You really can mix blood and lactated ringers

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jetproppilot

jetproppilot

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This post has

TINY RELEVANCE

but relevance nonetheless.

This is a

RESIDENT DRIVEN FORUM

as it should be...

I'm speaking to the dudes/dudettes out there working your ass es off as anesthesia residents making personal pennies while you staff operating rooms for pennies on the dollar for the place that is training you (it's symbiosis man...hang in there it'll be worth it)

So you're a STUD, AUTONOMOUS CA-3 in the heart room running an AVR by yourself from beginning to end, your attending is no where to be found, you're off pump (meaning the pump tech can't squeeze the units in), both your SVR and your HCT is low, as is the blood pressure.

You think to yourself DING!!! I gotta hang some RED CELLS.

But ALAS.... your resident colleague was a SLACKER the day before and didn't restock your cart adequately.

You reach for .9%NS to mix your blood with and you are

SLACKERIZED.

No Normal Saline!

Of course your initial reaction sans Normal Saline is

WHAT THE #$^&#& I'M GONNA #&^$$*)$# MY BUDDY WHO DIDN'T RESTOCK!!!

Yeah, I know I know.

But you're in the HEART ROOM, REMEMBER?!! Time to PROBLEM SOLVE

and keep your heart rate below 60 and keep your emotions thinking happy thoughts.

There's an ANESTHESIA DOGMA that's been passed down for generations saying you can only mix blood with normal saline and that mixing it with Lactated Ringers, because of the (microscopic) Ca++, will result in a clotted line since PRBCs contain citrate.

IT AIN'T GONNA HAPPEN MAN.

THREE mEq of calcium is not gonna ruin your day.

Back to you in the heart room...it's probably 6pm by the way and noone is around....no need to panic man...

HANG THE BLOOD WITH THE RINGERS. Mix it up just like you would with the normal saline!! Hell, pretend you're a bartender shaking a twenty dollar martini for the hot chick in front of you at The Delano on South Beach. It's gonna be OK.

Wanna know what's more important in eliminating an IV line from being obstructed from hanging blood?

DRUM ROLL PLEASE

THE ADD ON ORANGE FILTER THINGHYS.

Use those orange filters...a new one for every unit...and you'll be

GOLDEN and you'll never have to replace your blood filter IV line during a case even if you used Lactated Ringers.

But you haffta be diligent with the orange add on Filter Thinghys. One per unit.

Yeah, I agree this a TINY LITTLE THING, but knowing this at 6pm in the heart room after being SLACKERIZED will save you alotta brain cells. Precious brain cells you can use later. In private practice deciding IMPORTANT STUFF like do I want the gray or the black Denali?

It's important The Residents know sh i t like this!!!!!!!!

This ends JET'S RIDICULOUS, DIMINUTIVE, "NEED TO KNOWS."

Signing off.

BUH BYE NOW.
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Last edited:
I don't do massive trauma, but I've never used more than one blood filter for a case
 
I think it's awesome that you're addressing some of the dogmatic things we see/do on a daily basis "because that's how I was taught" or "we've always done it that way".

One of my favorite exercises with students is to have them look up the evidence for thiamine before dextrose to prevent wernickes encephalopathy.
 
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ur probably right, but the truth is just because the lixture of LR and PRBC has done nothing in ur work experience, doesnt mean it hasnt had an adverse effect somewhere else. i had an attending in residency who refused to place an a-line sterilly, instread just doing a small alcohol wipe of the area. His logic: ive never had an a-line infected. The matter was brought before the dept and what was decided was that if the dogma of using a sterile prep for a-line as opposed to a normal alcohol swab was overkill, then he should do a proper research, with controls and what not. to simply say "it didnt happen to me" was insufficient bec these standards, many but not all, have a root in some evidence based research and unless u have something just as evidence based to debunk it, its prudent to follow the standards of care. just my 2 cents.
 
As the previous two links illustrate...it all depends. If you slowly drip 50cc of pRBC into your IV filter chamber with 50cc of LR and let it sit it will eventually form clot. But in any real life scenario you will be fine since we are usually giving blood for a reason and are not interested in hanging it on a pump and setting the pump at a TKO rate.
 
Arrgh. This has got to be at least the third time we have gone over this here. Once again, I will just quote myself.


periopdoc said:
... quoted text posted below as plain text to improve readability
Click to expand...


(For those of you who don't want to read the whole thing, the evidence suggests that LR and PRBCs are compatible as long as the ratio of LR to PRBCs does not exceed 1:1. A safety margin of 1:2 is probably a good idea)


In 1975, Ryden and Oberman published the first data on the Compatibility of Common Intravenous Solutions with CPD Blood. Working with CPD preserved whole blood, they demonstrated grossly visible clot formation in vitro in samples of LR and whole blood at a citrate: calcium ratio of 4:1 or lower when incubated for 5 minutes. Largely based on these findings, AABB incorporated the prohibition against the combination of LR and blood components when they developed their guidelines.


Then, in 1991, Cull and Lally looked at the Compatibility of (CPD preserved) packed erythrocytes and Ringer's lactate solution.. They examined a variety of ratios of CPD PRBCs: LR from 5:1 to 1:20. Clotting was observed in the 1:1 dilution, but not in the 2:1 or 5:1 dilutions at up to two hours. Units of PRBCs diluted with LR and passed through a 170 micron filter were compared to PRBCs similarly diluted with NS. No difference in flow rate was found.


In 1998, Lorenzo et al advised that blood bank guidelines be revised to allow the use of LR in the rapid transfusion of PRBCs when they assessed infusion time, filter weight, and clot formation after admixing whole blood and PRBCs with NS, LR, and LR with increasing concentrations of added calcium chloride from 1g to 5g. They found no differences except for the presence of visible clot in the LR + 5g calcium chloride mixture.


In 2009, Albert et al found that Ringer's lactate is compatible with the rapid infusion of AS-3 preserved packed red blood cells. when they used ELISA to compare prothrombin activation fragment 1 + 2 (the breakdown products of thrombin generation) levels in units of PRBCs similarly diluted in NS and LR then run through filters and fluid warmers (to simulate intraoperative transfusion practices) and found the levels of F1+2 to be sub-physiologic.


Finally in 2010, Levac et al demonstrated that Ringer's lactate is compatible with saline-adenine-glucose-mannitol preserved packed red blood cells for rapid transfusion.. "Samples from 12 units of SAGM-PRBC were diluted from 0-97.5% with RL and normal saline (NS), incubated for 30 min, and passed through 40 μm filters." F1+2 levels were measured via ELISA. 8 samples were diluted with LR and incubated for 30 to 240 min and analyzed in a similar manner. At 120 minutes and up, some clotting was observed, but there was no clotting at 60 minutes. They concluded that LR/ PRBC co-administration is safe as long as cells are administered over 60 minutes or less.



Though generally resulting in benign hemoglobinemia and hemoglobinuria, there are case reports of serious sequelae from acute non-immune hemolytic transfusion reaction (pseudo-hemolytic transfusion reaction) including renal failure and hypotension. However, lysis of cells was never the concern with LR. It is an accurate concern if red blood cells are diluted/ co-administered in hypotonic solutions like D5W which should never be done.


To my knowledge, there are no papers refuting the safety of PRBC/LR co-administration with modern anticoagulant techniques. If you know of any, please share.

I am not aware of any study of the effect of LR other factors, although platelet activation might occur. That would be an interesting thing to look at.

Personally, I still make a good-faith effort to dilute/ transfuse with NS because the guidelines exist and have not been update to reflect the data (the number one problem with guidelines IMHO). However, I don't go out of my way if there is LR hanging and I need to give products rapidly. I do always run platelets through their own line so the latter is essentially a null issue to me.

- pod
 
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ether123 said:
i had an attending in residency who refused to place an a-line sterilly, instread just doing a small alcohol wipe of the area. His logic: ive never had an a-line infected. The matter was brought before the dept and what was decided was that if the dogma of using a sterile prep for a-line as opposed to a normal alcohol swab was overkill, then he should do a proper research, with controls and what not. to simply say "it didnt happen to me" was insufficient bec these standards, many but not all, have a root in some evidence based research and unless u have something just as evidence based to debunk it, its prudent to follow the standards of care. just my 2 cents.
Click to expand...

unless you are using sterile prep and gloves for every peripheral IV start, the standard of care for peripheral vascular access has already been set. Just because the department didn't agree, doesn't mean they were right.
 
Mman said:
unless you are using sterile prep and gloves for every peripheral IV start, the standard of care for peripheral vascular access has already been set. Just because the department didn't agree, doesn't mean they were right.
Click to expand...

Irrespective of how we feel about sterile prep for a-lines and LR with RBCs, his/her point was a valid one: an individual clinician's experience is probably an insufficient metric by which to judge what is and what isn't safe, particularly with regard to very rare complications. Think of of it as a being an underpowered, unblinded, biased study with a follow-up interval only as long as the anesthetic case.
 
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ether123 said:
ur probably right, but the truth is just because the lixture of LR and PRBC has done nothing in ur work experience, doesnt mean it hasnt had an adverse effect somewhere else. i had an attending in residency who refused to place an a-line sterilly, instread just doing a small alcohol wipe of the area. His logic: ive never had an a-line infected. The matter was brought before the dept and what was decided was that if the dogma of using a sterile prep for a-line as opposed to a normal alcohol swab was overkill, then he should do a proper research, with controls and what not. to simply say "it didnt happen to me" was insufficient bec these standards, many but not all, have a root in some evidence based research and unless u have something just as evidence based to debunk it, its prudent to follow the standards of care. just my 2 cents.
Click to expand...

:rolleyes:

Typical academic B.S.
I was not taught in residency to use a sterile field for an A line.
I've placed...I dunno... a thousand? Two thousand?... A lines using an alcohol swab only. Every colleague I know does not use a sterile prep for an A line.
I've
NEVER
had an A line infection.

PUH LEASE SHOW ME your "evidence based research" that has been replicated enough scientifically showing a sterile prep for an A line is necessary.
 
jetproppilot said:
:rolleyes:

Typical academic B.S.
I was not taught in residency to use a sterile field for an A line.
I've placed...I dunno... a thousand? Two thousand?... A lines using an alcohol swab only. Every colleague I know does not use a sterile prep for an A line.
I've
NEVER
had an A line infection.

PUH LEASE SHOW ME your "evidence based research" that has been replicated enough scientifically showing a sterile prep for an A line is necessary.
Click to expand...

Hey man.... I really missed you! :love:
 
Puhleeeze tell me this isn't going to turn into another one of those why did they ban d712/ I can't quit you/ gay sex type threads.

:naughty:

-pod
 
cchoukal said:
Irrespective of how we feel about sterile prep for a-lines and LR with RBCs, his/her point was a valid one: an individual clinician's experience is probably an insufficient metric by which to judge what is and what isn't safe, particularly with regard to very rare complications. Think of of it as a being an underpowered, unblinded, biased study with a follow-up interval only as long as the anesthetic case.
Click to expand...

I completely agree. I'm pointing out that the idea of sterile gown/prep/glove etc for a radial a-line is also not supported by literature. It's from the same underpowered, unblinded, biased study with poor followup.

But when you think about it, the infection rate from a radial arterial line is likely LOWER than from a peripheral IV. We aren't giving meds through it, there isn't a large volume of fluid carrying potential bacteria with it through the cannula, and it's likely in place for a shorter duration of time than an IV. So if after billions of peripheral IV starts the last few decades hasn't resulted in the need for full sterile barrier precautions, why would a radial art line be different? Because somebody with a clipboard said so?

Before I finished residency, they were in the process of making every arterial line in the ICU be started with hat, mask, gown, sterile gloves, sterile prep, and FULL BODY DRAPE. The patient will be dead in the MICU before they can even finish draping the patient for the a-line.
 
FrankWhite said:
Haha. I am forced to GOWN AND GLOVE for a-lines.... true story!

Appreciate the post, would love to hear more JPPs "NEED to knows."
Click to expand...

To play devil's advocate, does anyone know what the surveillance rate of a-line "infections" is?

This study suggests a rate of 3.36 per 1000 catheter days (the "industry standard" parameter for catheter-related blood stream infections). This was defined as infection, not colonization, in this study. These lines were placed with CHG and sterile gloves, but not gowns.

http://www.ncbi.nlm.nih.gov/pubmed/21672552

I've seen other data suggesting a rate closer to 2 per 1000 catheter days. Either way, these estimates are higher than what is considered acceptable for central line related BSIs. Frankly, they're so high that it's hard to believe. And clearly, ICU a-lines are a different beast entirely compared to an a-line placed in the OR for the duration of the case, to be removed in PACU, in terms of its likelihood of getting infected.

I think we have to consider the possibility, though, that a-line infection rates only seem low because we don't go looking for them, and as such it's a little disingenuous to use "I do this every day and never have a problem" as evidence to guide others' practice.
 
cchoukal said:
To play devil's advocate, does anyone know what the surveillance rate of a-line "infections" is?

This study suggests a rate of 3.36 per 1000 catheter days (the "industry standard" parameter for catheter-related blood stream infections). This was defined as infection, not colonization, in this study. These lines were placed with CHG and sterile gloves, but not gowns.

http://www.ncbi.nlm.nih.gov/pubmed/21672552

I've seen other data suggesting a rate closer to 2 per 1000 catheter days. Either way, these estimates are higher than what is considered acceptable for central line related BSIs. Frankly, they're so high that it's hard to believe. And clearly, ICU a-lines are a different beast entirely compared to an a-line placed in the OR for the duration of the case, to be removed in PACU, in terms of its likelihood of getting infected.

I think we have to consider the possibility, though, that a-line infection rates only seem low because we don't go looking for them, and as such it's a little disingenuous to use "I do this every day and never have a problem" as evidence to guide others' practice.
Click to expand...

Agree. The ICU data strongly suggest we are way to flippant in how we place arterial lines.
Since 2010 I have made an effort to use sterile gloves and Chloraprep for arterial sticks.
Arterial lines left in place for less than 72 hours are less of a concern than those left in for more than several days. Again, the iCU literature on this is even suggesting that a biopatch be used for long standing arterial lines.
 
IV Literature
Central and arterial line infection risk
Posted by: IVTEAM on May 16, 2010 | No Comments

Intravenous literature: Lucet, J.C., Bouadma, L., Zahar, J.R., Schwebel, C., Geffroy, A., Pease, S., Herault, M.C., Haouache, H., Adrie, C., Thuong, M., Francais, A., Garrouste-Orgeas, M. and Timsit, J.F. (2010). Infectious risk associated with arterial catheters compared with central venous catheters. Critical Care Medicine. 38(4), p.1030-5.

Abstract:

BACKGROUND: Scheduled replacement of central venous catheters and, by extension, arterial catheters, is not recommended because the daily risk of catheter-related infection is considered constant over time after the first catheter days. Arterial catheters are considered at lower risk for catheter-related infection than central venous catheters in the absence of conclusive evidence.

OBJECTIVES: To compare the daily risk and risk factors for colonization and catheter-related infection between arterial catheters and central venous catheters.

METHODS: We used data from a trial of seven intensive care units evaluating different dressing change intervals and a chlorhexidine-impregnated sponge. We determined the daily hazard rate and identified risk factors for colonization using a marginal Cox model for clustered data.

RESULTS: We included 3532 catheters and 27,541 catheter-days. Colonization rates did not differ between arterial catheters and central venous catheters (7.9% [11.4/1000 catheter-days] and 9.6% [11.1/1000 catheter-days], respectively). Arterial catheter and central venous catheter catheter-related infection rates were 0.68% (1.0/1000 catheter-days) and 0.94% (1.09/1000 catheter-days), respectively. The daily hazard rate for colonization increased steadily over time for arterial catheters (p = .008) but remained stable for central venous catheters. Independent risk factors for arterial catheter colonization were respiratory failure and femoral insertion. Independent risk factors for central venous catheter colonization were trauma or absence of septic shock at intensive care unit admission, femoral or jugular insertion, and absence of antibiotic treatment at central venous catheter insertion.

CONCLUSIONS: The risks of colonization and catheter-related infection did not differ between arterial catheters and central venous catheters, indicating that arterial catheter use should receive the same precautions as central venous catheter use. The daily risk was constant over time for central venous catheter after the fifth catheter day but increased significantly over time after the seventh day for arterial catheters. Randomized studies are needed to investigate the impact of scheduled arterial catheter replacement.
 
Personally, I witnessed enough a-line site infections during training (of a lines placed in the OR that subsequently spent >24 hours in the ICU) that I went to using sterile technique for all a-lines that will be indwelling for more than 24 hours (chlorhex and sterile gloves). If I place an a-line emergently with aseptic technique, I remove within 24 hours and utilize a second site for sterile placement if the patient continues to need an a-line.

Of course I also observed enough gross violations of aseptic technique by people placing lines with alcohol wipes and non-sterile gloves to account for a higher than expected rate of a-line infections. For example, I observed one individual who actually pressed on the catheter itself with a non-sterile gloved finger as the catheter was being threaded. For what purpose, I could only guess. It appeared as if she was trying to get a bend in the needle/ catheter to get it to pass.

I personally have never had an catheter related infection of a catheter that I placed.

- pod
 
ether123 said:
ur probably right, but the truth is just because the lixture of LR and PRBC has done nothing in ur work experience, doesnt mean it hasnt had an adverse effect somewhere else. i had an attending in residency who refused to place an a-line sterilly, instread just doing a small alcohol wipe of the area. His logic: ive never had an a-line infected. The matter was brought before the dept and what was decided was that if the dogma of using a sterile prep for a-line as opposed to a normal alcohol swab was overkill, then he should do a proper research, with controls and what not. to simply say "it didnt happen to me" was insufficient bec these standards, many but not all, have a root in some evidence based research and unless u have something just as evidence based to debunk it, its prudent to follow the standards of care. just my 2 cents.
Click to expand...

I never understood why an iv is ok to do with minimal fanfare, but a peripheral aline is not.

Did they do said studies in peripheral iv's?
 
Mman said:
Before I finished residency, they were in the process of making every arterial line in the ICU be started with hat, mask, gown, sterile gloves, sterile prep, and FULL BODY DRAPE. The patient will be dead in the MICU before they can even finish draping the patient for the a-line.
Click to expand...

That's how it is in my hospital's icu's.
 
Planktonmd said:
All I know is that in anesthesia you need good position and good lubrication... were you taught otherwise???
Click to expand...

Wonder if we got trained by the same guy. He was/is the Michael Jordan of lines.

Good position and good lubrication get things done.
 
njac said:
I think it's awesome that you're addressing some of the dogmatic things we see/do on a daily basis "because that's how I was taught" or "we've always done it that way".

One of my favorite exercises with students is to have them look up the evidence for thiamine before dextrose to prevent wernickes encephalopathy.
Click to expand...

Out of curiosity, are you talking about adjacent administration or are you suggesting that dextrose without thiamine will not precipitate WE?
 
SpecterGT260 said:
Out of curiosity, are you talking about adjacent administration or are you suggesting that dextrose without thiamine will not precipitate WE?
Click to expand...

The latter.

The case series used to justify that thought process had patients who didn't receive thiamine for *days*. I'm not denying that it's important to get it in them, it's just not omg it must be ivp (vs po) and within minutes of their arrival in the ED.
 
njac said:
The latter.

The case series used to justify that thought process had patients who didn't receive thiamine for *days*. I'm not denying that it's important to get it in them, it's just not omg it must be ivp (vs po) and within minutes of their arrival in the ED.
Click to expand...

Well yes. The idea is sub clinical thiamine def turning into WC when treated like hypoglycemia.

I will say I was disappointed in the number of citations in the text and primary sources upon search, but I did find an animal study and a few case reports on the subject.

I wouldn't say a TD patient needs IV immediately. It took them days to get there, a few minutes wouldn't hurt. But the evidence does give me pause to do something like dextrose IV and thiamine PO.

Sent from my DROID RAZR using SDN Mobile
 
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