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Massive Transfusion Protocol

Massive Transfusion Protocol. K. Pavenski, MD FRCPC Head, Div. Transfusion Medicine October 31, 2013. Outline. What is massive hemorrhage/massive transfusion? Massive Transfusion Protocol (MTP) Team Activation criteria Initiation Blood products Transfusion goals Termination

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Massive Transfusion Protocol

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  1. Massive Transfusion Protocol K. Pavenski, MD FRCPC Head, Div. Transfusion Medicine October 31, 2013

  2. Outline • What is massive hemorrhage/massive transfusion? • Massive Transfusion Protocol (MTP) • Team • Activation criteria • Initiation • Blood products • Transfusion goals • Termination • Common errors and adverse events

  3. Introduction • There is no universal definition of massive hemorrhage (MH) or transfusion (MT) • Commonly used definition is a requirement for more than 6 units of red blood cells (RBC) in 4 hours • Rate of bleeding and likelihood of rapidly achieving hemostasis are important considerations • MH is a rare, complex and high stress medical scenario • MH is associated with a high mortality rate

  4. Introduction • Massive hemorrhage and massive transfusion may occur in the following clinical contexts: • Trauma • Post-partum hemorrhage • Cardiovascular complication (ex. ruptured abdominal aortic aneurysm) • Acute upper GI bleeding • Post surgery

  5. Introduction • MTP is an algorithm for management of a patient with a massive hemorrhage • MTPs have been shown to • Improve patient outcomes • Reduce patient mortality • Reduce wastage of blood products • St. Michael’s MTP can be found on CPPS

  6. MSICU MTP Stats • 62 MTP activations per year at SMH • 5 in MSICU • GIB – 3 • Bleeding due to drug overdose – 1 • Bleeding kidney mass - 1

  7. Principles of MT management • Early recognition of blood loss • Maintenance of tissue perfusion and oxygenation by restoration of blood volume and haemoglobin • Control of bleeding with early surgical, endoscopic or radiological intervention – “damage control surgery” • Early management of coagulopathy • Early administration of antifibrinolytics (ex. Tranexamic acid) • Maintenance of normothermia and normal calcium levels • Reversal of anticoagulant and/or antiplatelet medications if applicable • Monitoring for and management of complications of massive transfusion

  8. MTP Activation Criteria: General • In a bleeding patient, recognized need for uncrossmatched RBC • Actual substantial blood loss • estimated 1500cc of blood lost OR at least 6 RBC transfused with anticipated ongoing hemorrhage • Anticipated substantial blood loss requiring transfusion of at least 6 RBC within minutes to hours

  9. MTP Activation Criteria: Specific Trauma: • Penetrating trauma AND persistent hypotension (2 measurements of SBP< 90 mmHg taken 5 min apart). • Blunt trauma AND persistent hypotension AND one of the following: • Massive haemothorax • Positive FAST scan • Pelvic fracture

  10. MTP Activation Criteria: Specific Post partum haemorrhage (PPH): • >500 cc vaginal blood loss AND hypotension not responding to crystalloid bolus • >1000 cc blood loss following caesarean section AND hypotension not responding to crystalloid bolus • Suspected bleeding AND hypotension not responding to crystalloid bolus in a post-partum patient. Bleeding in cardiovascular patients: • Known/suspected ruptured or leaking abdominal aortic aneurysm • Postoperative chest tube drainage >1000 cc in 30 minutes or less • Cardiac or aortic rupture • Atrial leak

  11. MTP Activation: Where • MTP may be administered in the following clinical areas: • Emergency Department • Operating Rooms • Intensive Care Units • If the need for MTP arises in any other area, initiate MTP and transfer the patient as soon as practically possible to an appropriate location for further resuscitation

  12. MTP: Team • MTP lead • Is a physician in charge of patient care during MTP • In ER, ER physician or Trauma Team Leader • In OR, anaesthesiologist • In ICU, staff physician or clinical fellow • In all other areas, staff anaesthesiologist assumes the role of MTP lead

  13. MTP: Team • MTP assist • RN, RRT, or perfusionist • Administers IV fluids, medications, blood products, monitors patient’s vital signs, charts • Nurse assigned to the patient will become MTP assist

  14. MTP: Team • Transfusion Medicine (TM) • One technologist is usually designated to assist with MTP and will keep track of what products are issued and when • TM performs compatibility testing and prepares blood products for transfusion • TM regularly communicates with the team at patient’s bedside • TM may provide recommendations on optimal transfusion therapy

  15. MTP: Team • Additional resources may be necessary • Respiratory therapist • Assists with airway and oxygen therapy • Administers IV fluids and blood products • Perfusionist • Sets up cell salvage if appropriate • Administers IV fluids and blood products • Porter • Delivers laboratory samples to the laboratory and blood products from TM to the patient • Returns empty coolers and untransfused blood products to TM

  16. MTP: Activation • MD assesses the patient and makes a decision to activate MTP • MD (or delegate) calls Transfusion Medicine Laboratory (ext 5084) and requests to activate MTP

  17. MTP: Activation • MD (or delegate) is to provide the following information to TM: • Patient location and contact telephone number • Patient’s name and MRN • If patient’s identity is not known, state MRN, gender and approximate age • Name of the MD who will lead MTP • State whether the patient is/appears to be pregnant • May require CMV negative RBC and platelets • May need to activate CODE OB

  18. MTP: Activation • Assemble team • Designate MTP lead, assistants (RN, RRT) • Call locating if additional resources are necessary • Anaesthesia, porter, perfusionist, etc. • Porter • If your area has a porter or CA and he/she is available to assist, do not call portering services • Outside of ED/OR/ICU, call CCRT or Code Blue

  19. MTP: Initial Patient Management • Secure airway and provide oxygen • Obtain appropriate vascular access • 2xG14-16 i.v. or central line • Start IV fluids • Note: only 0.9% NaCl solution is compatible with blood products • Set up rapid infuser/blood warmer • Administer tranexamic acid if appropriate • Keep core temperature >35C • Place patient on continuous monitoring

  20. MTP: Initial Patient Management • For information on administration of tranexamic acid in trauma, refer to Protocol for intravenous administration of tranexamic acid (Cyclokapron) during trauma resuscitation (Pharmacy)

  21. MTP: Initial Laboratory Investigations • Send off laboratory investigations: • Group and screen (2 pink top tubes) • CBC (1 lavender top tube) • INR, aPTT, Fibrinogen (1 blue top tube) • Electrolytes, ionized calcium, creatinine (2 yellow top tubes) • Lactate (1 grey top tube) • VBG (syringe) • Place labeled specimens into a red plastic STAT bag and deliver to the labs as soon as possible

  22. MTP: Patient Monitoring • Clinical • BP, HR, SatO2, RR, temperature • Input and output • Laboratory • Send CBC, INR, fibrinogen every 1 h • ABG/VBG every 25-30 min • Creatinine/Magnesium/Lactate every 4h

  23. MTP: Transfusion • Follow the policy on Administration of Blood Products (CPPS) • Use blood warmer for RBC and plasma • Refer to Use of rapid infusion and blood warming devices for infusion of blood products and resuscitating fluids (CPPS) • Do not transfuse platelets and cryoprecipitate through a blood warmer • RBC and plasma will be transported and stored in a cooler during MTP • Platelets and cryoprecipitate should be kept at room temperature; do NOT place in the cooler

  24. MTP: Transfusion of RBC • RBC must be ABO compatible and crossmatch compatible • Following initiation of MTP, red blood cells (RBC) are immediately available for pick-up • If patient’s compatibility testing (group & screen, crossmatch) has not been completed, you will receive uncrossmatched RBC • If patient has RBC already crossmatched, you will receive crossmatch compatible RBC

  25. MTP: Transfusion of RBC • Notes: • For a new patient, it will take at least 45 minutes to obtain crossmatch compatible RBC from the time of specimen arrival in TM • For a patient with an in-date group and screen (with no crossmatched units available), time to compatible RBC will depend on whether the patient has RBC antibodies (5 min to few hours) • Patient will be switched to crossmatch compatible RBC as soon as they are available

  26. Time to Availability of RBC O Rh neg reserved for females of childbearing age * 1% risk

  27. MTP: Three approaches to transfusion Transfusion management of a massively bleeding patient may be: Lab-based Ratio-based (1:1 frozen plasma to RBC) Point-of-care testing driven Our protocol utilizes ratio-based resuscitation to guide plasma transfusion and lab-based approach to guide transfusion of platelets and cryoprecipitate

  28. MTP: Transfusion of Plasma • Plasma • Administered during MTP at a 1:1 ratio RBC to plasma: • 1st cooler: 4 units • 2nd and subsequent coolers: 4 units • Must be ABO compatible • Thawing plasma takes about 20 minutes • Upon initiation of MTP, plasma should be ready in 20 minutes • If patient blood group is not available, AB plasma will be issued • Patient will be switched to group specific plasma once patient’s blood group has been determined

  29. MTP: Transfusion of Platelets • Platelets • During MTP, administer if platelet count is <100 for CNS/spinal cord bleeding or traumatic brain injury; <50 for all others OR at any count if platelet dysfunction is suspected (ex. post-bypass) • Dose is “1 adult dose” • Available immediately • Note: For patients with PPH, platelets will be offered with the 1st cooler

  30. MTP: Transfusion of Cryoprecipitate • Cryoprecipitate • During MTP, administer if fibrinogen level is <1.5g/L • Dose is 10 units • Must be ABO compatible • Thawing and pooling cryoprecipitate takes 30 minutes • Note: For patients with PPH, cryoprecipitate will be offered with the 1st cooler

  31. MTP: What is in the shipment? • 1st shipment • Cooler with 6 units of RBC • 4 unit of plasma will be issued separately in the next 20 minutes • For PPH OR upon request • 1 adult dose of platelets (available immediately) • 10 units of cryoprecipitate (available in 20 minutes) • 2nd shipment and subsequent shipments • Cooler with 4 units of RBC, 4 units of plasma • Will be prepared every 30 minutes • Platelets and cryoprecipitate must be ordered as per clinical situation and laboratory results • These will be issued in a clear plastic bag

  32. MTP: Transfusion Goals The following should be used as a guideline only and not replace clinical judgment • Transfuse RBC to maintain Hgb>80g/L • Transfuse plasma at a 1:1 to 1:2 RBC to plasma ratio or maintain INR<1.5 and/or aPTT<1.5x upper limit of normal • Transfuse cryoprecipitate to maintain Fibrinogen >1.5 g/L • Transfuse platelets to maintain platelet count of 100x109/L for CNS/spinal cord bleeding or traumatic brain injury; platelet count for 50x109/L for all other bleeding patients • Note: If platelet dysfunction is suspected, transfuse platelets regardless of platelet count

  33. MTP: Supportive measures The principal aim is to achieve either surgical or medical haemostasis • Other potentially useful interventions: • Maintain normothermia • Replace calcium • Consider cell salvage • Consider tranexamic acid (TXA): 1 g loading dose over 10 minutes followed by 1g over 8 hours • Use of recombinant Factor VIIa (rFVIIa) is not recommended in the management of MT

  34. MTP: Termination • Termination criteria • bleeding is controlled or patient is deceased • Note: Re-assess need for ongoing MTP every 30 minutes; if transfusion requirements have decreased, consider terminating MTP and provide transfusions as necessary • Inform TM (ext 5084) that MTP has been terminated • Return MTP cooler(s) and any untransfused blood products as soon as possible to avoid wastage

  35. MTP: Common errors Consistently identified weaknesses during MTP: • Poor planning • Poor communication • Delay in activation of MTP • Failure to monitor laboratory parameters during MTP • Failure to monitor for and manage hypothermia • Failure to administer blood products as per MTP • Failure to administer cryoprecipitate • Delay in termination of MTP

  36. MTP: Adverse Events • Hypothermia • Citrate toxicity • Volume overload, abdominal compartment syndrome • Transfusion Reactions • Acute hemolytic transfusion reaction (ex. ABO incompatible transfusion due to clerical error) • Transfusion related acute lung injury (TRALI) • Transfusion associated cardiac overload (TACO) • Major allergic reaction

  37. Concluding Remarks • Be prepared – know the protocol • Practice - participate in mock MTP • During MTP, communicate with all members of the team, including those in TM • Re-assess need for ongoing MTP frequently • Return coolers and untransfused products ASAP

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