Massive Transfusion Protocol + Blood transfusions
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Transcript of Massive Transfusion Protocol + Blood transfusions
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MASSIVE TRANSFUSION PROTOCOL
A brief clinical review
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OBJECTIVES
HEMORRHGIC SHOCK
MASSIVE TRANSFUSION
TRANSFUSION COMPLICATIONS
CONCLUSION
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HEMORRHGIC SHOCK Tachycardia (early)
Decreased urine output (intermediate)
Hypotension (late)
Increased Mortality:• Comorbidities • Age • Medications (ASA, Plavix,
Warfarin, beta blockers)
Clinical presentation of hemorrhagic can vary with age (young vs old) and pregnancy
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HEMORRHGIC SHOCKSmall Blood Volume: tolerates blood loss poorly
Physiological Compromise: unable to compensate for blood loss
Physiological Reserve: may mask blood loss
Larger Blood Volume: increased blood volume may mask blood loss
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HEMORRHGIC SHOCKThe goal of care is to control bleeding and resuscitation (minimize IV fluids, blood products, avoid hypothermia and acidosis).
Hypothermia (below 35c) → Inhibits intrinsic & extrinsic coagulation pathways
Excessive IV Fluids → coagulopathy
Hypoperfusion + IV fluids (NS pH is 6.1) → Acidosis (inhibits coagulation and depresses cardiac function)
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MASSIVE TRANSFUSION PROTOCOL “Implementation of a Massive
Transfusion Protocol (MTP) promotes early and aggressive coagulation factor therapy as well as the limitation of crystalloid infusion, the prevention of coagulopathy, hypothermia and acidosis” (the ‘Lethal Triad’)
Indications & Goals?
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MASSIVE TRANSFUSION PROTOCOL
INDICATIONS GOALS
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MASSIVE TRANSFUSION PROTOCOL
Correct Anticoagulation• LWMH Protamine• Vitamin K+ Antagonist Vitamin K or PCC• Direct Thrombin Inhibitors No antidote • Antiplatelet Agents PLT
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MASSIVE TRANSFUSION PROTOCOL
Control the source of the bleeding and replace lost blood volume.
Blood products should approximate whole blood.
Correct coagulation abnormalities.
NURSING CARE:• VS Q1H + PRN• Double check all blood
products• Monitor for transfusion
reactions• Reassessment (meeting goals?)• Labs
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MASSIVE TRANSFUSION PROTOCOLPRBC:
ABO Rh specific Improve oxygen delivery (VO2) Replace lost volume (↑ Hgb & HCT) Cold (4C) Leukocyte reduced (reduces transfusion
reactions) Contains citrate Storage: 35 days K+↑ and 2,3 DGP ↓ with age Limited ATP stores Shape changes during storage (oval shaped)
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MASSIVE TRANSFUSION PROTOCOL
FFP: Correction of coagulation
disorders FFP contains all
coagulation factors in normal concentrations
No indicated for volume expansion
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MASSIVE TRANSFUSION PROTOCOL
PLT: Treatment of bleeding Prevention of bleeding
secondary to low platelets Preferred ABO Rh matching Administer rapidly Do no use an infusion
pump
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MASSIVE TRANSFUSION PROTOCOLBelmont Rapid Infuser
2.5 - 750cc/min 150 – 45,000 cc/hr Warms IV / blood if rate < 300cc/hr Bucket only required if you want to reticulate the IV fluid /
blood products Pressure limited: Flow will be reduced if the pressure is
excessive Lines:
• large bore IV (16G or 18G)• Cordis• RIC• May use dual-patient line to increase the flow rate by
attaching to two access points• Avoid micro-bore IV extensions
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MASSIVE TRANSFUSION PROTOCOL
Small extensions will inhibit flow.
Large bore extensions are less problematic.
Optional: Remove needles adaptors to increase flow (decreased resistance)
Add the dual lumen extension to the line to increase flow.
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MASSIVE TRANSFUSION PROTOCOL– The goal of the MTP is to
rapidly replace lost whole blood volume (red blood cells, platelets, and fibrinogen).
– Reassess frequently to see if goals have been achieved.
– – Avoid acidosis, hypothermia,
and coagulopathy.
– Be familiar with the Belmont Rapid Infuser and the enFlow fluid warmer. Don’t meet them for the first time during a major bleed!
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BLOOD
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ABO Karl Landsteiner, who identified the O, A, and B
blood types in 1900.
Alfred von Decastello and Adriano Sturli discovered the fourth type, AB, in 1902.
Antigen – marker expressed on the call wall
Antibodies –used by the immune system to neutralize pathogens
RBC – 100 to 120 day life span / oxygen transporters
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ABO Type A blood has type A antigen
expressed on its surface
Type B has type B antigen expressed on its surface
Type AB has type A & B antigen expressed on its surface.
Type O (sometimes referred to as type zero outside North America) has not antigen expressed on its surface.
Antibodies (anti-A, anti-B, or anti-A & anti b) antibodies will develop within
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RHESE FACTOR Discovered in 1937 by Karl Landsteiner and
Alexander S. Wiener.
Rh positive indicates that the type D antigen is expressed.
Rh negative indicates that the type D antigen is expressed.
You need to be exposed to antigen D (Rh +) to develop antibodies (i.e. mother-fetus)
Furthermore, many other antibodies exists and many be tested for in unique clinical situations.
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ABO +/-TYPE ANTIGEN ANTIBODIESA + A & D Anti-B antibodies
A - A Anti-B antibodies
B + B & D Anti-A antibodies
B - B Anti-A antibodies
AB + A, B & D No antibodies
AB - A & B No antibodies
O + Zero Anti-A and Anti B antibodies
O - Zero Anti-A and Anti B antibodies
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ABO +/- Blood Transfusions:
• AB+ is the universal recipient because the RBC expresses the A, B and D antigen. Therefore, any type of blood can be transfer without an antibody reaction.
• O- is the universal donor. Type O or type ‘zero’ RCB has no A, B or D antigens expressed on its surface. Therefore, when transfused won’t create an antibody reaction.
• Rh (+) recipients may receive a type specific Rh (-) transfusion.
• However, Rh (-) recipients may not receive a Rh (+) transfusion. D antibodies will develop causing a transfusion reaction
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TRANSUSION REACTIONS
Acute Hemolytic Transfusion Reaction (AHTR) Delayed Hemolytic Transfusion Reaction (DHTR) Febrile Non-hemolytic Reaction Allergic Reaction Anaphylaxis Transfusion Related Acute Lung Injury
!! DANGER !!
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TRANSUSION REACTIONSAcute Hemolytic Transfusion
Reaction:
• ABO incompatibility (40% lab error / 60% bedside error)
• Fever, chills, chest pain, shock, bleeding, death
• Rapid onset (antibody mediated)
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TRANSUSION REACTIONS
Delayed Hemolytic Transfusion Reaction:
• Seen in patients with previous transfusion or pregnancy
• Antibodies develop
• Develops days to weeks after the transfusion
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TRANSUSION REACTIONS
Allergic Reaction Anaphylaxis:
• Allergic reactions are common in transfusion recipients (1-3%).
• Allergic reactions are thought to be mediated by recipient antibodies to proteins or other soluble substances in donor.
• Anaphylaxis (rare): severe life threating allergic reaction
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TRANSUSION REACTIONSTransfusion Related Acute Lung Injury:
• Transfusion of inflammatory cytokines, active lipids, and/or antibodies.
• Respiratory distress (secondary ARDS)
• Sick patient + transfusion = TRALI
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TRANSFUSION COMPLICATIONS
Metabolic Effects:• Hyperkalemia (especially in patient with acidosis
and renal failure)• Citrate Toxicity: ↓Ca+ and metabolic alkalosis
Hypothermia • Associated with poor outcomes• Warm blood when possible
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