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Document ID: Ch-z-z-374

Title: Blood: Massive Transfusion Protocol Site where document is utilised: Coffs Harbour Health Campus Description: To assist and guide clinicians in making clinical decisions when managing patients with critical bleeding who require or are likely to require massive transfusion Subject: Blood, transfusion Keywords: blood, transfusion, bleeding, critical, MTP, massive

Replaces Existing Procedure No Registration Number of Superseded Documents: Related Legislation, Dept. of Health Policy or Circular, or other MNCLHD Documents:

Author: Tracey Moore, Quality Manager CHHC

Document Maintained By: Tracey Moore, Quality Manager CHHC Contact Details: 6656 7064, Tracey.Moore@ncahs.health.nsw.gov.au

Aboriginal Health Impact Statement Required? No Date: Registration Number:

MNCLHD Executive Director/Director Responsible for Communication, Implementation and Review: Dr Sergio Diez Alvarez CCN Director Clinical Services

Date Created: September 2009 Valid From: December 2014 Review Date: December 2017 Issue Date: January 2015 Date: on desktop 4.2.16

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MNCLHD Procedure Statement

Document Registration Number:

Ch-z-z-374

Author/s: Tracey Moore, Quality Manager CHHC

Executive Director/Director: Dr Annette Pantle, Acting CCN Director Clinical Services

Consultation: Dr Browne, VMO Haematologist; Dr Benson, VMO Haematologist; Dr Lorna McLeod, Staff Specialist – Emergency Department; Dr Matthew Geall, Anaesthetist; Dr David Gillespie, Anaesthetist; Dr John Neal, Director Intensive Care; Dr Gehan El Bialy, Staff Specialist Obstetrics & Gynaecology; Dr Hamish Bradley, RMO; Helen Westaway, Pathology Manager Pathology North; Patricia Lemin, District CNC Trauma; Joanne Rowley, Nurse Researcher; CHHC Obstetric Quality Committee

1.0 Title: Blood: Massive Transfusion Protocol 2.0 Related Policy: National Blood Authority. 2011. Patient Blood Management

Guidelines: Module 1 – Critical Bleeding/Massive Transfusion

3.0 Purpose: To assist and guide clinicians in making clinical decisions when managing patients with critical bleeding who require or are likely to require massive transfusion

4.0 Risk Management Generic information on Risk Management for use in documents can be accessed at: http://int.ncahs.nsw.gov.au/risk-management/index.php?pageid=4473&siteid=310

5.0 Background

The National Blood Authority (NBA) has developed a range of Patient Blood Management Guidelines that focus on evidence-based patient blood management including Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion.1

It is recommended that in critically bleeding patients requiring or anticipated to require, massive transfusion, a Massive Transfusion Protocol (MTP) should be used. This procedure outlines the localized MTP based on the NBA Massive Transfusion Protocol. ‘Massive transfusion’ is defined by the NBA as: • ADULTS: as a transfusion of half of one blood volume in 4 hours, or more than one blood volume in 24 hours (adult blood volume is approximately 70 mL/kg) • CHILDREN: as a transfusion of more than 40 mL blood/kg (blood volume of children older than neonates is approximately 80 mL/kg). Mortality is high in massive transfusion and its aetiology is multifactorial, which includes hypotension, acidosis, coagulopathy, shock and the underlying condition of the patient. You must note of the lethal triad—patients with acidosis, hypothermia and coagulopathy have the highest mortality.

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PROCEDURE:

The Massive Transfusion Protocol (Appendix 1) will be activated by a senior clinician when it is evident that a patient will;

o Require four (4) units of Packed Red Blood Cells (PRBC) in < 4 hours, + haemodynamically unstable, +/- anticipated ongoing bleeding

o Severe thoracic, abdominal, pelvic or multiple long bone trauma o Major obstetric, gastrointestinal or surgical bleeding

Massive Transfusion Goals

Procedure Comments

Request laboratory investigations

FBC, coags, fibrinogen, Xmatch, EUC, LFT, Ca, ABG’s

Repeat FBC, coags, fibrinogen every 4 hours or after 1/3 blood volume replacement or after other blood component infusion

Take samples at earliest opportunity as results may be affected by colloid infusion

Patient and component misidentification is commonest transfusion risk

May need to give components before results available

Request suitable red cells Uncross matched group O Rh negative in extreme emergency until blood group known

Group specific and fully cross matched blood when time permits

Use blood warmer and/or rapid infusion device

Employ blood salvage if available and appropriate

Rh positive is acceptable if patient is male or post-menopausal female

Laboratory will complete compatibility testing after issue

Further cross match not required after replacement of 1 blood volume (8-10 units)

Blood-warmer indicated if flow rates > 50ml/kg/hr in adults

Blood salvage contraindicated if wound heavily contaminated

Request platelets Anticipate platelet count <50x109 litre after 2 x blood volume replacement or sooner

Target platelet count

> 100x109 litre for multiple/CNS trauma or if platelet function abnormal

> 50 x109 litre for other situations 1 megapack = 4-6 units Not ABO compatible

Request FFP Allow 30 minutes thawing time INR >1.5 and APTT > 40 seconds correlates with increased surgical bleeding

Keep ionized calcium > 1.13 mmol/L

Request cryoprecipitate Replace fibrinogen, but usually not necessary if enough FFP given

Indicated if fibrinogen < 1.0g/L despite FFP replacement as above

Allow 10-15 minute thawing time

Fibrinogen <0.5gL strongly associated with microvascular bleeding

Fibrinogen deficiency develops early when plasma-poor red blood cells used for replacement

Recombinant FVIIa Can only be ordered by senior clinician in consultation with Haematologist

Dose 90µg/kg bolus over 3-5 minutes (round to nearest whole vial) + consider repeating at 20 minutes if no response

Needs adequate fibrinogen and platelet levels to be effective and patient should not be significantly acidotic or hypothermic

Consider prior to ‘extremis’ stage e.g. once > 10 PRBCs given

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6.0 Monitoring, Evaluation and Review The CCN Hospital Transfusion Governance Group will review compliance with the Massive Transfusion Protocol.

7.0 Key words: blood, transfusion, bleeding, critical, MTP, massive

8.0 Definitions Nil 9.0 References

PD2009_039 NSW Health Risk Management-Enterprise Wide Policy and Framework available at: http://www.health.nsw.gov.au/policies/pd/2009/PD2009_039.html

10.0 Appendices: 10.1 Appendix 1: Massive Transfusion Protocol 10.2 Appendix 2: Paediatric Massive Transfusion Pack 10.3 Tranexamic Acid

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APPENDIX 1: Massive Transfusion Protocol

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APPENDIX 2: PAEDIATRICS MASSIVE TRANSFUSION PACK

PAEDIATRIC – MASSIVE TRANSFUSION PACK

Immediate Dispatch: The following “pack” will be despatched immediately upon activation of the MTP3 according to patient weight:

Weight of Child * notify Pathology of child’s weight*

< 15kg 15 – 30kg 30-50kg >50kg 1 unit PRBC+ 1 unit FFP* 1 unit pooled platelets

2 unit PRBC 2 unit FFP 1 unit pooled platelets

3 unit PRBC 3 unit FFP 1 unit pooled platelets

4 unit PRBC 4 unit FFP 1 unit pooled platelets

Second Dispatch: Upon request for a second lot of blood products, the following will be issued according to weight:

< 15kg 15 – 30kg 30-50kg >50kg 1 unit PRBC+ 1 unit FFP* 2 units cryoprecipitate

2 unit PRBC 2 unit FFP 3 units cryoprecipitate

3 unit PRBC 3 unit FFP 5 units cryoprecipitate

4 unit PRBC 4 unit FFP 8 units cryoprecipitate

APPENDIX 3: TRANEXAMIC ACID

Tranexamic Acid

Tranexamic acid reduces mortality in adult trauma.

Due to the lack of published data on the use of tranexamic acid in paediatric patients who have undergone major trauma there is no evidence for a specific dose in this situation.

Consider in paediatric Major Trauma patient with suspected/potential life threatening bleeding.

Early administration is vital for efficacy – ideally within 1st hour, but consider up to 3 hours post injury.

Dosage - 15mg/kg Tranexamic acid loading dose (max 1g) over 10 minutes by slow intravenous infusion over 10-15 minutes; ideally within the first 3 hours of trauma.

Followed by 2mg/kg per hour over 8 hours in consultation with consulting services