Massive Transfusion

  • RCH Massive Transfusion Guideline

    This guideline aims to provide certainty for clinicians working with a critically bleeding infant, child or adolescent.  It outlines the responsibilities of the clinical Team Leader, the circulation nurse, Blood Bank and the Haematologist involved. It also provides a guide for pathology testing and other assessment (temperature, acid-base) and blood product provision.

    This clinical guideline has been developed using the  Patient Blood Management Guidelines: Module 1 Critical Bleeding/ Massive Transfusion, developed by the National Blood Authority (2010).

    Definitions:

    Critical Bleeding:  May be defined as a major haemorrhage that is life threatening and likely to result in the need for massive transfusion.

    Massive Transfusion:

    • In adult patients, a transfusion of half of one blood volume in 4 hours, or more than one blood volume in 24 hours (adult blood volume is approx 70mls/kg)
    • In children, a transfusion of more than 40mls/kg (blood volume of children older than a neonate is approximately 80mls/kg)

    Priorities for clinical staff managing the patient

    The Massive Transfusion Protocol (MTP) is in place to direct provision of large volumes of blood product (Red Cells, Plasma and Platelets) to a critically bleeding child.

    The  Massive Transfusion Protocol will mobilise significant resources and as such should be activated after considering the following points:

    WHO: MTP may be activated by the team leader in Emergency

    WHEN: MTP may be activated when it appears likely that a child will require massive transfusion.  This can be after assessment on patient arrival or based on credible information prior to patient arrival.  It is expected that this protocol will be activated INFREQUENTLY.

    WHAT: Massive Transfusion Protocol Activation will result in:

    • Mobilisation of Blood Bank and Haematology staff.
    • Priority processing of pre transfusion samples for the patient.
    • MTP packs will be prepared as soon as product is available.
    • Further product will be ordered from The Blood Service as required.

     

    1. Blood Product Ordering:

    Send a completed Blood Bank Release Order (Green form) with a patient bradma label via the Trauma PSA to the Blood Bank. Please tick Massive Transfusion Pack and document the working weight in the estimated weight space.

    Receipt of a patient bradma label with a bar code allows for rapid electronic assignment of blood product.  If this isn't available then this step will be performed manually.

    Green_card

    2. Pre transfusion specimen

    • Obtain a pretransfusion specimen in a 2.7ml (or greater) EDTA tube.
    • Label with the patients identity label checked against the patient and the pathology request form.
    • Inital, date and time the label attached to the specimen.
    • Sign, date and time the declaration on the bottom of the Pathology Request.
    • Place in a biohazard bag.
    • Send urgently to Blood Bank.

    Failure to do this will lead to delays in the provision of crossmatched blood and may exhaust O negative supplies very quickly.

    Identification_check

     

    3. Blood Product Support

    The Massive Transfusion Protocol is designed to ensure that when a patient has received or is likely to receive large volumes of Red Cell, adjunct support with clotting factors (FFP) and Platelets are also provided to manage coagulopathy and reduce the liklihood of dilutional coagulopathy.

    Retrospective studies suggest that transfusing Plasma and Platelets in similar ratios to Red Cells confers survival advantage in patients with critical traumatic bleeding.  Depending on product availability the Blood Bank will work to deliver the following products:

    blood_product_support_chart

    Green_bag

     

    4. rFVIIa (Recombinant Factor VIIa) is not a part of the RCH Massive Transfusion Guideline

    Due to the absence of credible evidence supporting its use, including

    • The guarded discussion regarding the use of rFVIIa in trauma patients in the Critical Bleeding Guideline (National Blood Authority, 2010 p 36).
    • No evidence of improved survival or reduced requirement for blood product in trauma patients.
    • Its high potential for adverse outcomes in trauma patients and
    • its high cost.

    It should only be used in a trauma patient who has ongoing bleeding despite adequate coagulation factor support, including normalization of fibrinogen and who is normothermic (temp>35°), and not significantly acidotic (pH >7.15), and where there is a reasonable expectation that the patient will survive their injuries.

    5. Other treatment priorities

    Normothermia

    • every effort should be made to maintain the patient's temperature above 35°
    • the use of blood warmer set to 41°
    • or rapid infuser

    Prevention of Acidemia

    • maintain the pH above 7.15
    • minimise the base excess becoming more negative than -6

    Use the Rapid Infuser

    • The rapid infuser is able to deliver warmed blood products/ fluids at a very fast rate
    • the rapid infuser should be used to warm and bolus blood products as they are available.
    • Infusing large volumes of crystalloid may lead to significant dilutional coagulopathy

    6. Deactivating the Massive Transfusion Protocol

    When the MTP is triggered a comprehensive response from the RCH Blood Bank will begin to thaw Plasma and order further product from The Blood Service.  It is crucial that the team leader inform the Blood Bank when the MTP is over or when the patient is transferred.  Significant wastage will result from late communication of this information.

    7. Documentation of the Blood Products administered

    Nursing staff will be responsible for maintaining accurate records of what blood products have been administered and how much.  This information will be required during the Massive Transfusion Protocol activation period and may be requested by the Team Leader or the On call Haemataologist.

    All of the empty bags should be placed into the Red bucket with the Rapid Infuser.  The transfusion records for all of these units should also be readily accessible at conclusion to ensure all relevant documents are signed.

    There is a trial Blood product fluid balance sheet which can be used to record the number of mls of each type of product.

    8. Communication

    Clear communication between team members is identified as an important component contributing to good patient outcomes. 

    • The MTP is activated by the Team Leader by phone call to the Blood Bank
    • Blood Bank will call and/ or urgently page the on call Haematologist to inform them of MTP activation.
    • On call Haematologist will call ED on the main ED phone number in the process of MTP they should be immediately connected to the Team Leader in charge of the Trauma.
      • Problem suspected reason for haemorrhage (Traumatic injury to vessels or Coagulopathic bleeding)
      • Progress (what has been given/ administered and impression on whether treatment is working)
      • Plan (patient transfer to another clinical area, withdrawal of care)
    • Team Leader to instruct Trauma PSA to collect MTP and return to ED (give green card)

    9. Blood Transport

    When a trauma page is initiated, it is received by the CARPS supervisor who will allocate a  PSA to the ED Resuscitation bays.  When the senior medical staff determine that they will require blood product they will instruct this PSA to go to the Blood Bank to collect the Massive Transfusion Pack.

    The Blood Bank staff will provide an estimated time for the second Massive Transfusion Pack to be prepared.

    10. Auditing

    Each activation of the MTP will be reviewed by the Haematology and Trauma teams and adjustments made to the protocol as required and as new evidence emerges.

    Resources.

    Nursing Education Powerpoint

    Medical Education Powerpoint