Blood Transfusion: New Topics and Old
Transcript of Blood Transfusion: New Topics and Old
Blood Transfusion: New
Topics and Old
Huntsville District Memorial Hospital December 5, 2018
Allison Collins MD FRCPC [email protected]
Blood Transfusion: New
Topics and Old
South Muskoka Memorial Hospital December 6, 2018
Allison Collins MD FRCPC [email protected]
Program Planning Committee
(PPC) Disclosure
The following steps have been taken to mitigate bias:
All PPC members and speakers have signed a COI form.
All speakers have been emailed the cert i f ication/accreditation requirements for
their presentation.
Each presentation wil l be reviewed by the academic coordinator prior to i ts
delivery. The coordinator wil l be looking for any signs of bias including use of
brand names and logos of pharmaceutical companies.
I f bias is detected the PPC would review it and the speaker would be notif ied so
that the bias can be corrected before the presentation is given. I f the bias cannot
be corrected or removed the session would be cancelled.
I f a bias is detected by a planning committee member during the presentation they
would question the speaker about i t .
All biases would be reviewed at the next PPC meeting.
Disclosures
• No conflicts of interest to declare
• ORBCoN is funded by the Ministry of
Health and Long Term Care
Objectives
1. Describe the 7 important elements of a Massive
Hemorrhage Protocol
• homework: find out how many massive
hemorrhages you have in a year and how
much blood you used for them
2. Explain the responsibilities of physicians and
nurses in obtaining consent for transfusion
3. List the two mammals who regularly remove
blood from other mammals
Massive Transfusion - Definitions
• Definitions vary:
– replacement of total blood volume in < 24 hr
– replacement of > 50% of blood volume in 3 hr
– ≥ 10 U RBC in 24 hrs
– bleeding rate of ≥ 150 mL/min
• These are reasonable for retrospective reviews
but not practical in ‘real time’
– 1U q2h x 20hrs ≠ 10U over 2 hrs
• Consider a 4U RBC order as a potential massive
transfusion
Pohlman. Blood Reviews 2015;29:251
Massive Transfusion Situations
• Trauma
• Upper GI bleeds
• Obstetrical catastrophe
• Surgical misadventure
• Vascular catastrophe
• Surgery: cardiac, vascular
• Complex situations with high mortality
– e.g. 50% mortality in trauma
These patients may have:
• Mechanical bleeding
• Coagulopathy
Massive Hemorrhage Protocol (MHP)
• An algorithm for management of a
massive hemorrhage
• May improve patient outcomes, including
mortality
– standardised care
– improved communication and coordination
– improved quality and safety of patient care
• Reduces wastage of blood components
Pavenski. CSTM meeting May 2015
Goals of a MHP
To improve patient outcomes including mortality – Specific Goals: early source control of bleeding,
monitoring of relevant hemostatic and physiological
parameters, transfusion, and supportive care
– General Goals: translate best evidence and best
practices, standardize care, improve communication
and coordination within a multi-disciplinary team,
reduce overtransfusion, reduce treatment
complications, and reduce wastage of blood
components
Slide credits next slides: Drs J. Callum and K. Pavenski
Where are we now?
• How many hospitals actually have a MHP?
• Staff confusion – staff who work/train in multiple hospitals
• Different names: MHO, MTP, code omega etc.
• Different activation route: written vs. verbal order, code (silent
vs. overhead)
• Different activation criteria
• Different contents of packs
– Different amounts/ratios of RBC and plasma
– Platelets and cryoprecipitate on demand vs. fixed
• Different monitoring, including patient temperature, labs
• Different team members (e.g. porter vs. no porter)
Chin et al. Injury (epub) https://doi.org/10.1016/j.injury.2018.11.026
Where are we now?
• Different (and perhaps outdated?) transfusion goals
• Different transfusion rules
• Issuing only O Rh negative RBC in emergencies (regardless of
recipient’s age and gender)
• 2 O Rh positive and 2 O Rh negative -> unable to interpret Rh
• Never switching to group specific components
• Different supportive care: TXA (not given or given too late),
temperature (not measured and not corrected), anticoagulant
reversal (not done), crystalloid (given too much)
• Different (and generally poor) records, challenging transfer of care
• No ability to compare to peers
Chin et al. Injury (epub) https://doi.org/10.1016/j.injury.2018.11.026
The T7 of a MHP
T
1 Triggering (activation)
2 Team
3 Testing
4 Tranexamic acid
5 Temperature
6 Transfusion
7 Termination
Triggering the MHP
• Triage
– MHP are activated in highly stressful situations
– easy to believe patient at risk for haemorrhagic death
– overtransfusion common (almost never needed for GI
bleeds)
• Under-triage?
– could be catastrophic, patient bleeds to death
• Over-triage?
– overtransfusion of RBCs “because they arrived”
– TACO and other transfusion complications
– blood wastage
GI Bleeds: RBC use
Villenueva Jairath
RBC policy Restrictive
Hb < 70
Liberal
Hb < 90
Restrictive
Hb < 80
Liberal
Hb <100
RBC
U/patient
mean +/-SD
1.5 (2.3) 3.7 (3.8) 2.4 (2.6) 3.4 (3.0)
% received
plasma
6 9 N/A N/A
% received
platelets
3 4 N/A
N/A
Villenueva. NEJM 2013;368:11. Jairath. Lancet 2015;386:136
Predicting Massive Bleed – ABC Score (Assessment of Blood Consumption)
• 1 point for each of:
• Penetrating mechanism
• Positive FAST
• Systolic BP ≤ 90 mm Hg
• Heart rate ≥ 120 bpm
• FAST = Focused Assessment for
the Sonography of Trauma
(bedside ultrasound looking for
free fluid in the pericardium,
hepatorenal recess, perisplenic
space and pelvis)
• Score of ≥ 2 has 75% sensitivity
and 86% specificity for massive
transfusion
Nunez. J Trauma Inj Inf Crit Care 2009;66:346
Over activation is a problem…
Do we need a slight speed bump to give time
for MDs to decide if a MHP is likely required?
Start with 2-4 units of group O
Boutefnouchet. Injury 2015; 46: 1772
Team
BIG • Physician Lead – “Local”
• Nursing Lead
• Charting Nurse
• Code Nurse
• Anesthesia resident
• Rapid Response Team
• Porter
• MLT – BB
• MLT – Coagulation
• OB: back up anesthesia, second call OB, neonatologist, NICU RN
• Chaplain
SMALL
• Physician Lead – “Local”
• Nursing Lead
• Charting Nurse
• Code Nurse
• Anesthesia
• Porter
• MLT – BB & Coagulation
• OB: Obstetrician on call
Timing of types of testing
HOURLY
+
Group and
Screen with
first set
PLUS
& LIS ORDER SET
Blood Test Tube Top Colour
CBC Lavender
INR/PTT/fibrinogen Blue
Ionised calcium Yellow
Lactate Grey
Electrolytes and ABG ABG syringe in ice bag
Antifibrinolytics: CRASH-2 trial
• 20,211 patients randomized to placebo vs. 1+1 gram of tranexamic acid (TXA)
• sBP <90, HR >110, at risk for significant hemorrhage
• TXA reduces death rate overall (OR 0.91) and death from bleeding (OR 0.85)
• Most effective in reducing risk of death from bleeding if given within the first hour from injury (OR 0.68)
• NNT to save 1 life = 67
• No increase in arterial or venous thromboembolic complications
Shakur. Lancet 2010;376:23
Hypothermia: Prevention & Management
• Minimal number of studies
• Poorly monitored during pre-hospital and pre-OR phase
• Temp <34°C associated with an increase in mortality
• Each 1°C increases blood loss by 16% and risk of
transfusion by 22% (maintain at 36°C or higher)
• In the pre-hospital phase, trauma patients with minor
injury have a fall in temperature with passive warming
(blankets), versus a rise (and normalization) in
temperature with resistive warming blankets AND they
are more comfortable on arrival!
Reynolds. J Trauma Acute Care Surg. 2012;73:486
Dirkmann. Anesth Analg. 2008;106:1627, Kober. Mayo Clin Proc 2001;76: 369
Walpoth.NEJM 1997:337:1500, Lundgren. Scand J Trauma Resusc Emerg Med 2011;19:59.
Pre-set transfusion protocol
• Blood groups for emergency uncrossmatched
components
• Number of RBC per pack
• Ratios for extreme hemorrhages
• Targets for resuscitation based on lab testing
– Maintain Hb > 80 g/L
– Maintain platelets > 50 x 109/L (ICH > 100)
– Maintain INR less than 1.8
– Maintain fibrinogen greater than 1.5 – 2.0 g/L
– Maintain ionized calcium greater than 1.15 mmol/L
Right ratio? 30-day mortality
Holcomb. JAMA 2015;313:471 Mesar. JAMA Surg 2017;152:574
PROPPR (all trauma) Harvard (various)
trauma 1:1:1
1:1:2
Right ratio? 30-day mortality
Holcomb. JAMA 2015;313:471 Mesar. JAMA Surg 2017;152:574
PROPPR (all trauma) Harvard (various)
vascular medicine
trauma
surgery
all non-trauma*
1:1:2
1:1:1
* = 89% of 865 hemorrhages
Platelets are Pooled at CBS!
FP x 4 or 2 apheresis
PLT x 1pool or 1 apheresis
RBC x 4
1:1:1 is really 4:1:4
Don’t waste
O neg by
using it for
everybody
regardless of
age and sex
North Simcoe Muskoka
FY2014-2018
99.5% of deliveries at
age 43 years or less
Collins 2018. Data source: CIHI
Risk of D alloimmunisation
• In D neg patients who received emergency issue
uncrossmatched D pos RBC
• Range: 11% to 30.4% – 11% (Dutton. J Trauma 2005;59(6):1445)
– 11.5% (Tchakarov. Immunohematology 2014;30(4):149)
– 12.5% (Meyer. Transfusion 2015;55:791)
– 21.4% (Gonzales.Transfusion 2008;48:1318 )
– 22% (Yazer. Transfusion 2007;47:2197)
– 20-26% (Selleng. Lancet Haematology 2017;4:218)
– 30.4% (Frohn.Transfusion 2003;43:893)
• Patients with trauma/hemorrhage do not appear to form
anti-D as readily as healthy volunteers (80%)
Ontario O neg policies
Chin et al. Injury (epub) https://doi.org/10.1016/j.injury.2018.11.026
Anticoagulant “reversal”
Drug Antidote
Warfarin PCC at 1000 IU/5min
INR<3 – 1000
INR 3-5 – 2000
INR >5 – 3000
INR unknown – 2000
Dabigatran Idarucizumab 5 grams over 10 min
Apixaban PCC 2000 IU *
Rivaroxaban PCC 2000 IU *
LMWH Protamine
Heparin Protamine
* Repeat in 1 hour if still bleeding
* Note: Andexanet antidote coming for anti-Xa inhibitors
T7 Summary
T
1 Triggering
2 Team
3 Testing
4 Tranexamic acid
5 Temperature
6 Transfusion
7 Termination
Smaller = more education, team building, simple
Standard tests, consider simple POCT
“European” strategy, clear transfer of care
Towards a Provincial MHP
• U of T Rounds May 2017, Drs. Callum and Pavenski
• Survey of Ontario practice November 2017
• Delphi-method exercise by multidisciplinary panel to reach consensus on recommendations
• Transfusion Committee Forum April 2018
• Further Delphi round post-TC Forum
• External stakeholder review of 42 recommendations (TM Med Directors, Charge Techs, TAC, ENAO)
• Working groups to develop provincial protocol and toolkit 2019
Massive Hemorrhage Protocols
Presentation library > Transfusion Committee Forum
Ontario MHP
Consensus
Panel
Informed Consent
Informed Consent
1. Voluntary
2. Given by a patient with the capacity to consent
(or SDM )
3. Informed
Explain the:
• nature of the procedure
• expected benefits
• material risks and side effects
• alternatives
• likely consequences of no treatment
Justice Horace Krever 1997
Evans KG. Consent: A guide for Canadian physicians www.cmpa-acpm.ca
CMPA Risk Fact Sheet Informed Consent 2016
Informed Consent
• obtained by the practitioner proposing
the treatment/procedure, barring
emergency
• in a language the patient will
understand
• allows for questions, repetitions, and
sufficient time for assimilation
• takes place well in advance, allowing
for alternatives to allogeneic
transfusion
Justice Horace Krever 1997
Role of the Nurse
• explain the transfusion process to the patient
• determine if informed consent has been
obtained
• but not to have the informed consent discussion
and obtain the informed consent
• CNO Practice Guideline: a nurse should not
provide a treatment if there is any doubt about
whether the patient understands and is capable
of giving consent, even if there is an order
CNO Practice Guideline: Consent 2017
“The only two mammals to remove
blood regularly from other
mammals are vampire bats…and
humans”
Burnum J. NEJM 1986;314:1250
Iatrogenic Anemia
Iatrogenic Anemia
= nosocomial anemia
= investigational anemia
• Phlebotomy-related blood loss
• Not uncommon, particularly in
– critically ill patients (ICU)
– children
Causes of Anemia in Critically Ill Patients
• more than 90% anemic by day 3
• bone marrow failure
• hemolysis
• disseminated intravascular coagulation
• renal failure
• sepsis
• overt or occult hemorrhage (e.g. GI bleeding, invasive procedures)
• phlebotomy for lab tests, ABGs
Phlebotomy volumes
Internal Medicine mL/day mL/stay
Smoller (NEJM 1986;314:1233) 12.4 175
Thavendiranathan (TGH 2005) (13.3) 74.6
ICU mL/day mL/stay
Smoller (US 1986) 41.5 762
Vincent (Europe 2002) 41.1 -
Chant (SMH 2006) 13.3 -
Thomas (Alberta 2009) 25 224
Corwin (USA 1995) 61-70
Other (hospital overall) mL/day mL/stay
Eyster (JAMA 1973;223:73) 54
Wisser (Clin Chem 2003;49:1651) 5 51
Most Phlebotomy Early in AMI Admission
Salisbury. Arch Int Med 2011;171:1646
Replacing Phlebotomy Losses
• Blood loss 20 mL/day can produce negative iron balance within days
• 1% red cell mass renewed daily in healthy individual
• = 50 mL blood/day if blood volume is 5 L
• Critically ill patients may have bone marrow depression and poor nutrition
• If the patient can’t ‘keep up’, additional measures need to be considered
Woodhouse MLO October 2001
Reducing blood loss due to lab testing
• Closed blood sampling techniques
• Small volume sample tubes
– may hide problem of over-ordering
• POCT
• Alteration of test ordering behaviour
– Batch orders
– Order sets/forms, practice guidelines
– Daily report to MDs on volumes drawn
– Variable success
Clin Chem 2003;49:1651
Am J Surg 1986;151:362
CAP Today 2010 Sept
Tinmouth CMAJ 2008;178:49
The most common indication for phlebotomy
Aryeh Shander, Anesthesiologist,
Englewood Hospital & Medical Center, NJ
and President of the Society for the
Advancement of Blood Management Sunrise!
Summary
1. MHPs should address: trigger, team,
testing, tranexamic acid, temperature,
transfusion and termination.
2. The ordering prescriber is responsible for
obtaining and documenting informed
consent for transfusion.
3. Phlebotomy blood losses may be more
serious in the ICU and pediatric
populations. Limit standing orders.
Questions?
Please consider
donating blood
or bone marrow
www.blood.ca
Please consider
registering as an
organ donor
www.beadonor.ca