Massive Transfusion and Emergency Blood (Medivac)

Document ID 02908 Version no. 1.0 Approval date 11/12/2014

Executive sponsor Executive Director Medical Service Effective date 11/12/2014

Author/custodian Bronwyn Williams, Chair Blood Management Committee Review date 11/12/2015

Supercedes Procedure 02901 Blood & Blood Products

Applicable to Medical and Nursing Staff at LCCH

Authorisation Sue McKee, General Manager Operations

Purpose This procedure describes the processes to be followed:

• when the Massive Transfusion Protocol (MTP) is activated

• when Emergency (Medivac) blood is requested without MTP activation and includes how Emergency use O Negative units stored in the Blood Fridge in the Lady Cilento Children’s Hospital (LCCH) should be used.

Scope This procedure applies to all LCCH and Pathology Queensland Staff involved in these processes.

Procedure • Critical bleeding is major haemorrhage that is life threatening. Massive transfusion is used in diverse

clinical scenarios in which critical bleeding occurs. Massive transfusion is defined based on the volume of blood loss or on the volume transfused. For practical purposes, massive transfusion in children may be defined as transfusion of > 40 mL blood/kg.

• Early recognition of critical bleeding, or its potential, is important to allow appropriate management including activation of MTP – see Appendix 1: CHQ-Protocol Massive Transfusion.

• Unexpected bleeding which requires blood product support in an urgent time frame may also occur outside of the setting of critical bleeding and timely supply of appropriate blood products is integral to optimal management.

• Massive Transfusion and Emergency Blood requests: o If blood is required immediately for a patient, the clinician must take full responsibility and should

bear in mind that it is more dangerous to give non-cross-matched blood to a patient who has been previously transfused or who is pregnant

o Group specific blood is preferable, and is available within ten (10) minutes of receipt of the specimen in the laboratory (allow at least 20 minutes transport time)

o All blood/blood products (including Fresh Frozen Plasma, Platelets and Cryoprecipitate) issued are ABO compatible with the patient’s blood group.

• Exceptions may rarely occur for platelets, Cryo and FFP if: o A patient requires urgent doses of FFP or Cryoprecipitate and their blood group is not available o Platelets are required for a bleeding patient and The Australian Red Cross Blood Service (ARCBS)

has no stocks of the patient group o The patient has received a Bone Marrow Transplant (BMT) and there is ABO incompatibility

between the recipient and donor.

• It is suitable for Rh(D) Negative red cells to be given to an Rh(D) Positive patient, but Rh(D) Negative female children should not receive Rh(D) Positive red cells.

Cross-match Requests for MTP or Medivac (Emergency O Negative) Blood

ALERT • Accurately labelled sample and request form must be provided to Blood Bank as

soon as possible. • Group O Negative units are often in short supply and cross over to patient group

specific blood conserves this precious resource.

• Pathology request form and specimen tube must be completed accurately to avoid sample rejection and delays in further supply and treatment. Required information must include:

o Patient Identification (full name) o UR number o DOB o Date and time of collection o Signature of collector (MUST match on specimen and request form) o The form must have the “All collectors must complete section” signed.

Massive Transfusion Protocol

The massive transfusion protocol is designed to ensure that appropriate blood products are provided in a timely way to manage a patient with actual or anticipated critical bleeding.

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Included in the protocol are: • Indications for activation of the protocol • Responsibilities of clinical and blood bank staff • Contact information for blood bank • Information on pack content relative to estimated patient weight and sequence of blood products which

will be provided in packs • Advice on appropriate infusion volumes for the various blood products • Laboratory testing which should be considered.

If the clinician is in doubt it is preferable that the protocol be activated. In the event that MTP is no longer needed the blood bank staff must be notified to “deactivate” or “standby” CHQ-Protocol Massive Transfusion

Medivac Blood

• Medivac Blood (uncross-matched Group O Rh (D) Negative) may be used in an emergency where cross-matched blood is not available and it is life threatening to wait.

• Group O Rh Negative blood can rapidly be supplied from LCCH Blood Bank by direct PTS (Patient transport system) to PICU, Operating Theatre and Emergency.

• For Emergency, if the patient has not yet arrived in the department, the Medivac blood will be supplied in an esky with Safe T Vue indicators attached.

ALERT Direct supply of Medivac blood from Blood Bank should be the primary method for obtaining emergency blood.

• Two (2) units of Group O Rh Negative RCC are stored in the LCCH Blood Fridge - these units should not be used unless Blood Bank is unable to provide the O negative blood within the required time frame.

• This blood is NOT irradiated. Risk versus benefit must be considered before use in patients who otherwise have an indication for irradiated RCC.

ALERT Ensure Blood Bank is notified when the Medivac blood in the LCCH Blood Fridge is used. This is to ensure that this stock is replaced in a timely manner and is necessary to meet documentation and traceability requirements in relation to units used.

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Checklist Before requesting issue of, or collecting the blood product from the transfusion service provider / remote refrigerator, the following should be checked by nursing / clinical staff:

• The prescription has been satisfactorily completed on Blood Product Prescription and Administration Record.

• Informed consent has been obtained and the indication for transfusion has been documented in the patient’s medical/clinical record.

• The patient has been assessed to determine whether it is appropriate to undertake the transfusion at the planned time.

• Intravenous access is appropriate and patent.

• Any pre-medication prescribed for the patient has been administered, and at a suitable time before the transfusion commences to allow it to be effective.

• Appropriately trained and competent staff are available for the duration of the transfusion, including two staff to perform the blood product and patient identity checks at the patient’s bedside.

• Clarify with parents/caregiver any previous reaction to blood products. Ensure medical officer is aware of previous reactions (date, blood product, symptoms of reaction and treatment), and clinical actions taken and document in the chart and Alert folder.

• Provide an age appropriate explanation of the procedure and potential adverse reactions to the child and parent/caregiver. Advise child/parent/carer to report any of the following immediately to nursing staff e.g.: fever, rigor, rash, difficulty breathing, pain at cannula/CVAD site, lower back pain, nausea, or any unusual feeling.

• Ensure child/adolescent is comfortable and has access to materials for diversion therapy while infusion is in progress.

• Check the Emergency trolley and that the suction/oxygen in the procedure area is in working order as per:

o CHQ NS 00252 Paediatric Patient – Foundations of Nursing Care o CHQ Procedure 64220 Medical Emergency Equipment

• Record baseline set of vital signs i.e. Temperature, Pulse, Respiration Rate, Blood pressure, Oxygen Saturation and Capillary refill on age appropriate CEWT form.

• Assessment of skin condition, prior to and during transfusion i.e. for the presence/absence of rash, can assist recognition of a transfusion related allergic reaction. Transfusion reactions should be considered if a change or deterioration in the patient’s condition occurs.

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If Medivac units are used: • Notify Blood Bank ext 3555 immediately to arrange replacement • File completed Medivac report in patient’s chart

Failure to notify blood bank will prevent timely resupply of O negative units and may compromise patient care if units are needed urgently for other patients.

Supporting documents Procedures, Guidelines and Protocols • CHQ Policy 02901: Blood & Blood Products • CHQ Protocol: Massive Transfusion

Consultation Key stakeholders who reviewed this version: • Dr Bronwyn Williams, Haematologist and Chair Blood Management Committee • Dr Chris Fraser, Division of Oncology • Sue Williams, Senior Scientist Transfusion, Pathology Queensland • Emma Brownrigg, Transfusion CN, LCCH • Paul Lee-Archer, Division of Critical Care • Dr Jane Peake, Division of Medicine • Jo Ritchie, Quality Manager Blood and Marrow Transplant Service • Professor Roy Kimble, Division of Surgery • Dr Shoma Baidya, The Transfusion Service (ARCBS) • Liz Lennox, The Transfusion Service (ARCBS)

References 1. Pathology Queensland – Blood Bank: http://qheps.health.qld.gov.au/pathology/tests/blood-bank/home.htm 2. Patient Blood Management Guidelines: Module 1 – Critical Bleeding Massive Transfusion

http://www.blood.gov.au/system/files/documents/pbm-module1_0.pdf 3. Australia and New Zealand Society of Blood Transfusion: http://www.anzsbt.org.au/publications/index.cfm

Audit/evaluation strategy Level of risk Very High

Strategy Monitor usage

Audit/review tool(s) attached

Nil

Audit/Review date Case by case basis

Review responsibility Manager – Clinical Governance & Blood Bank Staff

Key elements / Indicators / Outcomes

KPI 1 Number of units used / year (process indicator when compared with KPI 2) KPI 2 Appropriateness of usage (against what criteria? How to tell life threatening?) KPI 3 Reported Clinical Incidents on PRIME CI KPI 4 No Test Results for related Pathology testing KPI 5 Availability of Medivac Blood (Group O Rh (D) Negative) in LCCH Blood Fridge KPI 6 No of Medivac units wasted

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Procedure revision and approval history

Version No.

Modified by Amendments authorised by Approved by

1.0 Paediatric Haematologist / CN Haematology

Chair, Blood Management Committee General Manager Operations

Keywords Massive transfusion, emergency blood, Medivac

Accreditation references

EQuIPNational Standards: 1 – Governance for Safety & Quality in Health Service Organisations; 7 – Blood & Blood Products

Appendix 1: LCCH Massive Transfusion Protocol – CHQ Protocol Massive Transfusion

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Clinical Multimedia Nov’14 1033_jk

BLOOD BANK ACTIONS:Damage Control Resuscitation in the critically bleeding/trauma patient

RESUSCITATION TEAM ACTIONS:

Activate MTP with Blood Bank when sustained massive bleeding (>40ml/kg) is occurring or anticipated.

Suggested parameters for utilising a Damage Control Resuscitation Approach

Signs of Shock• Hypotension for age• Hypothermia• Any coagulation abnormalities• Metabolic acidosis

The Key Elements of DCR are• Aggressive control of bleeding• Restore/maintain normal coags• Avoid Hypothermia

Note : For all Trauma Attend Calls Source 2 Units of RCC from LCCH Blood Bank prior to patient arrival. In the emergent situation RCC can be delivered via the PTS from Blood Bank.

Triggers – in response to hourly blood test:

• If INR > 1.5 or aPPT >40s give additional 20mls/kg FFP• If Fibrinogen <1g/L give 5mls/kg cryoprecipate• If platelets <75x109 give 10mls/kg platelets (<100 for head injury)• If iCa2+ < 1 meq/L give: Ca Chloride 0.2mls/kg of 10% solution (if CVL) Ca Gluconate 0.5mls/kg of 10% solution (if peripheral IV)

Contact Phone NumbersEmergency conultant 1080

Emergency flow coordinator 1090

PICU Registrar 4441/4442

Operating Room Suite Team Leader 1375

Porter 4567

Blood Bank 3555 or fax 3559

Coagulation Laboratory 3547

Treating Team Responsibilities

Activate Massive Transfusion Protocol (MTP) with Blood Bank when sustained massive bleeding is occurring or anticipated

• Upon activation provide Blood Bank with approx. weight of child, UR number and contact number of clinical area• Hand deliver correctly identified specimen with appropriately completed form to LCCH Blood Bank• Collect MTP packs from Blood Bank every 20-30 minutes• Check all blood on arrival as per blood protocol• Use blood warmer• Document all blood products given and maintain fluid balance record• Notify Blood Bank when patient transferred, and when MTP deactivated• Ensure unused blood products are stored appropriately (not out of fridge or temp. controlled esky for more than 20 mins )• Return unused blood product, as well as all empty product bags if adverse event http://qheps.health.qld.gov.au/ hssa/ pathology/blood/administration/adverse-events.htm

Blood Bank—Expected critically bleeding/trauma patientActivation of MTP may occur when sustained massive bleeding (>40ml/kg) is occurring or anticipated.

Anticipated further bleeding

Activate MTP with Blood Bank (ph: 3555)

Stage 2

Platelet - 10ml/kgFFP - 20ml/kgRCC - 20 ml/kg

Stage 1

Repeat Stage 1 and 2 as necessary(Note Stage 4 is repeat of Stage 2, etc)

Please optimise use of each unit to minimise blood

product wastage

10ml/kg O-veTake FBC, Coags, CXM and blood gas

(incl ionised Ca2+) Hand deliver CXM specimen and form to Blood Bank

Give Tranexamic Acid (IV)If within 3 hrs of injury and requiring blood products

15mg/kg load + 15mg/kg maintenance over 8 hrs

10ml/kg O-ve

after 40ml/kg move to Stage 2

Minimise crystalloid use to <10ml/kg

Activate MTPIssue 1 Unit/10kg O-ve up to 4U RCC (>40kg)

(group specific if available)

MTP Pack 1

0-10kg: 1 RCC, 1 FFP/ELP, 1U Cryo11-25kg: 2 RCC, 2 FFP/ELP, 2U Cryo25-40kg: 3 RCC, 3 FFP/ELP, 3U Cryo>40kg: 4 RCC, 4 FFP/ELP, 4U Cryo

MTP Pack 2

0-10kg: 1 RCC, 1 FFP/ELP, 1 Platelet11-25kg: 2 RCC, 2 FFP/ELP, 1 Platelet25-40kg: 3 RCC, 3 FFP/ELP, 1 Platelet>40kg: 4 RCC, 4 FFP/ELP, 1 Platelet

Deactivate or ‘Standby’

Repeat MTP pack 1 and 2 as necessary

Supply 2 Units (O-ve RCC) for all trauma attends

Blood Bank Responsibilities

Blood Bank to notify Treating Team if CXM specimen does not arrive within 20 mins of MTP activation

Once MTP activated:

• Identify team leader (Critical Care Consultant)

• Notify all LCCH Laboratory staff and LCCH Central Specimen Reception staff

• Start thawing up to 4U FFP/ELP and up to 4U Cryo

• Source supply of platelets

• Continue to supply numbered MTP packs every 20-30 minutes as they are used per protocol.

RCC = Red Cell ConcentrateFFP = Fresh Frozen PlasmaCryo = CryoprecipateELP = Extended Life PlasmaFBC = Full Blood CountCXM = CrossmatchCoags = Coagulation ProfileMTP = Massive Transfusion Protocol

Consider repeat bloods for FBC/Coags/Blood gas (incl ionised Ca2+)

If plasma/cryo not available, continue with

RCC’s untilMTP Pack 1 arrives

repeat bloods for FBC/Coags/Blood gas

(incl ionised Ca2+)

Platelet concentrate may be used up to 4 hours after

breach of the bag

Stage 1

Cryoprecipitate - 5ml/kg FFP/ELP - 20ml/kg

RCC - 20ml/kgNote: FFP and ELP can be used interchangeably

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