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 Common errors and adverse events

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

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

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

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

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

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

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

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

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

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

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

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

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 Porter Delivers laboratory samples to the laboratory and blood products from TM to the patient Returns empty coolers and untransfused blood products to TM

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

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

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

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

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)

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

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

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

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

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 O Rh neg reserved for females of childbearing age * 1% risk 26

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

MTP: Transfusion of 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

MTP: Transfusion of 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

MTP: Transfusion of 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

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

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

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

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

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

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

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