a good idea, but without the chrystaloid you still run a high risk of clotting without the large bore blood tubing.
 
Veneficus said:
Make sure you have a bag of NS running through the same line at the same time.

Also if the blood is clotted in the tubing, you have to change the tubing.

Sometimes the blood clots in the catheter and you have to use a syringe to withdraw the clot out. (obviously don't push it in)

Pressure bag or bp cuff is a good idea, but without the chrystaloid you still run a high risk of clotting without the large bore blood tubing.
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It's my understanding that the NSS spiked with the blood on the "Y" tubing is only to prime the blood tubing and fill the blood chamber just above the filter so when the blood starts infusing it doesn't hit the filter and damage the cells in the blood. After this the NSS is to be turned off. Least this is my understanding.

I tried using a 60cc syringe to aspirate some blood from the line but wasn't able to. I tried pressure and blood would only fill the chamber. I'm thinking clotting occurred somewhere below the drip chamber and most likely the cassette was the problem.

I need to research this some more to see if anyone else has had success with blood running by gravity with pump tubing.
 
Weird, I've never had a problem running blood that was on a pump, by gravity instead, but like Vene said, I've always had a bag of NS running in conjunction. That being said, most of the time, the hospital allows me to take the pump with me, or they have the blood running by gravity already. Sorry I couldn't be of more help.
 
18G said:
It's my understanding that the NSS spiked with the blood on the "Y" tubing is only to prime the blood tubing and fill the blood chamber just above the filter so when the blood starts infusing it doesn't hit the filter and damage the cells in the blood. After this the NSS is to be turned off. Least this is my understanding.
Click to expand...

The saline does not have to be turned off. It is basically running blood and a volume expander through the same line.
 
fast65 said:
Weird, I've never had a problem running blood that was on a pump, by gravity instead, but like Vene said, I've always had a bag of NS running in conjunction. That being said, most of the time, the hospital allows me to take the pump with me, or they have the blood running by gravity already. Sorry I couldn't be of more help.
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But what is the reasoning behind having the NSS running along with the blood? At what rate do you run the NSS? If the patient is getting blood at say 200mL/hr, that rate and volume is all they need in some cases. If we run NSS at say 100mL/hr then the patient will be getting 300mL/hr of fluid.

So your saying that you have infused blood through pump tubing by gravity with no problem?
 
18G said:
But what is the reasoning behind having the NSS running along with the blood? At what rate do you run the NSS? If the patient is getting blood at say 200mL/hr, that rate and volume is all they need in some cases. If we run NSS at say 100mL/hr then the patient will be getting 300mL/hr of fluid.

So your saying that you have infused blood through pump tubing by gravity with no problem?
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Does the patient have a working kidney?
 
Veneficus said:
that is more troublesome...

blood due to anemia?
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Yes. Pt. was in for pneumonia refractory to outpatient treatment and had a change of status with hypotension and drop in Hgb. Pt. received Lovenox and developed some sort of hematoma in the hip with expansion into the abd.
 
18G said:
Pt. received Lovenox and developed some sort of hematoma in the hip with expansion into the abd.
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was there a catheter or a recent surgical/vascular procedure, because if not it sounds like a ruptured illiac aneurysm to me.

Remember how big it was?
 
No recent surgical procedure reported and no wound sites. Not sure of the size but physician giving report made it sound on the larger side. Pressure was hovering right around 100.
 
18G said:
But what is the reasoning behind having the NSS running along with the blood? At what rate do you run the NSS? If the patient is getting blood at say 200mL/hr, that rate and volume is all they need in some cases. If we run NSS at say 100mL/hr then the patient will be getting 300mL/hr of fluid.

So your saying that you have infused blood through pump tubing by gravity with no problem?
Click to expand...

From my understanding, and I'm sure I'm wrong here, but I've always been told the NS was to assist in flushing the line.

Yup, I've infused blood with pump tubing without a problem, however, I've had my fair share of problems with running other solutions through pump tubing.
 
I appreciate the feedback. Maybe it was just an isolated freak thing.. I have no idea.
 
OK - several things.

Blood and NS are perfectly compatible. In the OR, we use a Y-type blood infusion set and we'll run 100-200cc of NS into the blood bag before transfusing to make it less viscous. Some people run both at the same time or run NS following the blood to get all those red cells where they belong.

That may have been the problem with your line. Undiluted PRBC are really pretty thick, and of course the smaller the lumen of whatever catheter you're using, the lower the flow rate. If you have something really thick flowing through it, it's not that hard for it to slow down a lot or even stop, especially if your blood bag isn't hanging several feet above your patient. A pressure bag is a great idea if you don't have a pump. You can pump it up anywhere from 50-300mmHg, and just regulate the flows with a roller clamp.

If the patient needs blood, they need blood, and the volume really isn't all that much of a concern. In a cardiac patient, it can be given more slowly if you're worried about giving too much too fast. Renal failure patients get blood fairly frequently due to their chronic anemia, so it's not a concern there either. I wouldn't be wild about volume resuscitating a patient with blood during transport. If they need blood quickly, they need to be stabilized better before transport if at all possible. Otherwise, just a steady drip should be fine for anyone with minimal concerns about overload.

I'd be at least a little concerned about this being within a paramedic scope of practice. Maybe this is common - I have no idea. I know you're just continuing what the hospital started, but most hospitals and hospital labs are incredibly anal about blood transfusions and the paperwork that goes along with them. The rules and regulations that go along with blood transfusions are numerous and a royal pain to deal with, even for people like me who do it as part of our daily practice.
 
It does make sense to run the NSS with the blood to reduce the viscosity and make it flow a little better. I've just always learned that after tubing is primed to turn it off. And in this case the hospital had it clamped off as well and the blood was infusing just fine on the pump.

Maintaining blood products is within the scope of practice for an IFT Paramedic where I work. I disagree that it's outside of the scope of a Paramedic. The nursing staff does the double-checking, two provider confirmation of the patient identifiers and blood product being hung and monitors for transfusions reactions usually before we get to the patient. Protocol says blood needs to be infusing for at least 15mins just to ensure the patient doesn't develop a reaction. If a reaction does develop, a Paramedic can recognize it and address the same as a nurse.
 
Check your cartridge. Some have the pump in the cartridge (haven't seen one professionally since 1985), which is a series of rollers that milk a length of flexible tubing. Unless there is a way to relieve the pressure from the rollers, the cartridge is a block to whole blood, or most fluids. Some medical staff might not remember that because a tech sets it up for them, like they do with small O2 cylinders etc.
 
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