Massive Transfusion Protocol + Blood transfusions

Review of blood transfusions (ABO Rh+/- and transfusion reactions) for ICU nurses. Plus, the role of the massive transfusion protocol (MTP).

1. MASSIVE TRANSFUSION PROTOCOL A brief clinical review

2. OBJECTIVES HEMORRHGIC SHOCK MASSIVE TRANSFUSION TRANSFUSION COMPLICATIONS CONCLUSION

3. 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

4. HEMORRHGIC SHOCK Small 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

5. HEMORRHGIC SHOCK The 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 → c oagulopathy Hypoperfusion + IV fluids (NS pH is 6.1) → Acidosis (inhibits coagulation and depresses cardiac function)

6. 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?

7. MASSIVE TRANSFUSION PROTOCOL INDICATIONS GOALS

8. MASSIVE TRANSFUSION PROTOCOL Correct Anticoagulation LWMH  Protamine Vitamin K+ Antagonist  Vitamin K or PCC Direct Thrombin Inhibitors  No antidote Antiplatelet Agents  PLT

9. 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

10. MASSIVE TRANSFUSION PROTOCOL PRBC: 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)

11. MASSIVE TRANSFUSION PROTOCOL FFP: Correction of coagulation disorders FFP contains all coagulation factors in normal concentrations No indicated for volume expansion

12. 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

13. MASSIVE TRANSFUSION PROTOCOL Belmont 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

14. 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.

15. 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!

16. BLOOD

17. 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

18. 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 i ts 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

19. 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.

20. ABO +/- TYPE ANTIGEN ANTIBODIES A + 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

21. 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

22. 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 !!

23. TRANSUSION REACTIONS Acute Hemolytic Transfusion Reaction: ABO incompatibility (40% lab error / 60% bedside error) Fever, chills, chest pain, shock, bleeding, death Rapid onset (antibody mediated)

24. TRANSUSION REACTIONS Delayed Hemolytic Transfusion Reaction: Seen in patients with previous transfusion or pregnancy Antibodies develop Develops days to weeks after the transfusion

25. 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

26. TRANSUSION REACTIONS Transfusion Related Acute Lung Injury: Transfusion of inflammatory cytokines, active lipids, and/or antibodies. Respiratory distress (secondary ARDS) Sick patient + transfusion = TRALI

27. 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