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Chapter 16

Chapter 16

Plastic Bags For Intravenous Infusions: Observations in Korea with Saline, Dextran and Blood

Lieutenant Colonel Curtis P. Artz, MC, USA
Captain John M. Howard, MC, USAR
Captain John H. Davis, MC, USAR
First Lieutenant Russell Scott, Jr., MC, USAR

An extensive trial of saline, dextran and blood in plastic bags was carried out during the last 18 months of the Korean conflict. Observations were made on the adaptability of the bag to conditions of shipping, storage and field use. A pliable plastic bag has a number of advantages over a glass bottle as a container for fluids. These advantages are of particular value when considering use in a combat theater. The packed weight of 500 cc. of dextran in a plastic container is slightly less than 1.5 pounds, whereas the weight in a bottle is 2.5 pounds. Tables 1 and 2 outline certain comparative figures concerning transportation requirements of solutions in glass and in plastic containers.2 The plastic bag withstands shipping well. Of approximately 1,450 plastic bags shipped to Korea, only one was broken. It is believed that plastic containers would be sturdy enough to permit delivery of solutions by parachute drop.

Table 1. Comparative Space Requirements for Glass and Plastic Solution Containers (1,000 cc. capacity)2

 

Overseas Pack*

Glass

Plastic†

Number of containers per pack

12

20

Gross weight per pack (pounds)

64

64

Gross weight per container (pounds)

5.3

3.2

Gross cube per pack (cubic feet)

2.2

1.5

Gross cube per container (cubic feet)

0.18

0.08

*Six glass containers or ten plastic containers in a corrugated box; two corrugated boxes packed in another corrugated box, and an additional outer wooden box lined with waterproof barrier.
†Each plastic container in a square-bottom barrier.


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Table 2. Shipping Comparison of Glass and Plastic Solution Containers2 (1,000 cc. capacity)

 

Glass Container

Plastic Container

Number of liters needed at destination

100,000

100,000

Over-all breakage rate (estimated)

15%

0

Number needed at point of origin

118,000

100,000

Number of cases*

9,850

5,000

Gross weight (pounds)

625,000

320,000

Gross cube (cubic feet)

21,600

7,500

Square feet of space needed to store, stacked 10 feet high

2,160

750

Number of 20-ton trucks needed to haul

16

8

Men required to load shipment with lift trucks in 8 hours

16

8

*12 glass containers per 64-pound case, 20 plastic containers per 64-pound case.

During the winter months, one of the major problems in the forward aid stations was the freezing of solutions as a result of low temperature. Many glass containers cracked and their contents were lost because of breakage from freezing. The plastic bag was tested under these conditions and, although it was cold enough to freeze the solution within the bag, the bag itself did not break. By squeezing the plastic bag, the speed of administration of a solution can be increased. Empty plastic bags can be disposed of more easily than glass containers. The dangers of broken glass are avoided. No reactions of any type were observed while using the bags.

Normal saline solution in plastic bags (Fenwal-PRJ-681) was used at various echelons of medical care. In testing 350 of these units, each containing 500 cc. of saline, it was found that the solution in this type of bag was very satisfactory. However, since saline is normally used in 1-liter quantities, it would be better to have bags containing 1,000 cc. solution rather than 500 cc. The bag tested was encased for shipment and storage in a small, round, light-weight, metal container for protection. When most of these containers were opened, there were several cubic centimeters of fluid around the bag. This type of metal container was not very satisfactory because it required considerable time to open and it took up more space than the laminated aluminum and paper cover subsequently employed.

Recommendations for Electrolyte Solutions in Plastic Bags

For use in overseas theaters, normal saline solutions, glucose solutions, and lactated Ringer's solution should be put in plastic bags (1,000 cc. per bag), encased in a laminated aluminum and paper cover.


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Plastic Bags For Dextran

Two hundred and fifty plastic bags filled with dextran were received in Korea for evaluation. They were used in three battalion aid stations and two forward surgical hospitals. The bags were prepared by Don Baxter Inc., Glendale, California, Model P-1, Lot S-322X, containing dextran injection, 6 per cent, 500 cc. (Fig. 1).

Observations at the Battalion Aid Station.1, 5, 6 All medical officers felt that it was quite desirable to use plastic bags in the forward area. The size and configuration of the plastic bag was such that it could be carried easily in a jacket pocket, or it could be attached to the aid man's belt by the loop on the bag. An airway was unnecessary,

FIGURE 1. Plastic bag filled with dextran (Model P-1, Don Baxter, Inc., Glendale, California). The recipient set is attached and needle is encased in sterile plastic tube at top of bag. A segment of rubber tubing covers an area of the recipient plastic tubing so that injections of other medications can be made into the tubing without subsequent leakage.


222

thereby eliminating the necessity of extra needles. The contents could be administered very quickly. Flow could be increased either by elevation of the bag or by application of manual pressure. Table 3 shows the different pressures exerted on the plastic bag when it was placed under different areas of three patients on litters. It appeared that fluids were infused more rapidly when the bag was placed under the sacrum. The 17-gauge needle proved difficult to insert, particularly when the veins were collapsed in patients with severe hypotension. It was the general opinion that an 18-gauge needle would be preferable. A drip chamber, although not essential, would be a desirable feature. There appeared to be a weak connection in the unit where the tubing was attached to the bag.

Table 3. Pressures Exerted on Plastic Bag at Different Locations Beneath the Supine Body
(Fluid Pressure in Feet)

Weight of Patient

Type of Solution

Location

Head

Shoulder

Center of Back T-6

Buttocks

Sacrum

140 lbs.

Saline

1.5

3

3

3

5

Plasma

1.25

1.25

3

1.5

3

Blood

 

1.75

2.5

1.5

2.5

165 lbs.

Saline

1.5

2.75

4.25

2.75

6.75

Plasma

1.75

2.25

2.5

2.25

3.35

Blood

1.5

2

2.25

1.75

3

200 lbs.

Saline

1.5

4.25

5.75

4.5

6.25

Plasma

1.75

2.5

3

3

3.50

Blood

1.5

1.5

3

2

3

The plastic bag was of considerable value to the surgeon in the forward areas because an aid man could easily carry several in the pockets of his fatigues or looped over his belt. Early replacement of blood volume could therefore be facilitated.

Observations at the Forward Hospital.3 It was believed that the recipient set needs a drip chamber to permit observation of the flow of solution. Compressing the bag with a blood pressure cuff or squeezing it by hand, although safer than pumping air into the bottle, was not as easy a method of forcing flow. A detachable or universal recipient set might prove advantageous for hospital use because various type of fluids and blood could be administered merely by changing the recipient set without disturbing the needle. The unit appeared


223

to be sturdy in all respects except at the attachment of the recipient tubing to the bag. Two units broke at this junction. The outer container of paper and laminated aluminum foil was quite satisfactory. The units were easily handled and well protected by this container. No reactions were seen from dextran in plastic bags.

Recommendations for Dextran in Plastic Bags

It is recommended that dextran in plastic bags be standardized. A plastic bag, similar to the item tested and packed in laminated aluminum foil, would be acceptable for use in the division area if the following revisions are made: (1) an 18-gauge needle to be substituted for the present 17-gauge needle; and (2) the point of attachment of the tubing to the bag to be made stronger and more durable. For use in the hospital, it is desirable to have detachable tubing and a drip chamber. The plastic containers for hospital use should be a standard bag with interchangeable recipient sets for all electrolyte solutions and dextran.

Plastic Bags for Blood

A total of 250 units of blood in plastic bags was received in Korea and approximately 200 units were used in the treatment of patients. The bags were Fenwal plastic blood packs, catalogue No. JA-2 (C), with 75 cc. of acid-citrate-dextrose solution. No bags were broken and transportation was facilitated because of the decreased weight. The blood pack was easily used when blood was given by the normal rate of drip. The small slit at the top of the bag was not suitable for hanging the bag during administration. The recipient set attached easily to the bag. The drip chamber filled too easily and obscured vision of rate of flow. The plastic tubing (with insert of rubber tubing) proved to be very satisfactory for injection of other medications.

The bag was unsuitable, however, for use in a forward hospital because it was impossible to give blood rapidly under pressure to several patients at the same time. No practical method was found for forcing blood out of the plastic bag. It was possible to squeeze the bag, but it was impractical to assign one corpsman to each bag when 8 or 10 pressure transfusions were being given simultaneously to various patients. The use of the Fenwal plastic box, with rubber bag insert for exerting pressure on the blood pack was impractical. The chief deterrent to the acceptance of the present plastic container for blood is that the bag is not easily adapted to the rapid administration of blood. This is extremely important because about 30 per cent of the blood given in a forward surgical hospital must be given under pressure.


224

Storage of Blood in Plastic Bags. Serum potassium determinations were carried out by Lieutenant John B. Frawley on several units of blood in bottles and blood in plastic bags. The bottles and bags were filled in the United States and were then shipped to a forward hospital under identical conditions. The results of these determinations are outlined in Table 4. In the 19-day-old blood, the average serum potassium of blood in plastic bags was 28 mEq. per liter in comparison to 18 mEq. per liter for blood in bottles. The 20-day-old blood showed about the same difference in potassium concentration. These results are supplementary to earlier studies by this laboratory which indicated that blood in Fenwal and Cutter plastic bags compared favorably with blood in bottles during shipment and storage.4

Desirability of Plastic Bags for Blood. It would be desirable to have some type of plastic container for blood and all intravenous solutions. It would be particularly advantageous to have a plastic bag from which blood could be given under pressure. The present practice of pumping air into a bottle to force rapid infusion of blood carries the danger of air embolism. At least four casualties died from air embolism during the last year of the Korean conflict. If practical, it might be possible to put a second plastic bag outside the bag containing blood into which air could be pumped to exert pressure on the inner bag. This would permit a rapid and safe method of administering blood under pressure.

Recommendations Concerning the Plastic Bag for Blood

A plastic container for blood is desirable.

The plastic blood bag was unsuitable for field use because blood in these bags could not be satisfactorily given under pressure. Continued efforts should be made to develop a bag or suitable attachment whereby blood from the plastic container could be forced into a vein under pressure.

Summary

In the latter part of the Korean conflict, observations were made on the use of plastic containers, 350 filled with saline, 250 with blood, and 250 with dextran. When covered with paper and laminated aluminum foil, these bags were most satisfactory for electrolyte solutions and dextran. The plastic bag for blood was not suitable because transfusions could not be given satisfactorily under pressure to a large number of patients at the same time.

The following recommendations are made:


225

Table 4. Plasma Potassium Levels of Stored Blood Bottles and Fenwal Plastic Bags

Blood in Bottles

Blood in Plastic Bags

No.

Age Days

mEq./L. K

No.

Age Days

mEq./L. K

No.

Age Days

mEq./L. K

No.

Age Days

mEq./L. K

2

19

18.3

20

20

21.3

1

19

27.6

19

20

27.9

4

19

16.8

22

20

21.6

3

19

30.0

21

20

31.5

6

19

15.9

24

20

18.9

5

19

26.1

23

20

29.4

8

19

19.8

26

20

21.0

7

19

30.3

27

20

30.6

10

19

25.2

28

20

23.4

9

19

29.7

29

20

26.7

12

19

16.2

32

20

19.2

11

19

28.5

31

20

31.5

14

19

18.6

34

20

21.0

13

19

28.8

33

20

29.7

16

19

18.0

---

---

---

15

19

30.0

35

20

31.5

18

19

17.4

---

---

---

17

19

24.9

37

20

29.7

---

---

---

---

---

---

---

---

---

39

20

28.8

---

---

---

---

---

---

---

---

---

41

20

33.0

Averages: 18.4

20.9

28.4

30.0


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a. Within the limitations of this study it is recommended that plastic bags, filled with dextran, be standardized for use within the division area. The recipient set should be attached to the bag but a drip chamber would be desirable.

b. Plastic bags (1,000 cc. capacity) should be standardized for overseas use for glucose, saline, glucose and saline, and lactated Ringer's solution. Similarly, plastic bags (500 cc. capacity) with interchangeable recipient sets should be standardized for dextran for hospital use.

c. Further efforts should be carried out to develop a suitable plastic bag for blood. These bags must be able to administer blood under pressure satisfactorily in order to meet the requirements of a forward hospital.

References

1. Boone, R. D.: Personal communication.

2. Cherkin, A. C.: Personal communication.

3. Hughes, C. F.: Personal communication.

4. Knoblock, E. C., Olney, J. M., Crosby, W. H., Howard, J. M., Pilhorn, H. R., and Haynes, G. R.: In-Vitro Studies of Whole Blood during Shipment and Storage. (Chapter 10, this volume.)

5. Otto, J. F.: Personal communication.

6. Torralba, R. S.: Personal communication.

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