Safe Blood Transfusion

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Safe Blood Transfusion

  1. 1. West Midlands Regional Training Package for Safe Blood Transfusion Practice The West Midlands Regional Transfusion Committee MODULE 13: Massive Transfusion
  2. 2. Module 13: Massive Transfusion <ul><li>Contents: </li></ul><ul><li>Initial Resuscitation </li></ul><ul><li>Requesting of Blood Products </li></ul><ul><li>Complications of Massive Transfusion </li></ul>Aim: Increase staff awareness and knowledge and thus improve patient safety and reduce blood transfusion errors. <ul><li>Objectives: </li></ul><ul><li>To recall the definition of a massive transfusion. </li></ul><ul><li>To describe how to appropriately manage patients who present with massive blood loss. </li></ul><ul><li>To recognise the correct sequence of blood products to be used in a patient presenting with massive blood loss. </li></ul><ul><li>To recognise the appropriate laboratory tests to request in an emergency situation and when to request them. </li></ul><ul><li>To recognise the complications of massive transfusion. </li></ul>
  3. 3. Introduction Module 13: Massive Transfusion It must be remembered, massive transfusion is only a part of patient management prior to definitive management / surgery <ul><ul><ul><li>Massive transfusion is defined as the replacement of total blood volume (  10 units of red cells in an average adult) in a 24-hour period. A general indication for massive transfusion is haemorrhagic shock / hypovolaemic shock resulting from rapid blood loss. </li></ul></ul></ul>
  4. 4. Massive blood transfusion - procedure Module 13: Massive Transfusion Initial Resuscitation Oxygen should be administered. It is also important to maintain the patient’s body temperature (coagulation proteins may be less effective at lower temperatures, increasing the risk of blood loss). Crystalloids and/or synthetic colloids should be infused initially to restore circulating volume, until an acceptable systolic blood pressure is restored. Red cells should then be transfused to maintain adequate oxygen delivery to tissues. Laboratory tests should be performed as early as possible to obtain baseline values: FBC, PT, APTT, fibrinogen, biochemistry profile, blood gases and blood bank samples will be required. The FBC and coagulation samples should be repeated regularly to guide blood component replacement.
  5. 5. Requesting of blood products - Red cells Module 13: Massive Transfusion Extra care should be taken if the patient’s details are not fully known and a temporary A+E number is being used – this is an area of risk for positive patient identification where errors can occur. <ul><ul><ul><li>As soon as the patient’s blood group has been determined a switch should be made from O </li></ul></ul></ul><ul><ul><ul><li>Rh (D) negative blood to ABO group specific blood. Medical staff must accept full responsibility for administration of un-crossmatched blood – the patient may have </li></ul></ul></ul><ul><ul><ul><li>unidentified / undetected antibodies – the use of un-crossmatched blood in these patients may result in a life threatening Haemolytic Transfusion Reaction. </li></ul></ul></ul>Emergency group O Rh D negative units can be given while the patient’s blood group is being determined. Immediately Un-crossmatched ABO group specific blood can be provided. 15 min after receipt of sample in blood bank Fully crossmatched blood can be provided in most cases. 45 min after receipt of sample in blood bank
  6. 6. Module 13: Massive Transfusion Requesting of blood products - Red cells Points for consideration: <ul><li>If large volumes of blood are to be transfused rapidly a blood warmer should be used. </li></ul><ul><li>Adults receiving infusion of blood at rates greater than 50ml/kg/hr </li></ul><ul><li>Infants receiving infusion of blood at rates greater than 15ml/kg/hr </li></ul><ul><li>(Note: cold blood infused faster than 100 ml / minute has been reported to cause cardiac arrest). </li></ul><ul><li>Refer to Module 9 – Administration of Blood / Blood Components </li></ul>If available, the use of cell salvage should be considered.
  7. 7. Requesting of blood products - platelets Module 13: Massive Transfusion Platelet count will usually drop to <50 x 10 9 /l following 1.5 - 2 x blood volume replacement. An FBC sample must be taken before platelets are transfused. Target platelet count should be >75 x 10 9 /l (or >100 x 10 9 /l for multiple trauma or trauma involving CNS). Adults / larger child (>15kg) one adult therapeutic dose should be given. Neonate / small child 10 - 20 ml/kg body weight.
  8. 8. Requesting of blood products - fresh frozen plasma (FFP) Module 13: Massive Transfusion Remember: FFP requires approx 30 minutes thawing time Depletion of coagulation factors usually occurs after 1-1.5 x blood volume has been lost. A coagulation sample for PT, APTT and fibrinogen should be taken before FFP is transfused. FFP should be administered if the PT and/or APTT results are >2 x control. Target PT and PTT results should be <1.5 x control. Adults 12-15 ml/kg body weight or 4 units Neonate / small child 10-20 ml/kg body weight.
  9. 9. Requesting of blood products - cryoprecipitate Module 13: Massive Transfusion Remember: cryoprecipitate requires approx 30 minutes thawing time Cryoprecipitate should be considered to replace fibrinogen and factor VIII when the fibrinogen result is <1.0 g/l. Target fibrinogen level should be >1.0 g/l. Adults 2 packs of pooled cryoprecipitate
  10. 10. Pharmacological Support Module 13: Massive Transfusion Recombinant Factor VIIa (rFVIIa) May be available / considered. A recent trial has demonstrated that rFVIIa may have the potential to reduce the need for massive transfusion in penetrating trauma. In addition, mortality may be reduced in blunt trauma. Tranexamic Acid: Tranexamic acid can inhibit fibrinolysis by impairing fibrin dissolution. Is currently undergoing trials in bleeding associated with trauma. Beriplex: Beriplex is a prothrombin complex concentrate which can rapidly reverse the anticoagulant effect of warfarin should life threatening bleeding occur. The suggested dose is between 25 - 50u/kg and it should be used in conjunction with vitamin K. Beriplex should only be used in life-threatening situations for anticoagulation reversal, as it is potentially thrombogenic. It is contraindicated in patients with DIC or uncompensated liver disease.
  11. 11. Complications of massive transfusion Module 13: Massive Transfusion <ul><ul><li>Hypothermia : </li></ul></ul><ul><ul><li>This is often present, usually because </li></ul></ul><ul><ul><li>of shock due to loss of thermal regulation. </li></ul></ul><ul><ul><li>Rapid transfusion of blood at 4  c and a cold environment can add to this problem so the patient should always be kept warm and a blood warmer should be used when the infusion rate is above 50 ml/kg/hr. </li></ul></ul>Hypocalcaemia : FFP and platelets contain citrate anticoagulant. Red cell units also contain small amounts of citrate. This can lower plasma calcium levels, which can be a problem in patients with impaired liver function, hypothermic patients and neonates. If there is ECG, clinical or biochemical evidence of hypocalcaemia, calcium should be given until the ECG is normal but it is unusual for this to be required. Adult respiratory distress syndrome (ARDS) : Both under and over-transfusion are associated with an increased risk of ARDS; the risk can be minimised by maintenance of good perfusion and oxygenation. When ARDS occurs during or following massive transfusion, transfusion-associated acute lung injury (TRALI) should be considered. Hyperkalaemia : Stored blood contains high levels of potassium which, when infused, can be taken up by the red cells. Transfusion-related hyperkalaemia can be seen in patients with renal failure, hypothermia or in neonates. This can lead to cardiac arrest and is avoided by keeping the patient warm. However, most patients receiving massive transfusion require potassium supplementation because of hypokalaemia.
  12. 12. Key Points Module 13: Massive Transfusion <ul><ul><li>Massive transfusion is defined as the replacement of total blood volume (  10 units of red cells) in a 24-hour period. </li></ul></ul><ul><ul><li>FBC and coagulation samples should be repeated regularly to guide blood component replacement. </li></ul></ul><ul><ul><li>Emergency group O Rh (D) negative units can be given while the patients’ blood group is being determined. However, as soon as the patients’ blood group has been determined a switch should be made from O Rh (D) negative blood to ABO group specific blood. </li></ul></ul><ul><ul><li>If large volumes of blood are to be transfused rapidly a blood warmer should be used. </li></ul></ul><ul><ul><li>If available, the use of cell salvage should be considered. </li></ul></ul><ul><ul><li>Depletion of coagulation factors usually occurs after 1-1.5 x blood volume has been lost. </li></ul></ul><ul><ul><li>Pharmacological support to help reduce bleeding (such as Factor VIIa) may be available – discuss with senior staff. </li></ul></ul><ul><ul><li>Complications of massive transfusion include hypothermia, hypocalcaemia, hyperkalaemia and Adult Respiratory Distress Syndrome (ARDS). </li></ul></ul>
  13. 13. Module 13 - Quiz <ul><li>Question 1 of 7 </li></ul><ul><li>Massive transfusion is defined as the replacement of total blood volume (  10 units of red cells) in a 24-hour period. </li></ul><ul><li>True / False </li></ul>Module 13: Massive Transfusion
  14. 14. Module 13 - Quiz <ul><li>Question 2 of 7 </li></ul><ul><li>Red cells should be transfused immediately to restore the circulatory volume. </li></ul><ul><li>True / False </li></ul>Module 13: Massive Transfusion
  15. 15. Module 13 - Quiz <ul><li>Question 3 of 7 </li></ul><ul><li>As soon as the patient’s blood group has been determined, a switch should be made from O Rh (D) negative blood to ABO group specific blood. </li></ul><ul><li>True / False </li></ul>Module 13: Massive Transfusion
  16. 16. Module 13 - Quiz <ul><li>Question 4 of 7 </li></ul><ul><li>Blood warming is contra-indicated in massive transfusion </li></ul><ul><li>True / False </li></ul>Module 13: Massive Transfusion
  17. 17. Module 13 - Quiz <ul><li>Question 5 of 7 </li></ul><ul><li>Depletion of coagulation factors usually occurs after 0.25 x blood volume has been lost. </li></ul><ul><li>True / False </li></ul>Module 13: Massive Transfusion
  18. 18. Module 13 - Quiz <ul><li>Question 6 of 7 </li></ul><ul><li>Beriplex is a prothrombin complex concentrate which can rapidly reverse the anticoagulant effect of heparin should life-threatening bleeding occur. </li></ul><ul><li>True / False </li></ul>Module 13: Massive Transfusion
  19. 19. Module 13 - Quiz <ul><li>Question 7 of 7 </li></ul><ul><li>Hypercalcaemia is a complication of massive transfusion </li></ul><ul><li>True / False </li></ul>Module 13: Massive Transfusion
  20. 20. Module 13: Massive Transfusion Go to Answer Sheet Go to Module 14 Go to Index

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