1. Transfusion
Anthony Holley
Intensive Care
Royal Brisbane and Women’s
Hospital
Bedside Critical Care
2012

2. Acknowlegdements
• National Blood Authority
• All our colleagues in the Clinical Reference
Group
Bedside Critical Care
2012

3. A Sad Case
“Names and places have been changed to protect
innocent practitioners involved”
Bedside Critical Care 2012

4. A Sad Case
• 36 yr old dirt bike rider
• Comes off his motorcycle at 80 Km/hr
• Lands with his abdomen over a log
• Attended to by Ambos at the scene
• GCS 15, HR 125 bpm BP 124/68
• +++ abdominal pain
• Given morphine and metoclopramide
Bedside Critical Care 2012

5. Arrives at Gunadulotsa Base Hospital
• GCS 15, but very distressed
• HR 130 bpm BP 105/58
• Features of an acute abdomen
Bedside Critical Care 2012

6. Retrieval Activated
• 3000 ml crystaloid with ongoing background
maintance of 120 ml/hr
• 3 units of PRBC given
• Original Hb returns 146
• Repeat Hb 168
• Progressive respiratory distress
• Intubated, FiO2 0.8
Bedside Critical Care 2012

7. Arrives at Royal Elsewhere’s and
Men’s Hospital
• Full and extensive work up in the emergency
Department
• CT demonstrates a fractured liver and little else
• To OT
• Hb 132
• Plts 105
• INR 1.6
Bedside Critical Care 2012

8. On Return to Intensive Care
• Receives 6 units FFP
• Hb 103
• Transfused a further 2 units PRBC
• Post transfusion Hb 127
• Given tranexamic acid 1 g followed by an
infusion of 1g over 8 hours
• Given 1 bag pooled Platelets
Bedside Critical Care
2012

9. Progress
• Partial hepatectomy fast and effective
• But develops a fever, rising WBC, Bilateral
pulmonary infiltrates and increasing ventilatory
requirement
• Bilateral DVTs on U/S
• After a prolonged ICU admission with a difficult
respiratory wean discharged to surgery with
trauma team input.
Bedside Critical Care
2012

10. Bedside Critical Care 2012

11. Mount Cockup
Bedside Critical Care 2012

12. Lessons from the Black Box
1. Massive transfusion protocols
2. Transfusion triggers
3. Transfusion ratios
4. The role of Tranexamic acid
Bedside Critical Care
2012

13. Bedside Critical Care
2012
http://www.nba.gov.au/guidelines/order/index.html
http://www.nba.gov.au/guidelines/review.html

14. National Blood Authority
2001 National Health and Medical Research Council/
Australasian Society of Blood Transfusion
(NHMRC/ASBT)
Clinical practice guidelines on the use of blood components
Now replaced by NBA:
Patient Blood Management Guidelines: Modules 1-6
Bedside Critical Care
2012

15. Patient blood management aims to improve clinical
outcomes by avoiding unnecessary exposure to blood
components
It includes the three pillars of:
1. Optimisation of blood volume
and red cell mass
2. Minimisation of blood loss
3. Optimisation of the patient’s
tolerance of anaemia.
Bedside Critical Care
2012

16. So What is the Utility of Massive
transfusion Protocols?
Bedside Critical Care
2012

17. Recommendation I
It is recommended that institutions develop an
MTP that includes the dose, timing and ratio of
blood component therapy for use in trauma
patients with, or at risk of, critical bleeding
requiring massive transfusion (Grade C)
Bedside Critical Care
2012

18. Practice Point
In patients with critical bleeding requiring
massive transfusion, the use of an MTP to
facilitate timely and appropriate use of RBC and
other blood components may reduce the risk of
mortality and ARDS.
Bedside Critical Care
2012

19. Senior clinician
• Request:a
o 4 units RBC
o 2 units FFP
• Consider:a
o 1 adult therapeutic dose platelets
o tranexamic acid in trauma patients
• Include:a
o cryoprecipitate if fibrinogen < 1 g/L
a Or locally agreed configuration
Massive transfusion protocol (MTP) template
Senior clinician determines that patient meets criteria for MTP activation
Baseline:
Full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistry,
arterial blood gases
Notify transfusion laboratory (insert contact no.) to:
‘Activate MTP’
Bleeding controlled?
Laboratory staff
• Notify haematologist/transfusion specialist
• Prepare and issue blood components
as requested
• Anticipate repeat testing and
blood component requirements
• Minimise test turnaround times
• Consider staff resources
Haematologist/transfusion
specialist
• Liaise regularly with laboratory
and clinical team
• Assist in interpretation of results, and
advise on blood component support
NOYES
Notify transfusion laboratory to:
‘Cease MTP’
OPTIMISE:
• oxygenation
• cardiac output
• tissue perfusion
• metabolic state
MONITOR
(every 30–60 mins):
• full blood count
• coagulation screen
• ionised calcium
• arterial blood gases
AIM FOR:
• temperature > 350C
• pH > 7.2
• base excess < –6
• lactate < 4 mmol/L
• Ca2+ > 1.1 mmol/L
• platelets > 50 × 109/L
• PT/APTT < 1.5 × normal
• INR ≤ 1.5
• fibrinogen > 1.0 g/L
The information below, developed by consensus, broadly covers areas that should be included in a local MTP. This
template can be used to develop an MTP to meet the needs of the local institution's patient population and resourcesBedside Critical Care
2012

20. Bedside Critical Care
2012
So in patients with critical bleeding requiring
massive transfusion, which parameters should
be measured early and frequently?

21. In patients with critical bleeding requiring massive
transfusion, the following parameters should be
measured early and frequently:
1. Temperature
2. Acid–base status
3. Ionised calcium
4. Haemoglobin
5. Platelet count
6. PT/INR
7. APTT
8. Fibrinogen level.
With successful treatment, values should trend towards normal.
Bedside Critical Care 2012
Practice Point

22. Values indicative of critical physiologic
derangement include:
1. Temperature < 35°C
2. pH < 7.2, base excess > –6, lactate > 4 mmol/L
3. ionised calcium < 1.1 mmol/L
4. platelet count < 50 × 109/L
5. PT > 1.5 × normal
6. INR > 1.5
7. APTT > 1.5 × normal
8. fibrinogen level < 1.0 g/L.
Bedside Critical Care 2012
Practice Point

23. So what product ratios should we be
using?
Bedside Critical Care 2012

24. Ratios

25. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, Gonzalez EA,
Pomper GJ, Perkins JG, Spinella PC, Williams KL, Park MS. Increased plasma and platelet to red
blood cell ratios improves outcome in 466
massively transfused civilian trauma patients. Ann Surg 2008; 248:447-458.

26. Product ratios
• Massive data base ~ 25 000
• 16% transfused
• 11.4% received massive transfusions
• Logistic regression identified the ratio of FFP to PRBC use as
an independent predictor of survival.
• With a higher the ratio of FFP:PRBC, a greater probability of
survival was noted.
• The optimal ratio in this analysis was an FFP:PRBC ratio of
1:3 or less.
Teixeira PG, Inaba K, Shulman I, Salim A, Demetriades D, Brown C,
Browder T, Green D, Rhee P. Impact of plasma transfusion in massively transfusedtrauma
patients. J Trauma 2009; 66:693-697.

27. Practice Point
In patients with critical bleeding requiring
massive transfusion, insufficient evidence was
identified to support or refute the use of specific
ratios of RBCs to blood components.
Bedside Critical Care 2012

28. Practice Point
In patients with critical bleeding requiring
massive transfusion, suggested doses of blood
components are:
1. FFP: 15 mL/kg
2. platelets: 1 adult therapeutic dose
3. cryoprecipitate: 3–4 g.
Bedside Critical Care
2012

29. Haemoglobin trigger???
Bedside Critical Care 2012

30. Practice Point
In patients with critical bleeding requiring
massive transfusion, haemoglobin concentration
should be interpreted in the context of
haemodynamic status, organ perfusion and
tissue oxygenation.
Bedside Critical Care
2012

31. Practice Point
In patients with critical bleeding requiring
massive transfusion, the use of RBC and other
blood components may be life saving.
However, transfusion of increased volumes of
RBC and other blood components may be
independently associated with increased
mortality and ARDS.
Bedside Critical Care
2012

32. What Adjuctive Therapy should we
employ?
Bedside Critical Care
2012

33. Recommendation 2
The routine use of rFVIIa in trauma patients with
critical bleeding requiring massive transfusion is
not recommended because of its lack of effect on
mortality (Grade B) and variable effect on
morbidity (Grade C).
Bedside Critical Care 2012

34. Practice Point
1. An MTP should include advice on the administration of rFVIIa
when conventional measures – including surgical haemostasis
and component therapy – have failed to control critical bleeding.
2. NB: rFVIIa is not licensed for this use. Its use should only be
considered in exceptional circumstances where survival is
considered a credible outcome
3. When rFVIIa is administered to patients with critical bleeding
requiring massive transfusion, an initial dose of 90 μg/kg is
reasonable.
Bedside Critical Care 2012

35. Crash 2
In trauma patients with or at risk of significant
haemorrhage, tranexamic acid (loading dose 1 g
over 10 minutes, followed by infusion of 1 g over
8 hours) should be considered.
No systematic review was conducted on
tranexamic acid in critical bleeding/massive
transfusion. The study population was not
restricted to critical bleeding requiring massive
transfusion.
Bedside Critical Care
2012

36. Bedside Critical Care
2012
Tranexamic Acid

37. Bedside Critical Care
2012
Tranexamic Acid

38. The routine use of rFVIIa in trauma patients is not recommended due to
its lack of effect on mortality (Grade B) and variable effect on morbidity
(Grade C). Institutions may choose to develop a process for the use of
rFVIIa where there is:
• uncontrolled haemorrhage in salvageable patient, and
• failed surgical or radiological measures to control bleeding, and
• adequate blood component replacement, and
• pH > 7.2, temperature > 340C.
Discuss dose with haematologist/transfusion specialist
b rFVIIa is not licensed for use in this situation; all use must be part of practice review.
• Warfarin:
• add vitamin K, prothrombinex/FFP
• Obstetric haemorrhage:
• early DIC often present; consider cryoprecipitate
• Head injury:
• aim for platelet count > 100 × 109/L
• permissive hypotension contraindicated
• Avoid hypothermia, institute active warming
• Avoid excessive crystalloid
• Tolerate permissive hypotension (BP 80–100 mmHg systolic)
until active bleeding controlled
• Do not use haemoglobin alone as a transfusion trigger
• Identify cause
• Initial measures:
- compression
- tourniquet
- packing
• Surgical assessment:
- early surgery or angiography to stop bleeding
• If significant physiological derangement, consider
damage control surgery or angiography
• Consider use of cell salvage where appropriate
• Actual or anticipated 4 units RBC in < 4 hrs, + haemodynamically unstable, +/– anticipated ongoing bleeding
• Severe thoracic, abdominal, pelvic or multiple long bone trauma
• Major obstetric, gastrointestinal or surgical bleeding
Specific surgical considerations
ResuscitationInitial management of bleeding
Dosage
Cell salvage
Considerations for use of rFVIIab
Special clinical situations
Suggested criteria for activation of MTP
ABG arterial blood gas FFP fresh frozen plasma APTT activated partial thromboplastin time
INR international normalised ratio BP blood pressure MTP massive transfusion protocol
DIC disseminated intravascular coagulation PT prothrombin time FBC full blood count
RBC red blood cell rFVlla activated recombinant factor VII
Platelet count < 50 x 109/L 1 adult therapeutic dose
INR > 1.5 FFP 15 mL/kga
Fibrinogen < 1.0 g/L cryoprecipitate 3–4 ga
Tranexamic acid loading dose 1 g over 10 min,
then infusion of 1 g over 8 hrs
a Local transfusion laboratory to advise on number of units
needed to provide this dose
Bedside Critical Care
2012

39. Bedside Critical Care
2012