Emergency & Massive Transfusion Brian Poirier, MD UCDavis Medical Center

Learning Objectives Define Massive Transfusion. List the types of shock. Understand estimations of blood loss and fluid resuscitation. Discuss the indications for red cells, platelets and plasma in massive transfusion. Become aware of the risks of emergency release blood.

Massive Transfusion 10 or more pRBC units (TBV) in <24 hours. Others: Replacement of 50% of TBV within 3 hours. Blood loss >150 ml/min.

Massive Transfusion Clinical Settings Trauma Surgery (e.g. Liver, Cardiovascular) GI bleeding Obstetrics

Storm King Mountain Colorado

SHOCK

Types of Shock Hypovolemic – Hemorrhage Cardiogenic – MI, cardiomyopathy Obstructive – Tamponade, PE Distributive – Sepsis, Anaphylaxis Hypovolemic – Hemorrhage

Class I <750ml blood loss, 10-15% Pulse <100, BP Normal Pulse Pressure Normal or Increased Resp Rate 14-20 Urine Output >30ml/hr CNS: Slightly Anxious Fluid Replacement - Crystalloid

Class II 750-1500ml 15%-30% Blood Loss Pulse >100, BP Normal Pulse Pressure Decreased Resp Rate 20-30 Urine Output 20-30ml/hr CNS Mildly Anxious Fluid replacement Crystalloid

Class III 1500-2000ml 30%-40% Blood Loss Pulse >120, BP Decreased Pulse Pressure Decreased Resp Rate 30-40 Urine Output 5-15ml/hr CNS Anxious and Confused Fluid Replacement - Crystalloid & Blood

Class IV >2000ml 40% or more Blood Loss Pulse >140, BP Decreased Pulse Pressure Decreased Resp Rate >35 Urine Output Negligible CNS Confused & Lethargic Fluid Replacement - Crystalloid and Blood

Can Estimate Blood Loss by Response to Fluid Bolus

Laboratory Values to Monitor in Trauma Hgb/Hct INR/PTT Fibrinogen Platelet Count Blood Gases Electrolytes

Blood Products RBC Plasma Platelets Cryoprecipitate

Blood Products

Blood Orders Patient Blood Sample Available Type & Screen Type and Crossmatch Patient Blood Sample Not Available Emergency Release (Universal Donor/Pink Sheet) Massive Transfusion Guideline

Emergency Release Blood - Universal Donor O, RhD neg/pos RBCs – 5 min AB or A Plasma/Platelets

Type & Screen Initial sample gets ABO, Rh type and antibody screen. Time ~ 40min. When blood is needed an immediate spin crossmatch is done. Time ~ 10-15 min.

Type & Crossmatch Initial sample gets ABO, Rh type, antibody screen and crossmatch. Time ~ 60min. When blood is needed it has already been fully tested. Time~5min.

Probability of Safe Transfusion

Other Emergency RBC Problems Incomplete compatibility testing Unexpected antibodies found Compatible blood not available

Washout Curve Y/Y0= e-x Y = Final concentration of substance Y0 = Initial concentration of substance X = total number of volumes exchanged Derksen 1984

Coagulation Factors-% Needed for Hemostasis II 10-25% V 10-30% VII >10% VIII 30-40% IX 15-40% X 10-40% XI 20-30%

Reed 1985 Showed that platelet counts after massive blood loss did not decline according to standard apheresis wash out equations More platelets became physiologically available Possible splenic reservoir

Platelets & Massive Blood Loss (Toy 1991) Massive Transfusion Patients Resuscitated with only RBCs & Crystalloid After 20 units 75% showed plt count < 50K No documentation of microvascular bleeding

UCD Platelet Usage 1992 1.5% of Trauma patients required platelets 1.43% of blunt injury patients 2.3% of penetrating injury patients

UCDMC Non-MTG Indications for Platelets & Hemostatic Factors FFP if INR> 1.5 or PT >1.5 X Normal Platelets if Count <50K-100K Cryoprecipitate if Fibrinogen <100mg/dl (each unit contains ~250 mg)

“It saves more lives than you could believe” Gen. George S Patton

Massive Exanguination “Triad of Death” Acidosis Hypothermia Coagulopathy

Blood Warmer

Massive Transfusion Protocol Mortality in massive transfusion is high – up to 57% (patients transfused >50 RBC units) Coagulopathy is present early and not only a factor of hemodilution (Gonzalez et al 2007) A recent retrospective review shows an increase in survival with a 1:1:1 ratio of plasma: platelets: RBCs

Massive Transfusion Study (Holcomb 2008)

Massive Transfusion Study (Holcomb 2008)

Massive Transfusion Study (Holcomb 2008)

Massive Transfusion Study (Holcomb 2008)

Massive Transfusion Protocol New Trend to give RBCs, FFP and Platelets to simulate whole blood Typical Published Ratios of RBC:FFP:Platelets using Typical Products 6 units RBC Adult (250ml/unit) 6 units FFP (~250ml/unit) 6 units Platelet Concentrate (50ml/unit)

UCDMC Massive Transfusion Guideline (Established 2008) Adult Replacement Volumes established based on Acute Blood Loss of 50% and maintenance of a RBC:FFP:Platelet ratio of whole blood AND using the products available at UCDMC 6 units RBC Adult (250ml/unit) 3 units FFP Jumbo (400ml/unit) 1 unit Plateletpheresis (250ml/unit)

Massive Transfusion Protocol Example

Pediatric MTG Used Pediatric Growth Charts to determine the weights of children at various age groups and adult dosages were downsized proportionally MTG specifies what you will receive in the box NOT necessarily the exact dosage for the patient Each child will need a dosage calculation or estimate based on their size and extent of hemorrhage

Problems of the MTG Is it translatable to civilian practice? Is it needed for all patients or only the most severely injured ? Wastage of (precious) AB plasma. Will it increase acute pulmonary events - TACO & TRALI?

Potential Adverse Effects of Massive Transfusion Metabolic Disturbances Transfusion Reactions Infectious Disease Risks

Massive Transfusion Citrate Toxicity Hyperkalemia Decreased Oxygen Delivery Hypothermia

Acute/Immediate Transfusion Reactions Acute Hemolytic Reactions Bacterial Contamination of Blood Products Anaphylaxis Transfusion Related Acute Lung Injury Severe Febrile Reactions Transfusion Associated Circulatory Overload Metabolic Problems of Massive Transfusion Air Emboli & Microemboli Hypotensive Response to Plasma

Transfusion Mortality FDA Reports

Sources of Error (NY Data 1999) 58% Outside blood bank 17% In blood bank & outside 25% In blood bank

Sources of Error 58% Outside of the Blood Bank 43% Failure to identify patient 11% Phlebotomy error 3% Incorrect order/No ID at bedside

Sources of Error 17% In & Outside of Blood Bank 15% blood issued for another patient/not detected at bedside 2% Inconsistent order sent/not detected in blood bank

Sources of Error 25% In Blood bank 1% Used wrong sample 11% wrong blood group issued 7% Incorrect typing-technical 6% incorrect typing - clerical

Preventing Errors Non-punitive error reporting system to uncover systemic/organizational problems Process Control to Neutralize Human Error Strict DOE policy (name change requires ABO verification) ABO Verification on all 1st time recipients System Audits

Phlebotomy Errors Highest Single Source has always been ER 1994 Study showed ER as Major contributor of Mislabelled Specimens Current Audits still show ER submits many mislabelled specimens but they’ve improved

Thank You! მადლობა

Thanks to: Carol Marshall, MD L. Fernando, MD Rosemary Howard, CLS

References Gonzalez EA, Moore FA, Holcomb JB, et al. (2007) Fresh frozen plasma should be given earlier to patients requiring massive transfusion. The Journal of Trauma, 62: 112-119. Holcomb JB, Wade CE, Michalek JE, et al. (2008) Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Annals of Surgery, 248: 447-458. Ho AMH, Dion PW, Cheng CAY, et al. (2005) A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage. Canadian Journal of Surgery, 48(6):470-478. The Face of Mercy: A Photographic History of Medicine at War created and produced by Matthew Naythons, ISBN 0-679-42744-9, New York, NY, Random House/Epicenter Inc, 1993.