Beruflich Dokumente
Kultur Dokumente
K. Pavenski, MD FRCPC
Head, Div. Transfusion Medicine
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Introduction
• Massive hemorrhage and massive transfusion
may occur in the following clinical contexts:
– Trauma
– Post-partum hemorrhage
– Cardiovascular complication (ex. ruptured
abdominal aortic aneurysm)
– Acute upper GI bleeding
– Post surgery
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Introduction
• MTP is an algorithm for management of a
patient with a massive hemorrhage
• MTPs have been shown to
– Improve patient outcomes
– Reduce patient mortality
– Reduce wastage of blood products
• St. Michael’s MTP can be found on CPPS
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MSICU MTP Stats
• 62 MTP activations per year at SMH
– 5 in MSICU
• GIB – 3
• Bleeding due to drug overdose – 1
• Bleeding kidney mass - 1
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Principles of MT management
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MTP Activation Criteria: Specific
Trauma:
• Penetrating trauma AND persistent
hypotension (2 measurements of SBP< 90
mmHg taken 5 min apart).
• Blunt trauma AND persistent hypotension
AND one of the following:
a. Massive haemothorax
b. Positive FAST scan
c. Pelvic fracture
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MTP Activation Criteria: Specific
Post partum haemorrhage (PPH):
• >500 cc vaginal blood loss AND hypotension not responding to
crystalloid bolus
• >1000 cc blood loss following caesarean section AND hypotension
not responding to crystalloid bolus
• Suspected bleeding AND hypotension not responding to crystalloid
bolus in a post-partum patient.
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MTP Activation: Where
• MTP may be administered in the following clinical
areas:
– Emergency Department
– Operating Rooms
– Intensive Care Units
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MTP: Team
• MTP assist
– RN, RRT, or perfusionist
– Administers IV fluids, medications, blood
products, monitors patient’s vital signs, charts
– Nurse assigned to the patient will become MTP
assist
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MTP: Team
• Transfusion Medicine (TM)
– One technologist is usually designated to assist
with MTP and will keep track of what products are
issued and when
– TM performs compatibility testing and prepares
blood products for transfusion
– TM regularly communicates with the team at
patient’s bedside
– TM may provide recommendations on optimal
transfusion therapy
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MTP: Team
• Additional resources may be necessary
• Respiratory therapist
– Assists with airway and oxygen therapy
– Administers IV fluids and blood products
• Perfusionist
– Sets up cell salvage if appropriate
– Administers IV fluids and blood products
• Porter
– Delivers laboratory samples to the laboratory and blood
products from TM to the patient
– Returns empty coolers and untransfused blood products to
TM
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MTP: Activation
• MD assesses the patient and makes a decision
to activate MTP
• MD (or delegate) calls Transfusion Medicine
Laboratory (ext 5084) and requests to activate
MTP
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MTP: Activation
• MD (or delegate) is to provide the following
information to TM:
– Patient location and contact telephone number
– Patient’s name and MRN
• If patient’s identity is not known, state MRN, gender and
approximate age
– Name of the MD who will lead MTP
– State whether the patient is/appears to be pregnant
• May require CMV negative RBC and platelets
• May need to activate CODE OB
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MTP: Activation
• Assemble team
– Designate MTP lead, assistants (RN, RRT)
– Call locating if additional resources are necessary
• Anaesthesia, porter, perfusionist, etc.
• Porter
– If your area has a porter or CA and he/she is available to assist, do not call
portering services
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MTP: Initial Patient Management
• Secure airway and provide oxygen
• Obtain appropriate vascular access
– 2xG14-16 i.v. or central line
• Start IV fluids
– Note: only 0.9% NaCl solution is compatible with
blood products
• Set up rapid infuser/blood warmer
• Administer tranexamic acid if appropriate
• Keep core temperature >35C
• Place patient on continuous monitoring
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MTP: Initial Patient Management
• For information on administration of
tranexamic acid in trauma, refer to Protocol
for intravenous administration of tranexamic
acid (Cyclokapron) during trauma
resuscitation (Pharmacy)
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MTP: Initial Laboratory Investigations
• Send off laboratory investigations:
– Group and screen (2 pink top tubes)
– CBC (1 lavender top tube)
– INR, aPTT, Fibrinogen (1 blue top tube)
– Electrolytes, ionized calcium, creatinine (2 yellow top
tubes)
– Lactate (1 grey top tube)
– VBG (syringe)
– Place labeled specimens into a red plastic STAT bag and
deliver to the labs as soon as possible
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MTP: Patient Monitoring
• Clinical
– BP, HR, SatO2, RR, temperature
– Input and output
• Laboratory
– Send CBC, INR, fibrinogen every 1 h
– ABG/VBG every 25-30 min
– Creatinine/Magnesium/Lactate every 4h
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MTP: Transfusion
• Follow the policy on Administration of Blood
Products (CPPS)
• Use blood warmer for RBC and plasma
• Refer to Use of rapid infusion and blood warming devices for infusion
of blood products and resuscitating fluids (CPPS)
• Do not transfuse platelets and cryoprecipitate through a blood
warmer
• RBC and plasma will be transported and stored in a
cooler during MTP
– Platelets and cryoprecipitate should be kept at room temperature;
do NOT place in the cooler
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MTP: Transfusion of RBC
• RBC must be ABO compatible and crossmatch
compatible
• Following initiation of MTP, red blood cells (RBC)
are immediately available for pick-up
– If patient’s compatibility testing (group & screen,
crossmatch) has not been completed, you will receive
uncrossmatched RBC
– If patient has RBC already crossmatched, you will
receive crossmatch compatible RBC
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MTP: Transfusion of RBC
• Notes:
– For a new patient, it will take at least 45 minutes to obtain
crossmatch compatible RBC from the time of specimen
arrival in TM
– For a patient with an in-date group and screen (with no
crossmatched units available), time to compatible RBC will
depend on whether the patient has RBC antibodies (5 min
to few hours)
– Patient will be switched to crossmatch compatible RBC as
soon as they are available
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Time to Availability of RBC
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MTP: Transfusion of Platelets
• Platelets
– During MTP, administer if platelet count is <100
for CNS/spinal cord bleeding or traumatic brain
injury; <50 for all others OR at any count if platelet
dysfunction is suspected (ex. post-bypass)
– Dose is “1 adult dose”
– Available immediately
– Note: For patients with PPH, platelets
will be offered with the 1st cooler
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MTP: Transfusion of Cryoprecipitate
• Cryoprecipitate
– During MTP, administer if fibrinogen level is
<1.5g/L
– Dose is 10 units
– Must be ABO compatible
– Thawing and pooling cryoprecipitate takes 30
minutes
– Note: For patients with PPH, cryoprecipitate
will be offered with the 1st cooler
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MTP: What is in the shipment?
• 1st shipment
– Cooler with 6 units of RBC
• 4 unit of plasma will be issued separately in the next 20
minutes
– For PPH OR upon request
• 1 adult dose of platelets (available immediately)
• 10 units of cryoprecipitate (available in 20 minutes)
• 2nd shipment and subsequent shipments
– Cooler with 4 units of RBC, 4 units of plasma
– Will be prepared every 30 minutes
• Platelets and cryoprecipitate must be ordered as per
clinical situation and laboratory results
– These will be issued in a clear plastic bag
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MTP: Transfusion Goals
The following should be used as a guideline only and not replace
clinical judgment
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MTP: Supportive measures
The principal aim is to achieve either surgical or medical
haemostasis
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MTP: Common errors
Consistently identified weaknesses during MTP:
• Poor planning
• Poor communication
• Delay in activation of MTP
• Failure to monitor laboratory parameters during MTP
• Failure to monitor for and manage hypothermia
• Failure to administer blood products as per MTP
• Failure to administer cryoprecipitate
• Delay in termination of MTP
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MTP: Adverse Events
• Hypothermia
• Citrate toxicity
• Volume overload, abdominal compartment
syndrome
• Transfusion Reactions
– Acute hemolytic transfusion reaction (ex. ABO
incompatible transfusion due to clerical error)
– Transfusion related acute lung injury (TRALI)
– Transfusion associated cardiac overload (TACO)
– Major allergic reaction
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Concluding Remarks
• Be prepared – know the protocol
• Practice - participate in mock MTP
• During MTP, communicate with all members
of the team, including those in TM
• Re-assess need for ongoing MTP frequently
• Return coolers and untransfused products
ASAP
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