1. Blood Transfusion and Catheter Size
Lynda S. Cook MSN, RN, CRNI
Vascular Access Specialist
Greensboro, NC
May 6, 2017

2. Abstract:
The administration of blood is associated with a certain amount of dogma that professionals carry with them from nursing school or the first day on the job. Certain philosophies become imbedded in practice without judgement until situations force a review of their logic. Illumination occurs with simple questions such as, “If blood has to go through a 20- or 18- gauge needle, how is it given to a newborn?” In this session, we will examine some of the common practices of blood administration and determine if they are dictated by pathology or are simply learned behavior.

3. Objectives:
Examine how red blood cell pathology and catheter physiology intertwine in infusion dynamics.
Evaluate three common transfusion practices and their potential to lead to mechanical hemolysis.

4. Disclosures
Clinical Outcomes Specialist for 3M Critical and Chronic Care Division
No conflicts to disclose

5. Challenge Question:
What size catheter should be used to transfuse blood?
Initial response:
What do the experts say?

6. Expert Opinion
Weinstein SM, et al. Plummer’s Principles and Practice of I.V. Therapy. 9th ed. Wolters-Kluwer: Philadelphia, PA
Phillips L, et al. Manual of I.V. Therapeutics: Evidenced-Based Practice for Infusion Therapy. 6th ed. F.A. Davis: Philadelphia, PA. 2014
Infusion Therapy Standards of Practice. J Infus Nurs (1S)
Fung, MK, et al. Technical Manual. 18th ed. AABB: Bethesda, MD

7. Consensus? Generally: - Adults 20-18g - Rapid infusion 16-14g
- Pediatrics 22-24g
But . . .
Use the smallest catheter necessary

8. So Why Am I Confused? Maryland – 20-18g adults, 24g neonates only
Georgia – 20-18g adults; 22g pediatrics
Tennessee – 22-18g adults; 24 neonates
Texas
Galvaston – 24-14g
Austin – 20g preferred; 22g with pump
So why am I confused?
Because, when you review hospital policy around the U.S. it is not uncommon to mandate a specific catheter size.

9. Saskatoon, Saskatchewan – 18g adults; 25g min for peds
National Blood Users Group, Dublin, Ireland – depends on vein size and desired rate
ATI training schools – preferred but smaller can be used
NursesLab web-based data base – 18g
And this trend is also seen by other professional organizations.

10. What about central lines?
Often not addressed
References have stated:
Central lines ok
Use PICCs with caution
UVC preferred for neonates
Neonatal PICC not recommended
Refer to manufacturer’s guidelines

11. It’s Making Me Dizzy!

12. Better question:
What concern is related to catheter gauge?
Answer:
Mechanical hemolysis

13. *Presentation of symptoms depends on the combination of above.
Hemolysis:
The rupture or destruction of a red blood cell not related to senescence
Classifications:
- Extrinsic / Intrinsic
- Intravascular / Extravascular
- Immune / Non-immune
Autoimmune / Alloimmune
*Presentation of symptoms depends on the combination of above.

14. Genetic predisposition
Intrinsic:
- Genetic malfunction or malformation that may be hereditary or autoimmune
- Abnormalities of the red blood cell membrane, enzymatic pathways or the hemoglobin molecule
- i.e., the cell is not normal at the time of formation
Extrinsic:
- External influences cause the cell to be marked for destruction
- i.e. the cell was normal; damage is 2o to an external force

15. Location of Hemolysis Extravascular vs. Intravascular
Hemolysis is also classified by the location where hemolysis takes place. Extravascular refers to outside of circulation; intravascular refers to hemolysis within the blood stream. There are three main components of the red cell that are considered during lysis: stroma (the structural portion of the cell), potassium and hemoglobin. The effect these have on the body depends on where lysis occurs and how effectively the body deals with their removal.
What happens to the by-products?
stroma, potassium, hemoglobin

16. Senescence Anticipated destruction
Life span 120 days ( if cell not metabolically active)
Stroma – ingested by the RES and removed
Potassium – available for uptake
Hemoglobin
Heme - broken down for re-use
Iron – transported to cells
Porphyrins – degrade to form bilirubin
Senescence refers to the plan destruction of a red cell as it ages. Usually, cell death occurs around days in circulation. (This period is increased when a cell is not metabolically active, such as when stored for transfusion.)
Aged red cells are marked by cytokines which activate phagocytosis. They are ingested by macrophages and removed from circulation. All cell destruction and redistribution takes place within the macrophage.
This slide shows the picture of extravascular hemolysis.
Globin - reduced to amino acids which
join the protein pool

17. Just in case your more of a picture-person, I couldn’t resist including this slide.

18. Extravascular Hemolysis
Red cell is marked for destruction by surface
markers that appear on the cell;
cytokines / antibodies
Phagocytosis occurs; macrophage removes cell,
usually to spleen
Hemolysis takes place entirely within the
macrophage
Symptoms are few and depend on # cells involved:
- increased bilirubin
- anemia or low rise in hematocrit after transfusion

19. Intravascular Hemolysis
Red cell contents are spilled directly into the blood
stream
Unexpected need to remove cellular by-products
Systems of elimination are overwhelmed
- Oxidative effects of free hgb damages organs
- Hyperkalemia with potential cardiac involvement
- Excessive stroma activates the clotting cascade
and kinin systems
Inflammatory response cause fever, hypotension, mobilization of leukocytes from bone marrow, induction of adhesion molecules, and release of tissue factor from endothelial cells as well as activation of neutrophils leading to protease release causing endothelial damage.
Symptoms may be severe and depend on # cells
involved:
- DIC - Cardiac arrest
- Shock - Renal failure

20. Autogenic vs. Allogenic
Contributing Factor
Immune vs. Non-immune
Autogenic vs. Allogenic
Autogenic – the antigen is from self; autoimmune disease e.g.
Allogenic – the antigen is from non-self (donor cells, invading particles, etc.

21. Immune Hemolysis
Antibody-mediated against an antigen on the red cell surface (i.e. surface marker)
Antibody fixes complement
- Acute intravascular hemolysis
- Delayed intravascular hemolysis
- Extravascular hemolysis
Result of complement activation
Release of histamine and serotonin  hypotension
Severe inflammatory response
Intravascular hemolysis – antigen has not been previously introduced to system
Extravascular hemolysis – antibody has previously formed and is reactivated.
Classical pathway – starts with cleaving of C1. This is route of transfusion-related intravascular hemolysis
Alternative pathway starts at C3 and does not rely on antibody binding.
May occur with few cells

22. Antibodies are gamma globulins. Not all antibodies fix complement.
IgM
IgG3
IgG1
IgG2
IgG4
IgA
IgD
IgE
Activation is complete;
Intravascular destruction of red cell
Poor or incomplete activation; Opsonization of the cell; Extravascular destruction of cell
Do not fix complement;
Not associated with cell lysis

23. Complement Activation
If the cascade does not advance past C3, the antigen (cell) is marked for destruction is phagocytized.
Complete activation results in damage to the cell membrane and complete destruction of the cell occurs intravascularly.

24. Non-Immune Hemolysis
Cellular destruction is not triggered by markers on the red cell surface; the influence is external
The complement system is not activated
Severity depends on
Number of cells lysed
Location of hemolysis
intravascular or extravascular

25. Hemolysis Characteristics from 6 Origins
Genetic
Location
Immune
Extrinsic
Intrinsic
Intra-vascular
Extra-vascular
Non-immune
ABO incompatibility x
Rh incompatibility
Sickle cell
Thalassemia
Malaria parasitic rupture
Bacterial sepsis

26. The cell was normal prior to the exertion of outside influences
Transfusion-Related Mechanical Hemolysis
Extrinsic
extrinsic
The cell was normal prior to the exertion of outside influences

27. Transfusion-Related Mechanical Hemolysis
Intravascular
intravascular
extrinsic
The contents of the cell are freed while in the bag and spilled directly into the blood stream

28. Transfusion-Related Mechanical Hemolysis
Non-Immune
intravascular
extrinsic
non-immune
No antibody-antigen reaction
No activation of complement

29. Symptoms are based on this combination of classification
Non-immune
extrinsic
intravascular
= S&S

30. Mechanical Hemolysis Signs & Symptoms Mild (few cells involved):
no symptoms detectable
Moderate:
Possible increased bilirubin
Lack of anticipated rise in hematocrit
Severe (massive cell involvement)
Hyperkalemia – cardiac arrhythmias
Renal failure
DIC
Shock

31. What size catheter should be use to give blood?

32. How big is a red cell? Average RBC count is 4.5 – 6.0
million/μL RBCs suspended in plasma
Average diameter of a red cell is  8 micrometers
1 mL = contains > 5,000,000,000
1 tsp = contains > 25,000,000,000
(5 ml)
The RBC count is the number of red cells suspended in plasma; the average accounts for a hematocrit of 40-50%. Therefore, packed cells will have a much higher red cell count per ml.
1μm3 = 1 picoliter
contains 512 RBCs
1 mL = 1,000,000,000 picoliters
contains 5,120,000,000
1 tsp = 5 mL
contains 25,600,000,000

33. As long as rate remains consistent
The risk of catheter-related hemolysis when blood is run to gravity is . . .
As long as rate remains consistent

34. To maximize flow, use the largest diameter and shortest length possible.
Type
Gauge
Length
mL/min
Peripheral 20
1.8” 60 18
105 16
200
1http://emupdates.com/2009/11/25/flow-rates-of-various-vascular-catheters/
2https://

35. Resistance  as length 
Type
Gauge
Length
Minutes/L
Peripheral
14g
2.5”
1.3
5.2”
2.1
CVC
8.0”
5.2
High
PICCs not recommended for blood transfusion
Resistance
Excessive pressure may rupture PICC lines
Low
Short
Long
Length

36. French (catheter) Standard (needle) 1.7 0.566 1.779 24 0.559 0.292 2.1
gauge
Diameter mm
circumference
Outer diameter* mm
Inner diameter mm
1.7
0.566
1.779 24
0.559
0.292
2.1
0.700
2.198 22
0.711
0.394
2.7
0.900
2.826 20
0.902
0.584
3.8
1.260
3.970 18
1.270
0.838
5.0
1.660
5.230 16
1.651
1.194
6.3
2.100
6.594 14
2.108
1.600
*Outer diameter will vary with needle wall thickness
French: outer circumference
SAI infusion technology
Conversion tables
Viewed on line
French: size  as # 
Standard: size  as # 
French: Diameter = Fr x 0.333
Circumference = D x 
French size determined by circumference
Standard gauge determined by inner diameter
By convention, needles or single lumen catheters are sized by gauge and multi-lumen catheters are measured by French size. Whereas French size and diameter are related directly, gauge and size are related inversely; a lower gauge indicates a greater diameter. Gauge designations generally go no lower than (bigger than) 10 ga.
Standards exist for the inner and outer diameters of needles of a particular gauge, but standards exist only for the outer diameter of catheters1, even those with a single lumen,
Standard Gauge:
inner diameter

37. French/Standard gauge conversion not associated with multi-lumen catheters
Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J Mar;28(3): Epub 2010 Jun 26. PMID:
7 Fr
7 Fr
8.5 Fr
Reddick Emerg Med J Mar;28(3):201-2.
Epub 2010 Jun 26. PMID:
Silastic catheters are thicker than polyurethane;  same French size ≠ same internal diameter

38. Height makes Might!!!

39. . . . and density of the cells (viscosity)
Velocity depends on catheter gauge, rate of administration, height of fluid
Volume = height x r2
1 mm3 = ml
Ex. 24 mm3 = ml
 24g – diameter = 0.292
Radius = 0.146
Height = ¾” mm
V = 19.05(3.14)(0.146)2
V = ml
22g – diameter = 0.394
Radius = 0.197
Height = 1.0” mm
V = (25.4)(3.14)(0.197)2
V = ml
20g – diameter = 0.584
Radius = mm
V = (25.4)(3.14)(0.292)2
V = ml
18g – diameter = 0.838
Radius = 0.419
Height = 1.5” mm
V = (38.1)(3.14)(0.419)2
V = ml
16g – diameter = 1.194
Radius = 0.597
Height = 2” mm
V = (50.8)(3.14)(0.597)2
V = ml
14g – diameter = 1.600
Radius = .800
Height = 2.25” mm
V = (57.15)(3.14)(0.8)2
V = ml
. . . and density of the cells (viscosity)

40. Velocity+ Viscosity = Flow
Poiseuille’s law
Viscosity of commonly infused intravenous solutions range from 1.0 centiPoise to 40.0 cP
Viscosity of common fluids:
1.0 cP Lactated Ringers
10.0 cP Whole blood
7,000 cP - molasses
50,000 cP Ketchup
1,000,000 cP Crisco shortening
Example of increased flow with rate – squeezing the ketchup bottle
The viscosity of a fluid is not just a matter of the physical feel but also includes the ability to move. It is determined by the shear force applied as the fluid moves forward

41. Flow rate to gravity depends on viscosity of the blood
Whole blood
PRBCs with AS
Washed cells
PRBCs
Hct: 38% minimum;
450 ml
Hct: 65-80%; ml
Hct: 55-65%; ml
Hct: 70-80%; less than 0.6% plasma

42. . . . still the only solution approved for use
0.9% Sodium Chloride . . .

43. Lactated Ringers Solution
Does not cause mechanical hemolysis
Contains calcium
Binds with citrate in CPDA preservative
Activates clotting within bag
Studies to support use
1991 Cull et al; concurrent administration
1998 Lorenzo et al; diluent
No study replicas found. FDA does not approve concurrent use or use as diluent

44. 5% Dextrose in Water Cause osmotic hemolysis Dextrose
Makes the solution isotonic in the bag
Is immediately utilized by the cells for energy
Water
The solution becomes profoundly hypotonic after administration
Cells absorb water and rupture

45. Higher and consistent velocity results in laminar flow.
As velocity , viscosity  because cells begin to orient the same direction.
Higher and consistent velocity results in laminar flow.
(Hint: think about flushing a NSL)
As the rate increases, the red cells begin to move in a more uniformed direction which decreases resistance and, therefore, decreases viscosity. Slow rates through large catheters cause the cells to move without uniformity so turbulence results. This turbulence may increase the risk of hemolysis.

46. Low rates + large catheter =  turbulence
Gravity flow:
Low rates + large catheter =  turbulence
20g catheter may contain million cells)
14g catheter may contain million cells

47. Velocity + viscosity + temperature = flow
Poiseuille’s law
Viscosity decreases as temperature increases.
org/poiseuilles_law_iv_fluids/
Warm blood recommended for:
Rapid, massive transfusion
Neonates receiving exchange transfusion
Clinical presence of hypothermia
May be considered for cold agglutinins
Due to reimbursement considerations, use of blood warming devices is not recommended as a general method of increasing rate

48. Lysis of cells is potential if blood is warmed above 42oC (107.6oF)
Approve blood warming apparatuses
Not approved for use!
AABB: Standards for blood banks and transfusion services, ed 25, Bethesda, Md, 2014

49. Too cold is bad, too! Blood is stored between 1-6oC (33.8-42.8oF)
Blood stored at 0oC (32oF) or below will lyse if not protected
Contact with freezer blocks or freezer elements may destroy a unit

50. Increasing pressure maximizes flow.
Velocity + Viscosity + Temperature + Pressure = Flow
Poiseuille’s law
Increasing pressure maximizes flow.
External pressure must be applied evenly over entire bag
Do not use pressure cuffs
Use FDA approved bags with pressure gauge
Maximum pressure 300 mmHg
Infusion pumps certified by manufacturer

51. Flow rates NS to gravity and with external pressure at 300 mmHg
As cath length , flow rate 
Intravenous catheters
Rate of flow with gravity (ml/min)
Rate of flow w/ pressure (ml/min) %
14G 50 mm cannula
236.1
384.2
62.7
14G 14 cm Abbocath
197
366
85.8
14G 15 cm Leadercath
117.3
211.1 80
16G 50 mm cannula
154.7
334.4
116.2
16G 3-port (distal)
69.4
116.1
67.3
18G 45 mm cannula
98.1
153.1 56
18G 3-port (proximal)
29.7
79.3
167
20G 33 mm cannula
64.4
105.1
63.2
22G 25 mm cannula
35.7
71.4
100
An 18G x 1.5” peripheral catheter had better flow than the distal or proximal lumen on a 3-port
Distal lumen on a 3-port provided no better flow than a 20G peripheral catheter
Proximal lumen on a 3-port provided no better flow than 22G peripheral catheter
Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J Mar;28(3): Epub 2010 Jun 26. PMID:

52. Used for trauma resuscitation Warming capability Pressurized delivery
Rapid infusion pumps
Used for trauma resuscitation
Warming capability
Pressurized delivery
Not associated with hemolysis
Kim P, et al. (2004). Can J
Surg. Aug; 47(4):
Rapid-infusion catheter
8.5 Fr x 6.5 cm
Kim P, Chin-Yee I, Eckert K, Malthaner RA, Gray DK. (2004). Hemolysis with rapid transfusion systems in the training. Can J Surg. Aug; 47(4):
Hemolysis was tested by running cells through a 16G catheter at 500 ml/min at a pressure of 300 mmHg

53. Pressure Tidbits and Caveats
300 mmHg maximum is to prevent splitting of bag seams
I.V. pumps are certified for safety of the pumping mechanism, not cath gauge
Lysis occurs when blood is forced through a too-small catheter or needle.

54. Syringe Pumps vs. Manual pressure Syringe size Max pressure PSI
mmHg range
equivalent 1 mL
8,584 – 25,857 3
4,189 – 14,118 5
1,707 – 5,844 10
1,241 – 4,240 20
724 – 2,585 60
362 – 1,603
Hayward WA, Haseler LJ, Kettwich LG, Michael AA, Sibbitt WI Jr, Bankhurst AD. (2011). Pressure generated by syringes: implications for hydrodissection and injection of dense connective tissue lesions. Scand J Rheumatol. 40(5):
Reason for using a syringe pump instead of manual push for pediatrics
*******
Standard catheters are rated at PSI
Plumb, Murphy G. (2011). Br J Radiol. Mar; 84(999)
Hayward (2011). Scand J Rheumatol. 40(5):

55. Excessive suction can be as problematic as excessive pressure
The combination of syringe size with the suction act together to impact the quality of the drawn blood

56. Hemolysis Potential - Large needle; high vacuum
- Small needle; large syringe
- No needle; excessive pull on syringe barrel
Hemolysis is a significant issue with phlebotomy. It is not uncommon for practitioners to impose these issues on transfusion but the two procedures are really quite different.

57. Smaller syringes created less than vacuum than larger syringes.
Visual hemolysis
- by syringe draws = 19%
- by evacuated systems = 3%.
Bush V,. (2003). Lab Notes. Winter; 13(1).
Excessive pulling on syringe plunger can increase the pressure and hemolyze the cells.
Smaller syringes created less than vacuum than larger syringes.
- 10 ml syringe generated −435 Torr
- 20 ml generate −517 Torr
Bush V, Mangan L. (2003). The Hemolyzed Specimen: Causes, Effects, and Reduction. Lab Notes. Winter; 13(1).
Also:
Small bore 25-gauge may hemolyze blood cells as they pass thru. Hemolysis is increased if a vacuum or negative pressure exists, such as with a syringe.
Syringe use allows the user to pull back on the plunger as slowly as necessary to maintain blood flow. However, excessive pulling can increase the pressure and hemolyze the cells.
The vacuum created when small veins area phlebomized with a vacutainer can be minimized if a small vacutainer is used. The collapse of the vein does not increase the risk of hemolysis.
16 g for donation because less risk of hemolysis
mc/articles/PMC /

58. Provided by Charter, Medical, Winston-Salem, NC
Slowly pull required amount of product through filter into syringe at a rate not exceeding 2 mL/second.
IFU should be on file at facility and should be referenced when writing P&P

59. AABB is formerly known as the American Association of Blood Banks
AABB Standards
A syringe pump should be used over manual pressure.
Pulsating flow increases risk of lysis.
The smallest catheter that should be used to infuse with a syringe pump to infuse red cells is 25G.
Pulsating flow increases the risk of hemolysis because of shearing that occurs with turbulence
AABB is formerly known as the American Association of Blood Banks

60. Wrap Up
Severe mechanical hemolysis is a rare but potentially life-threatening complication.
Catheter selection for blood administration is a multi-faceted decision; catheter gauge should not be a sole consideration.
Decision of catheter: patient’s age, condition of veins, component to be administered, required rate

61. Wrap Up
A larger bore catheter may be a safer and more effective method than a pressure bag to achieve high flow rates.
It is not the application of a pressure bag that causes hemolysis; it is the rate at which the blood tries to get through the needle.
Decision of catheter: patient’s age, condition of veins, component to be administered, required rate

62. Wrap Up
PRBCs with additive solutions have the same approximate flow potential as whole blood.
Short peripheral catheters provide better flow than comparable CVC lumens
The use of I.V. pumps is supported to maintain flow but manufacturer’s or hospital’s validation is required.

63. Thank you
Lynda S. Cook, MSN, RN, CRNI

64. References
Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J Mar;28(3): Epub 2010 Jun 26. PMID:
Kim P, Chin-Yee I, Eckert K, Malthaner RA, Gray DK. (2004). Hemolysis with rapid transfusion systems in the training. Can J Surg. Aug; 47(4):
Hayward WA, Haseler LJ, Kettwich LG, Michael AA, Sibbitt WI Jr, Bankhurst AD. (2011). Pressure generated by syringes: implications for hydrodissection and injection of dense connective tissue lesions. Scand J Rheumatol. 40(5):
Bush V, Mangan L. (2003). The Hemolyzed Specimen: Causes, Effects, and Reduction. Lab Notes. Winter; 13(1).
Weinstein SM, et al. Plummer’s Principles and Practice of I.V. Therapy. 9th ed. Wolters-Kluwer: Philadelphia, PA
Phillips L, et al. Manual of I.V. Therapeutics: Evidenced-Based Practice for Infusion Therapy. 6th ed. F.A. Davis: Philadelphia, PA. 2014
Infusion Therapy Standards of Practice. J Infus Nurs (1S)
Fung, MK, et al. Technical Manual. 18th ed. AABB: Bethesda, MD

65. References
SAI infusion technology Conversion tables; Viewed on line ;
AABB: Standards for blood banks and transfusion services, ed 25, Bethesda, Md, 2014