TransfusionAnthony Holley Bedside Critical CareIntensive Care 2012Royal Brisbane and Women’sHospital
Bedside Critical Care 2012Acknowlegdements• National Blood Authority• All our colleagues in the Clinical Reference Group
Bedside Critical Care 2012A Sad Case“Names and places have been changed to protect innocent practitioners involved”
Bedside Critical Care 2012A 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 2012Arrives at Gunadulotsa Base Hospital• GCS 15, but very distressed• HR 130 bpm BP 105/58• Features of an acute abdomen
Bedside Critical Care 2012Retrieval 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 2012Arrives at Royal Elsewhere’s andMen’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 2012On 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 2012Progress• 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 2012Lessons from the Black Box1. Massive transfusion protocols2. Transfusion triggers3. Transfusion ratios4. The role of Tranexamic acid
Bedside Critical Care 2012http://www.nba.gov.au/guidelines/order/index.html http://www.nba.gov.au/guidelines/review.html
Bedside Critical Care 2012 National Blood Authority2001 National Health and Medical Research Council/ Australasian Society of Blood Transfusion (NHMRC/ASBT)Clinical practice guidelines on the use of blood componentsNow replaced by NBA:Patient Blood Management Guidelines: Modules 1-6
Bedside Critical Care 2012 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 mass2. Minimisation of blood loss3. Optimisation of the patient’s tolerance of anaemia.
Bedside Critical Care 2012So What is the Utility of Massivetransfusion Protocols?
Bedside Critical Care 2012Recommendation IIt 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 2012Practice PointIn 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.
Massive transfusion protocol (MTP) templateThe information below, developed by consensus, broadly covers areas that should be included in a local MTP. This Bedside Critical Caretemplate can be used to develop an MTP to meet the needs of the local institutions patient population and resources 2012 Senior clinician determines that patient meets criteria for MTP activation OPTIMISE: • oxygenation • cardiac output Baseline: • tissue perfusion Full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistry, • metabolic state arterial blood gases MONITOR Notify transfusion laboratory (insert contact no.) to: (every 30–60 mins): ‘Activate MTP’ • full blood count • coagulation screen • ionised calcium • arterial blood gases Senior clinician Laboratory staff • Request:a • Notify haematologist/transfusion specialist o 4 units RBC AIM FOR: • Prepare and issue blood components o 2 units FFP as requested • temperature > 350C • Consider:a • Anticipate repeat testing and o 1 adult therapeutic dose platelets • pH > 7.2 blood component requirements o tranexamic acid in trauma patients • base excess < –6 • Minimise test turnaround times • Include:a • lactate < 4 mmol/L • Consider staff resources o cryoprecipitate if fibrinogen < 1 g/L • Ca2+ > 1.1 mmol/L Haematologist/transfusion a Or locally agreed configuration • platelets > 50 109/L specialist • PT/APTT < 1.5 normal • Liaise regularly with laboratory • INR ≤ 1.5 and clinical team Bleeding controlled? • fibrinogen > 1.0 g/L • Assist in interpretation of results, and advise on blood component support YES NO Notify transfusion laboratory to: ‘Cease MTP’
Bedside Critical Care 2012So in patients with critical bleeding requiringmassive transfusion, which parameters shouldbe measured early and frequently?
Bedside Critical Care 2012Practice PointIn patients with critical bleeding requiring massivetransfusion, the following parameters should bemeasured 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.
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 redblood cell ratios improves outcome in 466massively transfused civilian trauma patients. Ann Surg 2008; 248:447-458.
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.
Bedside Critical Care 2012Practice PointIn 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 2012Practice PointIn patients with critical bleeding requiring massive transfusion, suggested doses of blood components are:1. FFP: 15 mL/kg2. platelets: 1 adult therapeutic dose3. cryoprecipitate: 3–4 g.
Bedside Critical Care 2012Haemoglobin trigger???
Bedside Critical Care 2012Practice PointIn 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 2012Practice PointIn 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 2012What Adjuctive Therapy should weemploy?
Bedside Critical Care 2012 Recommendation 2The 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 2012Practice Point1. 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 outcome3. When rFVIIa is administered to patients with critical bleeding requiring massive transfusion, an initial dose of 90 μg/kg is reasonable.
Bedside Critical Care 2012Crash 2In 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/massivetransfusion. The study population was not restricted to critical bleeding requiring massive transfusion.
Suggested criteria for activation of MTP • Actual or anticipated 4 units RBC in < 4 hrs, + haemodynamically unstable, +/– anticipated ongoing bleeding Bedside Critical Care • Severe thoracic, abdominal, pelvic or multiple long bone trauma 2012 • Major obstetric, gastrointestinal or surgical bleeding Initial management of bleeding Resuscitation • Identify cause • Avoid hypothermia, institute active warming • Initial measures: • Avoid excessive crystalloid - compression • Tolerate permissive hypotension (BP 80–100 mmHg systolic) - tourniquet until active bleeding controlled - packing • Do not use haemoglobin alone as a transfusion trigger • Surgical assessment: - early surgery or angiography to stop bleeding Special clinical situations Specific surgical considerations • Warfarin: • add vitamin K, prothrombinex/FFP • If significant physiological derangement, consider • Obstetric haemorrhage: damage control surgery or angiography • early DIC often present; consider cryoprecipitate • Head injury: Cell salvage • aim for platelet count > 100 109/L • permissive hypotension contraindicated • Consider use of cell salvage where appropriate Dosage Considerations for use of rFVIIab The routine use of rFVIIa in trauma patients is not recommended due to Platelet count < 50 x 109/L 1 adult therapeutic dose its lack of effect on mortality (Grade B) and variable effect on morbidity INR > 1.5 FFP 15 mL/kga (Grade C). Institutions may choose to develop a process for the use of rFVIIa where there is: Fibrinogen < 1.0 g/L cryoprecipitate 3–4 ga • uncontrolled haemorrhage in salvageable patient, and Tranexamic acid • failed surgical or radiological measures to control bleeding, and loading dose 1 g over 10 min, then infusion of 1 g over 8 hrs • adequate blood component replacement, and • pH > 7.2, temperature > 340C. Discuss dose with haematologist/transfusion specialist a Local transfusion laboratory to advise on number of units needed to provide this dose b rFVIIa is not licensed for use in this situation; all use must be part of practice review.ABG arterial blood gas FFP fresh frozen plasma APTT activated partial thromboplastin timeINR international normalised ratio BP blood pressure MTP massive transfusion protocolDIC disseminated intravascular coagulation PT prothrombin time FBC full blood countRBC red blood cell rFVlla activated recombinant factor VII