Massive Transfusion

Suggested doses

- start with:

- 4 units RBC

- 4 units plasma

*if X-matched product not available can use emergency supply

Def'n

Phase 2: Management of an MTP

The rapid transfusion of large volumes of blood products in a massive bleeding event. Active transfusion management of blood loss must be considered where there is hemorrhage requiring:

• 6 or more units RC in one bleeding episode with ongoing losses

• 3 or more units RC in one hour with ongoing losses

- Clinical contact (can be RN)

-communicate with TM

- arrange transport

Roles:

- MD:

- continued assessment of patient (shared with RN)

- communication with clinical contact

- communication with transfusion medicine physician as required

Massive Transfusion

Types of Massive Transfusion Events

Nursing considerations

VCH identifies 2 protocols:

1) Massive transfusion protocol (MTP)

- GI bleed

- obstetric catastrophes

2) Exsanguination protocol (Ex P)

- Trauma

- only used in ED

Overview

- Establish x2 large bore IV (initiate crystalloids when appropriate)

- Continuous monitoring

- Ensure bloodwork drawn (G+S if not already done, CBC, INR, PTT, lytes, Ca, fibrinogen, lactate

- Definition of massive transfusion (MT)

- Types of MT events

- Explore VCH protocol for MT

- Phases of MT and clinical responsibilities

- Goals of MT

- Suggested doses of blood products

- Adjunct therapies

- Complications and considerations

Phase 1- Declaration

Phase 1- Declaration

- By MD

- Identify Key Clinical Contact (can be RN)

Role:

- communicates with TM (name, MRN, sex age, clinical etiology of bleed)

- assess G+S status

VCH Protocol

To Tube or not to tube?

-During a MT event it is acceptable to use the pneumatic tube system

- A coloured flasher will be added to the tube along with a corresponding coloured dot on the product

- If another MT event is declared a different colour will be assigned to help quickly distinguish the correct tube for the patient

A coordinated plan developed by a multidisciplinary team to restore blood volume rapidly and effectively in a massively bleeding patient.

Phase 1- Lab Roles

Who's writing this down?

- ID key lab contact to clinical contact

- Immediately thaw 4 units of plasma

- Communicate with transfusion medicine physician on-call

When a MT is declared verbal communication to transfusion medicine is all that's required in order to initiate and obtain blood products.

Complications and considerations

Phase 3: Stand Down

- Acidosis

-often precedes MT, due to state of prolonged hypoperfusion

- Hypothermia

- can be due to prolonged hypoperfusion state or MT (consider blood warmer)- further worsens bleeding state through diminishing coagulation cascade

- Metabolic alkalosis

- due to sodium citrate and citric acid added to blood products to prevent coagulation- breaks down to bicarbonate in body

- Hypokalemia

- as a response to alkalosis, hydrogen ions move out of cells through H+/K+ transporters

- Hyperkalemia

- Potassium level can increase in blood during long term storage. Typically seen with rapid infusion through central line.

- Hypocalcemia

- Citrate (in blood products) binds to calcium rendering it inactive

- TACO/TRALI

When MTP deemed no longer necessary a "stand down" order is communicated via the clinical contact to TM.

Inventory taken of remaining products on unit, and arrangements made to return to TM.

Goals of MT

References

Adjunct Therapies

https://v2.printsys.net/References/VCHealth/VCHGroup/Static-Forms/VCH.0603.pdf

https://v2.printsys.net/References/VCHealth/VCHGroup/Static-Forms/VCH.0595A.pdf

https://www.ncbi.nlm.nih.gov/books/NBK499929/

-Hemodynamic stability

-Controlled bleeding

-Labs:

- Hemoglobin >70

- Platelets >100

- INR ≤1.8

- Fibrinogen > 1.5

- Temp >36

- Ionized calcium >1.1

* repeat labs q45-60 mins

- Cell saver (autologous transfusion)

- primarily used in surgery

- TXA

- 1g bolus dose ideally wihtin 3 hours of start of bleed

- Calcium administration

- hypocalcemia can occur as a result of citrate additive in blood products which binds to endogenous calcium and renders it inactive