Massive Transfusion. Joint Theater Trauma System Clinical Practice Guidelines. Presented by: CPT Daniel Wiggins, MT (ASCP)

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1 Massive Transfusion Joint Theater Trauma System Clinical Practice Guidelines Presented by: CPT Daniel Wiggins, MT (ASCP)

2 Outline: Goal Purpose/Principles Available Products Guidelines Training Pros and Cons Lessons Learned Conclusion 2

3 Goal Provide retrospective insight for Massive Blood Transfusion in a deployed environment. Lessons Learned 3

4 Purpose Summarize Blood Bank/Transfusion Service procedures for Mass Transfusions. Provide Guidelines for safe administration of blood products. Identify possible adverse effects and potential pitfalls of massive transfusion procedures. 4

5 Principles of Mass Transfusion (MT) Mass Transfusion (MT) protocol is vital for trauma support. Failure to prepare or follow established practices can potentially cause patient harm or death. Mass Transfusion (MT) event may require emergency blood release (no pre-transfusion testing). ABO group and Rh type-specific or compatible RBCs and plasma (may need uncrossmatched type compatible components for emergency release). 5

6 Federal Regulatory Definition: Blood products are considered both a biologic and a drug. Require a prescription order before blood can be issued by the blood bank. 6

7 Massively Transfused Casualties (Revisited) > 10 units RBCs in 24 hours High mortality rate (22% at 48 hrs, 44% at 30 days) Large retrospective cohort studies from OIF and OEF demonstrate significant survival benefit for the massively transfused casualty when RBCs, FFP and platelets are transfused in a 1:1:1 ratio 7

8 Available Blood Products (MT) Packed Red Blood Cells (prbc) augment oxygen carrying capacity must be ABO compatible Rh negative cells reserved for females of child bearing age and children 8 Indications: hypoxia & hemodynamically unstable patients hypoxia with HCT <25% uncontrolled hemorrhage - typical MT scenario

9 Available Blood Products (MT) Fresh Frozen Plasma (FFP) Prevent or treat coagulopathy Must be ABO compatible Rh status irrelevant >24 hrs Thawed Plasma (TP); 4 days shelf-life 9 Indications: INR >1.5 hemodynamically unstable patients significant burn percentage

10 Available Blood Products (MT) Platelets (PLT) correct deficient PLT counts no need to ABO match; (1) PLT = 6 to 8 donors Indications: PLT count < 50 (ten to the third microliters) hemodynamically unstable patient with PLT < 80 hemodynamically unstable trauma patient requiring Mass Transfusion usually relfexed every 6 RBCs 10

11 Available Blood Products (MT) Fresh Cryoprecipitate (Cryo) Used as a source of: Factor VIII Factor XIII vwf Does not need to be ABO compatible. 11

12 Guidelines Specimen Submission: ID or Trauma Number must be on all samples and written on paperwork (Typenex may also be used). EDTA purple top tube with patient ID (trauma number with Typenex label if used), date, and two verifying initials. Completed Emergency Release form or SF

13 Guidelines Blood Product Issue: Product must be inspected and verified when issued. Two person verification for compatibility. Inspect unit condition (clots, discoloration and/or leaks). Unit information is accurate and readable. 13

14 Guidelines Blood Product Issue: Verify information. Patient ID or Trauma Number. Blood product type (RBC, FFP, etc.). Unit ABO/Rh. Patient ABO/Rh. Product expiration date. 14

15 Guidelines Blood Product Administration: If issued in cooler, leave in cooler until ready to use. Unit can not be spiked unit until ready for use. For Mass Transfusion it is recommended that PRBCs and Plasma be hung alternately. Baseline vitals must be obtained and recorded. 15

16 Guidelines Transfusion Paperwork: Initials of the two verifiers. Time placed in cooler and time removed (if used). Amount and type of units transfused. Any reaction(s) noted. 16 Copy of completed paperwork returned to Blood Bank.

17 Training MT Training throughout hospital: Conducted during MASCAL exercises and Mass Transfusion FWB drive training. Continued education is a must (OR and ER). Section specific MT training. Documented and kept on file. 17

18 Pros MT is often essential. Component therapy provides FDA approved products. Component therapy allows for maximizing capabilities with limited blood on shelf. Decreased risk of transmitted blood-borne diseases, bacterial contamination from field conditions 18

19 Cons Blood inventory and storage challenges. Extreme environments and power. Limited number of O Neg units; female casualties of child bearing age should be an Rh match. Blood management and resupply in a deployed setting can be challenging. Air resupply isn t always possible. Many areas are remote and difficult to resupply. 19

20 Lessons Learned (Prep) Prepare O Neg & O Pos units for EMR. Work with PAD to ensure trauma packets have EMRs, SF 518, and typenex (if used). Continuous training; be aware of staff turn over or cross-training; OR blood administer. 20 Minimize handling or inventory of frozen products; new frozen product labels.

21 Lessons Learned (During MT) Be aware of in-coming causalities to better manage blood resources. Contact BDC if MT is expected (SIPR). Thawing FFP in a deployed setting can be challenging. 21 Be aware of Air EVAC status; prep blood for transport; organize FWB Drive as needed.

22 Conclusion Thank you. 22

23 References 1 Joint Theater Trauma System Clinical Practice Guideline, Fresh Whole Blood Transfusion, January CENTCOM FRAGO : Joint Theater Blood Program Update: 4 May Emergency War Surgery, 2004, Third US Revision, Chap 7: Shock and Resuscitation 4 Theater MTF- specific Standard Operating Procedures (SOPs) 5 Technical Manual, AABB, Bethesda Maryland, 15 th Edition, Standards for Blood Banks & Transfusion Services, AABB, 25 th Ed, February 2008

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