What is the appropriate gravity IV administration set that would be used to administer blood?

Final bedside checking procedure

All patients who require the administration of any blood component MUST have a legible wrist band in situ which includes minimum of the three key identifiers, full name, date of birth and unique patient identifier number.

If two patients are to be transfused on the same ward, the transfusions must be staggered. Once the first unit is started, the blood for the second patient can be sent for. This ensures that two units will not be required at the same time.

Before the transfusion is commenced, the staff member setting up the transfusion must make a final identity check, in conjunction with another registered nurse or doctor.

At the patient’s bedside both individuals must first check the name, unit number and date of birth against the patients care pathway document. Then the details on the donor unit compatibility/traceability tag are checked. Check for any special instructions on the compatibility/traceability tag i.e. ‘complete by’

Check and confirm the Bag number (G092 310…) are the same on both the compatibility/traceability tag and the pack label. Then check the expiry date on the unit.

Where possible, ask the patient to verbally confirm their name and date of birth. FINALLY, check and confirm the patient’s identification (name, unit number and DOB) against the patient’s wrist band and the Blood bag tag

Blood Component administration

Please note; traceability labels are attached to every blood component/product issued by Blood Bank. Dept. staff are responsible for there completion and return at the first convenient opportunity.

RED BLOOD CELLS (RBC’s)

Depending on the administration rate can be documented on either the standard or rapid / emergency care pathways
The transfusion should be started within 30 minutes from removal from Blood Bank fridge (controlled temperature of 4°) or returned.
Transfused via a standard gravity feed blood transfusion giving set.
The giving set line should be primed with normal saline prior to first unit.
Each unit should be administered over maximum of 4 hours from the time the unit was removed from Blood Bank fridge. Patients requiring blood to be transfused urgently due to their clinical condition can be transfused STAT.
RBC’s can be stored in an un-opened cool box for a maximum of 3 hours, but once opened the 30-minute rule re-applies. However, if blood arrives in the clinical area in a cool box and is not going to be used imminently it must be returned to the Blood Bank and not stored in a cool box.

PLATELETS

Documented on a rapid / emergency blood transfusion care pathway.
Should be commenced as soon as possible once removed from the agitator (If delayed must be used or discarded after 2 hours from issue)
Never stored in a cool box
Transfused via a platelet giving set (170-200μm ‘screen’ filter) however if not available a standard blood giving set can be used but NOT if it is has already been used for RBC
Each unit is administered over around 30 minutes.

Fresh Frozen Plasma (FFP)

Documented on a rapid / emergency blood transfusion care pathway.
Average adult therapeutic dose is calculated by body weight (usually dose 3-4 units – to be prescribed individually)
Once thawed FFP must be transfused as quickly as possible as prolonged post-thaw storage will result in a decline of labile coagulation factors (maximum storage time 24 hours in the controlled blood bank fridge)
Administer via a standard blood transfusion giving set. (No need to prime the line prior to transfusion)
Each unit administered over 20 – 30 minutes

Cryoprecipitate (CRYO)

Documented on a rapid / emergency blood transfusion care pathway
Average adult therapeutic does is 10units (each pack contains 5units)
Once thawed must not be re-frozen or stored in a fridge and should be transfused as soon as possible. If delay is unavoidable the unit must be transfused or discarded within 4hours.
Administer via a standard blood transfusion giving set. (No need to prime the line prior to transfusion)
Each unit can be transfused in around 15-20 minutes

ALBUMIN

Recorded as administered on the patient’s prescription chart only
Administered via a standard intravenous fluid giving set
Each bottle should be infused over 1 to 2 hours
Albumin must be administered with caution as a too rapid infusion can lead to circulatory overload or interstitial dehydration
Once the bottle has been ‘spiked’ the contents must be used or discarded after 4 hours.

Paediatric administration

The principles are the same as for adult administration. Blood administrations sets containing 170-200microm filters should be used. Paediatric blood administration sets appropriate for small volume transfusions are available from NNU / Ward 38

It is vital for the medical team to specify both the volumes in mls and the time over which the transfusion should take place when prescribing for young children and infants.

NURSING ALERT

No drugs or other intravenous fluid to be added to OR administered via the same cannula during the transfusion of any blood component.

Flushing through the remainder of the blood in the line with 0.9% Sodium Chloride is unnecessary and is not recommended because it may result in particles being flushed through the filter.

If another IV infusion is to take place after the blood transfusion, a new IV fluid administration set must be used to reduce the risk of incompatible fluids or drugs causing haemolysis of any residual red cells which may be left in the administration set.

If multiple units of RBC’s are being transfused, the administration set should be changed at least every 12 hours to prevent bacterial growth. Additionally, in cases of massive haemorrhage, where different components are to be given in rapid succession is best practice to use a new set for each component

N.B For further guidance, all clinical staff should refer to the Trust individual blood component guidelines located on the TAD website or Blood Products sharepoint website.

Chapter 8. Intravenous Therapy

Intravenous fluids are administered through thin, flexible plastic tubing called an infusion set or primary infusion tubing/administration set (Perry et al., 2018). The infusion tubing/administration set connects to the bag of IV solution. IVs are then run either by gravity or by an intravenous infusion pump, sometimes referred to as electronic infusion device (EID).

Primary IV tubing is used to infuse continuous or intermittent fluids or medication. It consists of the following parts (see Figure 8.15):

Figure 8.15 IV tubing (primary & secondary)

Sterile spike: Connects the tubing into the IV bag.
Drip chamber: Used to observe flow of IV fluids and / or to calculate drops per minute.
Backcheck valve: Prevents fluid or medication from travelling up the IV.
Access ports: Used to infuse secondary medications and give IV push medications.
Roller clamp: Used to regulate the speed of, or to stop or start, a gravity infusion.
Extension set: 10 to 20 cm IV tubing attached to IV cannula. Helps to reduce micro-movements at IV insertion sites and protects from BBF exposure during IV tubing changes.
Slide clamps: Used to stop the infusion. Are needed to open and close IV infusion pump (a.k.a. EID).

The following table is intended to familiarize you with common IV equipment.


Primary IV tubing	IV tubing/administration set that connects to the bag of IV solution. May or may not contain injection ports. See Table 8.9 Frequency of IV Tubing Changes. Primary IV tubing is either a macro-drip solution administration set that delivers 10, 15, or 20 gtts/ml, or a micro-drip set that delivers 60 drops/ml. Macro-drip sets are used for routine primary infusions. Micro-drip IV tubing is used mostly in pediatric or neonatal care, when small amounts of fluids are to be administered over a long period of time (Perry et al., 2014). The drop factor can be located on the packaging of the IV tubing. Figure 8.16 Drop factor located on IV tubing package Note: Suppliers provide different kinds of tubing for different purposes. Read the packaging and choose tubing that is appropriate.
Secondary tubing	It is shorter in length than primary tubing, with no access ports or backcheck valve. It is connected to a primary line via an access port near the top of the set. It is used to infuse intermittent medications or fluids. Secondary tubing should be changed every 24 hours.
IV bags	IV solutions come in a variety of solutions, concentrations, and volumes. They are considered medication, and as such the 7 Rights apply. The prescriber will order the IV solution and rate. The nurse monitors for signs of complications related to the solution and IV equipment. IV bags and tubing should have a sticker or label with the date, time, and initials of the healthcare provider marked on them to be valid. IV bags and/or IV tubing should be changed if: IV tubing is disconnected or becomes contaminated by touching a non-sterile surface Less than 100 ml is left in the IV solution bag Cloudiness or precipitate is found in the IV solution Equipment (date and time) is outdated IV solution is outdated (24 hours since opened) Figure 8.17 Different volumes of IV bags
Extension sets	A.k.a. “add on device,” 10 to 20 cm of IV tubing attached to IV cannula. Helps to reduce micro-movements at IV insertion sites, and protects from BBF exposure during IV tubing changes. Should be added to all PVAD-short and CVADs that do not have permanent extension tubing as part of their structure if tubing changes are expected. If added at the time of insertion—does not require routine changing—it is considered part of the IV cannula. If added after the insertion, change when integrity is compromised and at each tubing change. PVAD-short – Saline lock with extension and needleless cap
Needleless cap	Added to the distal end of all extension sets of all lumens of VADs to prevent backflow of blood and BBF exposure to healthcare provider. Also added to indwelling subcutaneous devices (butterflies) to allow needleless access when administering medications. Can be bonded to the extension set or can be separate (add on) to the extension set. Must be sanitized according to agency policy prior to accessing. Can be neutral, negative displacement, and positive pressure. Negative caps are not recommended. Changed q 7 days; each time a site is changed; following blood draws; following blood product administration; when all residual blood cannot be cleared for the device; when contamination is suspected or confirmed. Check agency protocols for correct flushing technique. Figure 8.18 Different types of needleless caps
IV tubing with filter	Used to filter bacterial particulate and candida. Available with different filter capabilities. Used when administering packed red blood cells, PN, and some medications. Refer to your agency’s parenteral practices guidelines. When administering packed red blood cells, always use a special blood administration set with a filter.
Vented set	IV administration set used for solutions that are supplied in glass containers.
Volume control set	A type of reservoir that holds a controlled volume of fluid from the IV bag. Limits volume of IV fluids or medications able to infuse into the patient. Often used in pediatrics. IV fluids are attached above the buretrol and refilled manually as the volume decreases. Figure 8.19 volume control set
Data sources: Interior Health, 2012; Perry et al., 2018; Vancouver Coastal Health, 2008

Frequency of IV Tubing Changes

Primary and secondary administration sets should be changed regularly to minimize risk and prevent infection (CDC, 2017; Fraser Health Authority, 2014). Change IV tubing according to agency policy. Table 8.8 lists the frequency of IV tubing change.


All IV tubing must be changed using principles of asepsis. IV tubing is changed based on the type of tubing, time used, and the type of solution. If possible, coordinate IV tubing changes with IV solution changes. Tubing that contains a large amount of blood and is suspected of being clotted requires immediate changing to prevent risk of introducing a thrombus into circulation.

Every 72 to 96 hours	For continuous primary infusion sets with hypotonic, isotonic, or hypertonic solution, when insertion site is changed, or when indicated by the type of solution or medication being administered.
Every 24 hours	As of 2017, the CDC is saying no recommendation can be made regarding the frequency for replacing intermittently used administration sets. Historical thinking was that when an intermittent infusion is repeatedly disconnected and reconnected for infusion, there is increased risk of contamination at the catheter hub, needleless connector, and the male Luer end of the administration set, potentially increasing risk for CR-BSI. Follow agency protocol. Note: Agency policy sometimes recommends secondary tubing be changed every 24 hours.
Every 24 hours	Infusions containing fat emulsions (IV solutions combined with glucose and amino acids infused separately or in a 3-in-1 admixture). Example: Parenteral nutrition (PN).
4 hours or 4 units, whichever comes first, or between products	Blood and blood products
Data sources: CDC, 2017; Interior Health, 2012

Assessing an IV System

All patients with IV therapy (PVAD-short, midline catheters, and CVADs) are at risk for developing IV-related complications. The assessment of an IV system (including the IV site, tubing, rate, and solution) should take into account the IV administration system AND the patient. Checklist 65 provides general guidelines for assessing an IV system.


IV systems must be assessed according to agency protocols. This might mean every 5 minutes when administering specific medications, to hourly, to every 1 to 2 hours, or to once per shift. An IV system should be assessed whenever the electronic infusion device alarms or sounds, or if a patient complains of pain, tenderness, or discomfort at the IV insertion site. Review the patient’s chart to determine insertion date and type of solution ordered. A PVAD-short catheter is usually replaced every 72 to 96 hours, depending on agency policy. If a venous access device is not in use (i.e., it is locked) care and maintenance are still required to keep the site patent. Refer to agency policy for flushing guidelines. IV therapy is considered medication. Document according to agency guidelines. Patients with cardiac or renal disease, as well as the elderly and young, are at a higher risk for IV-related complications. Elderly patients often have fragile veins and may require closer monitoring.

1. Perform hand hygiene.	This step reduces the transmission of microorganisms.
2. Introduce yourself and explain the purpose of the assessment.	This builds trust with patient and allows time for the patient to ask questions.
3. Confirm patient ID using two patient identifiers (e.g., name and date of birth), and compare the MAR printout with the patient’s wristband.	This step ensures you have the correct patient and complies with agency standard for patient identification. Compare MAR with patient wristband
4. Assess the IV insertion site and transparent dressing on IV site.	Check IV insertion site for signs and symptoms of phlebitis or infection. Check for fluid leaking, redness, pain, tenderness, and swelling. IV site should be free from pain, tenderness, redness, or swelling. Ensure patient is informed to alert the healthcare provider if they experience pain or notice swelling or redness at the IV site. If patient is unable to report pain at IV site, more frequent checks are required.
5. Inspect the patient’s arm for streaking or venous cords; assess skin temperature.	Assess complications on hand and arm for signs and symptoms of phlebitis and infiltration / extravasation.
6. Assess IV tubing for kinks or bends.	Kinks or bends in tubing may decrease or stop the flow of IV fluids. Ensure tubing is not caught on equipment or side rails on bed. Tubing should be properly labelled with date and time the tubing was initiated.
7. Check the rate of infusion for the primary and secondary IV solutions. Verify infusion rate in physician orders or medication administration record (MAR).	If IV solution is on gravity, calculate and count the drip rate for one minute. If solution is on an IV pump, ensure the rate is correct and all clamps are open as per agency protocol. If secondary IV medication is infusing, ensure clamp on secondary IV tubing is open. The EID is unable to distinguish if the primary bag or secondary bag is infusing.
8. Assess the type of solution and label on bag indicating when it was hung. Check volume of solution in bag. Assess labels on IV tubing for information about when tubing needs to be changed.	IV solutions become outdated every 24 hours. Ensure the correct solution is given. If 100 ml of solution or less is left in the bag, change the IV solution and document according to agency guidelines. If an IV pump is used, ensure it is plugged into an outlet. This ensures good battery charge. If IV tubing is due to be changed, consider priming a new bag and hanging it on the IV pole until the current bag is infused.
9. Assist patient into comfortable position, place call bell in reach, and ensure necessary side rails are used.	These precautions prevent injury to the patient.
10. Perform hand hygiene.	This step prevents the spread of microorganisms.
11. Document procedure and findings as per agency policy.	Timely and accurate documentation promotes patient safety.
Data sources: Fulcher & Frazier, 2007; Perry et al., 2018