Safe IV solutions; supply storage; indicator strips; recommended practices; latex; physicians' orders - Clinical Issues

AORN Journal, Oct, 2001 by Ramona Conner

Question: I read that either lactated Ringer's or saline solution can be infused concurrently with blood transfusions. Our facility policy states and I have been taught that only saline solution can be used. Can lactated Ringer's solution be safely infused with blood transfusions?

Answer: Lactated Ringer's solution should not be used because it contains calcium, which combines with the anticoagulation citrate in the blood component's preservative solution and causes clotting. Five percent dextrose solution also should not be used because it is hypotonic and may cause red blood cells to hemolyze. (1) The American Association of Blood Banks (AABB) states,

   No medications or solutions may be routinely added to or infused through
   the same tubing with blood or components except 0.9% sodium chloride. (2)

The AABB further states that other solutions intended for IV use may be used in an administration set or added to blood or blood components if

* they have been approved by the US Food and Drug Administration or

* there is documentation that addition of the component involved is safe and efficacious.

The AABB states that 5% albumin, ABO-compatible plasma, plasma protein fraction, or other suitable plasma expanders may be used if approved by the patient's physician. Lactated Ringer's solution or other electrolyte solutions containing calcium should never be added to or administered concurrently with blood or blood components collected in an anticoagulant containing citrate. Five percent albumin, 0.9% sodium chloride, and compatible plasma are the only solutions that should be concurrently infused through the same IV line as blood products.

Question: We need more storage space for our specialty supply carts (eg, vascular carts for grafts, laparoscopic trocars, and disposable supplies). Some nurses have suggested that we convert part of our clean instrument processing area into storage for these items. The clean processing area would be moved into the decontamination area. This would mean that there would be no physical barrier separating the clean section of the processing area from the dirty decontamination area. We are due for a Joint Commission on Accreditation of Healthcare Organizations inspection next June, and I believe we might receive a citation if this action is taken.

Answer: Although the need for additional storage is an almost universal concern for surgical facilities, it is not acceptable to eliminate the physical barrier between the processing areas (eg, decontamination area, clean area). The Joint Commission, most state departments of health, and AORN endorse and recommend that facilities follow the Association for the Advancement of Medical Instrumentation standards for steam sterilization and sterility assurance. (3) The standard states,

   Walls or partitions should separate functional work areas to control
   traffic flow and contain contaminants generated during processing.

Elimination of the physical barrier could lead to contamination of the clean processing area. More appropriate storage solutions for the supply carts should be explored.

Question: A sterilizer equipment representative recently presented an inservice program at our facility about sterilizers. To our surprise, he told us that the chemical indicator strips we use do not indicate sterility but indicate only whether the item was exposed to heat. He said we needed to use "integrator strips." We run an air-removal test and a biological indicator every day. Our staff members use the strip indicators that turn black, which we were told indicate sterility. The sterilizer technician told us that this type of indicator strip can be placed on the dashboard of a car, and it will turn block. What is the standard requirement to ensure that items sterilized in a steam sterilizer ore indeed sterile?

Answer: The sterilizer equipment representative probably is correct that the process indicator strips you use indicate only that the item has been through the sterilization process. There are, however, many chemical indicator products on the market, and the effect of heat on the indicator depends on the product. Integrating indicators are only one type of chemical indicator. There are five classes of chemical indicators, which each respond to different parameters (ie, time, temperature, pressure).

Class one, internal and external indicators. Internal indicators often are printed on peel pouches, instrument protectors, strips, and load record cards. The most common type of external indicator is sterilizer tape. Both internal and external indicators usually change from white to black when exposed to the sterilization process. They do not indicate that all the sterilization parameters were met; they only indicate that the item has been through the sterilization process. Placing these strips in any location with high heat may cause them to change. Based on this, most chemical indicators should be stored away from heat and sunlight, according to the manufacturer's written instructions.