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Introduction ⬇

A massive infusion device is a mechanical device used in patients who need rapid fluid replacement with IV fluids or blood products. It can warm IV fluids or blood products to room temperature to prevent hypothermia and then administer the fluid rapidly at rates of up to 45,000 mL/hour. 1 The device requires specialized IV tubing that expands under pressure. 2

Examples of a massive infusion device include the Level 1 infuser, the Belmont infuser, and the ThermaCor 1200 Rapid Infuser. The Level 1 infuser warms fluids through a sealed heat exchanger that contains recirculating solution. Pressure chambers apply pressure and deliver the prescribed fluids at a rapid rate. The administration set tubing contains a gas vent filter and the heat exchanger. An air detector clamp monitors for the presence of air; when it detects air, the clamp closes off the line and alerts the clinician of the presence of air in the system. 3 The Belmont infuser administers the prescribed fluids through the administration set tubing using a roller-type peristaltic fluid pump. Fluid passes through a heat exchanger that consists of a plastic device housing stainless steel rings, which transfer heat to the fluid. The infuser also contains a pressure sensor that monitors the line pressure of the infusate. If the sensor detects pressure that exceeds the limit set by the clinician, the pump automatically slows the infusion. If line pressure suddenly increases, the device shuts down and an alarm sounds. 1 The ThermaCor 1200 Rapid Infusor has a single-use disposable cassette that warms the fluid and provides an administration set with single and dual patient lines. The system has an air-trapping capability that triggers the air volume sensors when enough air is trapped. 4

Patients with life-threatening conditions such as severe trauma, burns, or GI, postoperative, or postpartum hemorrhage may require the use of a rapid infusion device to receive large volumes of fluids within a short period. 2 Sterile no-touch technique is required during massive infusion administration to reduce the risk of vascular catheter-associated infection.

HOSPITAL-ACQUIRED CONDITION ALERT Keep in mind that the Centers for Medicare and Medicaid Services considers vascular catheter–associated infection to be a hospital-acquired condition because it can be reasonably prevented using best practices. Follow evidence-based infection prevention practices, such as performing a vigorous mechanical scrub of the needleless connector and using sterile no-touch technique, to reduce the risk of vascular catheter–associated infections.5,6,7,8

Equipment ⬆ ⬇

Equipment

Massive infusion device • prescribed IV fluids or blood products • prefilled 10-mL syringe (or a syringe specifically designed to generate lower injection pressure) containing preservative-free normal saline solution • appropriate administration set with warming device or heat exchanger1,3 • replacement filter or vent or large-capacity reservoir, as indicated1,3 • IV pole • gloves • antiseptic pads (chlorhexidine-based, povidone iodine, or alcohol) • labels • blankets • stethoscope • vital signs monitoring equipment • disinfectant pad • Optional: indwelling urinary catheter, central venous access catheter or pulmonary artery catheter insertion and monitoring equipment, arterial catheter insertion and monitoring equipment, supplies for blood gas sampling, gown, mask with face shield or mask and goggles.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Male sure that the equipment is safe for massive, rapid, or pressurized infusion.

Inspect all IV equipment and supplies; if a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility. 9

Set up and use the massive infusion device, warming device, or heat exchanger following the manufacturer’s instructions for use. Make sure that the system is plugged into an outlet to ensure that the infused fluid is heated properly.1,3 Make sure that the device alarm limits are set appropriately, and that the alarms are turned on, functioning properly, and audible to staff. 10,11 Troubleshoot alarms according to the specific manufacturer’s instructions for use. 1,3

Implementation ⬆ ⬇

Implementation
  • Verify that the practitioner’s orders for the prescribed solution, rate, and route of administration are appropriate for the patient’s age, condition, and access device. Address concerns about the order with the practitioner, the pharmacist, or your supervisor, and (if needed) the risk management department, or as directed by your facility. 12
  • Verify the baseline coagulation studies and hematocrit, electrolyte, and hemoglobin levels, and results of coagulation and other studies, as ordered, to serve as benchmarks for comparison and help guide fluid replacement.2
  • Check the patient history for allergies, as indicated.
  • Perform hand hygiene. 13,14,15,16,17,18
  • Confirm the patient’s identity using at least two patient identifiers. 19
  • Provide privacy. 20,21,22,23
  • Reinforce the practitioner’s explanation of the procedure according to the patient’s and family’s individual communication and learning needs to increase communication, allay their fears, and enhance cooperation.24 Answer any questions.
  • Raise the bed to waist level before providing care to prevent caregiver back strain.25
  • Perform a baseline physical assessment (before obtaining blood for transfusion, if ordered), including vital signs and respiratory status. Assess for conditions that can increase the risk of adverse effects of therapy, such as heart failure, fever, kidney disease, and risk of fluid volume excess. 26
  • If the patient doesn’t already have one in place, insert an indwelling urinary catheter, as ordered, to help monitor fluid resuscitation efforts. (See the "Indwelling urinary catheter insertion" procedure.)
  • Perform hand hygiene. 13,14,15,16,17,18
  • Put on gloves and other personal protective equipment as needed to comply with standard precautions.27,28
  • Make sure the patient has two patent, large-bore (14G to 18G) IV catheters. 15 If not, insert two IV catheters to administer IV fluid and medications, as needed, until a central venous catheter is possible.29 (See the "IV catheter insertion and removal" procedure.) If you’re unable to establish venous access, initiate intraosseous access, if indicated. 2,30 (See the "Intraosseous infusion" procedure.)
  • Assist the practitioner, as needed, with insertion of a central venous or pulmonary artery catheter to facilitate administration of large fluid volumes and to help monitor the patient’s hemodynamic status.2
  • Assist the practitioner, as needed, with arterial catheter insertion for continuous blood pressure assessment.2
  • Turn on the infusion device according to the manufacturer’s instructions to allow the system to warm up.2
  • If you’re infusing blood products, perform a pretransfusion blood verification with another qualified health care provider. A pretransfusion verification by two qualitied health care providers is required to prevent life-threatening blood incompatibility errors.19,26,31 (See the "Transfusion of blood and blood products" procedure.)

HOSPITAL-ACQUIRED CONDITION ALERT Keep in mind that the Centers for Medicare and Medicaid Services considers blood incompatibility errors to be a hospital-acquired condition because they can be reasonably prevented using best practices. Be sure to follow evidence-based prevention practices, such as carefully identifying the patient and the blood sample for compatibility testing and participating in a two-person verification process before blood and blood products administration, to reduce the risk of blood incompatibility errors.5

  • Remove the appropriate administration set from its packaging. Inspect the administration sets for loose or missing Luer and spike caps to ensure sterility.1,3

Using the Level 1 Infuser

  • Install the appropriate administration set into the infusion device according to the manufacturer’s instructions. 3
  • Secure the heat exchanger and gas vent filter in their proper positions and turn them on, following the manufacturer’s instructions. 2,3
  • Close all of the clamps on the Y-administration set. 3
  • Invert and spike the fluid or blood product bag. Squeeze the bag to remove all air and connect the ordered fluid or blood product to the Y-set. Then hang the bag on the hooks provided within the rapid infuser pressure chambers. 2 Close the pressure chamber door and secure the latch. Repeat for each fluid line you’ll use. 3
  • Open the clamps above the drip chamber for each IV fluid bag you’ll use. 3 Fill the drip chambers on the administration set halfway by squeezing them to prevent air from entering the tubing.2 Repeat with each fluid line, as indicated. 3
  • Open the remaining clamps above the heat exchanger so that fluid will flow into the gas vent filter assembly.3
  • Gently tap the gas vent filter assembly to dislodge air bubbles from the filter screen, according to the manufacturer’s instructions. Inspect the tubing and filter when finished to make sure there are no air bubbles.2
  • Remove the male Luer cap from the distal end of the administration set tubing. 3
  • Open the pinch clamp below the gas vent filter assembly. Allow fluid to flow until you no longer observe air in the tubing and the line is primed with fluid to prevent air embolism. Then close the roller clamp. Put a new needleless connector on the end of the tubing. 3,32
  • Perform a vigorous mechanical scrub of the needleless connector on the vascular access device for at least 5 seconds using an antiseptic pad, and allow it to dry completely. 6,32
  • While maintaining sterility of the syringe tip, attach a 10-mL syringe or a syringe specifically designed to generate low injection pressure containing preservative-free normal saline solution to the needleless connector. Unclamp the catheter and slowly aspirate for blood return that is the color and consistency of whole blood. If no blood return occurs, take steps to locate an external cause of obstruction. 33
  • If blood return occurs, slowly inject preservative-free normal saline solution into the catheter. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if you meet resistance. 33
  • Clamp the catheter and remove and discard the syringe in a puncture-resistant sharps disposal container. 34
  • Carefully remove the needleless connector from the vascular access device. Perform a vigorous mechanical scrub of the catheter hub for at least 5 seconds using an antiseptic pad; then allow it to dry comple­tely. 6,35,36
  • Trace the tubing from the patient to its point of origin to make sure that you’re attaching the tubing to the proper port.37,38
  • Connect the distal end of the tubing to the patient’s vascular access catheter. If the patient has other tubing and catheters that have different purposes, route the tubing using a standardized approach. If you’re using multiple IV lines, label each tubing at the distal end (near the patient connection) and the proximal end (near the source container) to reduce the risk of misconnection.38
  • Complete functional testing of all audible and visual alarms according to the manufacturer’s instructions. If any visual indicator doesn’t illuminate or the audible signal doesn’t sound, remove the device from service immediately. 3,39,40
  • After confirming proper infusion device operation, unclamp the tubing and begin the infusion, adjusting the infusion rate as needed. 2

Using the Belmont Infuser

  • Install the appropriate administration set into the infusion device according to the manufacturer’s instructions. 1
  • Confirm that the heat exchanger is secured properly. 1
  • As needed for infusion of larger volumes of fluid, replace the reservoir chamber with the larger-capacity reservoir. Using sterile technique, remove the reservoir chamber from the administration set by disconnecting the Luer connectors. 1
  • Attach the reservoir holder onto the IV pole and place the larger reservoir into the holder. 1
  • Attach the three fluid supply tails onto the top of the larger reservoir to be used. 1
  • Connect the larger reservoir to the administration set. Adjust the reservoir holder to make sure that the connection leads underneath the reservoir aren’t stretched or kinked.1
  • Hang the fluid bag on the IV pole. 1
  • Close the bag clamps and remove the bag spike cap. Perform a vigorous mechanical scrub of the port with an antiseptic pad for at least 5 seconds and allow it to dry completely. Then spike the fluid bag, piercing it fully to ensure that fluids flow freely.1
  • Repeat with additional fluid lines that you’ll use. 1
  • Open the bag clamps. 1
  • Prime the main system by pressing the PRIME button to recirculate 100 mL of fluid at 500 mL/minute to remove air and replace the main system with fluid.1
  • Prime the remainder of the administration tubing by opening the roller clamp and removing the male Luer cap at the distal end of the tubing. Press the PT. LINE PRIME button once to prime at 50 mL/minute and press and hold the button to prime at 200 mL/minute. Press the STOP button after inspecting the tubing to make sure there are no air bubbles. Press the PT. LINE PRIME button again to remove any remaining air.1
  • Perform a vigorous mechanical scrub of the needleless connector of the vascular access device for at least 5 seconds with an antiseptic pad, and allow it to dry completely. 6,32,35,36
  • While maintaining sterility of the syringe tip, attach a prefilled 10-mL syringe or a syringe specifically designed to generate low injection pressure containing preservative-free normal saline solution to the needleless connector. Unclamp the catheter and slowly aspirate for blood return that is the color and consistency of whole blood. If no blood return occurs, take steps to locate an external cause of obstruction. 33,35,36
  • If blood return occurs, slowly inject preservative-free normal saline solution into the catheter. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if you meet resistance. 33
  • Clamp the catheter and remove and discard the syringe in a puncture-resistant sharps disposal container. 34
  • Carefully remove the needleless connector from the vascular access device. Perform a vigorous mechanical scrub of the catheter hub for at least 5 seconds using an antiseptic pad; then allow it to dry complet­ely. 32,35,36
  • Trace the tubing from the patient to its point of origin to make sure that you’re attaching the tubing to the proper port.37,38
  • Connect the distal end of the tubing to the patient’s vascular access catheter. 1 If the patient has other tubing and catheters that have different purposes, route the tubing using a standardized approach. If you’re using multiple IV lines, label each tubing at the distal end (near the patient connection) and the proximal end (near the source container) to reduce the risk of misconnection.38
  • Unclamp the catheter, press INFUSE to start infusing, and adjust the flow rate, as needed. 1

Using the Thermacor 1200 Rapid Infuser

  • Unlatch and remove the component guard from the unit. 41
  • Turn the latch into the load position. Place the cassette on the load bar (at the bottom of the unit) at a 45-degree angle and then lift and press the cassette directly into the unit. Close the latch into the lock position. 41
  • Open the roller pump door and push the roller tubing all the way to the back to reduce the incidence of improper loading of the tubing. Close the pump door. 41
  • Connect the three-spike in-flow set to the cassette by following the color-coded caps. Connect the blue to blue and the yellow to yellow.41
  • Connect the patient line by following the color-coded caps. Connect the red to red. 41
  • Connect one or more of the spikes from the in-flow set to an IV fluid bag and hang it on the pole. 41
  • Open the clamp closest to the fluid or blood bag and observe for fluid filling the filter. When the filter is ⅔ full, push the PRIME button for the system to autoprime. As needed for infusion of larger volumes of fluid, replace the fluid infusion bag with the larger-capacity reservoir. 41
  • When the system beeps, push and hold the PRIME button and observe as fluid primes the tubing that connects to the patient to ensure that all air is removed from the system.41
  • Perform a vigorous mechanical scrub of the needleless connector on the vascular access device for at least 5 seconds using an antiseptic pad. Then let it dry completely. 6,32,35,36
  • While maintaining sterility of the syringe tip, attach a prefilled 10-mL syringe or a syringe specifically designed to generate lower injection pressure containing preservative-free normal saline solution to the needleless connector. Unclamp the catheter and slowly aspirate for a blood return that’s the color and consistency of whole blood. If you don’t obtain a blood return, take steps to locate an external cause of obstruction. 33,35,36
  • If you obtain a blood return, inject preservative-free normal saline solution slowly into the catheter. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if you meet resistance. 33
  • Clamp the catheter and remove and discard the syringe in a puncture-resistant sharps disposal container. 34
  • Carefully remove the needleless connector from the vascular access device. Perform a vigorous mechanical scrub of the catheter hub for at least 5 seconds using an antiseptic pad. Then let it dry completely. 32,35,36
  • Trace the tubing from the patient to its point of origin to make sure that you’re attaching the tubing to the proper port.37,38
  • Connect the distal end of the tubing to the patient’s vascular access catheter. If the patient has other tubing and catheters that have different purposes, route the tubing using a standardized approach. If you’re using multiple IV lines, label each tubing at the distal end (near the patient connection) and the proximal end (near the source container) to reduce the risk of misconnection.38
  • Choose the mode of operation (slow, rapid, or bolus) for fluid delivery and then push the start button. 41

Completing the Procedure

  • Monitor the patient’s vital signs every 5 to 15 minutes, as indicated. As the patient’s condition stabilizes, monitor vital signs less frequently (every 30 minutes until the patient’s blood pressure is stable for longer than 2 hours).2
  • Monitor core temperature every 15 to 30 minutes and maintain a core temperature no lower than 96.8° F (36° C) to prevent hypothermia-induced coagulopathies.2
  • Assess the patient’s hemodynamic parameters every 15 to 30 minutes and urine output every 30 to 60 minutes, as ordered, to evaluate the patient’s fluid volume status, which indicates the effectiveness of fluid resuscitation and can be used to guide therapy.2
  • Inspect IV sites every 15 minutes, because rapid infusion increases the risk of infiltration.2
  • If the patient is receiving blood products, monitor closely for signs of a transfusion reaction, such as fever, chills, flushing, nausea, chest tightness, restlessness, apprehension, and back pain. 2,26
  • Obtain an arterial blood gas sample, as ordered, to monitor oxygenation and acid-base balance. (See the "Arterial puncture for blood gas analysis" procedure.)
  • When the infusion is complete, change the IV fluid or blood bag according to the specific manufacturer’s instructions.
  • Discard the empty infusion bag in the proper receptacle27,34 or, if required by your facility, return empty blood transfusion bags to the blood bank.
  • Obtain blood samples for hemoglobin level, hematocrit, lactic acid level, and electrolyte levels, and for coagulation studies and thromboelastography, as ordered. (See the "Venipuncture" procedure.)
  • Report all critical test results to the practitioner within the time frame established by your facility to prevent life-threatening treatment delays.42
  • Return the bed to the lowest position to prevent falls and maintain patient safety.43
  • Discard used supplies in appropriate receptacles. 27,34,44
  • Provide warming measures, such as additional blankets, to keep the patient warm and prevent hypothermia.2
  • Remove and discard your gloves and other personal protective equipment, if worn. 27,34,45
  • Perform hand hygiene. 13,14,15,16,17,18
  • Clean and disinfect your stethoscope with a disinfectant pad. 46,47
  • Perform hand hygiene. 13,14,15,16,17,18
  • Document the procedure. 48,49,50,51

Special Considerations ⬆ ⬇

Special considerations
  • Replace gas vent filters and reservoirs according to the manufacturer’s instructions. 1,3 Change the tubing and filter of a Level 1 transfuser according to the manufacturer’s recommendations. 52 Clean and disinfect the device according to the manufacturer’s recommendations.
  • If you’re administering blood products, prime the system with a compatible IV solution; don’t prime with the blood product. 1,3

Complications ⬆ ⬇

Complications

Possible complications include electrolyte imbalances, fluid overload, acid-base imbalance, infiltration or extravasation, pulmonary edema, heart failure, interstitial edema, acute respiratory distress syndrome, and hypothermia. 2

Documentation ⬆ ⬇

Documentation

Document the transfusion of all blood products in the patient’s record, including the product type, date and time of the infusion, and unique number or lot number for blood products. Document the infusion site used, access device, and site condition. Record the patient’s core temperature before the start of a massive infusion and at intervals during and after the procedure. Documentation should include a meticulous account of the amounts and types of fluids and correlating vital signs. Record the patient’s response to the procedure, the practitioner notified of any complications of the procedure, and actions taken to address the complications. Incorporate documentation of massive fluid infusion into the existing required documentation protocol for resuscitation documentation. 48,49 Record teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

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