In vitro compatibility of whole blood with commonly used medications in the pediatric trauma setting

Current guidelines do not endorse co-infusion of blood with medication due to concerns for hemolysis and/or clotting. However, concomitant delivery may be required in emergency situations with limited intravenous access. The purpose of this study was to explore the physical compatibility of nine medications used in pediatric emergencies with leukoreduced group O whole blood.

Blood was manually mixed with study medication and centrifuged at 6500 RPMs for three minutes. A mixture of normal saline and whole blood served as the control. The supernatant was tested for hemolysis using lactate dehydrogenase activity. Each sample was inspected for coalescence or separation. Two separate experiments were performed to demonstrate reproducibility. Compatibility was defined as the absence of gross clot formation/separation provided that lactate dehydrogenase concentrations remained below control values and increased by no more than10% from baseline.

Lactate dehydrogenase activity was measured at two intervals: 15 to 30min and 30 to 60min post-mixing. Cefazolin, epinephrine, succinylcholine, and tranexamic acid in combination with whole blood yielded lactate dehydrogenase concentrations that were stable and below the control values - thus, these were considered compatible at 30-60min. Etomidate and rocuronium could not be analyzed due to either mechanical interference or high analyte concentrations and were considered incompatible. Norepinephrine, calcium chloride, and sodium bicarbonate were considered incompatible as they exceeded the 10% threshold, exhibited lactate dehydrogenase values above control, or showed evidence of separation.

Co-infusion of select medications with whole blood may be considered in the setting of limited intravenous access.