Massive Transfusion Protocol

K. Pavenski, MD FRCPCHead, Div. Transfusion Medicine

October 31, 2013

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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

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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

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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

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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

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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

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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

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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

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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:a. Massive haemothoraxb. Positive FAST scanc. Pelvic fracture

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MTP Activation Criteria: SpecificPost 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

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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

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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

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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

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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

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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

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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

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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

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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

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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 >35C• Place patient on continuous monitoring

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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)

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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

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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

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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

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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

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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

Time to Availability of RBC

RBC Product Turn-Around Time Comments

Uncrossmatched blood(O Rh pos or O Rh neg)

<5 minutes Only in emergencies (when risk of delaying transfusion is higher than the risk of acute hemolysis*)

Group-specific, uncrossmatched RBCs

10 minutes (to perform group) As above; superior, because matching for ABO and RhD preserves O-Neg stock

Crossmatched RBCs 45 minutes to hrs (to perform group and screen, antibody investigation if appropriate, crossmatch)

Preferred choice, as the serologically cleared product is the safest product available

* 1% riskO Rh neg reserved for females of childbearing age

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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

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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

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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

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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

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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

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MTP: Transfusion GoalsThe 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

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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

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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

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MTP: Common errorsConsistently 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

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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

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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