Autotransfusion Devices: Pleur Evac

1.  Assess for signs and symptoms of hypovolemia, hypoperfusion, and hemothorax.
2.  Perform hand hygiene and apply gloves.
3.  The physician or nurse practitioner inserts a large-bore chest tube(s).
4.  This autotransfusion system requires prior assembly; therefore consider routinely setting the autotransfusion component for patients who are at high risk for hemothorax. Otherwise, blood that drains immediately on chest-tube insertion is lost to recovery.
5.  Obtain consent if possible.
6.  Prophylactic broad-spectrum antibiotics may be given prior to reinfusion.
7.  Prepare the chest-drainage unit.
8.  Attach the autotransfusion bag if the unit is not ready for autotransfusion. Attach the autotransfusion bag (A-1500) to the side of the Pleur-Evac chest tube drainage system. Use the foot hook and the ATS hanger on the side of the unit:
  a.  Close the two white clamps on the top of the A-1500 replacement bag.
  b.  Close the white clamp on the Pleur-Evac patient tubing and milk the blood distally from the tubing into the Pleur-Evac.
  c.  Detach the red and the blue connectors.
  d.  Remove the red protective cap from the collection tubing on the A-1500 replacement bag and connect it to the patient chest-drainage tubing using the red connectors.
  e.  Remove the blue protective cap from the tubing on the A-1500 replacement bag and connect it to the Pleur-Evac tubing using the blue connectors.
  f.  Open all the clamps and make sure all the connections are airtight.
9.  If prescribed, inject anticoagulant into the collection unit as soon as possible during or before blood collection. Anticoagulant options include the following:
  a.  Citrate phosphate dextrose (CPD) is a commonly used anticoagulant. One milliliter of CPD for every 7 ml of blood is recommended. Because it is difficult to estimate the amount of blood in a patient's chest, one approach is to instill enough CPD to anticoagulate one unit of blood initially (60 ml). When 1 unit of blood has been collected (about 500 ml total volume of blood plus CPD), it may be reinfused, or additional CPD may be added to continue the collection. The CPD injection may be facilitated by the use of a volume-control intravenous chamber; run the desired amount of CPD into the chamber and then infuse the CPD via the intravenous tubing to the injection port.
  b.  Citrate phosphate dextrose adenine (CPDA-1) may also be used at a ratio of 1 ml per 7 ml of blood. Instill as described in step a above.
10. Collect blood. When one unit of blood has been collected (about 500 ml of blood plus volume of anticoagulant), it may be reinfused, or additional anticoagulant may be added to continue collection. If bloody drainage is ongoing, prepare a new collection bag and inject anticoagulant as described in steps 8 and 9 before disconnecting the filled collection bag for reinfusion.
11. Discontinue collection:
  a.  Use the high-negativity relief valve to reduce excessive negativity.
  b.  Close the white clamps on the patient tubing and on top of the autotransfusion bag.
  c.  Detach all the red and the blue connectors.
  d.  Attach the red and the blue connectors on top of the autotransfusion bag.
  e.  Securely attach the red and the blue connectors by joining the patient tube (red) to the Pleur-Evac tube (blue).
  f.  Open the white clamps on the patient tube so that the drainage can be collected in the Pleur-Evac.
  g.  Remove the autotransfusion bag from the Pleur-Evac by removing the collection-bag frame from the hanger on the side of the unit. Disconnect the foot hook from the Pleur-Evac unit and slide the bag off the wire frame.
12. To change the autotransfusion bag, refer to preceding steps 8a through 8f.
13. Prepare for reinfusion as follows:
  a.  Invert the bag so that the spike port points upward, remove the protective cap, and insert blood tubing into the spike port by using a constant twisting motion. A microfilter is suggested when infusing the collected blood.
  b.  Remove the air from the bag. Keeping the unit inverted, squeeze all the air from the bag carefully through the filter and the drip-chamber assembly. Close the infusion set clamp, invert the autotransfusion bag, and suspend it from an IV pole with the plastic strap. Open the infusion set, and flush the administration line carefully to remove all of the air.
14. Initiate reinfusion:
  a.  Be sure to remove all air from the bag before infusing under pressure.
  b.  Attach the distal end of the infusion set to the IV line and infuse the blood using gravity or pressure.
15. Discard supplies, remove gloves, and perform hand hygiene.
16. Document the procedure in the patient's record.
17. Assess cardiopulmonary status and vital signs frequently until 1 hour after the transfusion is complete.
18. Monitor laboratory data to include hematocrit, prothrombin time, partial thromboplastin time, platelet count, serum lactate, and arterial blood gas values.
19. Monitor and mark amount and type of drainage from collection system hourly for 8 hours, then every 2 hours because volume loss can cause hypovolemia.
20. Evaluate and maintain drainage tube patency every 2 to 4 hours. Report inability to establish patency to physician or advanced practice nurse.
21. Mark the drainage level on the outside of the drainage-collection chamber in hourly or shift increments and document in patient record.