Massive Transfusion Guideline

Massive Transfusion Guideline

Version / 3
Name of responsible (ratifying) committee / Hospital Transfusion Committee
Date ratified / 25/04/2014
Document Manager (job title) / Peter McQuillan
Date issued / 13th May 2014
Review date / 1st May 2016
Electronic location / Intranet Clinical Policies and Guidelines
Related Procedural Documents / Blood Transfusion Policy
Key Words (to aid with searching) / Massive transfusion, massive haemorrhage, bleeding, hypovolaemia, shock, blood

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
3 / 25/04/2014 / Section 5 – Flowchart process / P McQuillan

CONTENTS

QUICK REFERENCE GUIDE…………………………………………………………………………PAGE 3

1. INTRODUCTION…………………………………………………………………………………….PAGE 4

2. PURPOSE……………………………………………………………………………………………PAGE 4

3. SCOPE………………………………………………………………………………………………..PAGE 4

4. DEFINITIONS……………………………………………………………………………………… PAGE 4

5. DUTIES AND RESPONSIBILITIES……………………………………………………………….PAGE 5

6. PROCESS (ALGORHYTHM)………………………………………………………………………PAGE 6

7.COMMUNICATION AND LOGISTICS…………………………………………………………….PAGE 7

8. NOTES AND CAVEATS…………………………………………………………………………….PAGE 8

9. TIMELINE OF EVENT RECORD…………………………………………………………………PAGE 12

10. REFERENCES……………………………………………………………………………………PAGE 13

QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

Recognise bleeding is severe and potentially uncontrolled

Stop the bleeding if possible

Reverse any drugs or processes preventing normal clotting

Activate the Massive Transfusion Guideline by

Stating that you want to activate the guideline to the attendant staff
Phone the lab and say “I want to activate the Massive Transfusion guideline”

Send blood samples to the lab

Label samples using the patients wristband for identification
Send samples to the lab rapidly via a nominated “runner”

Ensure there is a clinician looking after the patient – the clinical arm of the guideline

Ensure there is a coordinator nominated to undertake the organization of the process and use the audit form as both a process guide and an audit trail of the timings involved

Restore the circulating volume of the patient and clotting factors

GIVE EMERGENCY O NEGATIVE UNITS UNTIL PACK A IS READY

Bear in mind that it might be reasonable to tolerate a degree of hypotension (permissive hypotension) to prevent further bleeding – e.g. in a ruptured aortic aneurysm scenario
Current best evidence suggests that concurrent administration of platelets, FFP and blood maximizes effectiveness of massive transfusion therapy.

Keep the patient warm, calcium levels up. Monitor the patient.

Maintain clear and concise communication channels between clinicians, coordinators, lab staff and transport team members. Remain calm and professional to maximize efficiency.

INTRODUCTION

Massive bleeding may occur in a variety of circumstances including trauma, gastro-intestinal bleeding or during surgery. Rapid, decisive action is required when potentially uncontrollable bleeding occurs. The guideline provides a framework and organisational structure to enable efficient management of this life-threatening problem.

1.PURPOSE

The purpose of the document is to:

Provide a structure and organisational process to deal with massive bleeding
Point out the roles involved which include
The activities of the hands-on clinicians finding the cause, stopping the bleeding, reversing any anticoagulation or correcting bleeding diatheses, resuscitating and transfusing fluids and blood products
The importance of the co-ordinator, ensuring the basic processes are accomplished in a slick and timely manner, communication occurs and samples and blood products are delivered appropriately

It has been developed to simplify clinical practice and as part of a NPSA requirement.

2.SCOPE

The document applies to any patient presenting with severe, potentially uncontrollable bleeding, from whatever cause.

Staff should be aware that patients may have personal or religious reasons to decline transfusion of blood products. Staff should make reasonable attempts, under the circumstances, to establish the wishes of the patient. This may not always be feasible and the guideline may be enacted in best interests of the patient where there is no clear patient refusal or availability of advance directives

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

3.DEFINITIONS

Massive Haemorrhage: clinically significant bleeding which seems uncontrollable. This is deliberately simple to ensure there are no delays in enacting the processes within this document; too many activations are better than undue delay, which may pose a greater risk to the patient.

Red box: a red-coloured box, located in strategic places where massive haemorrhage may occur, containing a copy of the guideline and the necessary forms and blood bottles to begin the process. It already exists in most of these locations and the guideline simply formalises the process

4.DUTIES AND RESPONSIBILITIES

Hospital Transfusion Practitioner will ensure massive transfusion / haemorrhage is added to the educational programme for staff.

Transfusion Department Managers will ensure that sufficient resources, including manpower, are available including: laboratory staff; portering; transportation; training and education, to maintain a credible service as sanctioned by regulatory authorities.

Trust Clinicians must follow the policy appropriately and fill in the audit form to facilitate analysis of events and hence improve structure, process and organisation within the Trust

Hospital Transfusion Team will function as the facilitators of the processes involved in this policy

Hospital Transfusion Committee will:

Oversee the audit of massive haemorrhage events and facilitate appropriate action where necessary
Review this document by the required review date, or sooner if pertinent advice or evidence arises

Massive Transfusion Guideline : Version 3 2014Review date: 2016 (unless requirements change)

5. PROCESSMassive Transfusion Guideline(NB Give emergency O negs until Pack A ready)

Massive Transfusion Guideline : Version 3 2014Review date: 2016 (unless requirements change)

Massive Transfusion Guideline: Notes and Caveats

Recognition of Massive Bleeding

Definition: clinically significant massive haemorrhage, which seems uncontrollable.
This is a deliberately simple definition, without specific volumes: to prevent delays measuring volumes or waiting specific lengths of time to trigger a massive haemorrhage alert. It is better to trigger too many alerts (with the benefit of the retrospectoscope) than have too many delayed diagnoses of major haemorrhage.
If it looks like massive bleeding that seems uncontrollable – then it probably is!

Phone blood bank x6539, 6492: state “I want to activate the Massive Transfusion Guideline”
Give patient identification details and site of patient (ED, ward) and send blood samples

Cross-Matching & Bloods

Send cross-match bloods, FBC, U&E, Coagulation profile.
All the necessary forms should be available in areas likely to experience massive bleeding. An excellent example is in Maternity, where a “red box” exists, containing the blood bottles and forms needed for urgent sampling. It also contains a laminated copy of the guideline.

Blood bank may already have a group & screen sample (e.g. in elective surgical patients) and can thus issue blood immediately but otherwise it takes 5 mins to obtain a blood group. Important to use the appropriate group FFP.

RBCs / FFP / Plats / Cryo
Pack A / 6 / 6 / 1 / ------
Pack B / 6 / 6 / 2 / 2

Volume & Coagulation Factors

Best outcomes occur with concurrentuse of RBC, FFP, platelets (in ration 6:6:1), with cryo (cryoprecipitate) every 6-12 units RBC. Minimise the volumes of crystalloids & colloids.
The lab provides Pack A and Pack B will become available automatically shortly thereafter, unless a cancellation occurs & is communicated.Platelets may not be onsite, so may be delayed.
In obstetric haemorrhage only use FFP with Pack B (in phase 2), as patients initiallyhypercoagulable.
Further blood products will be provided on basis of blood results (timed according to the algorithm) and liaison with consultant haematologist.
Cell salvaged blood (CSB) contains no clotting factors. Count cell salvaged blood in transfusion count. CSB has high Hct, so 250 ml CSB = 1 unit. For example: 6 units bank blood + 1500 ml CSB = 12 units total and requires 12 units FFP.

Give tranexamic acid in major trauma (1g IV over 10 mins, 1 g infusion over 8 hrs)

Organisation

This is the key strategy – to appoint roles to individuals, working to a plan/guideline, as a cohesive team.

Seeking help & support
These situations are very labour intensive and several people are required.
Calling for help early is imperative.In theatre at least two anaesthetists are required.

Clinical Leader:has overall responsibility and leads (ideally hands off to allow situational awareness)

Emergency Dept (ED) = consultant or most senior ED clinician

Theatre = consultant or most senior anaesthetist

MAU/SAU/Wards = consultant or most senior clinician

The Clinical Leader has responsibility for clinical interventions

The coordinator role
to liaise with the clinical team leader and others to ensure the guideline is followed
to ensure the appropriate measures take place in a timely, planned, organised manner
to document and time the key points & events
to offload administrative and telephone work from the clinical leader
to ensure any problems with structure or process are highlighted, to be addressed & sorted
to ensure a copy of the timings/events form is sent to the transfusion practitioner (x1793, bleep 0123, blood bank) for audit and quality assurance

There is a checklist element to this role, ticking the cockpit drill domains. Other clinicians should understand this role and despite the pressure & tension of the urgent clinical situation, should remain professional & courteous when asked questions they feel are obvious and simple.

Appointing roles
The clinical leader has overall leadership for the resuscitation. If there is sufficient manpower and skill-mix, the clinical leader should remain “hands-off” the patient to maintain situational awareness. The roles of clinical leader & coordinator are complimentary. The most senior doctor may choose to take either role or neither role, allowing a trainee to take the helm.
Coordinator may be a doctor, senior nurse or an experienced ODP.
The ED has tabards to identify the team roles, and they include: team leader, doctor one, doctor two, nurse one, nurse two, airway doctor and ODP, radiographer and scribe. Runners are separately detailed by team leader.

Noise & overcrowding
The clinical area can become overcrowded and excessively noisy. Clinical leader may ask people to stand back or leave; radio or music should be turned off.
Clearly these events are rare and afford useful learning opportunities.
Stressful situations require quick thinking staff and quiet, calm and efficient support.

Haematology Consultant: bleep 1972, day mobile 07775 800240, at night via operator

Equipment

Forced air warmers and Rapid Infusion Devices – Level 1 are available in ED, Theatre, Critical Care, Maternity. These devices are crucial & are needed urgently.

Reversal of Pharmacological Anticoagulation

A) Warfarin

Vit K 1-2 mg increments & Octaplex (Human Prothrombin Complex) 2000 units.
Vit K in doses of 5-10 mg will prevent later rewarfarinisation for some time.

B) Anti-platelet drugs

Platelet transfusion likely to be most effective measure. Avoid DDAVP in this situation.

C) Heparin

Heparin has a short half-life & protamine causes significant hypotension.
Consider Protamine with care & reluctance. Probably ineffective in treating SC heparin.

D) LMW Heparin (e.g. clexane)

FFP is of no use in reversing heparin of any sort. In theory it could increase the anticoagulant effect by providing further antithrombin.
Consider protamine but effect is variable, has intrinsic anticoagulant effects itself and may cause hypotension. Give slowly<5mg/min I.V. and do not exceed guidelines below.

LMWH Heparin regime / 40mg (Prophylactic dose) / 1.5mg/kg (Treatment dose)
Time since LMWH dose / 8 hrs / 8-12hrs / > 12 hrs / 8 hrs / 8-12hrs / > 12 hrs
Protamine Dose / 50 mg / 20 mg / None / 50 mg / 20 mg / None

E)Factor Xa Inhibitors (e.g. Rivaroxaban) & Thrombin Inhibitors (e.g. Dabigatran)

Not easily reversed. Seek advice from haematologist.

Treatment of hypocalcaemia

10-20ml 10% calcium gluconate (kinder to peripheral veins) or calcium chloride 10% 10ml.

Haemodynamic Monitoring

Monitor pulse rate, BP, CRT, peripheral perfusion/warmth, urine output, mentation.
Pain, anxiety or awareness, cold climate, beta blockade may influence these signs.
Consider resuscitation using a goal of a palpable radial pulse. Permissive hypotension i.e. targeting a modest BP, as in blunt trauma care, may have a place but is bad for head injuries and there is evidence of poor outcomes if persists beyond an hour.
Do not waste time on an arterial line in a shocked, hypovolaemic patient – resuscitate first.
Monitor the continuing blood loss if this is feasible.
Central venous pressure measurements are much less useful than historical prejudice suggests.

Oesophageal Doppler may give a better indication of vascular filling

Massive Transfusion Guideline : Version 3 2014Review date: 2016 (unless requirements change)

Surname, 1st name / Location
DoB / Hosp # / Cause of bleeding
Time
1 / : / Time of declaration of Major Haemorrhage Alert
2 / : / HCSW/Porter summoned (if already present = P) / 1 / 2 / 3 / 4 / 5 / 6
3 / : / Blood samples taken & labelled (4 ID items) / Time
4 / : / Blood samples despatched to lab / Method
5 / : / Lab phoned / Haemacue
6 / : / Arrival of Red Box Pack A / Hb
7 / : / Surgery considered / Plats
8 / : / Surgery starts / APTR
9 / : / Reveral of any pharmacological contributors (warfarin etc) / INR
10 / : / Rapid infusor device started / Fibrinogen
11 / : / Cell saver started / ABG/VBG?
12 / : / Forced air warmer started (Bair Hugger equivalent) / [Hb]
13 / : / HCSW/Porter summoned (if already present = P) / pH
14 / : / Phase 2 blood samples taken & labelled (4 ID items) / H+
15 / : / Phase 2 blood samples sent to lab / Po2
16 / : / Phone call to consultant haematologist / Pco2
17 / : / Arrival of Red Box Pack B / Std Bic
18 / : / HCSW/Porter summoned (if already present = P) / BXS
19 / : / Phase 3 blood samples taken & labelled (4 ID items) / Sat
20 / : / Phase 3 blood samples sent to lab / Lactate
21 / : / Phone call to consultant haematologist / Glucose
22 / : / Arrival of 3rd set of blood products / Na+
23 / : / HCSW/Porter summoned (if already present = P) / K+
24 / : / 4th blood samples taken & labelled (4 ID items) / Cl-
25 / : / 4th blood samples sent to lab / iCa2+
26 / : / Phone call to consultant haematologist
27 / : / Arrival of 4th set of blood products

Massive Transfusion Guideline : Version 3 2014Review date: 2016 (unless requirements change)

Make notes of problems in (1) the structure & organisation and (2) the process of delivery of care to this patient). What could have been improved?

(use the numbers to help identify times and events)

5.TRAINING REQUIREMENTS

Massive haemorrhage issues will be included in the Trust blood awareness education programme, overseen by the Transfusion Practitioner. Blood awareness education is already a bi-annual requirement for Trust staff, as part of the Trust’s Training Needs Analysis.

6.REFERENCES AND ASSOCIATED DOCUMENTATION

External

Coagulopathy: its pathophysiology and treatment in the injured patient.World J Surg;2007:31:1055-64. Tieu BH et al

Early prediction of massive transfusion in trauma: simplified ABC (Asssessment of Blood Consumption).J Trauma 2009;66:346-52. Nunez TC et al

Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 2007:62;112-9. Gonzalez EA et al

Guidelines for prehospital fluid resuscitation in the injured patient. J Trauma 2009:67;389-402. Cotton BA et al

The cellular, metabolic and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006:26;115-21. Cotton BA et al.

Massive transfusion practices around the globe and suggestion for a common massive transfusion protocol. J Trauma2006:60;S91-S96

Improvements in early mortality and coagulopathy are sutained better in patients with blunt after institution of a massive transfusion protocol in a civilian level 1 trauma centre.Trauma2009;66:1616-24. Dente CJ et al

Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. 2009;61:41-9. Cotton BA et al

Damage control hematology: the impact of a trauma exsanguinations protocol on survival and blood product utilization. J Trauma 32008:1177-83. Cotton BA et all

Trauma associated severe haemorrhage (TASH)-score: probability of mass transfusion as surrogate of life threatening haemorrhage after major trauma.J Trauma 2006:1228-1237

Resuscitation and transfusion principles for traumatic haemorrhagic shock. Blood reviews 2009: doi:10.1016/j.bire.2009.07.003. Spinella PC et al

Internal

Blood Transfusion Policy
Policy for the Management of Serious Incidents Requiring Investigations (SIRIs)

7.EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

8.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assurance compliance.

Minimum requirement to be monitored / Lead / Tool / Frequency of Report of Compliance / Reporting arrangements / Lead(s) for acting on Recommendations
Each massive haemorrhage event: to ensure appropriate process followed in 100% of the time / Hospital Transfusion Team / Audit Data Collection Form / Annually / Policy audit report to:

Hospital Transfusion Committee

/ Chair of Hospital Transfusion Committee
Policy audit report to:
Policy audit report to:

The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.

The details of the monitoring to be considered include:

The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required. In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary.

Massive Transfusion Guideline : Version 3 2014Review date: 2016 (unless requirements change)