QUESTION OF PRACTICE
Changing Blood Transfusion Policy and Practice Can smaller-than-20-gauge catheters be used safely? An evidence-based practice project finds that they can. OVERVIEW: It is often an accepted practice that a 20-gauge-or-larger catheter is used for the safe transfusion of blood in adult patients, but it is unclear what evidence supports this practice. This article tells the story of how a small team of oncology nurses designed and implemented an evidence-based practice project to challenge that convention. A literature search and a consultation with the standards of the American Association of Blood Banks and the Infusion Nurses Society determined that a smaller-than-20-gauge catheter can be used safely to transfuse blood in adults, a discovery that led to a change in policy and practice at the authors’ institution. Keywords: blood transfusion, catheter, evidence-based practice, hemolysis, hyperkalemia
T
he American Red Cross estimates that about every two seconds someone in the United States requires a blood transfusion.1 A variety of patients may need a transfusion of red blood cells (RBCs), but most have anemia, which may be acute (caused by rapid blood loss) or chronic (caused by debilitating conditions such as kidney disease or cancer). When it comes to anemia, patients with cancer are a particularly vulnerable group. Anemia is highly prevalent in cancer,2 but its causes are poorly understood.3 Still, it is well known that aggressive cancer treatments can disrupt RBC production, necessitating frequent blood transfusions, sometimes even daily during chemotherapy.1, 4 Typically, RNs are responsible for administering blood, monitoring for transfusion reactions, and promoting comfort and safety. By convention, nurses have come to accept that a 20-gauge catheter (or larger) should be used when transfusing blood. But the patient’s age and condition, as well as the condition and size of the vein to be used, often suggest that a smaller catheter would be more suitable. The rationale for using a 20-gauge-or-larger catheter to transfuse blood in nonemergency situations is not well documented. Nevertheless, in practice, use of the 20-gauge-or-larger catheter persists, as though it merited no explanation. For example, one commonly referenced nursing-procedures handbook states that when starting an iv line for blood transfusion, “perform a venipuncture, using a 20G 50
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or larger-diameter catheter. Avoid using an existing line if the needle or catheter lumen is smaller than 20G.”5 No reasons for these precautions are given, and the statement isn’t referenced. But hemolysis may be a concern; as one reference manual has noted, “Use of an 18-gauge (or larger) needle prevents mechanical damage to and hemolysis of RBCs.”6 Again, no research is cited to support the assertion that the use of larger catheters “prevents” hemolysis or, conversely, that the use of smaller catheters causes hemolysis. At our institution, a National Cancer Institute– designated comprehensive cancer center, policy states that when a blood transfusion is needed, “start an 18-gauge angiocath if possible,” but the policy provides no lower limit on catheter size. Also, because the practice has been that a catheter no smaller than 20 gauge be used for transfusions, patients may be subjected to unnecessary needlesticks, as in the following description of one of our patients (identifying details have been changed). Mr. S. came to our outpatient clinic expecting just one needlestick for blood to be drawn for routine laboratory work. What he did not expect, though, was that his hemoglobin level would be low, requiring a blood transfusion. A clinic nurse unsuccessfully attempted to draw blood for a type and cross-match test, used to check for blood-type compatibility and antibodies, costing the patient another needlestick. Next, Mr. S. was sent to the infusion center, where ajnonline.com
the iv technician drew blood for the type and cross-match test and placed an iv catheter for transfusion. Mr. S. was delighted: no more needlesticks would be needed. Unfortunately, the iv technician had inserted a 22-gauge catheter without considering that Mr. S. might need a larger catheter for transfusion. Although policy directs the nurse to “start with an 18-gauge” catheter, nurses rarely do because it is difficult to find a peripheral vein that will accommodate such a largebore catheter. The RN caring for Mr. S. thought a 20-gauge catheter (or larger) should be used. When the RN informed the patient that a 20-gauge catheter was needed, Mr. S. and his family became quite upset because of the unexpected number of needlesticks. This forced us to ask ourselves: What evidence supports the use of a 20-gaugeor-larger catheter for blood transfusions? The clinical nurse leader of the outpatient chemotherapy infusion center took this clinical concern to the nurse practice committee, where she was advised to discuss the matter with the clinical nurse specialist (CNS) to determine whether an evidence-based practice (EBP) project might be called for. It was decided that an EBP project would be a good approach for addressing the longstanding concern of what size catheter can be used to transfuse blood safely.
GETTING STARTED
We would have to begin by forming a team and searching the literature. Teams are different from small groups, we learned; teams come together for a specific, goal-directed purpose, and team members have specific roles, perform specific tasks, and work to achieve a common goal or outcome.7 Our goal was to find the scientific evidence that supports using a 20-gauge-or-larger catheter for blood transfusions and disallows using a smaller-than-20-gauge catheter. We assembled a five-member team: an infusion nurse, two clinical nurse leaders, one clinical nurse manager, and one CNS. The clinical nurse leader of the outpatient chemotherapy infusion center served as the EBP team leader—a critical role for scheduling meetings and holding team members accountable for completing tasks on deadline. The other clinical nurse leader (from our bone marrow transplantation center) and the infusion nurse (from our phase 1 clinical trials infusion center) collaborated with other team members in planning the project and accessing, appraising, and synthesizing the evidence found. The clinical nurse manager (also from the outpatient [email protected]
Photo © Thinkstock.
By Catherine Stupnyckyj, RN, Sheryl Smolarek, BSN, RN, OCN, Colleen Reeves, BSN, RN, OCN, Judith McKeith, BSN, RN, CMSRN, and Morris Magnan, PhD, RN
chemotherapy infusion center) scheduled time off for team work, set up meeting space, and arranged for financial support when needed to develop a poster presentation. Finally, the CNS mentored team members throughout the project, helping them to overcome barriers and insecurities. Since team members, except for the CNS, had no prior experience conducting an EBP project, we used our first meeting to orient the team to the scope of the project and the team members’ roles. At our institution a framework is used for all approved EBP projects in nursing (see Figure 1). The framework guides nurses from identifying a “practice concern” to revising standards of care and standards of practice, as well as in grounding the project in our facility’s patient-centered, relationship-based care model, Partners in Practice.8, 9 By studying the framework, team members could see that EBP projects do not end when the “best evidence” to support practice is found. Rather, they move forward to initiate changes in practice that will be continuously evaluated. The framework for EBP projects at our institution incorporates the Iowa model.10 The steps and decision points in the Iowa model were reviewed and discussed at our first team meeting. As a result, team members came to a much fuller understanding that EBP projects entailed using a step-by-step, systematic approach to identify and appraise evidence for practice. Several team members expressed a sense of relief knowing that they were not “flying blind” but actually had an EBP roadmap to follow. The team undertook the task of formulating a question based on the PICOT mnemonic: Population, AJN ▼ December 2014
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QUESTION OF PRACTICE
Sustain practice change
Practice concern -or-
Evaluate EBP Cycle through the Iowa model: 1. Build an EBP team 2. Search for evidence 3. Critically appraise evidence 4. Pilot test/or reject/or move directly to practice change
Implement EBP
Patient-centered evidence-based practice
Propose practice change
Write/revise policy Write/revise SOC and SOP
Incorporate patient and family values and preferences
Incorporate expertise and experience from interdisciplinary team (such as medicine, social work, respiratory therapy)
Figure 1. The Karmanos Cancer Center’s Framework for Evidence-Based Practice in a Partners-in-Practice Environment. EBP = evidence-based practice; SOC = standard of care; SOP = standard of practice.
Intervention, Comparison intervention, Outcome, and Time.11 After several attempts, we settled on the following question: In adults receiving blood transfusions (P), what is the effect of using a smaller-than20-gauge catheter (I) versus using a 20-gauge-or-larger catheter (C) on hemolysis or potassium level or both (O) within 24 hours of transfusion (T)? We chose hemolysis as our principal outcome because we were concerned that we would limit the therapeutic benefit of the transfusion if RBCs ruptured with the use of a smaller-gauge catheter. We chose posttransfusion potassium level as an additional outcome because serum potassium levels can rise as a result of RBC rupture. By formulating a PICOT question, our team was able to come to a clearer understanding of what kind of evidence was needed to address the clinical concern; also, we narrowed the parameters for our search for evidence.11
FINDING, APPRAISING, AND SYNTHESIZING THE EVIDENCE
We were now ready to plan our search for evidence, which we decided to conduct in two areas: the 52
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s cientific literature and authoritative sources. A literature search was performed using the following keywords: blood transfusion needle gauge, transfusion guidelines, transfusions and hyperkalemia, hemolysis and needle gauge, and hemolysis and transfusions. The search engines used included MEDLINE, CINAHL, Google Scholar, and the Cochrane Database of Systematic Reviews. We also consulted the standards of care of the American Association of Blood Banks (AABB) and the Infusion Nurses Society (INS). Each team member chose keywords and search engines. Finding the evidence. In our first pass at searching the literature, abstracts meeting the search criteria were downloaded for screening by the team; abstracts were screened and excluded if they were not research or did not address variations in needle gauge or the outcomes of interest. Of the 26 abstracts screened, only three12-14 seemed appropriate for more in-depth evaluation. The full articles were distributed to the team members for critical review. Another five manuscripts were identified by a search ajnonline.com
of references, in which the team took note of articles cited repeatedly in the three articles. These five were also distributed to the team members for review. In total, eight research articles were eligible for full review because they examined the effect of infusing blood through needles or catheters of different sizes on one or both of the outcome criteria—hemolysis or hyperkalemia after the transfusion. Team members constructed an evidence table to categorize information from each article. Since the critical review of research was new to most of us, our CNS guided us through the review of one article.12 While most found it helpful, we still did not feel confident in our ability to extract information from the articles, a barrier to EBP projects frequently cited in the literature.15 Ultimately, we found it easier to work with the CNS and review articles as a group. After reviewing all the articles, we placed the extracted information into an evidence table (see Table 112-14, 16-20). Then we validated the accuracy of our table by checking it against the original articles.
be placed in studies with strong research designs such as systematic reviews (lower numbers) than in those with weaker research designs such as qualitative research (higher numbers). All the studies we reviewed for this project involved a laboratory performing an experiment repeatedly without comparison groups or randomization. Typically, blood was run through a catheter of a particular size on a number of occasions; each occasion constituted a “trial” in which outcomes were measured. Such laboratory studies are not on the hierarchy of evidence we used. Still, we rated these studies Level III—that is, we determined that the methods used were more rigorous than those of cohort or case–control studies (Level IV) but less rigorous than those of a randomized controlled trial (Level II). None of the studies reviewed used human subjects (one study used an animal [dog] model).19 Most of the studies reported finding no statistically significant difference in free hemoglobin (hemolysis) and potassium levels before and after bagged blood flowed
We reviewed the current policy (use an 18-gauge iv catheter to start), but found it vague regarding how to proceed when a vein could not be found that would accommodate an 18-gauge catheter. Appraising the evidence. Critical appraisal involves evaluating the validity, reliability, and applicability of the study’s methods and findings.21 Questions on the applicability of the studies were the easiest to address: we could tell readily whether a study applied to our population and outcomes of interest. But assessing the validity and reliability of the studies was more difficult. Validity involves the soundness of the scientific methods used; reliability involves the accuracy of the findings and whether they can be attributed to the intervention (in our case, whether hemolysis and hyperkalemia resulted when a smaller catheter gauge was used).21 We struggled to understand how the concepts of validity and reliability applied to each study, ultimately deferring to the judgment of our doctorally prepared CNS. Finally, we weighed the strength of the findings using the “hierarchy of evidence” proposed by Melnyk and Fineout-Overholt.21 This hierarchy weighs evidence on a scale of I to VII: more confidence can [email protected]
through catheters ranging in size from 27 gauge to 16 gauge. One article, in comparing aspiration of blood through needles of various sizes, reported “no detectable hemolysis with any size needle.”19 Across articles, flow rates ranging from as little as 20 mL/hr to as much as 999 mL/hr did not significantly affect hemolysis. One study reported that blood more than nine days old was more susceptible to hemolysis than blood that was two days old, but the authors concluded that the amount of nine-day RBCs affected, 0.2% or lower, was “tolerable under most circumstances.”20 Similarly, a study found that when infusion rate was enhanced by applying external pressure (as high as 300 mmHg), the tendency for hemolysis increased, but according to the authors this small increase was “unlikely to be clinically significant.”14 Several team members asked about the effect of infusion pumps on hemolysis, an important area of concern. But after much discussion we decided to let the PICOT question guide our search AJN ▼ December 2014
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Purpose To examine the relationship between needle size and hemolysis
To address the stated problem
To assess the resulting RBC hemolysis and the effects on it of infusion rate and storage age of the blood transfused
Problem
The admonition to use a larger-bore needle to avoid hemolysis during blood sampling has not been substantiated by evidence.
It is unclear how fast blood should infuse or what needle gauge should be used to avoid hemolysis (during transfusion in children).
In low-birth-weight infants, the standard approach is to administer blood using a constant-rate syringe delivery infusion pump and a 25-gauge thinwalled scalp vein needle, but the hazards of this technique have not been investigated.
Article
Moss G, Staunton C. Blood flow, needle size and hemolysis— examining an old wives’ tale. N Engl J Med 1970;282(17): 967.19
Herrera AJ, Corless J. Blood transfusions: effect of speed of infusion and of needle gauge on hemolysis. J Pediatr 1981;99(5):757-8.18
Wilcox GJ, et al. Does transfusion using a syringe infusion pump and smallgauge needle cause hemolysis? Transfusion 1981; 21(6):750-1.20
Table 1. Blood Transfusion Evidence Tablea
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In vitro repeatedtrials study using citrate-phosphatedextrose anti coagulated blood that was 2 days old and 9 days old
In vitro multiplesample study using whole blood and packed RBCs
In vivo (animal model; dog) experiment
Sample, Setting, Design
Varied infusion rates: 70 mL/hr, 20.5 mL/hr, 10.6 mL/hr
Varied needle sizes (27, 25, 23, 21 gauge) and flow rates (20, 50, 100 mL/hr)
Aspiration of blood through 25-, 22-, and 20-gauge needles
Intervention/ Manipulation
Plasma-free hemoglobin and potassium levels
Plasma hemoglobin level as measured by spectrophotometry
Tagged 51Cr RBCs; hemolysis calculated from appearance of radioactively labeled iodine on serum or plasma
Outcome Measures
Fresher blood is less sensitive to hemolysis.
For 2-day-old blood, potassium increase not significant, regardless of rate; for 9-day-old blood, hemolysis significant at all rates
No significant difference in plasma hemoglobin at highest speed using smallest needle
No detectable hemolysis with any needle size with aspiration; an increase in delivery pressure (150 lb. per square inch) produced minimal (0.17%) hemolysis with the 25-gauge needle: 8.3% for the 22-gauge needle and 15% for the 20-gauge needle
Results/ Recommendations
QUESTION OF PRACTICE
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[email protected]
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De la Roche MR, Gauthier L. Rapid transfusion of packed red blood cells: effects of dilution, pressure, and catheter size. Ann Emerg Med 1993;22(10):1551-5.13
Angel JL, et al. Infusion of packed erythrocytes: an in vitro study of hemolysis. Obstet Gynecol 1987;69(6): 948-50.16
Gibson JS, et al. Effects of intra venous delivery systems on infused red blood cells. Am J Hosp Pharm 1984; 41(3):468-72.17
To examine flow rates and RBC destruction in the transfusion of packed RBCs by varying the dilution, pressure, and catheter size of the infusion apparatus
“To determine whether hemolysis of packed erythrocytes occurs during currently advocated methods for intrauterine fetal intravascular blood transfusion”
The effect of intrauterine intravascular transfusion using 20- and 22-gauge spinal needles on hemolysis is unknown.
No studies (to date) provide information on the effect on RBC destruction and infusion rate of 3 components of transfusion: catheter size, pressure, and dilution.
“To determine the influence of intravenous delivery systems and procedures on the integrity of administered whole blood and packed RBCs”
No guidelines are available to direct the use of infusion techniques to avoid RBC hemolysis.
In vitro repeated trials, experimental
In vitro multiple samples design
In vitro repeated trials experiment; factorial design
Packed RBCs infused through various catheter sizes (22, 20, 18, and 16 gauge) using various pressures (none, 150 mmHg, 200 mmHg) and dilutions (0 mL NS, 100 mL NS, 250 mL NS
Continuous infusion pump used to deliver packed RBCs at 1–6 mL/min through 20- and 22-gauge 3.5-inch spinal needles
Variables examined were tubing diameter, tubing length, needle gauge (18 and 23 gauge), iv flow rate, type of infusion pump, and type of blood product
Potassium level
RBC count
Plasma-free hemoglobin
Reduction in erythrocyte count compared with erythrocyte count of infusate
Plasma-free hemoglobin
“Mild” variability (from –8% to +18%) in potassium level with all catheter sizes
Variable changes in hemoglobin, hematocrit, and RBC count compared with baseline measures but no consistent pattern of change with respect to catheter size
“No clinically important hemolysis was noted even with a hematocrit of 80% and flow rates as high as 360mL/hour (6 mL/min).”
Blood infusion through standard 20- and 22-gauge spinal needles, with varying hematocrit and rates of 1–6 mL/ min, did not result in significant erythrocyte hemolysis.
Consideration of specific guidelines NOT justified
Small and variable changes (not significant) in plasmafree hemoglobin seen when needle gauge varied
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To determine level of hemolysis by using catheters of different sizes and by varying the flow rate
Institutional policy requires use of 22-gauge or larger catheter for blood transfusion but patients’ veins often do not accommodate this, necessitating placement of a central line.
Acquillo G. Blood transfusion flow rate. Journal of the Association for Vascular Access: JAVA 2007;12(4):225-6.12
NS = normal saline; RBC = red blood cell. a All articles in this table have a level of evidence of III.
“To evaluate hemolysis occurring during a simulated transfusion of RBC units of varying ages via cannulas of different diameters”
“The effect of using external pressure on hemolysis has not been clarified in the literature. Also, it is unknown whether other factors such as needle gauge affect hemolysis during transfusion.”
Frelich R, Ellis MH. The effect of external pressure, catheter gauge, and storage time on hemolysis in RBC transfusion. Transfusion 2001; 41(6):799-802.14
Purpose
Problem
Article
Table 1. Continued
In vitro repeated trials experiment using an outdated (expired) unit of autologous blood and an “indated” unit of autologous blood
In vitro repeated trials laboratory study
Sample, Setting, Design
Varied catheter sizes (18, 20, 22, 24 gauge) and through each catheter size varied the infusion rate in cc/hr (100, 125, 150, 999)
Simulated transfusion via 16-, 18-, 20-, and 22-gauge catheters with varying infusion pressures: none, 150 mmHg, 300 mmHg
Intervention/ Manipulation
Plasma-free hemoglobin by hemoglobinometry
Hemoglobin, hematocrit, RBC, free hemoglobin, lactate dehydrogenase, and potassium levels
Outcome Measures
Small rise in hemoglobin when outdated blood infused through 22-gauge (small increase in hemolysis at 999 mL/hr) and 24-gauge (small increase in hemolysis at all infusion rates) catheters using expired blood; no hemolysis with all catheter sizes and all flow rates when “indated” blood used
The diameter of the catheter was a significant determinant of hematocrit, RBC count, and free hemoglobin concentration only
Increase in potassium level using different needle gauge and pressure was not significant for fresh blood or old blood
Results/ Recommendations
QUESTION OF PRACTICE
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for evidence. Consequently, we set aside for future investigation questions on the effects of infusion pumps on hemolysis during transfusion. Synthesizing the evidence. Our goal was to construct meaningful statements related to our outcomes of interest—posttransfusion hemolysis and hyperkalemia—in particular how findings cut across studies and compared with the recommendations of our two authoritative sources: the AABB and the INS (see Table 212-14, 16-20, 22, 23). The findings of these sources were considered supplementary since they included recommendations on catheter size for transfusion but no information on posttransfusion hemolysis or hyperkalemia. In summary, our review of the literature and authoritative sources provided us with the evidence we needed to challenge our long-held belief that blood must be transfused though a 20-gauge-orlarger catheter. Evidence suggests that smaller-than20-gauge catheters may be safely used for blood transfusion.
ENGAGING THE STAKEHOLDERS
Next, we developed a poster to present our findings to members of committees such as the nurse practice and EBP/nursing research committees. With help from the CNS, we produced a poster addressing the background and purpose of our project; how we accessed, appraised, and synthesized data; the major findings; and our team’s recommendations. With financial support from the clinical nurse manager’s cost center, the poster was printed for display during our presentations. Having a professional-looking poster enhanced the presenters’ credibility. The CNS and clinical nurse manager also helped by scheduling rehearsal sessions where team members could practice and get feedback on their presentation. We delivered our presentation with confidence. We argued that changing practice by using a smaller catheter gauge would promote patient comfort and save money (because there would likely be fewer unnecessary needlesticks). Both committees encouraged us to move quickly in making a concrete recommendation.
Table 2. Findings from the Literature Table 2. Findings fromrelated the Literature Synthesis of findings to posttransfusion hemolysis 1. No significant or clinically important hemolysis occurred when blood was infused through catheters of varying gauge sizes (27,18 25,18, 20 24,12 23,17, 18 22,12, 13, 16 21,18 20,12, 13, 16 18,13, 17 1613) or aspirated through needles of various sizes (25, 22, and 20 gauge19). 2. Varying the flow rate12, 16-18 from 20 mL/hr to as much as 999 mL/hr did not significantly affect hemolysis as long as blood was not outdated (more than 9 days old or designated “expired”).12, 14, 20 3. The amount (the number of studies) and strength of support showing no adverse hemolysis effects when using a 22-gauge catheter to infuse blood12, 13, 16 are comparable to the amount and strength of support for using 20-gauge12, 13, 16 and 18-gauge13, 17 catheters. 4. Across studies, infusion technique (syringe pump,20 continuous infusion pump12, 16) did not increase hemolysis; however, external bag pressure did increase hemolysis.13 Synthesis of findings related to posttransfusion hyperkalemia 1. No clinically significant increase in potassium occurred when a syringe infusion pump was used to infuse blood through a 25-gauge thin-walled needle at rates of 70 mL/hr, 20.5 mL/hr, and 10.6 mL/hr.20 2. There was mild variability (–8% to +18%) in potassium levels when packed RBCs were infused through 22-, 20-, 18-, and 16-gauge catheters at varying pressures (0 mmHg, 150 mmHg, 200 mmHg) and dilutions (0 mL, 100 mL, 250 mL normal saline).13 3. No significant increase in potassium level occurred in fresh blood or old blood using different needle gauges (16, 18, 20, and 22 gauge) under different external pressures (0 mmHg, 150 mmHg, 300 mmHg).14 Summary of findings from authoritative sources 1. “The nurse should be aware that a short peripheral catheter of 14-24 gauge for adults and 22-24 gauge for pediatric[s] or neonates can generally be used for administration of blood or blood products.”22 2. Blood and blood components can safely be transfused through a 22-to-24-gauge short peripheral catheter.23 [email protected]
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QUESTION OF PRACTICE
Table 3. New Recommendations for Catheter Size in Blood Transfusion Catheter size (gauge)
Clinical application related to blood transfusion
14, 16, 18
Reserve for rapid infusion of blood
20
Preferred for routine blood transfusion (if vein will accommodate)
22
May be used for blood transfusion to accommodate vein size or patient preference
24
May be used for blood transfusion (small vein)
CHANGING POLICY AND PRACTICE
As our understanding of the benefits of using a smaller-than-20-gauge catheter grew, so did our awareness of the need to propose a change to policy and practice at our institution. The team reviewed the current policy (use an 18-gauge iv catheter to start), but found it vague regarding how to proceed when a vein could not be found that would accommodate an 18-gauge catheter. The new wording we suggested was “choose a catheter gauge (14–24) based on consideration of the purpose of the transfusion, patient condition, patient preference, and vein size.” At our cancer center, patients have had many needlesticks and may be dehydrated or have other health issues. This policy change would allow nurses to choose catheter size according to patients’ overall condition as well as the condition of their veins. To assist with the change, we offered guidelines for nurses’ use in various circumstances—guidelines that were ultimately incorporated into the institution’s blood transfusion policy (see Table 3).
recommend pilot testing when introducing new EBPs,10 we argued that the evidence we found was sufficient to support immediate implementation. Moreover, it seemed likely that conducting a pilot test with posttransfusion monitoring of hemolysis and potassium levels would place an unnecessary burden on patients and staff and incur costs for additional laboratory tests, which are not routinely conducted after transfusions. In keeping with the framework for EBP projects, we consulted medical colleagues and infusion nurses from our iv drug therapy team about the proposed policy change. Both the team’s clinical leader and the chairperson of the transfusion committee endorsed the proposed change to policy. Once the policy was approved, we involved our nursing education department to help orient nurses in the ambulatory and inpatient settings to the change in policy and practice. Orienting the entire nursing staff to this change was completed within 60 days of its approval. Currently, newly employed nurses are informed of the policy and practice as part of their new employee orientation.
Our review of the literature and authoritative sources provided us with the evidence we needed to challenge our long-held belief that blood must be transfused though a 20-gauge-or-larger catheter. After we shared the results of our EBP project with members of the two committees and received positive feedback, we were ready to recommend an immediate change, which meant there would be no pilot testing. Thus, the change to practice would be effective as soon as the change to policy was approved. Although others 58
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In conclusion, our team demonstrated the value of questioning “fabled” standards of practice. Our timeline for this project was remarkably short—six months, from start to finish—and we believe that several factors contributed to our success. First, we had an enthusiastic and engaged team who believed that a ajnonline.com
change in practice could promote patient comfort. Second, the culture of care at our institution is one in which EBP is highly regarded. Third, our EBP/ nursing research committee provided support, consultation, and guidance. And finally, nursing management endorses the use of EBP and encourages nursing participation in EBP projects. The literature speaks extensively to the barriers staff nurses face when it comes to getting involved in EBP.24 Our biggest barrier involved fitting this important project into our already busy lives. Like many nurses, we work full time and have family responsibilities. Sometimes we felt so overwhelmed we couldn’t move forward. It helped when the CNS or clinical nurse manager offered words of encouragement or took time to mentor us. Despite the added work, participating in this project taught us many things about teamwork, public speaking, and ourselves. With respect to EBP, we felt more confident that we could write a good PICOT question and evaluate a research article, extract relevant information from the article, and organize information into an understandable grid for analysis. Also, we came to a new appreciation of teamwork and collaboration. The guidance provided by the CNS and the clinical nurse manager helped us to achieve our goals, change policy and practice, and improve the patient experience. Our experience mirrors what has been reported in the literature on the importance of mentors in promoting EBP.25 While we have not yet formally evaluated the impact of this change in clinical practice, we have learned something important: that sometimes you have to step out of your comfort zone to make good things happen for patients. ▼ Catherine Stupnyckyj and Sheryl Smolarek are clinical nurse leaders at the Barbara Ann Karmanos Cancer Institute, Detroit, where Colleen Reeves is a clinical nurse, Judith McKeith is a clinical nurse manager, and Morris Magnan is a clinical nurse specialist. Contact author: Morris Magnan, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. American Red Cross. Blood facts and statistics. n.d. http:// www.redcrossblood.org/learn-about-blood/blood-facts-andstatistics. 2. Barrett-Lee P, et al. Management of cancer-related anemia in patients with breast or gynecologic cancer: new insights based on results from the European Cancer Anemia Survey. Oncologist 2005;10(9):743-57. 3. Hurter B, Bush NJ. Cancer-related anemia: clinical review and management update. Clin J Oncol Nurs 2007;11(3):349-59. 4. Gillespie TW. Anemia in cancer: therapeutic implications and interventions. Cancer Nurs 2003;26(2):119-28. 5. Lippincott Williams and Wilkins, ed. Lippincott’s nursing procedures. 5th ed. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins; 2009. [email protected]
6. Merck Manual of Diagnosis and Therapy. Topics in trans fusion medicine: technique of transfusion. Merck Sharp and Dohme Corp. 2014. http://www.merckmanuals.com/ professional/hematology_and_oncology/transfusion_medicine/ technique_of_transfusion.html?qt=techniques%20of%20 transfusions&alt=sh. 7. Sargeant J, et al. Effective interprofessional teams: “contact is not enough” to build a team. J Contin Educ Health Prof 2008;28(4):228-34. 8. Koloroutis M, ed. Relationship-based care: a model for transforming practice. Minneapolis: Creative Health Care Management, Inc.; 2004. 9. Maklebust J. Engaging the patient and family as partners in practice. Nursing 2011;41(6):23-4. 10. Titler MG, et al. The Iowa model of evidence-based practice to promote quality care. Crit Care Nurs Clin North Am 2001; 13(4):497-509. 11. Melnyk BM, et al. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs 2010; 110(1):51-3. 12. Acquillo G. Blood transfusion flow rate. Journal of the Association for Vascular Access: JAVA 2007;12(4):225-6. 13. De la Roche MR, Gauthier L. Rapid transfusion of packed red blood cells: effects of dilution, pressure, and catheter size. Ann Emerg Med 1993;22(10):1551-5. 14. Frelich R, Ellis MH. The effect of external pressure, catheter gauge, and storage time on hemolysis in RBC transfusion. Transfusion 2001;41(6):799-802. 15. Klem ML, Weiss PM. Evidence-based resources and the role of librarians in developing evidence-based practice curricula. J Prof Nurs 2005;21(6):380-7. 16. Angel JL, et al. Infusion of packed erythrocytes: an in vitro study of hemolysis. Obstet Gynecol 1987;69(6):948-50. 17. Gibson JS, et al. Effects of intravenous delivery systems on infused red blood cells. Am J Hosp Pharm 1984;41(3):46872. 18. Herrera AJ, Corless J. Blood transfusions: effect of speed of infusion and of needle gauge on hemolysis. J Pediatr 1981; 99(5):757-8. 19. Moss G, Staunton C. Blood flow, needle size and hemolysis—examining an old wives’ tale. N Engl J Med 1970;282(17):967. 20. Wilcox GJ, et al. Does transfusion using a syringe infusion pump and small-gauge needle cause hemolysis? Transfusion 1981;21(6):750-1. 21. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. 2nd ed. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins; 2011. 22. Infusion Nurses Society. Infusion nursing standards of practice. Vascular access device selection and placement J Infus Nurs 2011;34(1S):S37-S49. 23. Roback J, et al. Technical manual. 16th ed. Bethesda, MD: American Association of Blood Banks; 2008. 24. Solomons NM, Spross JA. Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review. J Nurs Manag 2011;19(1): 109-20. 25. Melnyk BM, et al. Nurses’ perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: implications for accelerating the paradigm shift. Worldviews Evid Based Nurs 2004;1(3):185-93.
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Changing Blood Transfusion Policy and Practice Can smaller-than-20-gauge catheters be used safely? An evidence-based practice project finds that they can. OVERVIEW: It is often an accepted practice that a 20-gauge-or-larger catheter is used for the safe transfusion of blood in adult patients, but it is unclear what evidence supports this practice. This article tells the story of how a small team of oncology nurses designed and implemented an evidence-based practice project to challenge that convention. A literature search and a consultation with the standards of the American Association of Blood Banks and the Infusion Nurses Society determined that a smaller-than-20-gauge catheter can be used safely to transfuse blood in adults, a discovery that led to a change in policy and practice at the authors’ institution. Keywords: blood transfusion, catheter, evidence-based practice, hemolysis, hyperkalemia
T
he American Red Cross estimates that about every two seconds someone in the United States requires a blood transfusion.1 A variety of patients may need a transfusion of red blood cells (RBCs), but most have anemia, which may be acute (caused by rapid blood loss) or chronic (caused by debilitating conditions such as kidney disease or cancer). When it comes to anemia, patients with cancer are a particularly vulnerable group. Anemia is highly prevalent in cancer,2 but its causes are poorly understood.3 Still, it is well known that aggressive cancer treatments can disrupt RBC production, necessitating frequent blood transfusions, sometimes even daily during chemotherapy.1, 4 Typically, RNs are responsible for administering blood, monitoring for transfusion reactions, and promoting comfort and safety. By convention, nurses have come to accept that a 20-gauge catheter (or larger) should be used when transfusing blood. But the patient’s age and condition, as well as the condition and size of the vein to be used, often suggest that a smaller catheter would be more suitable. The rationale for using a 20-gauge-or-larger catheter to transfuse blood in nonemergency situations is not well documented. Nevertheless, in practice, use of the 20-gauge-or-larger catheter persists, as though it merited no explanation. For example, one commonly referenced nursing-procedures handbook states that when starting an iv line for blood transfusion, “perform a venipuncture, using a 20G 50
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or larger-diameter catheter. Avoid using an existing line if the needle or catheter lumen is smaller than 20G.”5 No reasons for these precautions are given, and the statement isn’t referenced. But hemolysis may be a concern; as one reference manual has noted, “Use of an 18-gauge (or larger) needle prevents mechanical damage to and hemolysis of RBCs.”6 Again, no research is cited to support the assertion that the use of larger catheters “prevents” hemolysis or, conversely, that the use of smaller catheters causes hemolysis. At our institution, a National Cancer Institute– designated comprehensive cancer center, policy states that when a blood transfusion is needed, “start an 18-gauge angiocath if possible,” but the policy provides no lower limit on catheter size. Also, because the practice has been that a catheter no smaller than 20 gauge be used for transfusions, patients may be subjected to unnecessary needlesticks, as in the following description of one of our patients (identifying details have been changed). Mr. S. came to our outpatient clinic expecting just one needlestick for blood to be drawn for routine laboratory work. What he did not expect, though, was that his hemoglobin level would be low, requiring a blood transfusion. A clinic nurse unsuccessfully attempted to draw blood for a type and cross-match test, used to check for blood-type compatibility and antibodies, costing the patient another needlestick. Next, Mr. S. was sent to the infusion center, where ajnonline.com
the iv technician drew blood for the type and cross-match test and placed an iv catheter for transfusion. Mr. S. was delighted: no more needlesticks would be needed. Unfortunately, the iv technician had inserted a 22-gauge catheter without considering that Mr. S. might need a larger catheter for transfusion. Although policy directs the nurse to “start with an 18-gauge” catheter, nurses rarely do because it is difficult to find a peripheral vein that will accommodate such a largebore catheter. The RN caring for Mr. S. thought a 20-gauge catheter (or larger) should be used. When the RN informed the patient that a 20-gauge catheter was needed, Mr. S. and his family became quite upset because of the unexpected number of needlesticks. This forced us to ask ourselves: What evidence supports the use of a 20-gaugeor-larger catheter for blood transfusions? The clinical nurse leader of the outpatient chemotherapy infusion center took this clinical concern to the nurse practice committee, where she was advised to discuss the matter with the clinical nurse specialist (CNS) to determine whether an evidence-based practice (EBP) project might be called for. It was decided that an EBP project would be a good approach for addressing the longstanding concern of what size catheter can be used to transfuse blood safely.
GETTING STARTED
We would have to begin by forming a team and searching the literature. Teams are different from small groups, we learned; teams come together for a specific, goal-directed purpose, and team members have specific roles, perform specific tasks, and work to achieve a common goal or outcome.7 Our goal was to find the scientific evidence that supports using a 20-gauge-or-larger catheter for blood transfusions and disallows using a smaller-than-20-gauge catheter. We assembled a five-member team: an infusion nurse, two clinical nurse leaders, one clinical nurse manager, and one CNS. The clinical nurse leader of the outpatient chemotherapy infusion center served as the EBP team leader—a critical role for scheduling meetings and holding team members accountable for completing tasks on deadline. The other clinical nurse leader (from our bone marrow transplantation center) and the infusion nurse (from our phase 1 clinical trials infusion center) collaborated with other team members in planning the project and accessing, appraising, and synthesizing the evidence found. The clinical nurse manager (also from the outpatient [email protected]
Photo © Thinkstock.
By Catherine Stupnyckyj, RN, Sheryl Smolarek, BSN, RN, OCN, Colleen Reeves, BSN, RN, OCN, Judith McKeith, BSN, RN, CMSRN, and Morris Magnan, PhD, RN
chemotherapy infusion center) scheduled time off for team work, set up meeting space, and arranged for financial support when needed to develop a poster presentation. Finally, the CNS mentored team members throughout the project, helping them to overcome barriers and insecurities. Since team members, except for the CNS, had no prior experience conducting an EBP project, we used our first meeting to orient the team to the scope of the project and the team members’ roles. At our institution a framework is used for all approved EBP projects in nursing (see Figure 1). The framework guides nurses from identifying a “practice concern” to revising standards of care and standards of practice, as well as in grounding the project in our facility’s patient-centered, relationship-based care model, Partners in Practice.8, 9 By studying the framework, team members could see that EBP projects do not end when the “best evidence” to support practice is found. Rather, they move forward to initiate changes in practice that will be continuously evaluated. The framework for EBP projects at our institution incorporates the Iowa model.10 The steps and decision points in the Iowa model were reviewed and discussed at our first team meeting. As a result, team members came to a much fuller understanding that EBP projects entailed using a step-by-step, systematic approach to identify and appraise evidence for practice. Several team members expressed a sense of relief knowing that they were not “flying blind” but actually had an EBP roadmap to follow. The team undertook the task of formulating a question based on the PICOT mnemonic: Population, AJN ▼ December 2014
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QUESTION OF PRACTICE
Sustain practice change
Practice concern -or-
Evaluate EBP Cycle through the Iowa model: 1. Build an EBP team 2. Search for evidence 3. Critically appraise evidence 4. Pilot test/or reject/or move directly to practice change
Implement EBP
Patient-centered evidence-based practice
Propose practice change
Write/revise policy Write/revise SOC and SOP
Incorporate patient and family values and preferences
Incorporate expertise and experience from interdisciplinary team (such as medicine, social work, respiratory therapy)
Figure 1. The Karmanos Cancer Center’s Framework for Evidence-Based Practice in a Partners-in-Practice Environment. EBP = evidence-based practice; SOC = standard of care; SOP = standard of practice.
Intervention, Comparison intervention, Outcome, and Time.11 After several attempts, we settled on the following question: In adults receiving blood transfusions (P), what is the effect of using a smaller-than20-gauge catheter (I) versus using a 20-gauge-or-larger catheter (C) on hemolysis or potassium level or both (O) within 24 hours of transfusion (T)? We chose hemolysis as our principal outcome because we were concerned that we would limit the therapeutic benefit of the transfusion if RBCs ruptured with the use of a smaller-gauge catheter. We chose posttransfusion potassium level as an additional outcome because serum potassium levels can rise as a result of RBC rupture. By formulating a PICOT question, our team was able to come to a clearer understanding of what kind of evidence was needed to address the clinical concern; also, we narrowed the parameters for our search for evidence.11
FINDING, APPRAISING, AND SYNTHESIZING THE EVIDENCE
We were now ready to plan our search for evidence, which we decided to conduct in two areas: the 52
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s cientific literature and authoritative sources. A literature search was performed using the following keywords: blood transfusion needle gauge, transfusion guidelines, transfusions and hyperkalemia, hemolysis and needle gauge, and hemolysis and transfusions. The search engines used included MEDLINE, CINAHL, Google Scholar, and the Cochrane Database of Systematic Reviews. We also consulted the standards of care of the American Association of Blood Banks (AABB) and the Infusion Nurses Society (INS). Each team member chose keywords and search engines. Finding the evidence. In our first pass at searching the literature, abstracts meeting the search criteria were downloaded for screening by the team; abstracts were screened and excluded if they were not research or did not address variations in needle gauge or the outcomes of interest. Of the 26 abstracts screened, only three12-14 seemed appropriate for more in-depth evaluation. The full articles were distributed to the team members for critical review. Another five manuscripts were identified by a search ajnonline.com
of references, in which the team took note of articles cited repeatedly in the three articles. These five were also distributed to the team members for review. In total, eight research articles were eligible for full review because they examined the effect of infusing blood through needles or catheters of different sizes on one or both of the outcome criteria—hemolysis or hyperkalemia after the transfusion. Team members constructed an evidence table to categorize information from each article. Since the critical review of research was new to most of us, our CNS guided us through the review of one article.12 While most found it helpful, we still did not feel confident in our ability to extract information from the articles, a barrier to EBP projects frequently cited in the literature.15 Ultimately, we found it easier to work with the CNS and review articles as a group. After reviewing all the articles, we placed the extracted information into an evidence table (see Table 112-14, 16-20). Then we validated the accuracy of our table by checking it against the original articles.
be placed in studies with strong research designs such as systematic reviews (lower numbers) than in those with weaker research designs such as qualitative research (higher numbers). All the studies we reviewed for this project involved a laboratory performing an experiment repeatedly without comparison groups or randomization. Typically, blood was run through a catheter of a particular size on a number of occasions; each occasion constituted a “trial” in which outcomes were measured. Such laboratory studies are not on the hierarchy of evidence we used. Still, we rated these studies Level III—that is, we determined that the methods used were more rigorous than those of cohort or case–control studies (Level IV) but less rigorous than those of a randomized controlled trial (Level II). None of the studies reviewed used human subjects (one study used an animal [dog] model).19 Most of the studies reported finding no statistically significant difference in free hemoglobin (hemolysis) and potassium levels before and after bagged blood flowed
We reviewed the current policy (use an 18-gauge iv catheter to start), but found it vague regarding how to proceed when a vein could not be found that would accommodate an 18-gauge catheter. Appraising the evidence. Critical appraisal involves evaluating the validity, reliability, and applicability of the study’s methods and findings.21 Questions on the applicability of the studies were the easiest to address: we could tell readily whether a study applied to our population and outcomes of interest. But assessing the validity and reliability of the studies was more difficult. Validity involves the soundness of the scientific methods used; reliability involves the accuracy of the findings and whether they can be attributed to the intervention (in our case, whether hemolysis and hyperkalemia resulted when a smaller catheter gauge was used).21 We struggled to understand how the concepts of validity and reliability applied to each study, ultimately deferring to the judgment of our doctorally prepared CNS. Finally, we weighed the strength of the findings using the “hierarchy of evidence” proposed by Melnyk and Fineout-Overholt.21 This hierarchy weighs evidence on a scale of I to VII: more confidence can [email protected]
through catheters ranging in size from 27 gauge to 16 gauge. One article, in comparing aspiration of blood through needles of various sizes, reported “no detectable hemolysis with any size needle.”19 Across articles, flow rates ranging from as little as 20 mL/hr to as much as 999 mL/hr did not significantly affect hemolysis. One study reported that blood more than nine days old was more susceptible to hemolysis than blood that was two days old, but the authors concluded that the amount of nine-day RBCs affected, 0.2% or lower, was “tolerable under most circumstances.”20 Similarly, a study found that when infusion rate was enhanced by applying external pressure (as high as 300 mmHg), the tendency for hemolysis increased, but according to the authors this small increase was “unlikely to be clinically significant.”14 Several team members asked about the effect of infusion pumps on hemolysis, an important area of concern. But after much discussion we decided to let the PICOT question guide our search AJN ▼ December 2014
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Purpose To examine the relationship between needle size and hemolysis
To address the stated problem
To assess the resulting RBC hemolysis and the effects on it of infusion rate and storage age of the blood transfused
Problem
The admonition to use a larger-bore needle to avoid hemolysis during blood sampling has not been substantiated by evidence.
It is unclear how fast blood should infuse or what needle gauge should be used to avoid hemolysis (during transfusion in children).
In low-birth-weight infants, the standard approach is to administer blood using a constant-rate syringe delivery infusion pump and a 25-gauge thinwalled scalp vein needle, but the hazards of this technique have not been investigated.
Article
Moss G, Staunton C. Blood flow, needle size and hemolysis— examining an old wives’ tale. N Engl J Med 1970;282(17): 967.19
Herrera AJ, Corless J. Blood transfusions: effect of speed of infusion and of needle gauge on hemolysis. J Pediatr 1981;99(5):757-8.18
Wilcox GJ, et al. Does transfusion using a syringe infusion pump and smallgauge needle cause hemolysis? Transfusion 1981; 21(6):750-1.20
Table 1. Blood Transfusion Evidence Tablea
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In vitro repeatedtrials study using citrate-phosphatedextrose anti coagulated blood that was 2 days old and 9 days old
In vitro multiplesample study using whole blood and packed RBCs
In vivo (animal model; dog) experiment
Sample, Setting, Design
Varied infusion rates: 70 mL/hr, 20.5 mL/hr, 10.6 mL/hr
Varied needle sizes (27, 25, 23, 21 gauge) and flow rates (20, 50, 100 mL/hr)
Aspiration of blood through 25-, 22-, and 20-gauge needles
Intervention/ Manipulation
Plasma-free hemoglobin and potassium levels
Plasma hemoglobin level as measured by spectrophotometry
Tagged 51Cr RBCs; hemolysis calculated from appearance of radioactively labeled iodine on serum or plasma
Outcome Measures
Fresher blood is less sensitive to hemolysis.
For 2-day-old blood, potassium increase not significant, regardless of rate; for 9-day-old blood, hemolysis significant at all rates
No significant difference in plasma hemoglobin at highest speed using smallest needle
No detectable hemolysis with any needle size with aspiration; an increase in delivery pressure (150 lb. per square inch) produced minimal (0.17%) hemolysis with the 25-gauge needle: 8.3% for the 22-gauge needle and 15% for the 20-gauge needle
Results/ Recommendations
QUESTION OF PRACTICE
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[email protected]
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De la Roche MR, Gauthier L. Rapid transfusion of packed red blood cells: effects of dilution, pressure, and catheter size. Ann Emerg Med 1993;22(10):1551-5.13
Angel JL, et al. Infusion of packed erythrocytes: an in vitro study of hemolysis. Obstet Gynecol 1987;69(6): 948-50.16
Gibson JS, et al. Effects of intra venous delivery systems on infused red blood cells. Am J Hosp Pharm 1984; 41(3):468-72.17
To examine flow rates and RBC destruction in the transfusion of packed RBCs by varying the dilution, pressure, and catheter size of the infusion apparatus
“To determine whether hemolysis of packed erythrocytes occurs during currently advocated methods for intrauterine fetal intravascular blood transfusion”
The effect of intrauterine intravascular transfusion using 20- and 22-gauge spinal needles on hemolysis is unknown.
No studies (to date) provide information on the effect on RBC destruction and infusion rate of 3 components of transfusion: catheter size, pressure, and dilution.
“To determine the influence of intravenous delivery systems and procedures on the integrity of administered whole blood and packed RBCs”
No guidelines are available to direct the use of infusion techniques to avoid RBC hemolysis.
In vitro repeated trials, experimental
In vitro multiple samples design
In vitro repeated trials experiment; factorial design
Packed RBCs infused through various catheter sizes (22, 20, 18, and 16 gauge) using various pressures (none, 150 mmHg, 200 mmHg) and dilutions (0 mL NS, 100 mL NS, 250 mL NS
Continuous infusion pump used to deliver packed RBCs at 1–6 mL/min through 20- and 22-gauge 3.5-inch spinal needles
Variables examined were tubing diameter, tubing length, needle gauge (18 and 23 gauge), iv flow rate, type of infusion pump, and type of blood product
Potassium level
RBC count
Plasma-free hemoglobin
Reduction in erythrocyte count compared with erythrocyte count of infusate
Plasma-free hemoglobin
“Mild” variability (from –8% to +18%) in potassium level with all catheter sizes
Variable changes in hemoglobin, hematocrit, and RBC count compared with baseline measures but no consistent pattern of change with respect to catheter size
“No clinically important hemolysis was noted even with a hematocrit of 80% and flow rates as high as 360mL/hour (6 mL/min).”
Blood infusion through standard 20- and 22-gauge spinal needles, with varying hematocrit and rates of 1–6 mL/ min, did not result in significant erythrocyte hemolysis.
Consideration of specific guidelines NOT justified
Small and variable changes (not significant) in plasmafree hemoglobin seen when needle gauge varied
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To determine level of hemolysis by using catheters of different sizes and by varying the flow rate
Institutional policy requires use of 22-gauge or larger catheter for blood transfusion but patients’ veins often do not accommodate this, necessitating placement of a central line.
Acquillo G. Blood transfusion flow rate. Journal of the Association for Vascular Access: JAVA 2007;12(4):225-6.12
NS = normal saline; RBC = red blood cell. a All articles in this table have a level of evidence of III.
“To evaluate hemolysis occurring during a simulated transfusion of RBC units of varying ages via cannulas of different diameters”
“The effect of using external pressure on hemolysis has not been clarified in the literature. Also, it is unknown whether other factors such as needle gauge affect hemolysis during transfusion.”
Frelich R, Ellis MH. The effect of external pressure, catheter gauge, and storage time on hemolysis in RBC transfusion. Transfusion 2001; 41(6):799-802.14
Purpose
Problem
Article
Table 1. Continued
In vitro repeated trials experiment using an outdated (expired) unit of autologous blood and an “indated” unit of autologous blood
In vitro repeated trials laboratory study
Sample, Setting, Design
Varied catheter sizes (18, 20, 22, 24 gauge) and through each catheter size varied the infusion rate in cc/hr (100, 125, 150, 999)
Simulated transfusion via 16-, 18-, 20-, and 22-gauge catheters with varying infusion pressures: none, 150 mmHg, 300 mmHg
Intervention/ Manipulation
Plasma-free hemoglobin by hemoglobinometry
Hemoglobin, hematocrit, RBC, free hemoglobin, lactate dehydrogenase, and potassium levels
Outcome Measures
Small rise in hemoglobin when outdated blood infused through 22-gauge (small increase in hemolysis at 999 mL/hr) and 24-gauge (small increase in hemolysis at all infusion rates) catheters using expired blood; no hemolysis with all catheter sizes and all flow rates when “indated” blood used
The diameter of the catheter was a significant determinant of hematocrit, RBC count, and free hemoglobin concentration only
Increase in potassium level using different needle gauge and pressure was not significant for fresh blood or old blood
Results/ Recommendations
QUESTION OF PRACTICE
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for evidence. Consequently, we set aside for future investigation questions on the effects of infusion pumps on hemolysis during transfusion. Synthesizing the evidence. Our goal was to construct meaningful statements related to our outcomes of interest—posttransfusion hemolysis and hyperkalemia—in particular how findings cut across studies and compared with the recommendations of our two authoritative sources: the AABB and the INS (see Table 212-14, 16-20, 22, 23). The findings of these sources were considered supplementary since they included recommendations on catheter size for transfusion but no information on posttransfusion hemolysis or hyperkalemia. In summary, our review of the literature and authoritative sources provided us with the evidence we needed to challenge our long-held belief that blood must be transfused though a 20-gauge-orlarger catheter. Evidence suggests that smaller-than20-gauge catheters may be safely used for blood transfusion.
ENGAGING THE STAKEHOLDERS
Next, we developed a poster to present our findings to members of committees such as the nurse practice and EBP/nursing research committees. With help from the CNS, we produced a poster addressing the background and purpose of our project; how we accessed, appraised, and synthesized data; the major findings; and our team’s recommendations. With financial support from the clinical nurse manager’s cost center, the poster was printed for display during our presentations. Having a professional-looking poster enhanced the presenters’ credibility. The CNS and clinical nurse manager also helped by scheduling rehearsal sessions where team members could practice and get feedback on their presentation. We delivered our presentation with confidence. We argued that changing practice by using a smaller catheter gauge would promote patient comfort and save money (because there would likely be fewer unnecessary needlesticks). Both committees encouraged us to move quickly in making a concrete recommendation.
Table 2. Findings from the Literature Table 2. Findings fromrelated the Literature Synthesis of findings to posttransfusion hemolysis 1. No significant or clinically important hemolysis occurred when blood was infused through catheters of varying gauge sizes (27,18 25,18, 20 24,12 23,17, 18 22,12, 13, 16 21,18 20,12, 13, 16 18,13, 17 1613) or aspirated through needles of various sizes (25, 22, and 20 gauge19). 2. Varying the flow rate12, 16-18 from 20 mL/hr to as much as 999 mL/hr did not significantly affect hemolysis as long as blood was not outdated (more than 9 days old or designated “expired”).12, 14, 20 3. The amount (the number of studies) and strength of support showing no adverse hemolysis effects when using a 22-gauge catheter to infuse blood12, 13, 16 are comparable to the amount and strength of support for using 20-gauge12, 13, 16 and 18-gauge13, 17 catheters. 4. Across studies, infusion technique (syringe pump,20 continuous infusion pump12, 16) did not increase hemolysis; however, external bag pressure did increase hemolysis.13 Synthesis of findings related to posttransfusion hyperkalemia 1. No clinically significant increase in potassium occurred when a syringe infusion pump was used to infuse blood through a 25-gauge thin-walled needle at rates of 70 mL/hr, 20.5 mL/hr, and 10.6 mL/hr.20 2. There was mild variability (–8% to +18%) in potassium levels when packed RBCs were infused through 22-, 20-, 18-, and 16-gauge catheters at varying pressures (0 mmHg, 150 mmHg, 200 mmHg) and dilutions (0 mL, 100 mL, 250 mL normal saline).13 3. No significant increase in potassium level occurred in fresh blood or old blood using different needle gauges (16, 18, 20, and 22 gauge) under different external pressures (0 mmHg, 150 mmHg, 300 mmHg).14 Summary of findings from authoritative sources 1. “The nurse should be aware that a short peripheral catheter of 14-24 gauge for adults and 22-24 gauge for pediatric[s] or neonates can generally be used for administration of blood or blood products.”22 2. Blood and blood components can safely be transfused through a 22-to-24-gauge short peripheral catheter.23 [email protected]
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QUESTION OF PRACTICE
Table 3. New Recommendations for Catheter Size in Blood Transfusion Catheter size (gauge)
Clinical application related to blood transfusion
14, 16, 18
Reserve for rapid infusion of blood
20
Preferred for routine blood transfusion (if vein will accommodate)
22
May be used for blood transfusion to accommodate vein size or patient preference
24
May be used for blood transfusion (small vein)
CHANGING POLICY AND PRACTICE
As our understanding of the benefits of using a smaller-than-20-gauge catheter grew, so did our awareness of the need to propose a change to policy and practice at our institution. The team reviewed the current policy (use an 18-gauge iv catheter to start), but found it vague regarding how to proceed when a vein could not be found that would accommodate an 18-gauge catheter. The new wording we suggested was “choose a catheter gauge (14–24) based on consideration of the purpose of the transfusion, patient condition, patient preference, and vein size.” At our cancer center, patients have had many needlesticks and may be dehydrated or have other health issues. This policy change would allow nurses to choose catheter size according to patients’ overall condition as well as the condition of their veins. To assist with the change, we offered guidelines for nurses’ use in various circumstances—guidelines that were ultimately incorporated into the institution’s blood transfusion policy (see Table 3).
recommend pilot testing when introducing new EBPs,10 we argued that the evidence we found was sufficient to support immediate implementation. Moreover, it seemed likely that conducting a pilot test with posttransfusion monitoring of hemolysis and potassium levels would place an unnecessary burden on patients and staff and incur costs for additional laboratory tests, which are not routinely conducted after transfusions. In keeping with the framework for EBP projects, we consulted medical colleagues and infusion nurses from our iv drug therapy team about the proposed policy change. Both the team’s clinical leader and the chairperson of the transfusion committee endorsed the proposed change to policy. Once the policy was approved, we involved our nursing education department to help orient nurses in the ambulatory and inpatient settings to the change in policy and practice. Orienting the entire nursing staff to this change was completed within 60 days of its approval. Currently, newly employed nurses are informed of the policy and practice as part of their new employee orientation.
Our review of the literature and authoritative sources provided us with the evidence we needed to challenge our long-held belief that blood must be transfused though a 20-gauge-or-larger catheter. After we shared the results of our EBP project with members of the two committees and received positive feedback, we were ready to recommend an immediate change, which meant there would be no pilot testing. Thus, the change to practice would be effective as soon as the change to policy was approved. Although others 58
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Vol. 114, No. 12
In conclusion, our team demonstrated the value of questioning “fabled” standards of practice. Our timeline for this project was remarkably short—six months, from start to finish—and we believe that several factors contributed to our success. First, we had an enthusiastic and engaged team who believed that a ajnonline.com
change in practice could promote patient comfort. Second, the culture of care at our institution is one in which EBP is highly regarded. Third, our EBP/ nursing research committee provided support, consultation, and guidance. And finally, nursing management endorses the use of EBP and encourages nursing participation in EBP projects. The literature speaks extensively to the barriers staff nurses face when it comes to getting involved in EBP.24 Our biggest barrier involved fitting this important project into our already busy lives. Like many nurses, we work full time and have family responsibilities. Sometimes we felt so overwhelmed we couldn’t move forward. It helped when the CNS or clinical nurse manager offered words of encouragement or took time to mentor us. Despite the added work, participating in this project taught us many things about teamwork, public speaking, and ourselves. With respect to EBP, we felt more confident that we could write a good PICOT question and evaluate a research article, extract relevant information from the article, and organize information into an understandable grid for analysis. Also, we came to a new appreciation of teamwork and collaboration. The guidance provided by the CNS and the clinical nurse manager helped us to achieve our goals, change policy and practice, and improve the patient experience. Our experience mirrors what has been reported in the literature on the importance of mentors in promoting EBP.25 While we have not yet formally evaluated the impact of this change in clinical practice, we have learned something important: that sometimes you have to step out of your comfort zone to make good things happen for patients. ▼ Catherine Stupnyckyj and Sheryl Smolarek are clinical nurse leaders at the Barbara Ann Karmanos Cancer Institute, Detroit, where Colleen Reeves is a clinical nurse, Judith McKeith is a clinical nurse manager, and Morris Magnan is a clinical nurse specialist. Contact author: Morris Magnan, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.
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6. Merck Manual of Diagnosis and Therapy. Topics in trans fusion medicine: technique of transfusion. Merck Sharp and Dohme Corp. 2014. http://www.merckmanuals.com/ professional/hematology_and_oncology/transfusion_medicine/ technique_of_transfusion.html?qt=techniques%20of%20 transfusions&alt=sh. 7. Sargeant J, et al. Effective interprofessional teams: “contact is not enough” to build a team. J Contin Educ Health Prof 2008;28(4):228-34. 8. Koloroutis M, ed. Relationship-based care: a model for transforming practice. Minneapolis: Creative Health Care Management, Inc.; 2004. 9. Maklebust J. Engaging the patient and family as partners in practice. Nursing 2011;41(6):23-4. 10. Titler MG, et al. The Iowa model of evidence-based practice to promote quality care. Crit Care Nurs Clin North Am 2001; 13(4):497-509. 11. Melnyk BM, et al. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs 2010; 110(1):51-3. 12. Acquillo G. Blood transfusion flow rate. Journal of the Association for Vascular Access: JAVA 2007;12(4):225-6. 13. De la Roche MR, Gauthier L. Rapid transfusion of packed red blood cells: effects of dilution, pressure, and catheter size. Ann Emerg Med 1993;22(10):1551-5. 14. Frelich R, Ellis MH. The effect of external pressure, catheter gauge, and storage time on hemolysis in RBC transfusion. Transfusion 2001;41(6):799-802. 15. Klem ML, Weiss PM. Evidence-based resources and the role of librarians in developing evidence-based practice curricula. J Prof Nurs 2005;21(6):380-7. 16. Angel JL, et al. Infusion of packed erythrocytes: an in vitro study of hemolysis. Obstet Gynecol 1987;69(6):948-50. 17. Gibson JS, et al. Effects of intravenous delivery systems on infused red blood cells. Am J Hosp Pharm 1984;41(3):46872. 18. Herrera AJ, Corless J. Blood transfusions: effect of speed of infusion and of needle gauge on hemolysis. J Pediatr 1981; 99(5):757-8. 19. Moss G, Staunton C. Blood flow, needle size and hemolysis—examining an old wives’ tale. N Engl J Med 1970;282(17):967. 20. Wilcox GJ, et al. Does transfusion using a syringe infusion pump and small-gauge needle cause hemolysis? Transfusion 1981;21(6):750-1. 21. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. 2nd ed. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins; 2011. 22. Infusion Nurses Society. Infusion nursing standards of practice. Vascular access device selection and placement J Infus Nurs 2011;34(1S):S37-S49. 23. Roback J, et al. Technical manual. 16th ed. Bethesda, MD: American Association of Blood Banks; 2008. 24. Solomons NM, Spross JA. Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review. J Nurs Manag 2011;19(1): 109-20. 25. Melnyk BM, et al. Nurses’ perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: implications for accelerating the paradigm shift. Worldviews Evid Based Nurs 2004;1(3):185-93.
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