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Blood Transfusion

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Blood Transfusion

  1. 1. Transfusion Anthony Holley Intensive Care Royal Brisbane and Women’s Hospital Bedside Critical Care 2012
  2. 2. Acknowlegdements • National Blood Authority • All our colleagues in the Clinical Reference Group Bedside Critical Care 2012
  3. 3. A Sad Case “Names and places have been changed to protect innocent practitioners involved” Bedside Critical Care 2012
  4. 4. A Sad Case • 36 yr old dirt bike rider • Comes off his motorcycle at 80 Km/hr • Lands with his abdomen over a log • Attended to by Ambos at the scene • GCS 15, HR 125 bpm BP 124/68 • +++ abdominal pain • Given morphine and metoclopramide Bedside Critical Care 2012
  5. 5. Arrives at Gunadulotsa Base Hospital • GCS 15, but very distressed • HR 130 bpm BP 105/58 • Features of an acute abdomen Bedside Critical Care 2012
  6. 6. Retrieval Activated • 3000 ml crystaloid with ongoing background maintance of 120 ml/hr • 3 units of PRBC given • Original Hb returns 146 • Repeat Hb 168 • Progressive respiratory distress • Intubated, FiO2 0.8 Bedside Critical Care 2012
  7. 7. Arrives at Royal Elsewhere’s and Men’s Hospital • Full and extensive work up in the emergency Department • CT demonstrates a fractured liver and little else • To OT • Hb 132 • Plts 105 • INR 1.6 Bedside Critical Care 2012
  8. 8. On Return to Intensive Care • Receives 6 units FFP • Hb 103 • Transfused a further 2 units PRBC • Post transfusion Hb 127 • Given tranexamic acid 1 g followed by an infusion of 1g over 8 hours • Given 1 bag pooled Platelets Bedside Critical Care 2012
  9. 9. Progress • Partial hepatectomy fast and effective • But develops a fever, rising WBC, Bilateral pulmonary infiltrates and increasing ventilatory requirement • Bilateral DVTs on U/S • After a prolonged ICU admission with a difficult respiratory wean discharged to surgery with trauma team input. Bedside Critical Care 2012
  10. 10. Bedside Critical Care 2012
  11. 11. Mount Cockup Bedside Critical Care 2012
  12. 12. Lessons from the Black Box 1. Massive transfusion protocols 2. Transfusion triggers 3. Transfusion ratios 4. The role of Tranexamic acid Bedside Critical Care 2012
  13. 13. Bedside Critical Care 2012 http://www.nba.gov.au/guidelines/order/index.html http://www.nba.gov.au/guidelines/review.html
  14. 14. National Blood Authority 2001 National Health and Medical Research Council/ Australasian Society of Blood Transfusion (NHMRC/ASBT) Clinical practice guidelines on the use of blood components Now replaced by NBA: Patient Blood Management Guidelines: Modules 1-6 Bedside Critical Care 2012
  15. 15. Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components It includes the three pillars of: 1. Optimisation of blood volume and red cell mass 2. Minimisation of blood loss 3. Optimisation of the patient’s tolerance of anaemia. Bedside Critical Care 2012
  16. 16. So What is the Utility of Massive transfusion Protocols? Bedside Critical Care 2012
  17. 17. Recommendation I It is recommended that institutions develop an MTP that includes the dose, timing and ratio of blood component therapy for use in trauma patients with, or at risk of, critical bleeding requiring massive transfusion (Grade C) Bedside Critical Care 2012
  18. 18. Practice Point In patients with critical bleeding requiring massive transfusion, the use of an MTP to facilitate timely and appropriate use of RBC and other blood components may reduce the risk of mortality and ARDS. Bedside Critical Care 2012
  19. 19. Senior clinician • Request:a o 4 units RBC o 2 units FFP • Consider:a o 1 adult therapeutic dose platelets o tranexamic acid in trauma patients • Include:a o cryoprecipitate if fibrinogen < 1 g/L a Or locally agreed configuration Massive transfusion protocol (MTP) template Senior clinician determines that patient meets criteria for MTP activation Baseline: Full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistry, arterial blood gases Notify transfusion laboratory (insert contact no.) to: ‘Activate MTP’ Bleeding controlled? Laboratory staff • Notify haematologist/transfusion specialist • Prepare and issue blood components as requested • Anticipate repeat testing and blood component requirements • Minimise test turnaround times • Consider staff resources Haematologist/transfusion specialist • Liaise regularly with laboratory and clinical team • Assist in interpretation of results, and advise on blood component support NOYES Notify transfusion laboratory to: ‘Cease MTP’ OPTIMISE: • oxygenation • cardiac output • tissue perfusion • metabolic state MONITOR (every 30–60 mins): • full blood count • coagulation screen • ionised calcium • arterial blood gases AIM FOR: • temperature > 350C • pH > 7.2 • base excess < –6 • lactate < 4 mmol/L • Ca2+ > 1.1 mmol/L • platelets > 50 × 109/L • PT/APTT < 1.5 × normal • INR ≤ 1.5 • fibrinogen > 1.0 g/L The information below, developed by consensus, broadly covers areas that should be included in a local MTP. This template can be used to develop an MTP to meet the needs of the local institution's patient population and resourcesBedside Critical Care 2012
  20. 20. Bedside Critical Care 2012 So in patients with critical bleeding requiring massive transfusion, which parameters should be measured early and frequently?
  21. 21. In patients with critical bleeding requiring massive transfusion, the following parameters should be measured early and frequently: 1. Temperature 2. Acid–base status 3. Ionised calcium 4. Haemoglobin 5. Platelet count 6. PT/INR 7. APTT 8. Fibrinogen level. With successful treatment, values should trend towards normal. Bedside Critical Care 2012 Practice Point
  22. 22. Values indicative of critical physiologic derangement include: 1. Temperature < 35°C 2. pH < 7.2, base excess > –6, lactate > 4 mmol/L 3. ionised calcium < 1.1 mmol/L 4. platelet count < 50 × 109/L 5. PT > 1.5 × normal 6. INR > 1.5 7. APTT > 1.5 × normal 8. fibrinogen level < 1.0 g/L. Bedside Critical Care 2012 Practice Point
  23. 23. So what product ratios should we be using? Bedside Critical Care 2012
  24. 24. Ratios
  25. 25. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, Gonzalez EA, Pomper GJ, Perkins JG, Spinella PC, Williams KL, Park MS. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447-458.
  26. 26. Product ratios • Massive data base ~ 25 000 • 16% transfused • 11.4% received massive transfusions • Logistic regression identified the ratio of FFP to PRBC use as an independent predictor of survival. • With a higher the ratio of FFP:PRBC, a greater probability of survival was noted. • The optimal ratio in this analysis was an FFP:PRBC ratio of 1:3 or less. Teixeira PG, Inaba K, Shulman I, Salim A, Demetriades D, Brown C, Browder T, Green D, Rhee P. Impact of plasma transfusion in massively transfusedtrauma patients. J Trauma 2009; 66:693-697.
  27. 27. Practice Point In patients with critical bleeding requiring massive transfusion, insufficient evidence was identified to support or refute the use of specific ratios of RBCs to blood components. Bedside Critical Care 2012
  28. 28. Practice Point In patients with critical bleeding requiring massive transfusion, suggested doses of blood components are: 1. FFP: 15 mL/kg 2. platelets: 1 adult therapeutic dose 3. cryoprecipitate: 3–4 g. Bedside Critical Care 2012
  29. 29. Haemoglobin trigger??? Bedside Critical Care 2012
  30. 30. Practice Point In patients with critical bleeding requiring massive transfusion, haemoglobin concentration should be interpreted in the context of haemodynamic status, organ perfusion and tissue oxygenation. Bedside Critical Care 2012
  31. 31. Practice Point In patients with critical bleeding requiring massive transfusion, the use of RBC and other blood components may be life saving. However, transfusion of increased volumes of RBC and other blood components may be independently associated with increased mortality and ARDS. Bedside Critical Care 2012
  32. 32. What Adjuctive Therapy should we employ? Bedside Critical Care 2012
  33. 33. Recommendation 2 The routine use of rFVIIa in trauma patients with critical bleeding requiring massive transfusion is not recommended because of its lack of effect on mortality (Grade B) and variable effect on morbidity (Grade C). Bedside Critical Care 2012
  34. 34. Practice Point 1. An MTP should include advice on the administration of rFVIIa when conventional measures – including surgical haemostasis and component therapy – have failed to control critical bleeding. 2. NB: rFVIIa is not licensed for this use. Its use should only be considered in exceptional circumstances where survival is considered a credible outcome 3. When rFVIIa is administered to patients with critical bleeding requiring massive transfusion, an initial dose of 90 μg/kg is reasonable. Bedside Critical Care 2012
  35. 35. Crash 2 In trauma patients with or at risk of significant haemorrhage, tranexamic acid (loading dose 1 g over 10 minutes, followed by infusion of 1 g over 8 hours) should be considered. No systematic review was conducted on tranexamic acid in critical bleeding/massive transfusion. The study population was not restricted to critical bleeding requiring massive transfusion. Bedside Critical Care 2012
  36. 36. Bedside Critical Care 2012 Tranexamic Acid
  37. 37. Bedside Critical Care 2012 Tranexamic Acid
  38. 38. The routine use of rFVIIa in trauma patients is not recommended due to its lack of effect on mortality (Grade B) and variable effect on morbidity (Grade C). Institutions may choose to develop a process for the use of rFVIIa where there is: • uncontrolled haemorrhage in salvageable patient, and • failed surgical or radiological measures to control bleeding, and • adequate blood component replacement, and • pH > 7.2, temperature > 340C. Discuss dose with haematologist/transfusion specialist b rFVIIa is not licensed for use in this situation; all use must be part of practice review. • Warfarin: • add vitamin K, prothrombinex/FFP • Obstetric haemorrhage: • early DIC often present; consider cryoprecipitate • Head injury: • aim for platelet count > 100 × 109/L • permissive hypotension contraindicated • Avoid hypothermia, institute active warming • Avoid excessive crystalloid • Tolerate permissive hypotension (BP 80–100 mmHg systolic) until active bleeding controlled • Do not use haemoglobin alone as a transfusion trigger • Identify cause • Initial measures: - compression - tourniquet - packing • Surgical assessment: - early surgery or angiography to stop bleeding • If significant physiological derangement, consider damage control surgery or angiography • Consider use of cell salvage where appropriate • Actual or anticipated 4 units RBC in < 4 hrs, + haemodynamically unstable, +/– anticipated ongoing bleeding • Severe thoracic, abdominal, pelvic or multiple long bone trauma • Major obstetric, gastrointestinal or surgical bleeding Specific surgical considerations ResuscitationInitial management of bleeding Dosage Cell salvage Considerations for use of rFVIIab Special clinical situations Suggested criteria for activation of MTP ABG arterial blood gas FFP fresh frozen plasma APTT activated partial thromboplastin time INR international normalised ratio BP blood pressure MTP massive transfusion protocol DIC disseminated intravascular coagulation PT prothrombin time FBC full blood count RBC red blood cell rFVlla activated recombinant factor VII Platelet count < 50 x 109/L 1 adult therapeutic dose INR > 1.5 FFP 15 mL/kga Fibrinogen < 1.0 g/L cryoprecipitate 3–4 ga Tranexamic acid loading dose 1 g over 10 min, then infusion of 1 g over 8 hrs a Local transfusion laboratory to advise on number of units needed to provide this dose Bedside Critical Care 2012
  39. 39. Bedside Critical Care 2012

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