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Management of Massive Transfusion in Trauma Why? When? How?

Management of Massive Transfusion in Trauma Why? When? How?. Dr Jonathan Leung Fernando Candal Carbalido Dr Michelle Hamer Dr Jalal Maryosh Liz Brown CT2 ACCS Charge Nurse Consultant Consultant Transfusion Practitioner

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Management of Massive Transfusion in Trauma Why? When? How?

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  1. Management ofMassive Transfusion in Trauma Why? When? How? Dr Jonathan Leung Fernando Candal Carbalido Dr Michelle Hamer Dr Jalal Maryosh Liz Brown CT2 ACCS Charge Nurse Consultant Consultant Transfusion Practitioner Emergency Medicine Accident & Emergency Critical Care Medicine Accident & Emergency Pathology William Harvey Hospital William Harvey Hospital William Harvey Hospital William Harvey Hospital William Harvey Hospital

  2. Key Discussion Points • Definition • Complications of massive transfusion – focus on coagulopathy • Background evidence • Indication and pathway of Management of Massive Transfusion (MMT) • Cost effectiveness of MMT • Experiences and Outcomes

  3. Definition of Massive Transfusion • Replacement of a blood volume equivalent within 24hr • >10 unit within 24 hr • Transfusion > 4 units in 1 hr • Replacement of 50% of blood volume in 3hrs • A rate of loss >150ml/hr

  4. Importance of Massive Transfusion • 39% of trauma related deaths – uncontrollable bleeding (Leading cause of preventable death) • 2% of trauma patients – need massive transfusion Bleeding 2 main causes • Vascular injury (surgical) • Coagulopathy (non-surgical)

  5. Complications of massive transfusion

  6. Complications of massive transfusion

  7. What is Haemostatic Resuscitation? • A ground breaking concept! • Prevents post traumatic coagulopathy • Aims to reduce use of blood products in the intensive care phase. RBC:FFP 1:1 RBC:FFP:PLT 1:1:1

  8. Evidence of Haemostatic Resuscitation • Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol Debra L Malone, John R Hess, Abe Fingerhut ;The Journal of trauma. 01/07/2006; 60(6 Suppl):S91-6. • Suggested – RBC:FFP - 1:1 • Indications for early fresh frozen plasma, cryoprecipitate, and platelet transfusion in trauma Lloyd Ketchum, John R Hess, Seppo Hiippala; The Journal of trauma. 01/07/2006; 60(6 Suppl):S51-8. Early use of FFP,PLT - ↓ incidence of coagulopathy

  9. Coagulopathy of Massive TransfusionMortality Vs FFP/RBC ratio • Retrospective review of 246 patients receiving a massive transfusion (> 10 units of blood) Borgman MA. et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital J trauma, 2007. 66:805-813

  10. Pre-defined Massive Transfusion Protocols are associated with REDUCTION of organ failure and post injury complication J Trauma 2009 Jan ; 66(1) 41-48 Ratio 3:2 RBC : FFP 5:1 RBC : PLT

  11. Complications comparison

  12. Summation of US experience • Plasma saves lives • Early use of FFP improved survival at 48hrs and 30 days • MMT reduced total blood products used • Majority of death within 6 hours - Therefore Preventative Coagulopathy is KEY!

  13. The William Harvey Hospital • District General Hospital • Serving a population of 500,000 • Sits along side the M20 • Channel Tunnel • Major Accident & Emergency Department • Nearest Trauma centre – London • How can we improve the outcome of Trauma patients in our area???

  14. Collaboration • Listened to the research studies • Embraced a proactive approach • Devised a team to implement the Management of Massive Transfusion for Trauma protocol.

  15. Creating a Pathway • Transfusion Triage (Recognition) • Activation of MMT + Communication with Transfusion Department • Logistics • Haemostatic resuscitation • Target directed therapy – therapeutic end point • Termination of MMT order

  16. Transfusion Triage - recognition of ‘At Risk’ patient Pre-Hospital alert: • Systolic BP < 90 • Poor response to initial fluid resuscitation • Suspected active haemorrhage If so activate MMT

  17. Hospital Alert:- • SBP < 90 • HR > 100 • Ph < 7.35 • BE < - 2 • Uncontrollable active bleeding • Poor responder to fluid Activation of MMT by team leader only- Registrar or above.

  18. Target Clinical and Laboratory endpoints in severely injured patient • Evaluation of severity and mechanism of injury • Normothermia • Systolic pressure 80-100mmHg • Urine output > 40 ml/hr • CVP 0-5mmHg • Hb up to 8-10 g/dl (suggest 10g/dl) • Platelets > 50 x 109/l (suggest maintain >100 for polytrauma) • PT and APPT ratio < 1.5 • Normalise serum BE and lactate (Mx of bleeding following major trauma: a European guideline. Spahn et al. Crit Care 2007,11:R177) http://ccforum.com/content/11/1/r17

  19. Massive Transfusion Pack PACK ONE • 4 x O neg / O pos RBC • 4x FFP PACK TWO • 4 x O neg /O pos RBC /Group specific RBC • 4x FFP • 1x ATD platelet Continuous until Order terminated

  20. MANAGEMENT of MASSIVE TRANSFUSION (MMT) forTRAUMA PREVENT HYPOTHERMI A AC I DOS I S COAGULOPATHY Hospital MMT alert confirmation (patient requiring urgent transfusion) - SBP < 90 - HR > 100 - Ph < 7.35 - BE < - 2 - Obvious signs of uncontrollable active bleeding - Poor responder to fluid resuscitation (Trauma Team leader must declare MMT Activation to blood bank ,WHH Bleep no:8662) Co-ordinate Porter urgently to standby for Collection of MMT pack one • Pre-hospital MMT alert: • Systolic BP < 90 • Poor response to initial fluid resuscitation • Suspected active haemorrhage • If so activate MMT (match 3 of the ocriteria) MMT ACTIVATION For Trauma PATIENT ARRIVAL Take bloods (FBC, U&E, Clotting, fibrinogen and X-match and ABG) Send pink bottle with X-match form to blood bank urgently ( please obtain 2 samples for x-match at different time if possible) HAEMOSTASIS THERAPY TARGET end point: Hb: 8-10 g/dl Platelets > 100 PT&APTT (INR)< 1.5 Fibrinogen > 1.0 g/l Ca²⁺ > 1 mmol/l pH: 7.35-7.45 BE: ± 2 Tª > 36 °C MMT PACK 1 4 x O –ve RBC ( female) or O+ve(Male) 4 x AB FFP (or Group specific if possible) HAEMORRHAGECONTROL: Surgery Stabilize fractures Pelvic brace PREVENT HYPOTHERMIA Fail to reach targets RE-ASSESSMENT ABCDE If haemorrhage continue HAEMOSTATIC DRUGS: Consider the following if bleeding persist despite surgical interventions: Activated factor VII Beriplex (consider when patient who is on anti-coagulant) Antifibrinolitic agents Please discuss any of these therapeutic measures with Haematologist on call) Activate MMT PACK 2 Please, specify location of patient 2 x packs of Cryoprecipitate if Fibrinogen is < 1.0 g/l INTRA-OPERATIVE CELL SALVAGE: Transfuse 1 x FFP every 250 ml of blood Transfuse 1 x ATD platelets every 1000 ml of blood MMT PACK 2 Once administered check: FBC, Clotting, fibrinogen and ABG 4 X RBC 4 X FFP 1 X ATD Platelets When MMT stops Notify blood bank Return any unused products Resume standard ordering practices

  21. MANAGEMENT of MASSIVE TRANSFUSION (MMT) forTRAUMA PREVENT HYPOTHERMI A AC I DOS I S COAGULOPATHY Hospital MMT alert confirmation (patient requiring urgent transfusion) - SBP < 90 - HR > 100 - Ph < 7.35 - BE < - 2 - Obvious signs of uncontrollable active bleeding - Poor responder to fluid resuscitation (Trauma Team leader must declare MMT Activation to blood bank ,WHH Bleep no:8662) Co-ordinate Porter urgently to standby for Collection of MMT pack one • Pre-hospital MMT alert: • Systolic BP < 90 • Poor response to initial fluid resuscitation • Suspected active haemorrhage • If so activate MMT (match 3 of the ocriteria) MMT ACTIVATION For Trauma PATIENT ARRIVAL Take bloods (FBC, U&E, Clotting, fibrinogen and X-match and ABG) Send pink bottle with X-match form to blood bank urgently ( please obtain 2 samples for x-match at different time if possible) HAEMOSTASIS THERAPY TARGET end point: Hb: 8-10 g/dl Platelets > 100 PT&APTT (INR)< 1.5 Fibrinogen > 1.0 g/l Ca²⁺ > 1 mmol/l pH: 7.35-7.45 BE: ± 2 Tª > 36 °C MMT PACK 1 4 x O –ve RBC ( female) or O+ve(Male) 4 x AB FFP (or Group specific if possible) HAEMORRHAGECONTROL: Surgery Stabilize fractures Pelvic brace PREVENT HYPOTHERMIA Fail to reach targets RE-ASSESSMENT ABCDE If haemorrhage continue HAEMOSTATIC DRUGS: Consider the following if bleeding persist despite surgical interventions: Activated factor VII Beriplex (consider when patient who is on anti-coagulant) Antifibrinolitic agents Please discuss any of these therapeutic measures with Haematologist on call) Activate MMT PACK 2 Please, specify location of patient 2 x packs of Cryoprecipitate if Fibrinogen is < 1.0 g/l INTRA-OPERATIVE CELL SALVAGE: Transfuse 1 x FFP every 250 ml of blood Transfuse 1 x ATD platelets every 1000 ml of blood MMT PACK 2 Once administered check: FBC, Clotting, fibrinogen and ABG 4 X RBC 4 X FFP 1 X ATD Platelets When MMT stops Notify blood bank Return any unused products Resume standard ordering practices

  22. Wastage and Cost • From 1st April to 30th September 2010 there have been 7 MMT activations. • The wastage for this period directly as a result of MMT activation is: • 5 packs of FFP & • 3 packs of Platelets • Total cost £833.27 Wastage costs 7 MMT activations

  23. Summary • Improved patient outcome. • 4 of the 7 activations had positive outcomes. • Wastage costs negligible against improved management • Appropriate, timely, provision of blood products. • Improved interdepartmental communication.

  24. Thank you for listening……… • Any Questions?

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