We've talked about the rationale of massive transfusion a bunch on the EMCrit show:
- EMCrit Podcast 13: Trauma Resus II: Massive Transfusion
- Podcast 71: Critical Questions on Massive Transfusion Protocols with Kenji Inaba
- Podcast 144: The PROPPR trial with John Holcomb
- Podcast 081 – An Interview on Severe Trauma with Karim Brohi
- Hemorrhagic Shock Resus with Rick Dutton
Let's talk about the logistics of the actual administration of a massive transfusion protocol in an exsanguinating patient.
Calcium
Some of the Stuff Mentioned in the Show
Update
Removal of needle free valves had dramatic effect on flow rates1
(AANA Journal 2017;85(4):256)
Additional New Information
More on EMCrit
- EMCrit 296 – The French Connection, Part 1 – Resuscitation Geography, Logistics, & Ergonomics(Opens in a new browser tab)
- Massive Transfusion Protocol (MTP)
- EMCrit Podcast 13 – Trauma Resus II: Massive Transfusion
- GI Bleeding
Additional Resources
- EMCrit 387 – Emergency Department Charting for Legal Protection and Patient Safety - November 1, 2024
- EMCrit 386 – Liver I – Fulminant Acute Liver Failure (ALF) with Tasneem Pirani - October 19, 2024
- EMCrit Wee – Dirty Epi is Dumb, Mildly Messy Epi is OK! - October 10, 2024
As requested – Belmont user in a couple of centres in Wales, UK and love it for the simplicity in use once you get used to the slightly messy arrangement of tubes when initially loading it up. Self-priming so no garbage cans needed. Bolus delivery as fast as pressures allow with ongoing infusion rates if needed. No depressurising, just hang the next product on any available spike, open the clamp, bolus and go… Have used Level 1s but always found it to be confusing to set up and never the right nurses that know what they are doing when the… Read more »
Hey Scott, I’m a nurse and regular operator of the level 1 and belmont in the ED.. In my opinion the belmont is much better suited for the OR/ICU setting where you have more time and the situation is controlled. It takes longer to do the initial set up, even tougher under the pressure of a sick patient and the touch screen on the belmont is not friendly in a trauma bay, The controls wont respond if you have blood/fluid on your glove or on the screen. The simplicity and effectiveness of the level 1 make it ideal for ED… Read more »
Hello Jon,
We switched from the level one to the Belmont three years ago. At first, it was a mess. The Belmont is more complex and it was introduced without proper staff training. Lots of issues. However, we have done lots of simulations based training to increase staff comfort. Since the upgraded training things have gone well. Overall, the Belmont will deliver more volume than the level 1. All the best, David
I could see it being an upgrade in the sense of maximal flow rate and being able to give more exact amounts of volume when necessary. A big issue we run into is that many of our sickest trauma patients arrive with no pre notification (aka no time to set up) and in those situations the level 1 seems to be much quicker to get up and running smoothly. Possibly just more practice needed.
Hello Jon, I work in the ICU setting so fewer surprises!!! A few errors we noticed in training/simulations: 1. Pressure-Limit Alarm: When the line pressure is >300mmHg it will alarm. For example, you want 500cc/min but at 350cc/min the pressure is >300. It will alarm to notify you but it is still infusing at 350cc/min. Some nurses would assume that the Belmont was not working. They associated ‘alarms’ and ‘pumps’ as not working. 2. Removal of needles adapters (i.e. Claves) from lines. As a demo I would connect the Belmont to a #14 IV with and without a clave adapter.… Read more »
Our level-1 sets have a rubber connector in between the Y-clamps on the top of the drip chamber. I usually prime the set with a saline bag, piggy backed into that rubber connector and leave it on. That way I can use both lines for blood products from the start, and flush the line with saline between giving units.
smart!
Roger Browning Hi Scott, I am an anaesthesiologist working in a large womens hospital with a significant amount of major obstetric and surgical haemorrhage. We have had the Belmont for about 4-5 years and the level 1 for as long as I can remember. We hardly ever use the level 1 now as most of our staff prefer the Belmont, obviously takes awhile to get used to a new device though. We have now got to the point where we are going to replace our level 1 with a second Belmont. Two other points – we are advised by our… Read more »
Hi Scott – thanks for the superb podcasts! I was the operator of rapid infusers (Level One et al) for trauma teams at a London major trauma centre, and back when the Belmont first became available I think we were among the first in the UK to have one. I pretty much fell in love with it – I can’t think of another piece of equipment more likely to keep a patient alive when they’re exsanguinating in front of you. The change to Belmont was similar to how you’ve described CPR compression devices – we switched from several people running… Read more »
Scott,
RN, CCRN at the Shock Trauma ICU at Intermountain Medical Center in Utah. We currently hold a level 1 and a belmont on the unit. My experience is extensive in the use of both, and the belmont cannot be beaten. Set up is simple with minimal training, flow rates are unbeatable as I have dumped in blood at 1000cc/min. Excellent warmer, air detection, ect. The level one currently collects dust, unless there is the unfortunate scenario of running 2 large trauma cases at once. Cheers,
Mitch
We use HD catheters for trauma lines. Work well. You get two lumens, and true central line length (and can dialyze through it, I suppose… although usually by that time, your dirty lines should probably be out). I don’t know if you can truly maximize your throughput unless you literally hook a rapid infuser to BOTH lumens, which would be a bit silly, but even one lumen versus the Cordis is probably close enough as to make no odds. Really I think you would probably run out of blood (i.e. outrun your MTP) with any of these before the access… Read more »
I am an RN in an ICU where we frequently use the Level 1 and massive transfusion. Our Intensivists will place a double lumen MAC in these situations. This gives use 2 large bore (straight) ports for volume and the ability to add a slick through the introducer port for drips. If we already have a dialysis catheter in place, we use that. Our dialysis catheters come with a third infusion port – again helpful for drips. One RN runs the level one. 2 nurses outside the room check all products from cooler & make sure runner goes to blood… Read more »
sounds right
Hi Scott, Love your blog. To add my 2 cents, I concur with most of the other comments that the Level I is a paper chart compared to the Belmont as an EMR. Personally, I found the Level I a pain, while the Belmont is actually fun to use. The biggest problem I’ve found with it is the tendency (sometimes) to over-transfuse because it’s fun to dump product into the bowel and watch it squirt out. Check it out and you can use the Level I as a coat rack.
i want one!
Also you don’t have to use the big bucket/bladder attachment if you don’t want to. Once you establish a decent access you can just line up the hanging product bags and not even mess with the touch screen if you don’t want to and alternate a clamp-spike-clamp-spike rhythm, I find that when i teach new nurses to use it that makes it less intimidating …not that it’s that intimidating anyway… it was made for the military and as a vet i can tell you ANYONE in the room could be tasked with almost any job given certain circumstances.
The level-one is probably one the “shittiest” system ever made for fluid infusion. It is old, dangerous (gaz embolism) and as mentioned in your podcast, it can back flow in the other bag and make it explode. Massive transfusion requires a very reliable and convenient system. And actually, I’m really happy that other people’s comments support my review and thoughts. It looks like you never used something else than the Level-1. Trust me and the others here, there is way betttttttttteeerr! For sure. Pumps are for instance (look for Flowtherm, gamidatech), more secure and efficient. The Belmont is very nice… Read more »
newer ones (ours)
have ultrasonic air detection.
they are still pretty crappy though
At our shop, hemodialysis lines tend to be the access of choice. Two VERY large bore lumina, and the nurses are accustomed to caring for IHD caths. There also exists a model with an extra smaller lumen. Perfect for use until you add that triple lumen cvc for drips, meds etc.
yep
Hi Scott, I think good administration of MHP is difficult when you are distracted by multiple other factors and decisions in a trauma patient. We have repeatedly had large volume waste of our MHP, usually due to time running away from you, and as such I have worked on a combined chart for trauma transfusion. This replaces other blood authorisation and acts as a transfusion tool. This aims to log the first 2 MHP packs and target other transfusion interventions. We are just about to implement and hopefully look for an improvement in at least waste and documentation. Happy to… Read more »
thanks!
Several years ago, I was trying to decide between the Belmont and the Level 1 for use in the laboratory setting. I came across a study comparing the two devices. The upshot is that the Belmont does a better job at heating fluids and produces less air in the line. Here is the abstract:
https://www.ncbi.nlm.nih.gov/pubmed/14500158
nobody has mentioned cost–how do they stack up
Hi Scott,
Lots of great comments and great site keep up the awesome work!
Regarding vascular access debate: during major haemorrhage when we can’t get a large bore peripheral line we now use the arrow MAC catheter – very large bore infusion ports for rapid volume and ability to infuse vasopressors / other medications thru the built in side ports. We used to stock the swan sheath introducers but no one uses them now as this has it all… easier to secure it in place too.
Have never tried HD catheters.
yep, used to have macs. they were pretty good
Great stuff Scott.
Do you know of any evidence regarding the prohibition of platelets going in via warm infusion?
Cheers,
Sam
nope, just general practice. there are 2 old articles demonstrating no loss of platelet function. bigger problem is those bags are usually full of air. and there is no benefit to warming (they are already warm) and no benefit to pressure, they are low volume.
I’ve always given platelets the through the rapid infuser. I think it’s probably a theoretical myth that you shouldn’t, and I think the evidence if anything shows that it’s fine to do. While platelets are “warm” (room temp), they’re not “Level One warm” (normal body temp). Perhaps it makes no difference at all, but my personal bias is that I’d rather give a hemorrhagic shock patient getting MTP, products at body temperature rather than room temperature. I also haven’t noticed more air in platelet bags than PRBC bags, or any of the other products.
that’s what i just said–only evidence indicates it is fine, you will run amok of your blood bank however–they are universally an obsessive service (rightfully so)
One important thing to know about the Level 1 is that if you ignore the air detection alarms, they will self clear. You have to be pretty motivated to tune that sound out but I’m sure it can be done.
yep, been there
Belmont = CONTROL.. and no changing the set basically until the filter plugs. I’ve used both systems and prefer the Belmont in a heartbeat. As far as checking product.. what are they checking? In the initial MTP, lab usually doesn’t have the patient’s info on the bags.. O- or O+, not expired… READY GO! Even when you get type specific….. Correct type.. not expired… GO! I also have a MTP flow sheet for you that I built a few years ago.. I unfortunately don’t have it on my home PC and don’t’ have remote access. I’ll shoot you a copy… Read more »
gotcha!
“Ignorance is bliss.” Although the Level One is a fine device, it does not inform you that your awesome “#16 G” is about to blow, that your flow is slowed to molasses, or that ‘The Fine Device’ may be infusing air (potentially a VERY large amount). Level 1 does not keep track of the amount of total fluid you are slamming into your patient’s vasculature and/or tissues. Oh, and Albumin. Can that be helpful in an MTP?…. just saying. The Bellmont is a delicate flower; she’s finicky, but informative. Knowing that you have a potential problem, informed by annoying, and… Read more »
love the way this is written!
I work as an RN in a level 2 trauma center in the trauma ICU and we adopted the use of the Belmont about 2 years ago – I prefer it to the Level 1. I like that it automatically adjusts the pressure that the fluid enters the patient depending on the catheter used. It is at its best with a cordis (duh). It takes a proficient user to use it well so I think frequent in-services are needed for staff. You also only have to prime the entire tubing with one bag of saline and then you can hang… Read more »
thanks, Stacey
Question: do you not have to “flush” the line of the rapid infuser with NS in between each product? I love your technique of priming with NS, starting the first product and then getting rid of NS and getting next unit primed to follow but I’m used to just using one side for products and not running them from both sides (except for the old days when we only gave PRBCs)…what can I take to my hospital to change that practice because if it is a MTP case then it may need to be massive but it definitely needs to… Read more »
i never have and I’ve never seen a purpose to doing so. When i get a break in the administration, then I hook up a 250 ml bag and flush the system.
Where I did residency in EM, we exclusively used HD lines for trauma resus with a level 1 (except for our community rotation hospital that used cordis lines). That was also generally what we used on all exsanguinating medical patients. I only put in a couple cordis lines while in residency. Now in CC fellowship, we only use a cordis for massive transfusion (except for that one time that a patient on CVVHD popped an esophageal varix, but he got a cordis, too). Some of our anesthiologists like RICs, so we obviously leave them in post-op. A couple (most?) of… Read more »
Re: Trauma resuscitation lines….
We (The Alfred, Melbourne) have been using the ARROW MAC line as our trauma resuscitation line of choice for many years. 9 French resus port with additional side port. http://www.teleflex.com/usa/product-areas/vascular-access/vascular-access-catheters/central-access/mac-multi-lumen-access-catheters/
We’re teaching MAC line insertion on a cadaver model in the ASTAR Trauma Procedures Course https://theprocedurescourse.com/
Mike
what are you sticking through the cordis port?
Took me a while to get to this podcast. Very useful, though. We use the Belmont in and around Edinburgh. Once you’ve inserted the infusion lines the right way (colour-coded) and primed it (easy), it’s very intuitive. Certainly sounds a LOT less complicated than the Level 1 you refer to in the podcast. Displays any background infusion rate (with the flow rate achieved) and has easy-to-set boluses as required. We’re going to add a new Trauma-specific section to our learned.rocks website (Edinburgh EM site) soon which should also include a nurse-demonstrated video on how to use the Belmont so I’ll… Read more »
seems like everyone who gets a belmont loves it
Scott, love using the Belmont in my previous job while working in a urban Level I trauma center in Toledo, OH. The Belmont is far superior, and replaced our previous rapid infuser, the H-1200. We had 2 Belmont rapid infusers, one for each trauma room. The most beneficial aspect of the Belmont for me was that it has a air detection system that will pump out air through a reflux valve so you dont infuse an air embolus to a pt nor will it stop the infusion d/t air in the system. If air is detected and you run you… Read more »
you want to switch the massive trans to the SLIC and the pressors to the sideport if you want to keep great flows