Compound sodium lactate (Hartmann's) solution. Caution: risk of clotting

Abstract

We kuve observed blood doiring in blood administration sets nhere Hurtmann 's solution ( TravenoI) has preceded blood trunsfusion. This is due 10 calcium ions (Ca' ') contained in the Hartmann's solution and is more likely to occur at 37'C. We suggest that [hi.$ porential hazard be more widely realised and that the practice cease. Key wordsComplicarions; blood clotting. Inns; calcium. Transfusion; stored blood.Hartmann's solution is frequently used as volume replacement fluid during emergency and routine surgical procedures. Last year in our district, which serves a population of 245000, approximately 5000 litres of Hartmann's solution were used.One of us (J.M.) has noticed that clotting occurs in the blood administration sets if blood is infused following Hartmann's solution. No instructions against this practice can be found. No adverse patient reactions have been observed in patients here, but our findings suggest that the practice be reviewed. Methods and resultsFollowing the observation of clotting in routine clinical practice, we repeated standard practice procedures under controlled conditions in the laboratory. Expired whole blood was passed under gravity into a blood administration set (Travenol) to which was attached a blood warmer set connected to a Fenwal blood warmer. The blood was infused at a rate of 6 ml/minute. The infusion sets were primed with standard Hartmann's solution (Travenol) and a similar isotonic solution made without calcium by our district pharmacy.The experiment was carried out with the blood warmer switched on and with it off. Clot formation was seen in the distal drip chamber of the blood warmer set within 45 minutes of starting the blood infusion (Fig. I.). The clots extended into the two distal loops of the warmer set. Clots were only seen when Hartmann's solution (with calcium) was used as prime with the blood warmer switched on.In a simple mixing experiment carried out in plasticCorrespondence should be addressed to Dr P.J. Wyld please.

Ringer’s lactate is compatible with the rapid infusion of AS-3 preserved packed red blood cells

“…9,10 These standards are based on laboratory research conducted more than 20 years ago that have demonstrated that calcium-containing crystalloids could cause clotting to occur when combined with warmed blood components preserved with CPDA. 11,12 These guidelines have remained despite numerous reports that have shown that RL does not cause clotting in clinically relevant dilutions. 2,6,8,13 Blood preservatives utilize citrate to chelate calcium contained in blood products, thereby preventing activation of the clotting cascade.…”

“…9,10 These guidelines are based, in part, on research completed in the 1970s and 80s which showed that using calcium-containing crystalloids, such as RL, can cause clotting when combined with PRBC preserved with citratephosphate-dextrose-adenine (CPDA). 11,12 However, a number of studies have challenged the claim that it is unsafe to use RL to reconstitute PRBC, and to date, no study has shown RL to cause clotting in clinically relevant dilutions of PRBC to crystalloid. 2,6,8,13 It has been shown that mixtures of PRBC and crystalloid, in a ratio of 2:1 or higher, do not overwhelm the calcium-chelating ability of the citrate in the CPDA preservative solution.…”