Download Extrinsic

Blood Transfusion
and
Catheter Size
Lynda S. Cook MSN, RN, CRNI
Vascular Access Specialist
Greensboro, NC
May 6, 2017
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.
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.
Disclosures
Clinical Outcomes Specialist for 3M Critical and
Chronic Care Division
No conflicts to disclose
Challenge Question:
What size catheter
should be used to
transfuse blood?
Initial response:
What do the
experts say?
Expert Opinion
Weinstein SM, et al. Plummer’s Principles and Practice of I.V.
Therapy. 9th ed. Wolters-Kluwer: Philadelphia, PA. 2014.
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.
2016. 39(1S)
Fung, MK, et al. Technical Manual. 18th ed. AABB: Bethesda,
MD. 2014.
Consensus?
Generally:
- Adults 20-18g
- Rapid infusion 16-14g
- Pediatrics 22-24g
But . . .
Use the smallest
catheter necessary
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
Saskatoon, Saskatchewan – 18g adults; 25g min for peds
National Blood Users Group, Dublin, Ireland – depends
on vein size and desired rate
ATI training schools – 20-18 preferred but smaller can
be used
NursesLab web-based data base – 18g
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
It’s Making Me Dizzy!
Better question:
What concern is related to
catheter gauge?
Answer:
Mechanical hemolysis
Hemolysis:
The rupture or destruction of a red blood cell
not related to senescence
Classifications:
- Extrinsic / Intrinsic
- Intravascular / Extravascular
- Immune / Non-immune
o Autoimmune / Alloimmune
*Presentation of symptoms depends
on the combination of above.
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
Location of Hemolysis
Extravascular vs. Intravascular
What happens to the by-products?
stroma, potassium, hemoglobin
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
Globin - reduced to amino acids which
join the protein pool
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
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
Symptoms may be severe and depend on # cells
involved:
- DIC
- Shock
- Cardiac arrest
- Renal failure
Contributing Factor
Immune vs. Non-immune
Autogenic vs.
Allogenic
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
May occur with few cells
Antibodies are gamma globulins.
Not all antibodies fix complement.
IgM
IgG3
Activation is complete;
Intravascular destruction of red cell
IgG1
IgG2
Poor or incomplete activation;
Opsonization of the cell;
Extravascular destruction of cell
IgG4
IgA
IgD
IgE
Do not fix complement;
Not associated with cell lysis
Complement
Activation
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
Hemolysis Characteristics
from 6 Origins
Genetic
Extrinsic
ABO incompatibility
x
Rh incompatibility
x
Intrinsic
Location
Intravascular
Extravascular
x
Immune
Immune
Nonimmune
x
x
x
Sickle cell
x
x
x
Thalassemia
x
x
x
Malaria parasitic rupture
x
x
Bacterial sepsis
x
x
x
x
x
Transfusion-Related Mechanical Hemolysis
Extrinsic
extrinsic
The cell was normal prior to the exertion of
outside influences
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
Transfusion-Related Mechanical Hemolysis
Non-Immune
extrinsic
intravascular
non-immune
No antibody-antigen reaction
No activation of complement
Symptoms are based on this
combination of classification
Non-immune
extrinsic
intravascular
= S&S
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
What size
catheter should
be use to give
blood?
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 risk of
catheter-related
hemolysis when
blood is run to
gravity is . . .
As long as rate remains
consistent
To maximize flow, use the largest
diameter and shortest length possible.
Type
Gauge
Length
mL/min
Peripheral
20
1.8”
60
Peripheral
18
1.8”
105
Peripheral
16
1.8”
200
1http://emupdates.com/2009/11/25/flow
-rates-of-various-vascular-catheters/
2https://www.openanesthesia.org/poise
uilles_law_iv_fluids/
Resistance  as length 
Gauge
Length
Minutes/L
Peripheral
14g
2.5”
1.3
Peripheral
14g
5.2”
2.1
CVC
14g
8.0”
5.2
High
Type
Resistance
PICCs not
recommended for
blood transfusion
Low
Excessive pressure
may rupture PICC lines
Long
Short
Length
French (catheter)
Standard (needle)
gauge
Diameter
mm
circumference
mm
gauge
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
French: size  as # 
Standard: size  as # 
Standard Gauge:
inner diameter
SAI infusion technology
Conversion tables
Viewed on line 03-18-17
www.SAI-infusion.com
French: Diameter = Fr x 0.333
Circumference = D x 
French size determined by circumference
Standard gauge determined by inner diameter
French/Standard gauge conversion
not associated with multi-lumen
catheters
18g
16g
16g
18g
18g
7 Fr
16g
7 Fr
Silastic catheters are thicker than
polyurethane;  same French size
≠ same internal diameter
16g
20g
18g
8.5 Fr
Reddick Emerg Med J. 2011
Mar;28(3):201-2.
Epub 2010 Jun 26. PMID:
20581377.
Height makes
Might!!!
Velocity depends
on catheter
gauge, rate of
administration,
height of fluid
. . . and density of
the cells (viscosity)
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
https://www.openanesthesia.org/poiseuilles_law_iv_fluids/
Flow rate to gravity depends on
viscosity of the blood
Whole
blood
Hct: 38%
minimum;
450 ml
PRBCs
PRBCs
with AS
Hct: 65-80%;
225-350 ml
Hct: 55-65%;
300-400 ml
Washed
cells
Hct: 70-80%;
less than
0.6% plasma
0.9% Sodium
Chloride . . .
. . . still the only
solution
approved for use
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
https://www.openanesthesia.org/poiseuilles_law_iv_fluids/
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
https://www.openanesthesia.org/poiseuilles_law_iv_fluids/
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)
Gravity flow:
Low rates + large catheter =
 turbulence
20g catheter may
contain 30-50
million cells)
14g catheter may
contain 350-500
million cells
Velocity + viscosity +
temperature = flow
Poiseuille’s law
Viscosity decreases as temperature increases.
https://www.openanesthesia.
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
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
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
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
Flow rates NS to gravity and with
external pressure at 300 mmHg
Intravenous
catheters
Rate of flow
with gravity
(ml/min)
Rate of flow
w/ pressure
(ml/min)
As cath length , flow rate 
%
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
Reddick AD, Ronald J, Morrison WG. Intravenous fluid
resuscitation: was Poiseuille right? Emerg Med J. 2011
Mar;28(3):201-2. Epub 2010 Jun 26. PMID: 20581377.
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 3port provided no better
flow than 22G peripheral
catheter
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): 295-7.
Rapid-infusion catheter
- 8.5 Fr x 6.5 cm
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.
Syringe Pumps vs.
Manual pressure
Syringe size
Max pressure
PSI
mmHg range
equivalent
1 mL
363 + 197
8,584 – 25,857
3 mL
177 + 96
4,189 – 14,118
5 mL
73 + 40
1,707 – 5,844
10 mL
53 + 29
1,241 – 4,240
20 mL
32 + 18
724 – 2,585
60 mL
19 + 12
362 – 1,603
Hayward (2011). Scand J
Rheumatol. 40(5): 379-82
Excessive suction
can be as
problematic as
excessive pressure
Hemolysis Potential
- Large needle; high vacuum
- Small needle; large syringe
- No needle; excessive pull on syringe barrel
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
https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC3638030/
Provided by Charter, Medical,
Winston-Salem, NC
03-13-17
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
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.
AABB is formerly known as the American
Association of Blood Banks
Wrap Up
Severe mechanical hemolysis is a rare but potentially lifethreatening complication.
Catheter selection for blood administration is a multi-faceted
decision; catheter gauge should not be a sole consideration.
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.
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.
Thank you
Lynda S. Cook, MSN, RN, CRNI
[email protected]
References
Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg
Med J. 2011 Mar;28(3):201-2. Epub 2010 Jun 26. PMID: 20581377.
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): 295-7.
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): 379-82
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. 2014.
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. 2016. 39(1S)
Fung, MK, et al. Technical Manual. 18th ed. AABB: Bethesda, MD. 2014.
References
SAI infusion technology Conversion tables; Viewed on line 03-18-17; www.SAIinfusion.com
AABB: Standards for blood banks and transfusion services, ed 25, Bethesda, Md, 2014