MASSIVE TRANSFUSION PROTOCOL

A brief clinical review

OBJECTIVES

HEMORRHGIC SHOCK

MASSIVE TRANSFUSION

TRANSFUSION COMPLICATIONS

CONCLUSION

HEMORRHGIC SHOCK Tachycardia (early)

Decreased urine output (intermediate)

Hypotension (late)

Increased Mortality:• Comorbidities • Age • Medications (ASA, Plavix,

Warfarin, beta blockers)

Clinical presentation of hemorrhagic can vary with age (young vs old) and pregnancy

HEMORRHGIC SHOCKSmall Blood Volume: tolerates blood loss poorly

Physiological Compromise: unable to compensate for blood loss

Physiological Reserve: may mask blood loss

Larger Blood Volume: increased blood volume may mask blood loss

HEMORRHGIC SHOCKThe goal of care is to control bleeding and resuscitation (minimize IV fluids, blood products, avoid hypothermia and acidosis).

Hypothermia (below 35c) → Inhibits intrinsic & extrinsic coagulation pathways

Excessive IV Fluids → coagulopathy

Hypoperfusion + IV fluids (NS pH is 6.1) → Acidosis (inhibits coagulation and depresses cardiac function)

MASSIVE TRANSFUSION PROTOCOL “Implementation of a Massive

Transfusion Protocol (MTP) promotes early and aggressive coagulation factor therapy as well as the limitation of crystalloid infusion, the prevention of coagulopathy, hypothermia and acidosis” (the ‘Lethal Triad’)

Indications & Goals?

MASSIVE TRANSFUSION PROTOCOL

INDICATIONS GOALS

MASSIVE TRANSFUSION PROTOCOL

Correct Anticoagulation• LWMH Protamine• Vitamin K+ Antagonist Vitamin K or PCC• Direct Thrombin Inhibitors No antidote • Antiplatelet Agents PLT

MASSIVE TRANSFUSION PROTOCOL

Control the source of the bleeding and replace lost blood volume.

Blood products should approximate whole blood.

Correct coagulation abnormalities.

NURSING CARE:• VS Q1H + PRN• Double check all blood

products• Monitor for transfusion

reactions• Reassessment (meeting goals?)• Labs

MASSIVE TRANSFUSION PROTOCOLPRBC:

ABO Rh specific Improve oxygen delivery (VO2) Replace lost volume (↑ Hgb & HCT) Cold (4C) Leukocyte reduced (reduces transfusion

reactions) Contains citrate Storage: 35 days K+↑ and 2,3 DGP ↓ with age Limited ATP stores Shape changes during storage (oval shaped)

MASSIVE TRANSFUSION PROTOCOL

FFP: Correction of coagulation

disorders FFP contains all

coagulation factors in normal concentrations

No indicated for volume expansion

MASSIVE TRANSFUSION PROTOCOL

PLT: Treatment of bleeding Prevention of bleeding

secondary to low platelets Preferred ABO Rh matching Administer rapidly Do no use an infusion

pump

MASSIVE TRANSFUSION PROTOCOLBelmont Rapid Infuser

2.5 - 750cc/min 150 – 45,000 cc/hr Warms IV / blood if rate < 300cc/hr Bucket only required if you want to reticulate the IV fluid /

blood products Pressure limited: Flow will be reduced if the pressure is

excessive Lines:

• large bore IV (16G or 18G)• Cordis• RIC• May use dual-patient line to increase the flow rate by

attaching to two access points• Avoid micro-bore IV extensions

MASSIVE TRANSFUSION PROTOCOL

Small extensions will inhibit flow.

Large bore extensions are less problematic.

Optional: Remove needles adaptors to increase flow (decreased resistance)

Add the dual lumen extension to the line to increase flow.

MASSIVE TRANSFUSION PROTOCOL– The goal of the MTP is to

rapidly replace lost whole blood volume (red blood cells, platelets, and fibrinogen).

– Reassess frequently to see if goals have been achieved.

– – Avoid acidosis, hypothermia,

and coagulopathy.

– Be familiar with the Belmont Rapid Infuser and the enFlow fluid warmer. Don’t meet them for the first time during a major bleed!

BLOOD

ABO Karl Landsteiner, who identified the O, A, and B

blood types in 1900.

Alfred von Decastello and Adriano Sturli discovered the fourth type, AB, in 1902.

Antigen – marker expressed on the call wall

Antibodies –used by the immune system to neutralize pathogens

RBC – 100 to 120 day life span / oxygen transporters

ABO Type A blood has type A antigen

expressed on its surface

Type B has type B antigen expressed on its surface

Type AB has type A & B antigen expressed on its surface.

Type O (sometimes referred to as type zero outside North America) has not antigen expressed on its surface.

Antibodies (anti-A, anti-B, or anti-A & anti b) antibodies will develop within

RHESE FACTOR Discovered in 1937 by Karl Landsteiner and

Alexander S. Wiener.

Rh positive indicates that the type D antigen is expressed.

Rh negative indicates that the type D antigen is expressed.

You need to be exposed to antigen D (Rh +) to develop antibodies (i.e. mother-fetus)

Furthermore, many other antibodies exists and many be tested for in unique clinical situations.

ABO +/-TYPE ANTIGEN ANTIBODIESA + A & D Anti-B antibodies

A - A Anti-B antibodies

B + B & D Anti-A antibodies

B - B Anti-A antibodies

AB + A, B & D No antibodies

AB - A & B No antibodies

O + Zero Anti-A and Anti B antibodies

O - Zero Anti-A and Anti B antibodies

ABO +/- Blood Transfusions:

• AB+ is the universal recipient because the RBC expresses the A, B and D antigen. Therefore, any type of blood can be transfer without an antibody reaction.

• O- is the universal donor. Type O or type ‘zero’ RCB has no A, B or D antigens expressed on its surface. Therefore, when transfused won’t create an antibody reaction.

• Rh (+) recipients may receive a type specific Rh (-) transfusion.

• However, Rh (-) recipients may not receive a Rh (+) transfusion. D antibodies will develop causing a transfusion reaction

TRANSUSION REACTIONS

Acute Hemolytic Transfusion Reaction (AHTR) Delayed Hemolytic Transfusion Reaction (DHTR) Febrile Non-hemolytic Reaction Allergic Reaction Anaphylaxis Transfusion Related Acute Lung Injury

!! DANGER !!

TRANSUSION REACTIONSAcute Hemolytic Transfusion

Reaction:

• ABO incompatibility (40% lab error / 60% bedside error)

• Fever, chills, chest pain, shock, bleeding, death

• Rapid onset (antibody mediated)

TRANSUSION REACTIONS

Delayed Hemolytic Transfusion Reaction:

• Seen in patients with previous transfusion or pregnancy

• Antibodies develop

• Develops days to weeks after the transfusion

TRANSUSION REACTIONS

Allergic Reaction Anaphylaxis:

• Allergic reactions are common in transfusion recipients (1-3%).

• Allergic reactions are thought to be mediated by recipient antibodies to proteins or other soluble substances in donor.

• Anaphylaxis (rare): severe life threating allergic reaction

TRANSUSION REACTIONSTransfusion Related Acute Lung Injury:

• Transfusion of inflammatory cytokines, active lipids, and/or antibodies.

• Respiratory distress (secondary ARDS)

• Sick patient + transfusion = TRALI

TRANSFUSION COMPLICATIONS

Metabolic Effects:• Hyperkalemia (especially in patient with acidosis

and renal failure)• Citrate Toxicity: ↓Ca+ and metabolic alkalosis

Hypothermia • Associated with poor outcomes• Warm blood when possible