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Prevention of air embolism during/following infusion, transfusion and therapeutic injection

(Feil, 2012; Infusion Nurses Society, 2011a, 2011b)

  1. In advance of injection or infusion, fully prime all infusion tubing, and expel air from syringes.
  2. Catheters or other tubes inserted into the body should be inserted and removed using a technique that minimizes the possibility of air getting into the blood vessels.
  3. During surgical procedures, patients should be closely monitored to help ensure air bubbles do not form in blood vessels.
  4. Ensure all arterial and venous catheters and connections are intact and secure.
  5. Ensure that all self-sealing valves of arterial and venous catheters are functioning properly.
  6. Use infusion pumps with air-in-line sensors for all continuous infusions.
  7. Remove air from infusion bags before infusing fluids.
  8. Trace lines, double-check all connections, and take all steps necessary to prevent tubing disconnections.
  9. Inspect the insertion site, catheter, and all connections regularly to assess for breaks or openings through which air could enter the system.
  10. Ensure the integrity of the central line dressing surrounding the skin insertion site.

Prevention of air embolism secondary to insertion of central venous access device

(Feil, 2012; Joint Commission, 2010; Mirski et al., 2007)

  1. Take steps to increase the central venous pressure, decreasing the pressure gradient that would normally favour movement of air into the bloodstream. Central venous pressure is normally lower in all blood vessels located above the level of the heart and during inspiration.
    • Place the patient in the Trendelenburg position with a downward tilt of 10 to 30 degrees during central line placement.
    • Avoid insertion during patient inspiration. Instruct the patient to hold his or her breath, and perform a Valsalva maneuver, if able.
    • Hydrate the patient to correct hypovolemia prior to insertion whenever possible.
  2. Ensure all catheters and connections are intact and secure.

  3. Occlude the catheter and/or needle hub.
  4. Ensure that all self-sealing valves are functioning properly.

Prevention of air embolism secondary to removal of central venous access device

(Feil, 2012; Joint Commission, 2010; Mirski et al., 2007)

  1. Place the patient in the Trendelenburg position. If not possible, place in the fully supine position.
  2. Position the catheter exit site (e.g., neck, arm) at a height lower than the patient's heart.
  3. Cover the exit site with gauze and hold in place with gentle pressure while removing the catheter in a slow, constant motion.
  4. Instruct the patient to hold his or her breath, and perform a Valsalva maneuver as the last portion of the catheter is removed; if the patient is unable to do so, remove during patient's expiration phase.
  5. Place pressure on the site until hemostasis is achieved. One to five minutes is suggested.
  6. Apply a sterile occlusive dressing, such as gauze impregnated with petroleum jelly and covered with a transparent film dressing. Leave dressing in place for at least 24 hours. Changing every 24 hours until the exit site has healed. Plain gauze dressings have been associated with air passing through a persistent catheter tract into the bloodstream, resulting in air embolisms, as have occlusive dressings left in place for shorter periods of time.
  7. Instruct the patient to remain lying flat for 30 minutes after removal of the catheter.

Prevention of phlebitis secondary to intravenous catheterization

(O'Grady et al., 2002)

  1. When selecting the site for intravenous catheterization keep in mind that:
    • Lower extremity insertion sites are associated with a higher risk of infection than are upper extremity sites.
    • Hand veins have a lower risk for phlebitis than veins on the wrist or upper arm.
  2. Ensure good hand hygiene before catheter insertion or maintenance. Use proper aseptic technique during catheter manipulation to prevent infection.
  3. Consider use of in-line filters to reduce the incidence of infusion-related phlebitis.

Prevention of ABO incompatibility reaction

(Callum et al., 2016)

  1. Pay meticulous attention to identifying the patient and labelling the tubes at sample collection (to ensure that patient is assigned to the correct blood group).
  2. Pay meticulous attention to verifying the patient's identity, by checking their hospital identification band before transfusing.
  3. When possible, involve the patient or caregiver in the identification process.

Prevention of Rh incompatibility reaction with pregnant women

(National Heart Lung, and Blood Institute, 2011; Ontario Regional Blood Coordinating Network, 2016).

  1. Screen pregnant women to find out if they are Rh-negative.
  2. If the father of the infant is Rh-positive, or if his blood type is not known, the mother should be given an injection of Rh Immune Globulin during the second trimester. If the baby is Rh-positive, the mother will receive a second injection of Rh Immune Globulin within a few days of delivery.
  3. Ensure that women with Rh-negative blood receive Rh Immune Globulin (eg. RhoGAM or WinRho®):
    • During every pregnancy.
    • After a miscarriage or termination of pregnancy.
    • After prenatal tests such as amniocentesis and chorionic villus biopsy.
    • After injury to the abdomen during pregnancy.
    • After physical trauma (e.g. motor vehicle accident).
    • After placental abruption (bleeding in the uterus).
    • After giving birth to a Rh-positive baby.

Rh incompatibility due to a mismatched blood transfusion

(Callum et al., 2016)

  1. Pay meticulous attention to identifying the patient and labelling the tubes at sample collection (to ensure that patient is assigned to the correct blood group).
  2. Pay meticulous attention to verifying the patient's identity, by checking their hospital identification band before transfusing.
  3. When possible involve the patient or caregiver in the identification process.

Anaphylactic shock due to serum: prevention of recurrent anaphylaxis

(Callum et al., 2016)

  1. Pre-medicate with intravenous steroids and diphenhydramine.
  2. If a patient is found to be IgA-deficient with anti-IgA, the following products are recommended:
    • IgA-deficient blood products from IgA deficient blood donors, available from Canadian Blood Services.
    • Washed RBCs (2L normal saline in 6 wash cycles) or platelets.

Minor allergic reaction: prevention of recurrent urticaria

(Callum et al., 2016)

These precautionary measures may be used, although their efficacy is unknown:

  1. Pre-medicate with diphenhydramine, or other non-drowsy antihistamine and/or corticosteroids.
  2. Consider plasma depletion of RBCs or platelets.
  3. Consider use of washed RBCs or platelets.

Conduct Clinical and System Reviews (see details below)

Given the broad range of potential causes of complications from infusions, transfusions and injections, in addition to the above recommendations, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

If your review reveals that your cases of complications from infusions, transfusions and injections, are linked to specific processes, procedures or conditions you may find guidelines related to your specific procedure here:

  1. Canadian Blood Services, Professional Education
  2. Ontario Regional Blood Coordinating Network
  3. National Institute for Health and Care Excellence (NICE), Acute and Critical Care.
  4. National Institute for Health and Care Excellence (NICE), Hospitals.
  5. Norfolk D (Ed). Handbook of Transfusion Medicine, 5th Ed. United Kingdom Blood Services. 2013.

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.
  2. Use appropriate analytical methods to understand the contributing factors.
  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.

Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the Hospital Harm measure. Chart audits help identify quality improvement opportunities.

Useful resources for conducting clinical and system reviews: