Critical Bleeding Massive Transfusion - Adults · Web view10mL syringe 100mL sodium chloride 0.9% Infusion pump Blood pump infusion set Procedure Identify Patients requiring Massive

CHHS15/079

Canberra Hospital and Health ServicesClinical ProcedureCritical Bleeding /Massive TransfusionContents

Contents...................................................................................................................................1

Purpose.................................................................................................................................... 2

Alerts........................................................................................................................................2

Scope........................................................................................................................................3

Section 1 – Tranexamic Acid.....................................................................................................4

Section 2 – Massive Transfusion..............................................................................................5

Section 3 – Stand down of Massive Transfusion Protocol........................................................8

Section 4 – Massive Transfusion Activation – Responder after hours....................................10

Section 5 – Massive Transfusion Flow chart...........................................................................11

Implementation......................................................................................................................12

Related Policies and Standard Operating Procedures............................................................12

References..............................................................................................................................12

Search Terms..........................................................................................................................13

Doc Number Version Issued Review Date Area Responsible PageCHHS15/079 1 14/04/2015 01/06/2018 CMA - ACT Blood

Counts Transfusion CNC

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/079

Purpose

The purpose of this document is to give clear direction to staff to appropriately manage uncontrolled bleeding within the Canberra Hospital and Health Services. For all patients with critical bleeding requiring massive transfusion, the use of a Massive Transfusion Protocol (Massive Transfusion Protocol) to facilitate timely and appropriate use of Red Blood Cells (pRBC) and other blood components may reduce the risk of mortality and Acute Respiratory Distress Syndrome (ARDS).

Scope

AlertsLink to: Massive Transfusion Flow ChartLink to : Massive Transfusion Activation – Responder after hours

Measurement of ParametersMeasurement of parameters should be repeated after every 4-6 red cell units transfused.

Consultation with Haematologist Consultation with haematology should take place to confirm appropriateness of optimal conventional therapy for coagulopathy and the appropriate dosage of rFVlla.

Tranexamic AcidIn CRASH-2 study tranexamic acid given after 3 hours after injury was associated with an increased risk of death caused by bleeding (4.4% vs.3.1%);

Possible adverse effects Hypotension with rapid intravenous administration. Increased risk of thromboembolic events

Tranexamic acid should not be administered in the same line as blood products.

Contraindications: Injury greater than 3 hours ago Patients less than 16 years of age Pregnancy Isolated closed head injury Known thromboembolic disease Disseminated Intravascular Coagulation (DIC)

Obstetric Haemorrhage In the setting of major obstetric haemorrhage, early administration of cryoprecipitate or

fibrinogen concentrate may be necessary; and Doc Number Version Issued Review Date Area Responsible PageCHHS15/079 1 14/04/2015 01/06/2018 CMA - ACT Blood


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Aim to keep the fibrinogen level >2g/L for obstetric patients.

Recombinant Factor VIIa (rFVIIa) Dosage rFVIIa (90 mcg/kg) should only be considered in the event of failure to obtain haemostasis, where:

o Platelet and fibrinogen levels are adequate;o Bleeding continues; ando All appropriate surgical and embolisation procedures have been attempted.o Management of severe acidosis should be considered prior to administration of

rFVIIa

Scope

This procedure pertains to all staff involved in the care of patients with critical bleeding within the Canberra Hospital and Health Services.

Due to the unique environment of the pre-hospital Retrieval Service (South Care), which has dual reporting lines to ACT Ambulance Services, the initiation and administration of Emergency O Rh (D) negative red blood cell units in a critical bleeding in a retrieval situation will be covered in Retrieval (South Care) procedure. Haematologist Responsibilities Liaise regularly with laboratory and clinical team; and Assist in interpretation of results, and advise on blood component support.

Medical Officers Responsibilities

Determine that patient meets criteria for Massive Transfusion Protocol activation; Notify transfusion laboratory of Massive Transfusion Protocol activation x 44239; Ensure availability of pathology specimens for the purpose of measuring parameters; Comply with Blood and Fresh Blood Product Administration Procedure; and Notify laboratory when Massive Transfusion Protocol can be stood down.

NursesResponsibilities: Comply with Blood and Fresh Blood Product Administration procedure.

Laboratory ScientistsResponsibilities: Notify haematologist of activation of Massive Transfusion Protocol; Prepare and issue blood components as requested; Anticipate repeat testing and blood component requirements; Minimise test turnaround times; and Consider staff resources. Doc Number Version Issued Review Date Area Responsible PageCHHS15/079 1 14/04/2015 01/06/2018 CMA - ACT Blood


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Wards person/CouriersResponsibilities: Prioritise transport of specimens and blood products to minimise test turnaround times

for both specimens to the transfusion laboratory and blood components to clinical areas; and

Consider staff resources (dedicated person to support Massive Transfusion Protocol).

Activation of the Massive Transfusion Protocol should take into account: Cause and rate of the haemorrhage; Mechanism of injury (if present); Current physiological state; and Likely requirement for ongoing blood component support.

Section 1 – Tranexamic Acid

Tranexamic acid Alert:Loading dose of tranexamic acid 1 gram in 100mL sodium chloride 0.9% over 10 minutes, followed by infusion of tranexamic acid 1 gram in 100mL sodium chloride 0.9% over 8 hours

Tranexamic acid given after 3 hours after injury may be associated with an increased risk of death caused by bleeding;

Possible adverse effects include hypotension with rapid intravenous administration.The risk of thromboembolic events may increase.

Tranexamic acid should not be administered in the same line as blood products.

Contraindications Injury greater than 3 hours ago Patients less than 16 years of age Pregnancy Isolated closed head injury Known thromboembolic disease Disseminated Intravascular Coagulation

Tranexamic Acid

In trauma patients with or at risk of significant haemorrhage, tranexamic acid should be used, ideally within the first one hour since injury Use within 3 hours from time of accident for all trauma patients

o Judged to be 16 years or older,



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o Significant haemorrhage o Systolic blood pressure less than 90 mmHg and/or heart rate more than 110 beats

per minute or o Who have either significant haemorrhage, or who are considered to be at risk of

significant haemorrhage

Equipment Tranexamic acid 1 gram ampoule with diluent x 2 10mL syringe Sodium chloride 0.9% 100mL x 2 Infusion pump Intravenous administration set

ProcedureLoading dose of tranexamic acid 1 gram in 100mL sodium chloride 0.9% over 10 minutes, followed by infusion of tranexamic acid 1 gram in 100mL sodium chloride 0.9% over 8 hours

Back to Table of Contents

Section 2 – Massive Transfusion

In critically bleeding patients requiring, or anticipated to require, massive transfusion, a Massive Transfusion Protocol should be used.

Activation of the Massive Transfusion Protocol should take into account: Cause and rate of the haemorrhage; Mechanism of injury (if present); Current physiological state; and Likely requirement for ongoing blood component support.

Equipment Pathology specimen tubes and request forms EDTA Tube Citrate tube Arterial Blood Gas syringe

o Blood productso Blood warmero Forced air warming blanketo Warming mattresso Tranexamic acid 1 gram with diluento 10mL syringeo 100mL sodium chloride 0.9%o Infusion pumpo Blood pump infusion set



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Procedure1. Identify Patients requiring Massive Transfusion Protocol ActivationPotential patients are recognised as those suffering uncontrolled haemorrhage and coagulopathy. This will usually be in the setting of a massive transfusion represented by features such as: Immediate need for, or prior transfusion of, immediate release uncrossmatched

(usually O Rh (D) negative) pRBC due to rapid haemorrhage and anaemia; Blood loss exceeding 150 mL/min; The need for at least four pRBC units within 4 hours in the setting of continuing

uncontrolled bleeding; Replacement of 50% of the total blood volume within 3 hour (approximately 35mL/kg in

an adult patient); Replacement of the blood volume within a 24-h period; this corresponds to about 70

mL/kg of body weight, or 5 litres in a 70kg patient; Presence of diffuse micro vascular bleeding; and The need for plasma and/or platelet replacement.

Alert: It is recognised that massive trauma or pre-existing coagulopathy may induce massive non-surgical bleeding at losses less than these. Where there is a pre-existing coagulopathy, specific early correction is advised.

2. Notify Transfusion Laboratory The medical officer notifies the transfusion laboratory of activation Massive Transfusion

Protocol, phone number 6244 2918 or 44239; Once a patient has been identified as requiring massive transfusion, blood tests to

measure parameters should be labelled as Urgent Massive Transfusion; The transfusion laboratory will notify the on-call haematologist; The laboratory to thaw Fresh Frozen Plasma (FFP). Four group specific pRBC units may

be requested if current cross match sample available; and The laboratory will issue Red Cells to Plasma at a 1:1 ratio unless directed otherwise by

the haematologist on call.

3. Measure parametersThe following parameters should be measured early and frequently: Temperature; Acid–Base Status; Ionised Calcium; Haemoglobin; Platelet Count; PT; APTT; and Fibrinogen Level



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Alert: These should be repeated after every 4-6 red cell units transfused. With successful treatment, values should trend towards normal.

Values indicative of critical physiologic derangement include: Temperature < 35°C; pH < 7.2, base excess > – 6, lactate > 4 mmol/L; Ionised calcium < 1.1 mmol/L; Platelet count < 50 × 109/L or < 100 x 109/L in head injury; PT > 1.5 × normal; APTT > 1.5 × normal; and Fibrinogen level < 1.0 g/L or <2.0g/L in obstetric haemorrhage.

The majority of patients will initially be volume resuscitated with crystalloid, or possibly colloid: Red cells are used as anaemia develops. These may be uncrossmatched

(group O). In general, group specific red cells should be used as soon as they are available.

Transfusion of platelets is less predictable, and usually occurs much later with dilutional coagulopathy.

Cryoprecipitate is often unnecessary in simple dilutional coagulopathy if plasma is replaced adequately; however, DIC with hypofibrinoginaemia should prompt aggressive replacement therapy.

4. Ensure surgical definitive haemostasis procedures to arrest active bleeding are considered.

If mixed surgical and non-surgical bleeding continues in spite of treatment, initiation of damage control surgery should be considered, especially if the: pH <7.2 and/or; HCO3 < 15 mmol/L; Core body temp < 34°C; and There is ongoing coagulopathy.

This usually includes abandonment of definitive surgical repair, rapid haemostasis, packing and closure. The patient is then transferred to ICU for warming, coagulopathy and inotropic management. A later definitive procedure is then undertaken. This may include: Operative surgical exploration; Orthopaedic fixation; and Embolisation by interventional radiology.

5. Initiate measures to prevent and reverse hypothermia Utilise Blood/fluid warmers; and Utilise forced air warming blanket and warming mattress or under patient warmers.



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This equipment is available from acute care environments, e.g. Resuscitation room, Operating Rooms, Intensive Care Unit.

6. Initiate measures to prevent and reverse acidosisPrevention of tissue hypoxia is primarily used to prevent acidosis in the acute setting. In ICU, haemodialysis may be considered.

7. Specifically Correct Coagulation DeficienciesThe use of platelets and cryoprecipitate is generally guided by laboratory tests. However, coagulation testing and thawing of plasma products of necessity introduce significant delays in product availability, so empirical use of coagulation factors may be necessary in certain circumstance. Frozen plasma products are thawed under controlled conditions to ensure the viability

of the coagulation factors they contain. Consequently there is a delay of 20-30 minutes from the time of request until availability. Use may need to be anticipated; and

Cryoprecipitate is used primarily as a source of fibrinogen (but also contains FVIII, VWF and FXIII). This is found in adequate amounts in FFP, and in dilutional coagulopathy FFP alone may be adequate. Coexisting DIC may increase fibrinogen requirements. Empirical use is unnecessary. Use should be guided by fibrinogen determinations.


Section 3 – Stand down of Massive Transfusion Protocol

It is important to inform the transfusion laboratory that the massive transfusion protocol is stood down. Contact phone number x44239

Massive transfusion protocol may be stood down when the treating team consider the patient to be haemodynamically stable and urgent blood/ blood products support is no longer required.



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Alert:Obstetric Haemorrhage In the setting of major obstetric haemorrhage, early administration of cryoprecipitate or

fibrinogen concentrate may be necessary; and Aim to keep the fibrinogen level >2g/L for obstetric patients.

Recombinant Factor VIIa (rFVIIa)rFVIIa (90 mcg/kg) should only be considered in the event of failure to obtain haemostasis, where: Platelet and fibrinogen levels are adequate; Bleeding continues; and All appropriate surgical and embolisation procedures have been attempted.

ConsultationConsultation with on call haematologist should take place to confirm appropriateness of optimal conventional therapy for coagulopathy and the appropriate dosage of rFVlla. (Contact on call haematologist via Switch 62442222)

8. Follow upPatients should be considered for management in the intensive care unit following massive transfusion, where attention to perfusion and early identification of bleeding or oozing should be undertaken, particularly as further dilution may occur until volume is replaced. Replacement of coagulation factors is not necessary unless there is active bleeding. In the event of bleeding transfusion should aim to keep: Hb>80g/L; Platelets >50x109/L; and PT and APTT<1.5 x control.




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Section 4 – Massive Transfusion Activation – Responder after hours



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CHHSXX/XXX (number will be allocated byPolicy Register Manager after

final endorsement)

Section 5 – Massive Transfusion Flow chart

Doc Number Version Issued Review Date Area Responsible Page<xxxxx/xxx> Draft V9 <XX/XX/XXXX> <XX/XX/XXXX (> or = 3 yrs) XXXX 11 of 14

CHHSXX/XXX (number will be allocated byPolicy Register Manager after

final endorsement)

Doc Number Version Issued Review Date Area Responsible Page<xxxxx/xxx> Draft V9 <XX/XX/XXXX> <XX/XX/XXXX (> or = 3 yrs) XXXX 12 of 14

CHHS15/079

Implementation Medical Nursing Orientation Ward level in services conducted by Transfusion CNC and local areas CNC/CMC Communication VIA NQSHS SCOOP


Related Policies and Standard Operating Procedures Australia and New Zealand Society of Blood Transfusion Ltd 5th ed 2007. Guidelines for

pretransfusion laboratory practice. Australian Red Cross Blood Service 2008. National Transport Shipper – Blood out, pp 6-

18. CHHS Health Blood and Fresh Blood Products Administration Rudmann. Sally (Ed), Textbook of Blood Banking and Transfusion medicine. W. B

Saunders Co. Second Edition 2005 Health Professionals Act 2004 (ACT) Health Records (Privacy and Access) Act 1997(ACT) the Health Record Act. Medical Treatment (Health Directions) Act 2006 (ACT) NSQHS Standards standard 7 Blood and Blood Products Massive Transfusion Policy DCED 08 - 003 ACT Health Consent to Treatment Policy and Procedure DGD12-044 ACT Health Consent to Treatment: Capacity and Substitute Decision Maker Consent to treatment : Children or Young People Pathology Patient ID and Labelling Specimen Policy Australian & New Zealand Society of Blood Transfusion Inc. Royal College of Nursing

Australia (2004) Guidelines for the Administration of Blood Components. NHMRC Clinical Practice Guidelines for the transfusion on fresh blood products – Red

blood cells, platelets and plasma (2001).

References

Module 1 Critical Bleeding/Massive Transfusion http://www.blood.gov.au/pbm-module-1

Crash-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage: a randomised, placebo-controlled trial. Lancet 2010

Pfizer. Cyklokapron (tranexamic acid) Product Information

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http://www.blood.gov.au/pbm-module-1

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National Blood Authority Australia. Patient blood management guidelines: Module 1 Critical Bleeding/Massive Transfusion. 2011

CRASH-2 Collaborators (Intracranial Bleeding Study). Effect of tranexamic acid in traumatic brain injury: a nested randomised, placebo controlled trial (CRASH-2 Intracranial Bleeding Study). BMJ2011;343:d3795.

Lena M. Napolitano, Mitchell J. Cohen, Bryan A. Cotton, Martin A. Schreiber and Ernest E. Moore. (2013) Tranexamic acid in trauma: How should we use it? J Trauma Acute Care Surg Volume 74, Number 6:1575-1586.

Hess J et al. The Coagulopathy of Trauma: A Review of Mechanisms. J Trauma 2008

Rossaint R et al. Management of bleeding following major trauma: an updated European guideline. Crit Care 2010

Study Protocol: The WOMAN Trial (World Maternal Antifibrinolytic Trial): Tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Haleema Shakur, Diana Elbourne, Metin Gülmezoglu, Zarko Alfirevic, Carine Ronsmans, Elizabeth Allen and Ian Roberts. http://www.trialsjournal.com/content/11/1/40

Lena M. Napolitano,et al Tranexamic acid in trauma: How should we use it? J Trauma Acute Care Surg Volume 74, Number 6


Search Terms

Massive TransfusionMassive Transfusion ProtocolTranexamic acidrFVIIaFactor VIIaCritical bleeding

RetrievalSouth CareO Rh (D) negativeBloodTransfusion

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

Doc Number Version Issued Review Date Area Responsible PageCHHS15/079 1 14/04/2015 15/03/2017 ACT Blood


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http://www.trialsjournal.com/content/11/1/40

Documents

Critical Bleeding Massive Transfusion - Adults · Web view10mL syringe 100mL sodium chloride 0.9% Infusion pump Blood pump infusion set Procedure Identify Patients requiring Massive