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Removing The Confusion From Transfusion

EMS is dispatched to a scene for an 18 y/o female stab victim at Camp Crystal Lake. The victim was seen running through a dark, secluded, wooded area and was being pursued by a man in a white mask. The victim was running with her hands up and shrieking, and looked back to see if the assailant was behind her. She trips on the obvious log that was conveniently in front of her as she glanced back.  As she lands face down, she pushes up with her hands appearing unharmed. As she goes to turn over, the suspect, Jason Voorhees is “Calmly” walking up to her holding a machete. Upon arrival at the scene, you find a young woman awake, but lying in a very large puddle of blood. Spoiler alert, she's going to need blood!

Administering blood to some may seem normal, but if you are new to the game and unsure - then this blog is just for you. 

Blood administration in the prehospital setting is relatively simple and straightforward, but sometimes we need a little refresher. Blood transfusions have been around for a very long time. In 1628, British physician William Harvey discovered circulating blood, but it wasn’t until 1818 when the first human to human blood transfusion was performed by Dr James Blundell, for postpartum hemorrhage.

While knowing the different indications for blood transfusions or the correct products to infuse at the correct time is important, it is also important to know the little stuff. 

Today you’re going to read about the “behind the scenes” in what makes blood products the real hero. Storage, equipment, blood tubing, and compatibility of blood are at times overlooked, however are very important to the process of blood administration.

STORAGE: If your place of employment has a blood bank or lab that manages the storage of blood products, then this paragraph might not pertain to you, but for due diligence, keep reading. You never know. I tried to get an interview with Jeffery Dahmer for first hand

knowledge on storage, but alas he stopped taking interviews in 1994. Each program that handles the storage of their blood products has strict rules and regulations set up by the FDA. A refrigerator should be designated for the use of storing blood products only. The temperature of the refrigerator must remain between 1-6 deg Celsius. Alarms must be set to alert us when the temperature has fallen out of the set range. When blood is pulled from the storage and taken for potential uses: via trauma alerts, scene calls, or interfacility transports; a designated transport cooler should also be equipped with a thermometer and alarm. Temperature range on transport coolers can range from 1-10 deg Celsius, and typically can maintain that temperature for 24-72 hours (Kleinman).

When taking blood out of the refrigerator or the transport cooler you have 30 minutes max to think about if you want to use it, otherwise it needs to go back where it came from. When infusing blood in the emergency setting, we are typically infusing it as fast as we can without fluid overloading the patient and causing harm. However, there will be times when you come across an order to infuse 125 or 150 ml/hour. If that is the case we need to remember that not all units are created equal. Units of blood are based on weight not milliliters. One unit of whole blood can contain 450-500 mls. Taking that into consideration, a unit of blood can only be left out for 4 hours at room temperature. One of the big reasons we note our start time people! So being the nurse I am, my question is why. Why so many rules on temperature regulations? Simple. Bacteria proliferate at warmer temperatures.

The duration of storage also affects the viability of the RBC. Long term effects include membrane changes leading to passive cellular exchange, a drop in 2-3 DPG levels, and depletion of Adenosine Triphosphate (ATP). Potassium leaks from RBC due to passive leakage at a rate of 1mEq per day. Due to the depletion of ATP, potassium is not actively transported back into the cell. After 42 days, potassium levels can rise to 45-60 mEq. What is even more rad is the fact that hyperkalemia rarely occurs with blood administration because the volume of extracellular components in PRBCs is small. Of course, it does play a factor for kidney disease, massive transfusions and infants. Lab values should be monitored frequently, and the patient assessed for signs and symptoms of hyperkalemia. 2-3 Diphosphoglycerate (2-3DPG) levels begin to fall by week two. By weeks 5 and 6, levels can be at 10% of normal (Kleinman). The coolest part about this unwanted left shift, is that levels of 2-3 DPG begin to normalize at 6 to 24 hours post transfusion. It is noted that it is uncertain if this is even physiologically important as most of the oxygen delivered occurs from the unaffected cells (Hess).

PRESERVATIVE: In the 1940s the first anticoagulant preservative (AP) solution of acid citrate dextrose allowed blood to be stored for up to 21 days. Through modification of the AP solution, today we are able to store blood for 42 days. This citrate solution chelates to calcium. Calcium works with vitamin K and Fibrinogen in the clotting cascade. For those of you that don’t know, like me, chelate means to grab and bond to. In a nutshell, the donated blood doesn’t clot without calcium because the calcium is bound to the citrate. With infusion of the PRBCs, the calcium is still rendered useless, and hypocalcemia will ensue. Your patient will start displaying signs of increased anxiousness, carpopedal spasms, tetanic contractions and arrhythmias. Patient populations most affected by this include massive transfusions related to trauma, and patients with liver disease (Kleinman). Fortunately, our modern-day problem has a modern-day solution. That solution being the administration of calcium gluconate or citrate. Typically, calcium is administered prophylactically after 2-6 units of blood product infusion depending on your hospital and ems guidelines. Honestly, checking your BMP regularly is a very wise choice.

The AP solution also adds to the metabolic acidosis and alkalosis… yes, you read that correctly. Hear me out. The Ph of the donated unit of blood at the time of collection is typically 7.10.  Red blood cells produce lactic and pyruvate acids due to anaerobic metabolism. The AP solution causes the Ph to go down by 0.1 per week (Hess). Six weeks can leave the unit of blood at a staggering 6.5 Ph. Oofffff. Once administered, as long as tissue perfusion is restored and maintained, metabolic acidosis doesn’t develop. You can thank Aerobic metabolism for that. On the flip side, each mmol of citrate generates 3mEq of bicarb (more cowbell) totaling 23 mEq per unit, and metabolic alkalosis ensues(Hess). However, if the recipient has functioning kidneys, the bicarb adequately secretes any excess that is not needed (less cowbell).

BLOOD TUBING: Have you ever seen the horror movie called “The Ruins”? A group of, you guessed it, teens take a trip to ancient Maya ruins where carnivorous vines take over them. Blood tubing is kind of like that. If you have ever had to prime saline, flush, spike blood, set up a buddy light warmer, connect to extension and infuse blood in the back of an ambulance or in a

407, you know what I’m talking about. That shambolic mess consumes everything around you. Good luck trouble shooting for 15 minutes why the blood is all over the floor and splattered on

the side of the aircraft the patient isn’t even on, only to have your patient rip his IV out right at landing. It was my first time, it was bloody... leave me alone. Long story short you have to know how your blood tubing works.

Blood tubing is special in that it consists of regular tubing at the bottom, but about 2/3s of the way there is a filter that splits off two connection points.  Blood tubing is a necessity because of the filter. During collection and storage, blood products can contain clots, small clumps of platelets and white blood cells. Filters should be anywhere from 170 to 260 microns to remove these particles (Kleinman). For reference, a human hair is 50 to 150 microns.

Prepping and priming the tubing is fairly simple. Here is a link for Blood administration set up. I think being able to watch how it is done is much simpler. However, I do think there are some pearls you should take away from setting up blood tubing. 

1. Clamp all of your roller clamps. 

2. Always spike normal saline first, and only normal saline. NS is one of the very few things that are compatible with blood. Absolutely avoid dextrose solutions as it will cause the blood to lyse and Ringer’s  Lactate (RL) will cause the blood to clot. 

3. When priming with NS, make sure the Filter is completely covered with NS. If the blood product were to drop/fall onto the naked filter, it would cause the cells to lyse. This is why we prime with NS, so that we give that blood a cushion upon impact. 

4. Once you are ready to infuse, always keep your saline roller clamped so you are not getting blood back flow into your normal saline.

EQUIPMENT: Other than the blood tubing, we have equipment we should be familiar with, or at least know that it is out there for use. Rapid infusers, blood warmers, and pressure bags can all be utilized. Let’s start with blood warmers. They are a great tool to utilize, especially with a hypothermic trauma patient. Warming blood decreases the coagulopathy of blood and prevents cardiac arrhythmias. Giving one unit of 4 deg Celsius blood product to a 70 KG patient will drop the core body temperature by 0.25 deg Celsius (Sessler). No let's image adding that up after a mass transfusion. Might as well slap a triad of death sticker on their forehead *ch, ch, ch, ah, ah, ah*. When warming blood ideally, we warm the fluids up to 38 deg Celsius. Anything over 40 deg Celsius can cause hemolysis of the RBC. There are many brands of fluid warmers, and while I don’t want to go into detail about them, they are a handy little tool to have. Rapid infusers are also great. They do require a well established IV access . Not only do these devices warm your blood products but they deliver fluids at alarmingly fast rates. These bad boys can go roughly 2.5 to 1000ml per minute. Holy crap cakes Batman, that’s fast! Remember the rate can be determined by the size of your IV catheter as these run off of pressure as well. While on the topic of IVs, this is one of the few times that size matters. An 18g IV is ideal for rapid transfusion. Just like an ET tube, the smaller the diameter, the greater the pressure as large volumes are being delivered fast. A 23g and 22g can be used for smaller rates, but high flow rates can cause damage and hemolysis of the blood cell. This leads me to my next piece of equipment, a pressure bag.

This simple piece of equipment is placed on the unit of blood and provides even pressure distribution on the unit of blood. This is the exact reason to not use a blood pressure cuff. BP cuffs can unevenly distribute the pressure causing damage to the blood cells. Ideally 200 mmHg of pressure should be adequate, once you start getting close to 300mmHg hemolysis to the blood cells and damage to the bag can occur. (ALFA) Want to impress your patient who has an altered mental status due to severe blood loss? Just place your blood product in a pressure bag, hold the hole on the bulb up to the Christmas tree O2 connector and watch that cuff inflate faster than you can hand pump. Your patient won’t know how neat you are but might benefit from your efficiency.

It is nice to know the “why” for the things that we do. I have found that my practice in how I handle blood and administer blood has drastically changed once I found the reasoning for the madness. Properly storing your blood allows for a longer shelf life and a decreased chance for bacterial growth. Remember that with age comes potential breakdowns in the system: 2-3 DGP, hyperkalemia, and increased bicarb and lactic production. Preservatives are great but they do come with a price. Always monitor the number of units infused and your calcium levels. I love pretzel day but not while I am setting up my blood tubing, knowing how your tubing works can greatly decrease your agitation when the time comes to spike that Blood product. And last but not least know your equipment, they are valuable tools in your tool box that contribute to better patient outcomes. 

Hope you guys enjoyed it!! Peace Out ✌️

Brittany Grandfield


Blood Transfusion in Skills Lab. (n.d.). Retrieved October 22, 2020, from 

“Clinlab Navigator.” ClinLabNavigator,

Hess, J. R., MD. (2019, April 8). Massive blood transfusion. Retrieved October 22, 2020, from

“History of Blood Transfusions.” History Of Blood Transfusions 1628 To Now | Red Cross Blood Services,

Kleinman, S., MD. (2020, February 21). Practical aspects of red blood cell transfusion in adults: Storage, processing, modifications, and infusion. Retrieved October 22, 2020, from

Sessler, D., MD. (2020, May 27). Perioperative temperature management. Retrieved October 22, 2020, from

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