Anthony Holley gives an update on Blood Transfusion guidelines in Australia

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

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

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

4. Bedside Critical Care 2012
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

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

6. Bedside Critical Care 2012
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

7. Bedside Critical Care 2012
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

8. Bedside Critical Care
2012
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

9. Bedside Critical Care
2012
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.

10. Bedside Critical Care 2012

11. Bedside Critical Care 2012
Mount Cockup

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

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

14. Bedside Critical Care
2012
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

15. Bedside Critical Care
2012
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.

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

17. Bedside Critical Care
2012
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)

18. Bedside Critical Care
2012
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.

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

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

21. Bedside Critical Care 2012
Practice Point
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.

22. Bedside Critical Care 2012
Practice Point
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.

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

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. Bedside Critical Care 2012
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.

28. Bedside Critical Care
2012
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.

29. Bedside Critical Care 2012
Haemoglobin trigger???

30. Bedside Critical Care
2012
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.

31. Bedside Critical Care
2012
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.

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

33. Bedside Critical Care 2012
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).

34. Bedside Critical Care 2012
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.

35. Bedside Critical Care
2012
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.

36. Tranexamic Acid Bedside Critical Care
2012

37. Tranexamic Acid
Bedside Critical Care
2012

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

39. Bedside Critical Care
2012