Rapid infusion of additive red blood cells: alternative techniques for massive hemorrhage

Additive red blood cells (RBCs) have replaced packed RBCs for treatment of massive hemorrhage in many medical centers. Modifications in transfusion apparatus and RBC viscosity were tested for their ability to provide rapid flow of additive RBCs. Infusions through standard transfusion tubing and three types of large-bore transfusion tubing were compared using three large-bore catheters, two infusion pressures, and additive RBCs of three different viscosities. More than 13 minutes were required to infuse 1 unit 4 C RBCs using current accepted practice (16-gauge catheter, standard tubing, gravity flow). The most rapid technique resulted in an infusion time of 20 +/- 1 seconds for 22 C blood. The addition of pressure infusion, large-bore tubing, or an 8F catheter to a transfusion system reduced infusion times up to 74%, 82%, and 85%, respectively. The combination of all three techniques resulted in a maximum improvement of 96%. Saline predilution and warming did not consistently provide clinically important differences in infusion time but may be important for avoidance of hypothermia. Spectrophotometric measurement of free hemoglobin demonstrated no clinically significant hemolysis secondary to rapid infusion. Clinical management should address potential hypocalcemia and coagulopathy. We conclude that large-bore tubing, pressure infusion, and an 8F catheter can provide important decreases in infusion time of additive RBCs without evidence of significant hemolysis.