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Blood Transfusion and Catheter Size

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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

66


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