MASSIVE TRANSFUSION PROTOCOL

Indications and Goals

OBJECTIVES

HEMORRHGIC SHOCK

MASSIVE TRANSFUSION

TRANSFUSION COMPLICATIONS

CONCLUSION

HEMORRHGIC SHOCK Tachycardia (early)

Decreased urine output (intermediate)

Hypotension (late)

Increased Mortality:• Comorbidities • Age • Medications (ASA, Plavix,

Warfarin, beta blockers)

Clinical presentation of hemorrhagic shock can vary with age (young vs. old) and pregnancy .

HEMORRHGIC SHOCKSmall 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

HEMORRHGIC SHOCKThe goal of care is to control bleeding and resuscitation (minimize IV fluids, administer blood products, avoid hypothermia and acidosis).

Hypothermia (below 35c) → Inhibits the intrinsic & extrinsic coagulation pathways.

Excessive IV Fluids → coagulopathy

Hypoperfusion + IV fluids (NS pH is 6.1) → Acidosis (inhibits coagulation and depresses cardiac function)

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?

MASSIVE TRANSFUSION PROTOCOL

INDICATIONS GOALS

MASSIVE TRANSFUSION PROTOCOL

Correct Anticoagulation• LWMH Protamine• Vitamin K+ Antagonist Vitamin K or PCC• Direct Thrombin Inhibitors No antidote • Antiplatelet Agents PLT

MASSIVE TRANSFUSION PROTOCOL

Control the source of the bleeding and replace the 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

MASSIVE TRANSFUSION PROTOCOLPRBC:

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)

MASSIVE TRANSFUSION PROTOCOL

FFP: Correction of coagulation

disorders FFP contains all

coagulation factors in normal concentrations

No indicated for volume expansion

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

MASSIVE TRANSFUSION PROTOCOLBelmont 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

MASSIVE TRANSFUSION PROTOCOL

Small extensions will inhibit flow.

Large bore extensions are less problematic.

Optional: Remove needleless adaptors to increase flow (decreased resistance)

Add the dual lumen extension to the line to increase flow.

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.

– Labs: ABG, CBC, INR, PTT, fibrinogen, and Lytes.

– TAG (used in the OR) most accurate way to assess the coagulation process.

– 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!

THANK YOU!