• Remove the protective cap from the other end of the giving set.
• Squeeze and release the collecting chamber of the giving set until it is about half full.
Station 4 Cannulation and setting up a drip 9
• Open the regulating clamp and run fluid through the giving set to expel any air/bubbles.
• If using an extension ‘octopus’ connector, open and flush with normal saline so that no air
• Wash your hands (see Station 1) and follow the cannulation procedure above.
• Rather than capping the cannula immediately after removing the needle, connect the giving
set directly and flush with fluid from the bag.
• Apply the adhesive plaster or transparent film dressing to secure the cannula.
• Adjust the drip-rate (1 drop per second is equivalent to about 1 litre per 6 hours).
• Check that there is no swelling of the subcutaneous tissue i.e. that the line has not ‘tissued’.
• Discard clinical waste appropriately.
• Ensure that the patient is comfortable and inform him of possible complications (e.g. pain,
• Sign the fluid chart and record the date and time.
Examiner’s questions: complications of cannula insertion
• Infiltration of the subcutaneous tissue. • Phlebitis.
• Nerve damage. • Thrombophlebitis.
• Haematoma. • Septic thrombophlebitis.
• Embolism. • Local infection.
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the procedure and obtain his consent.
• Ask him which arm he prefers to have blood taken from.
• Gather the equipment in a clean tray.
• Aerobic and anaerobic blood culture bottles
• Winged collection set (or 18g needle and 20ml syringe)
• Non-sterile or sterile gloves
• For the blood culture bottles, check types (aerobic and anaerobic) and expiry dates, and ensure
that the broth is clear. Do not remove the barcodes.
Every effort to use aseptic technique should be made. If blood is being collected for other
tests, the blood culture sample should be collected first. Do not use existing peripheral lines
to obtain blood cultures. The most common skin contaminants include Staphyloccus
epidermidis, Corynebacterium spp., Propionibacterium spp., and Bacillus spp.
• Position the patient so that his arm is fully extended. Ensure that he is comfortable.
• Clean the venepucture site with the chlorhexidine sponge.
• Remove the flip tops from the culture bottles and disinfect the rubber caps each with a fresh
• Decontaminate your hands and don the apron and gloves.
• Warn the patient to expect a ‘sharp scratch’.
• Retract the skin to stabilise the vein and insert the butterfly needle into the vein.
• Fill each bottle with at least 10ml of blood, as per the markings on the bottle (let the vacuum in
the bottles do the job for you). Fill the aerobic bottle first to minimise the amount of air in the
anaerobic sample. If using a needle and syringe, collect at least 20ml of blood into the syringe
so as to inject a minimum of 10ml of blood into each bottle. (It is advised not to change needles
between drawing blood and injecting into culture bottles since the risk of needlestick injury
outweighs that of contamination of the sample with skin flora.)
• Withdraw the needle and apply pressure to the puncture site.
• Unscrew the adaptor and immediately dispose of the needle in the sharps bin.
• Ensure that the patient is comfortable.
• Dispose of clinical waste in a clinical waste bin.
• Label the bottles, including clinically relevant information e.g. the puncture site and any
antibiotics that the patient has been taking (ideally, blood cultures should be taken before the
administration of antibiotics; if not, they should be taken immediately before the next dose,
with the exception of children).
• Fill in a blood request form.
• Convey the samples to the microbiology laboratory without delay (or else incubate the bottles).
Specifications: This station requires you either to cannulate an anatomical arm and set up a blood
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the requirement for a blood transfusion, explain the risks, and obtain his consent.
• Ensure that baseline observations have been recorded (pulse rate, blood pressure, and
• Re-confirm the patient’s name and date of birth and check his identity bracelet.
• Extract 10 ml of blood into a pink tube (some hospitals may require two tubes for new patients).
• Immediately label the tube and request form with the patient’s identifying data: name, date of
• Fill out a blood transfusion form, specifying the total number of units required.
• Ensure that the tube reaches the laboratory promptly.
2. Blood transfusion prescription
• Prescribe the number of units of blood required in the intravenous infusion section of the
• If the patient is elderly or has a history of heart failure, consider prescribing furosemide (loop
diuretic) with the second and fourth units of blood.
• Arrange for the blood bag to be delivered. The blood transfusion must start within 30 minutes
of the blood leaving the blood refrigerator.
Ask a registered nurse or another doctor to go through the following checking procedures with you:
A. Positively identify the patient by asking him for his name, date of birth, and address.
B. Confirm the patient’s identifying data and ensure that they match those on his identity bracelet,
case notes, prescription chart, and blood compatibility report.
C. Record the blood group and serial number on the unit of blood and make sure that they match
D. Check the expiry date on the unit of blood.
E. Inspect the blood bag for leaks or blood clots or discoloration.
Station 6 Blood transfusion 13
• Attach one end of the transfusion giving set to the blood bag and run it through to ensure that
any air in the tubing has been expelled. Note that a transfusion giving set has an integral filter
and is not the same as a standard fluid giving set.
• Attach the other end of the giving set to the IV cannula which should be a grey (16G), wide-bore
cannula (minimum pink/20G, or larger for resuscitation situations).
• Adjust the drip rate so that the unit of blood is administered over 4 hours. Because one unit of
blood is 300 ml, and because 15 drops are equivalent to about 1 ml, this amounts to about 19
• Sign the prescription chart and the blood compatibility report recording the date and time the
transfusion was started. The prescription chart and blood compatibility report should also be
signed by your checking colleague.
• Record the patient’s pulse rate, blood pressure, and temperature at 0, 15, and 30 minutes, and
• Ensure that the nursing staff observe the patient for signs of adverse transfusion reactions such
as fever, tachycardia, hypotension, urticaria, nausea, chest pain, and breathlessness.
• Make an entry in the patient’s notes, specifying the reason for the transfusion, the rate of the
transfusion, the total number of units given, and any adverse transfusion reactions.
Examiner’s questions: complications of blood transfusion
Immune • Acute haemolytic reaction, (usually due to ABO incompatibility).
• Delayed haemolytic reaction, (usually due to Rhesus, Kell, Duffy,
• Non-haemolytic reactions such as febrile reactions, urticarial
Cardiovascular • Left ventricular failure from volume overload.
• Coagulopathy (from dilution of platelets and clotting factors).
• Citrate toxicity (from additive in bag of packed red blood cells).
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