Blood Products in a Community Emergency Room (2017)

1. Blood Products in a Community Emergency Room (2017)

2. Identifying what Resources are available Knowing what is available in a time of crisis is as valuable as knowing how to give it

4. FP- Frozen Plasma- about 293 ml volume Prepared from whole blood Plasma is frozen within 24 hrs of collection Contains all coagulation factors at levels similar to the levels in FFPA with the exception of factor V and VIII- which are slightly reduced After thaw is used within 5 days Types of Plasma

5. Apheresis Fresh Frozen Plasma ( FFPA)- Collected by apheresis Frozen within 8 hours of collection Average volume of 495 ml Once thawed can be stored at 1-6 degree Celcius for a max. of 24 hours

6. Frozen Plasma is stocked Plasma

7. Needs 25 min to thaw • Plasma is thawed by “Elmer”

8. This is Helmer. • Frozen Plasma goes into a warm water bath and is thawed after 25 min.

9. Platelets Not stored in any hospital blood bank in Winnipeg they are stored at CBS

10. Aug 2016 CMO77A Will require this requisition to order Platelets. Need to include the patient’s current platelet count on the requisition

11. PCCs are manufactured prothrombin complex concentrates derived from pools of 1000 – 2000 human plasma donations PCCs contain factors II, VII, IX, X and Proteins C and S, Heparin and Sodium Citrate What are Prothrombin Complex Concentrates?Octaplex

12. Indications for PCC Use • Emergent reversal of warfarin therapy of vitamin K deficiency in patients: • Exhibiting serious life-threatening bleeding manifestations • Requiring UNPLANNED / URGENT (<6 hours) interventions that carry a risk of bleeding For non-emergent reversal of warfarin or vitamin K deficiency, vitamin K should be used rather than PCCs

13. Hx of Heparin Induced Thrombocytopenia (HIT) Disseminated Intravascular Coagulation (DIC) Coagulopathy R/T liver dysfunction/disease Massive Transfusion Reversal of Anticoagulants other than Vitamin K antagonists Tx of elevated INRs without bleeding or need for surgical intervention. Don’t Use PCCs If:

14. Process – Step 1 1. Physician Order January 01, 2017 1300 I N R STAT Dr.Cutting Dr. Izzy Bella Cutting January 01, 2017 1300 Prothrombin Complex Concentrate 1000 IU IV STAT infused per protocol for warfarin reversal. Phytonadione 10 mg IV over 30 mins x 1 dose. Dr.Cutting Dr. Izzy Bella Cutting January 01, 2017 1300 Repeat INR 10-15 mins post-PCC infusion

15. Process Step 2 2. Complete & Fax Request to Blood Bank

16. Process – Step 3 4. Complete two nurse check

17. Reconstitution Instructions • Ensure vials are warmed to room temperature (37° C) • Ensure vials are firmly held on an even surface prior to puncture • Reconstituted octaplex is fully dissolved into a clear or slightly opalescent solution. Key Points At a Glance

20. Current Best Practice Guidelines can be found: BEST BLOOD MANITOBA WEBSITE- www.bestbloodmanitoba.ca Products

22. How long can I expect to Wait for the type and screen? • Type and Screen- 90 minutes • This time is only for patients who have no identified antibodies

23. * Should be checked with demographics page Transfusion Medicine Results Report

24. Fax the requisition to the blood bank Then phone the blood bank and let them know that req has been faxed Request for Blood or Plasma Protein Products

25. Blood or Blood Product Arrives to the Unit Where do we go from here?

26. Aug 2016

28. Record Of Transfusion Nursing Staff Must complete and return to facility blood blank. DO NOT PLACE in CHART Facility Blood Bank Must complete final disposition

29. Blood Bag Label Manilla tag on bag should be checked with blood bag label and then tken to patient’s bedside and checked with patient’ name band

30. Patient Monitoring • Ensure a Patent IV • Baseline Vital signs • Stay with patient for the first 15 minutes • Run blood/ product at 50ml/hr during this time period • Vital signs at the end of the 15 min, increase infusion rate to ordered rate • Vital signs every hour until infusion complete • For in-patients vital signs 1 hour after transfusion Manitoba best practice guideline number 4

31. Blood and Platelets and Plasma all require filtered Y blood tubing • Good for • 4 hours or • 4 units in that 4 hours or • Less than 30 minutes between same product • Start with one product- do not transfuse another product with same set • Albumin • Vented Set- no filter • Octaplex • Non port IV tubing- no filter required • IVIG • As per package directions • Vented tubing- should be changed after 4 hours if lot number is same on bottle Tubing and Priming

32. Need Blood STAT!!!Emergency Blood

33. Fax the Requisition and Phone the Blood Bank for Emergency Blood Requisition must be stamped with patients demographic card- if this is not available a MRN number at the very least is required If more than one unit is required please fill in- 2 emergency units required for multiple IV sites. Emergency Request For Blood Products

34. Emergency Red Blood Cells The Red Tag will be filled out by hand and delivered to the designated unit This still needs to be checked by 2 nurses before it is administered Type and Screen should be drawn before emergency blood given

35. Record of Transfusion- Emergency Component Must be signed by ordering Physician

36. Rh Immune GlobulinWin Rho

37. Documentation • Pre-transfusion Actions: • (Place in Pre-transfusion Actions column below when ALL • actions are complete*) • Consent for transfusion complete • Patient/Family education (includes type of product, reason • for administration, signs and symptoms of reactions, • patient action required) • Physician order for product • Intravenous site checked and patent • Pre-transfusion vital signs • Verification of correct blood products • Positive patient identification performed at bedside • *If any action(s) Not Complete (NC) document “NC” below • in Pre-transfusion Actions column and “state reason” in • Intervention section Alyson, Penelope 25/Dec/1943 PHIN: 123456789 Dr. I.B. Cutting Blood Products: See facility guidelines for complete list of blood products AFFP: Apheresis Fresh Frozen Plasma APLT: Apheresis Platelets Auto: Intended Use Donor Autologous Cryo: Cryoprecipitate CSP: Cryosupernatant Plasma DIV: Neonata Red Cells FFP: FreshFrozenPlasma FP-24: FrozenPlasma HSA: Albumin IVIG: Intravenous Immune Globulin PLT: Platelets RBC: Red Blood Cells RhIG: WinRho 04 JAN 2013 1045 yes RBC O neg 1234567898765432 120/80 36.6 86 18 98% 0 F.Night RN/ S. Boychk RN • ASSESSMENT PARAMETERS: • * Reference transfusion reaction algorithm • If symptomatic: document in assessment section and provide details in • Intervention section • 0 Asymptomatic • Chills and fever • Rash or urticaria • Back pain • Chest pain • Dyspnea and shortness of breath

38. After the Transfusion * Put blood tag in confidential waste *Throw out blood bag and tubing * Vital signs 1 hour post transfusion * Before discharge indicate on Bottom of CBPR that patient notification of a transfusion has been provided to family/facility

39. Have we eliminated the risk of a blood transfusion? The quality of blood that is issued is safer than it has been in the past. However the risk in administering blood and the possibility of having a transfusion reaction still exists.

40. Did You Know? Mislabeling tubes is the number one reason for near miss or possible transfusion reactions

42. Patient Blood Management What does this mean to you? Are there ways you practice this already?

43. Patient Blood Management Patient Blood Management (PBM) is the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort to improve patient outcomes.

44. Pre-operative EARLY DETECTION – screening blood work at least 4-6 weeks prior to surgery EVALUATION – etiology of anemia needed in order to treat MANAGEMENT – options may include: Diet modification and patient education to support adherence to plan Medication – oral or parenteral iron, ESA, vit B12, folic acid, tranexamic acid, OCP to control bleeding (pre-surgical with menorrhagia) Referrals to other services, i.e., hematology, gastroenterologist cell

45. Parenteral Iron Iron Sucrose(Venofer) Usual dose 200-500 mg IV infused over 90 minutes. Every other day. WRHA Iron clinic staffed by BMS nurses Very unique program- we are one of very few programs across Canada that have dedicated clinical space to administer IV iron/erythropoeitin to our patients

46. Erythropoietin Stimulating Agents in Elective Surgery Eligibility: Anemia without reversible cause, no contraindications to ESA. Hemoglobin <100 g/L > 10% Transfusion risk. Can use with FE alone or with PAD & FE. Use: Requires lead-up time of 4-6 weeks. Oral iron supplement for maximal benefit. Doses individually assessed Expected response is increase in HGB of 10-20 g/L & high reticulocyte count

47. Tranexamic Acid Evidence supports the routine use of TXA (Tranexamic acid) in hip and knee Arthroplasties to decrease intra and post-operative blood loss ( patient outcomes and adverse events considered) Economic evaluations support routine TXA as cost savings CADTH-Prophylactic Tranexamic Acid Administration for Patients Undergoing Hip and Knee Replacement

48. Fluid balance Appropriate fluid resuscitation peri/post operative & maintaining adequate perfusion pressure. Dehydration + low HGB = MORE dizziness & hypotension. Fluid boluses help pt to tolerate lower hgb levels. Assess for dehydration. Encourage oral fluid intake after IV discontinued & prompt treatment/prevention of PO/NV to prevent fluid losses.

49. Preoperative Autologous Donation (PAD) Refers to the donation of blood by a patient for their own use in scheduled elective surgery Few good quality RCT’s to highlight the benefits Discard rates are above 50% Donation process can result in donor complications at a rate reported as high as 12 times greater than with healthy volunteers

50. When do you Transfuse??