anthony holley on transfusion

TransfusionAnthony HolleyIntensive CareRoyal Brisbane and Women’s Hospital

Bedside Critical Care 2012

http://criticalcareevents.com.au/

Acknowlegdements

•National Blood Authority•All our colleagues in the Clinical

Reference Group


A Sad Case

“Names and places have been changed to protect innocent practitioners involved”


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


Arrives at Gunadulotsa Base Hospital

•GCS 15, but very distressed•HR 130 bpm BP 105/58•Features of an acute abdomen


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


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


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


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.


Mount Cockup


Lessons from the Black Box

1. Massive transfusion protocols2. Transfusion triggers3. Transfusion ratios4. The role of Tranexamic acid



http://www.nba.gov.au/guidelines/order/index.htmlhttp://www.nba.gov.au/guidelines/review.html

http://www.nba.gov.au/guidelines/order/index.html

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


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 loss3. Optimisation of the

patient’s tolerance of anaemia.


So What is the Utility of Massive transfusion Protocols?


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)


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.


Senior clinician• Request:a

o 4 units RBCo 2 units FFP

• Consider:a

o 1 adult therapeutic dose plateletso tranexamic acid in trauma patients

• Include:a

o cryoprecipitate if fibrinogen < 1 g/La 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. Thistemplate can be used to develop an MTP to meet the needs of the local institution's patient population and resourcesBedside Critical Care

2012


So in patients with critical bleeding requiring massive transfusion, which parameters should be measured early and frequently?

In patients with critical bleeding requiring massive transfusion, the following parameters should be measured early and frequently:

1. Temperature2. Acid–base status3. Ionised calcium4. Haemoglobin5. Platelet count6. PT/INR7. APTT8. Fibrinogen level.

With successful treatment, values should trend towards normal.


Practice Point

Values indicative of critical physiologic derangement include:

1. Temperature < 35°C2. pH < 7.2, base excess > –6, lactate > 4 mmol/L3. ionised calcium < 1.1 mmol/L4. platelet count < 50 × 109/L5. PT > 1.5 × normal6. INR > 1.57. APTT > 1.5 × normal8. fibrinogen level < 1.0 g/L.


Practice Point

So what product ratios should we be using?


Ratios

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 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.

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.


Practice Point

In 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.


Haemoglobin trigger???


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.


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.


What Adjuctive Therapy should we employ?


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).


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.


Crash 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/massive

transfusion. The study population was not restricted to critical bleeding requiring massive transfusion.


Bedside Critical Care 2012Tranexamic Acid


Tranexamic Acid

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 specialistb 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 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

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


anthony holley on transfusion

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