A SIMPLIFIED
INFUSION
SET
FOR
INFANTS
By
MACK SUTTON, M.D.Albany, Ga.
S
IMPLIFICATION of pediatric infusion and transfusion apparatus has been thesub-ject of extensive clinical experimentation. Since 1900, there have been more than seventy published reports’ on various transfusion assemblies. Most of these were designed
primarily for adult intravenous therapy and consequently were too cumbersome and
in-efficient to use for pediatric infusion therapy. Also, many of them required multiple
operators.
Transfusion technic has been given added impetus in the Tulane Pediatric Division of Charity Hospital, where almost all acutely ill infants and children receive parenteral
fluids. A systematic program was begun for the purpose of devising a simplified
prac-tical infusion assembly that would appeal to house staff and private practitioners alike. All pediatric services, premature, infant and juvenile wards, with their large number
of dangerously ill patients who required rapid fluid replacement, were included in the program.
The final assembly which proved satisfactory in more than a thousand procedures
performed by the resident staff and interested private practitioners is composed of the
following parts: 1. one 23 or 24 gauge short bevel needle, 4 cm.. in length, 2. one
continuous-flow automatic valve (Fig. 1),* 3. one Hoffman clamp, 4. one 5 cc. Luer-Lok
syringe, 5. 150 cm. of thin transparent rubber tubing, 6. one special (“Aloe”)
sleeve-type bottlestopper.* 7. one straight-tube pyrex connection, 8. the proximal 20 cm. of a no. 18 French rubber catheter. (See Fig. 2 for assembly.)
This set is operated satisfactorily in the following manner: the pumping portion is
checked prior to use by loading the entire circuit (Fig. 3),
and
by pumping after insert-ing the catheter portion of the assembly in a reservoir bottle of normal saline; this fills the tubing and so rids the system of air. Caution should be taken during this maneuverto avoid contaminating the catheter or sleeve stopper. The sterile catheter portion of the
loaded circuit is then transferred to another reservoir bottle containing the fluid to be
administered. The site of venipuncture is chosen; in almost all cases we have selected veins of the scalp (superficial temporal), hand (dorsal metacarpal), or arm (basilic
and median cubital). With the loaded syringe of the assembly in the right hand, the
operator assumes a comfortable and convenient position. The sharp but short bevel needle is introduced into a superficial vein; entrance is successful if no fluid accumulates
about the needle point after slight pressure is exerted on the piston of the syringe. To prevent dislodgment of the needle, pressure from the distal phalanx of the left middle finger should be exerted over the skin covering the proximal portion of the needle, with the thumb and index finger firmly grasping the Hoffman clamp attached to the hub of
the needle (Fig. 3). The apparatus can be comfortably held in this position for long
From the Department of Pediatrics, Tulane University School of Medicine and Charity Hospital
of Louisiana, New Orleans, La.
424 MACK SUTTON
periods of time. The push-pull” action of the syringe piston furnishes a continuous
flow into the needle; constant pressure on the piston is necessary to keep the small T-valve (Fig. 1) in the closed position while fluid is being administered. Back flow of fluid
indicates either insufficient piston pressure, or that a worn rubber T-valve should be re-placed. “Sticking” of syringes can be avoided by application of a small drop of mineral
oil to the piston of the syringe before sterilization; the use of small syringes (2 cc. Luer-Lok or 1 cc. tuberculin type) also reduces the frequency of this occasional nuisance.
Im-FIG. 1. Parts for infusion set.
mediately following completion of each transfusion, the circuit should be cleansed by
pumping cold water through it five or six times; then, as soon as convenient, the entire apparatus, particularly the automatic valve, should be taken apart, washed with soap and water, and thoroughly rinsed with distilled water.
When the apparatus is returned to the supply room, the following cleansing routine is used: 1. thorough flushing and rinsing of the entire assembly first with a 25%
hydro-gen peroxide solution and then with distilled water. One small drop of sterile mineral oil is applied to the syringe plunger, the set is assembled, placed in a folded towel, tied securely and autoclaved for 15 minutes at 137.7#{176} C. under 18 pounds of pressure. The
‘T” Iieces in the automatic valve, should be replaced after they have been used about 15
2 sodium hydroxide, 2. rinsing in tap water, 3. soaking for 30 minutes in a solution
of 1% hydrochloric acid, 4. rinsing with tap water, and finally with distilled water. Since
translucent intravenous tubing latex type,* available commercially, has already been so treated, only the hydrogen peroxide cleaning routine is necessary.
DeBakey’ makes this well-advised statement: “It is the lack of appreciation of
osten-sibly minor details and technical difficulties which may arise during the operation of
an intravenous apparatus that is responsible for the majority of failures in the procedure
FIG. 2. Apparatus assembled.
of blood transfusion.” We wish to direct attention to these details and to emphasize means of preventing failures.
Following are some errors that the beginner is apt to make with this apparatus:
1. Failure to load circuit with normal saline or 5% glucose solution and to check
valve action before insertion into vein.
2. Failure to check Luer-Lok connections for leakage before use.
3. Too wide variations in force applied to syringe plunger.
4. Failure to agitate citrated blood occasionally in reservoir bottle during transfusion. 5. Improper position of fingers, failure to hold needle firmly in vein.
426 MACK SUTTON
6. Failure to rinse apparatus immediately after use.
7. Failure to replace rubber T-valves after 15 transfusions. All poorly fitted, worn, or
overheated rubber T-valves should be discarded; their cost is negligible.
With this assembly, the operator has all phases of the entire procedure under his direct control. Furthermore, one hand is free most of the time to deal with any unexpected difficulties that may arise. In most cases, no trained assistance is necessary.
This closed circuit apparatus may be conveniently used for 1. bone marrow infusions,2
2. transfusions of whole blood, 3. administration of four times concentrated plasma,
FIG. 3. Operation of assembly.
-1. rapid-force transfusion for states of shock,3 5. transfusion of washed maternal cells
for erythroblastotic infants, 6. “exsanguination” or “replacement” transfusions for
ery-throblastotic infants (two sets working simultaneously, one in vein for blood replace-ment, other attached in suction position to plastic polyethylene tubing inserted into
umbilical vein for blood removal), and 7. in adults, rapid transfusion in treating mas-sive obstetric hemorrhage. Cole4 states, “When a patient is suffering shock from massive
blood loss, the ordinary drip method is wholly unsuitable. Forty per cent of total blood
lost should be replaced in one hour.” With this apparatus pumping blood into an arm
vein, rapid replacement is easily facilitated, and exceedingly large volumes lost can be
replaced quickly. Successful use of this assembly in over 300 bone marrow infusions in infants has been reported.2
A SIMPLIFIED INFUSION SET FOR INFANTS 427
blood. Some believe that blood should be given slowly, whereas others think that this has been overemphasized. DeBakey and Kilduffe1 point out that the possible danger of
too rapid administration has been overemphasized, has little rational basis, and has not
been demonstrated adequately
by
experimental study. Speed shock as described by Hirsch-field5 may often be better explained by incompatibility of blood.6 If large amounts offluids are needed for infants, one should proceed slowly however ; we have not exceeded
a rate of 10 cc./min. up to a total amount approximately 22 cc./kg. of body weight; this is roughly equivalent to about one fourth of the infant’s total blood volume.7 If a
changeover to a continuous drip is desired after initial pumping, the assembly can be disconnected at the needle hub, and a lightweight B-D adapter, Luer-Lok type,* inserted so
as to connect the needle hub to a regular drip infusion set. Needles should be carefully
taped in place ; the Hoffman clamp attached to the hub serves as a convenient taping
anchor. Application of a 1.5 cm. continuous-traction tapet over the adhesive tape will
provide a firm needle insertion that may remain in place longer.
Those using Baxter or Cutter transfusion sets as standard equipment will find it necessary to remove the rubber stopper and diaphragm completely, or to transfer
con-tents to another sterile container in order that the handy sleeve-stopper of this assembly
can be used.
Since the pediatric service has been using this assembly very few “cut-down”
proce-dures have been necessary. The assembly is inexpensive,II compact (25 cm. by 12.5 cm),
and can be easily carried in a physician’s bag.
SUMMARY
A simple, convenient, and compact apparatus for infusion and transfusion is described.
Its advantages and some common errors encountered during its use in over a thousand
infusions and transfusions to infants and children are discussed. Detailed instruction
for assembly and operation are given, and its convenience in home or hospital is
em-phasized.
REFERENCES
1. Kilduffe, R. A., and DeBakey, M., Blood bank and technique and therapeutics of transfusions, St. Louis, C. V. Mosby Co., 1942, p. 457.
2. Sutton, J. M., and Kelley, G. P., Intramedullary bone marrow transfusions, New Orleans M. & S. J.
100:266, 1947.
3. Tocantins, L. M., and Jones, H. W., Infusions of blood and other fluids via bone marrow, J.A.M.A. 117:1229, 1941.
4. Cole, J. T., Method of treating massive obstetric hemorrhage, J.A.M.A. 135:120, 1947.
5. Hirschfield, S., Hyman, H. T, and Wanger, J. J., Influence of velocity on response to intravenous
injections, Arch.
mt.
Med. 47:259, 1937.6. Rathmell, T. K., and Crocker, W. J., Velocity factor in blood transfusion, J. Lab. & Clin. Med.
19:1206, 1934.
7. Johnson, R. D., in ‘Brenneman’s Practice of Pediatrics, edited by I. McQuarrie, Hagerstown, Md.
W. F. Prior Co., Inc., 1948, vol. 1, chap. 14, p. 17.
* Becton, Dickinson and Co., Rutherford, N.J. t Davol Rubber Co., Providence, RI.
Baxter Laboratories, Glenview, Ill.
§Cutter Laboratories, Berkeley, Calif.
428 MACK SUTTON
SPANISH ABSTRACT
Aparato de infusi6n, simplificado, para uso en infantes
Este aparato puede hacerse con partes f#{225}ciles de obtener, y ha probado ser muy pr#{225}ctico y con-veniente para uso rutinario, especialmente en infantes. Se incluyen instrucciones completas para juntar
y usar el aparato.
