Massive Haemorrhage Response (MHR) Protocol...• Obtain rapid infuser from ED (for lower floor) or...

Mackay Hospital and Health Service

PROCEDURE Document ID: C-PRO 235 V4.1

MASSIVE HAEMORRHAGE RESPONSE (MHR) PROTOCOL MACKAY HOSPITAL AND HEALTH SERVICE

1. Purpose The purpose of this document is to assist and provide staff within the Mackay Base Hospital (MBH) and Mackay Health Service (MHHS) the correct course of action to manage patients with critical bleeding. 2. Scope This procedure relates to Medical, Nursing, Pathology and Operational Staff involved with the management of patients with critical bleeding. 3. Procedure for Massive Haemorrhage

Response (MHR) Protocol The management of critical bleeding should focus on early recognition of blood loss, rapid control of the source of bleeding and restoration of circulating blood volume. Definition Critical bleeding warranting MHR activation: • Loss of greater than 50% of blood volume in 3 hours and /

or ongoing blood loss of over 150ml/h. • Adults: blood volume is approximately 70ml / kg. • Children: blood volume in children over one month old is

approximately 80ml / kg. The MHR has been designed to: 1. Encourage prompt action. 2. Ensure good communication and coordination between

treating clinicians from differing specialities, diagnostic laboratories and the blood product provider.

3. Guide the use of appropriate blood components to minimise coagulopathy and blood loss, emphasize appropriate resuscitation targets and minimise complications.

Triggers for MTP Activation • Unstable haemodynamics and ongoing bleeding. • >4 (units) issued to one patient in <4 hours.

Custodian/Review Officer: Director Critical Care Services Version No: V4.1 Applicable To: All Clinical Staff, Pathology and Operational Staff Approval Date: 22/01/2018 Effective Date: 30/01/2018 Next Review Date: 25/01/2021 Approving Officer/s: Michael Rampton Nurse Educator Intensive Care Unit Date: 18 January 2018 Anni Paasilahti Consultant Intensive Care Unit Date: 18 January 2018 Ross Martin Health Practitioner Pathology Queensland Mackay Date: 22 January 2018 Update on Trauma App Supersedes: C-POC 55 V1.0 (2010) & C-PRO 235 V1.0 (2013); V2.0 (2014) & V3.0 (2016); V3.1 (2016) & V 3.2 (2017) Key Words: Critical Care; Massive Transfusion Accreditation References: Equip National 11, .12. NS 7. Standard 4 medication safety

Printed Copies are Uncontrolled of 18

Procedure: Massive Haemorrhage Response (MHR) Protocol


• Severe thoracic, abdominal, pelvic or long bone trauma. • Major obstetric, gastrointestinal or surgical bleeding. • Treating specialist otherwise concerned and requests MHR protocol activation. • Untyped (“O negative”) blood request (activated by lab).

Termination of Protocol • Terminated by consultant only (this is critical not to waste blood or FFP). • Can be terminated at any time.

• Patients should be haemodynamically stable, warm and not coagulopathic (normal ROTEM) before protocol terminated.

• As early as possible, once bleeding is controlled, notify pathology in order to conserve available blood products.

• If certain bleeding has ceased, instruct lab to “stand down”. • If doubt exists, instruct lab to “stand-by”. Best Available Blood When notified of MHR activation, laboratory will immediately release the most appropriate level of blood available at that time. In some instances, this will be O negative blood. However, for other patients, existing cross matching may mean a more appropriate typed blood will be released. This is referred to as “best available blood” in the text below. Any use of UNcrossmatched RBC must be preceded (or immediately followed) by a review of the patient’s medical history and / or phone call to Transfusion department to search for a history of clinically significant RC antibodies. O RhD Neg may not be the best choice / incompatible. If some or all of the units transfused are determined to be incompatible, then clinical intervention can be initiated to mitigate any adverse transfusion reactions. Transfusion Department Response Trauma Red Response – “PACK ZERO” • Switch will notify Pathology when a “Trauma RED “ is called. • Immediately prepare an esky with:

o 4 Medevac PRBC (usually O neg). o 2 vials of Riastap (fibrinogen concentrate).

• The pack will only be sent to Emergency upon request from the “Blood Doctor” (Intensive Care Unit (ICU) Principal House Officer (PHO) or Consultant) when more information is available and critical bleeding is anticipated.

• MHR would usually be activated upon request of the pack zero. Transfusion Department on MHR Activation • Defer all non-urgent investigations. • Commence defrosting of 3 units of apheresis cryoprecipitate (or 5 of cryoprecipitate). • Call in second person, notify Transfusion supervisor and ARCBS if MHR likely to exhaust

available blood and blood product stocks.




• Seek a supplementary source of platelets, discuss with transfusion supervisor. • Meet the sample runner at the door of pathology when called that ROTEM sample is

coming. • Perform ROTEM analysis, enter ALL patient details and save to ALL CHANNELS for

allowing viewing results remotely on secure viewer. Contact blood doctor if coagulation testing not received within 10 minutes of protocol activation, or request for O negative blood. ROTEM Guided Pathway (Preferred) The first MHR pack consists of: • 4 units of RBC. • 3 units apheresis cryo. • Repeat ROTEM 10 min after blood components. The Second pack in 20 min according to ROTEM results: • 4 PRBC. • Other products as per ROTEM algorithm. • Repeat ROTEM 10 min after blood components. For same amount of fibrinogen 5 cryoprecipitate = 3 apheresis cryo = 1g (1 vial) of Riastap = 2mm on FIBTEM A5 Non ROTEM Guided Pathway ADULT The first MHR pack consists of: • 4 units of RBC. • 3 units of apheresis cryo. The second MTP pack consists of: • 4 units RBC. • 3 units of apheresis cryo. • 2 units of FFP / ELP. • 1 pool PLT if PLT <75. Paediatric The first pack: • 0-10kg: 1 RCC, ½ U apheresis cryo. • 11-25kg: 2 RCC, 1U apheresis cryo. • 25-40kg: 3 RC, 2U apheresis cryo. • >40kg: 4 RCC, 3U apheresis cryo. The second pack in 20 min unless ROTEM analysis suggests otherwise: • 0-10kg: 1 RCC, ½ apheresis cryo, 1 U Platelet. • 11-25kg: 2 RCC,1 apheresis cryo, 1 U Platelet.




• 25-40kg: 3 RCC, 2 apheresis cryo, 1 U Platelet. • >40kg: 4 RCC, 3 apheresis cryo, 1 pool Platelet. • After initial provision of O negative blood, packed cells and component therapy are issued

every 20 minutes until bleeding is controlled. • Confirm contact number with “blood doctor”. (In Trauma Red always the ICU PHO 5461). • Notify “blood doctor” when blood products are available. • Request return of unused O negative blood when type specific blood is available. • Continue to prepare blood and component therapy as per protocol. • Once instructed to “standby”, do not continue preparing further packs. Do not return to

normal activities until “stand down” order given. If order not given within 20 minutes, contact the blood doctor for confirmation.

• Once instructed to “stand-down”, returns all blood products to stock and return to normal duties.

• Print ROTEM results. Send paper results with Lansom to the patient’s current location (ED / OT / ICU).

• Upload ROTEM results onto Auslab (ROTEMR). • If significant antibodies are already known, transfusion scientist will directly discuss with

clinical haematologist. Clinical Response Trauma Red Response – “PACK ZERO” • Switch will notify Pathology when a “Trauma RED” is called. • Transfusion Scientist will prepare a “PACK ZERO”:

4 PRBC (Medevac, usually O neg). 2 vials of Riastap (2g fibrinogen concentrate).

• When more information is available and critical bleeding is anticipated communicate with Transfusion Scientist (7316) and request an Operational Officer (OO) to collect the pack zero prior to the patient’s arrival for immediate use.

• MHR will be activated upon request of the pack zero. • No need to wait for the first ROTEM to administer Riastap for critically bleeding

patient if agreed by attending Consultants. • PRBC should always be administered according to the estimated and / or ongoing

blood loss irrespective of ROTEM results guided by Hb (target > 70g/L). MHR Activation • Notify transfusion scientist 7316 of massive haemorrhage response activation (this

automatically triggers delivery of the first MHR pack). Always give age and sex of patient (O positive blood may be appropriate). Communication is essential between scientist and blood doctor (5461) as product Rh status may change based upon age of patient and preservation of O Rh (Neg) units. It is the responsibility of the scientist and not the blood doctor to ensure appropriate blood products are provided.




Rh negative female < 50 yrs Rh negative male <18 yrs

Patients with immune anti D

issue Rh negative until ARCBS cannot supply. If likely to use or has used > 6 units in 2 hours (especially small inventories), inform ARCBS Medical officer Haematologist is to be advised if ARCBS cannot supply (RBH has laboratory Haematologist on call)

Rh negative female > 50 yrs Rh negative male >18 yrs

after 6 units the patient should be given Rh positive blood. If Rh Negative blood is in short supply, the patient may be provided with Rh D positive blood rather than using any Rh Negative units.

Female <50 yrs provide K neg units (Blood Service phenotyping) • Ensure Consultant involvement, consider getting additional assistance. • Obtain copy of the Massive Haemorrhage Response Protocol (Theatre Reception, ICU, ED

Resus Bay) and Massive Haemorrhage Response Box. • Allocate roles in the “blood team” and follow the job cards. Notify transfusion scientist of

dect number used by the blood team doctor. In trauma RED always the ICU PHO or Consultant.

• Obtain rapid infuser from ED (for lower floor) or anaesthetics (upper floors) and prime it. • Ensure collection of blood samples for (and order on ieMR except ROTEM on old paper

form with patient details and location– to order call transfusion scientist at 7316). o Blue top well filled (3.5ml) for ROTEM, not from IO (immediately delivered by runner to

pathology, scientist will meet at door – sample CAN’T BE SENT VIA LAMSON). o IO samples are only suitable for I-stat and Biochemistry testing. FBC / COAG /

Transfusion request on IO samples will be notested. IO samples present 2 inherent problems, firstly they have currently unvalidated reference range data in comparison with peripheral blood, secondly the bone fragments destroy small analysers with small apertures.

o Blood gas (or iSTAT). o Crossmatch, FBC, COAGS, CHEM20 can be sent via Lamson.

• Give early tranexamic acid if not already given within 3hrs of injury / start of bleeding (regardless of ROTEM results). (1g or 15mg / kg load over 10min followed by 1g or 15mg / kg over 8 hrs).

• Open Secure Viewer on your computer to see results and communicate with transfusion scientist to ensure appropriate products delivered and administered according to ROTEM results.

• If results not appearing within 5 min of sample being delivered, contact pathology to check why.

• Administer cold blood products ALWAYS with a fluid warmer. • Repeat ROTEM 10min after blood components given (not if just PRBC given).




• Replace calcium to keep ionized Ca>1.0mmol/L (blood gas). • Return all unused blood products and used product bags to pathology. • Remember to stand down massive transfusion when no longer needed by calling pathology. • Fill in MTP FEEDBACK form (appendix 3) and document the event in ieMR. Clinical targets • Temp >35 (use blood warmer / Bear hugger). • pH>7.2 (minimise crystalloid use). • BE -2 to -6, lact <4mmol/l. • Caion >1.0mmol/L. • Hb>70. • Plt >50x109/l. ROTEM Interpretation and Targets • Step 1 FIBTEM A5 < 12mm -> REPLACE FIBRINOGEN (see dosing table)

Repeat ROTEM • Step 2 EXTEM A5 < 35mm and FIBTEM A5 > 12mm => GIVE PLATELETS

Repeat ROTEM • Step 3 EXTEM CT > 80 secs and FIBTEM A5 >12mm => Give FFP or PCC

Repeat ROTEM • Step 4 EXTEM ML > 15% => Give more tranexamic acid (even if already given). Fibrinogen Dosing

FIBRINOGEN DOSING GUIDE FIBTEM A5 TARGET >12mm FIBTEM A5 Required AC* Riastap 9-11mm 2-3mm 3-4 IU 2 g 7-8mm 4-5mm 6-8 IU 3g 4-6mm 6-8mm 9-12IU 4g <4mm >9mm 15 IU 5g * AC= Apheresis Cryo Cryoprecipitate 5 units= Apheresis Cryo 3 units

Non ROTEM Guided TARGETS • Clottable fibrinogen >1.5g/l (obstetric >2.0 g/l). • INR<1.4 (INR of FFP is 1.5). • APTT <1.5x normal.




Paediatric Patients: • Follow ROTEM guided algorithm if able to use adult blue top tube (needs to be filled 3.5ml,

not from Intraosseous). • Doses for increments of blood products:

o Apheresis cryoprecipitate 2.5ml / kg or cryoprecipitate 5ml / kg. o RBC 20ml / kg. o Platelet 10ml / kg. o FFP / ELP 20ml / kg.

Tranexamic acid within 3 hrs; 15mg / kg load (10min) followed by 15mg / kg over 8 hrs. Fibrinogen Concentrate For same amount of fibrinogen 5 cryoprecipitate = 3 apheresis cryo = 1g (1 vial) of Riastap = 2mm on FIBTEM A5 • Fibrinogen is the first component to become depleted in massive haemorrhage. • Fibrinogen concentrate (Riastap1g / vial) offers immediate replacement avoiding thawing

and time taken administering multiple bags of cryoprecipitate. • Located in transfusion department (L2E block), authorized by 2 treating Consultant’s

(Trauma Red ICU & Anae). When To Use Riastap? • In severe trauma patient presenting hypotensive (SBP<90mmHg) and BE<-6 with obvious

massive haemorrhage BEFORE FIRST ROTEM. • FIBTEM A5<8mm and critical bleeding (haemodynamic instability) and can’t wait for

cryoprecipitate. • Use Riastap 1-2g to start fibrinogen replacement and continue with apheresis cryo as soon

as it becomes available. Repeat ROTEM to check adequate response. Calcium Supplementation • Monitor ionized Calcium from blood gas (keep >1.0 mmol/L). • Hypocalcaemia results in coagulopathy not correctable with blood products. • Rate of development relates to amount and rate of citrate containing products (mainly FFP)

infused and rate of hepatic metabolism of citrate as well as dilution and pH. • To replace Ca use preferably CaCl 10% (gluconate will compete with citrate metabolism in

the liver resulting in slower ionized Ca release) especially if pre-existing liver dysfunction or hypotension. o CaCl 10% 2-5ml per 500ml of products (citrate mainly in FFP). o Ca Gluconate 10% 10-20ml per 500ml of products. o Avoid overcorrection, aim for Caion >1.0mml/L.




O Negative Blood • Negative blood should be conserved wherever possible, and only used if blood is required

immediately. Special situations 2 Simultaneous MHR’s Treating Consultant(s) to triage which patient to use ROTEM on first. Only one ROTEM sample can be run at a time. Care must be taken if 2 patients are treated simultaneously that correct

results are acted upon correct patient-patient demographics are visible on the program.

(ROTEM samples must be sent with paper request with patient details on it, results sheet will have patient details). Warfarin • Vitamin K 5-10mg IV. • Prothrombinex 25 – 50 IU / kg. Dabigitran / Rivaroxiban Discuss with Haematologist. PCC (Prothrombinex) has limited benefit. Drug specific antibody available for dabigatran only (Pharmacy). Dialysable (if antibody not available) Antiplatelet Drugs • Platelet transfusion effective to reverse drug effect only for aspirin, not clopidogrel or

ticagrelol. • Standard ROTEM analysis not sensitive to the type of platelet dysfunction. • Consider Desmopressin 0.3mcg / kg in 50ml saline over 30 min (also for patients with von

Willebrand disease). Obstetric Haemorrhage • Target clottable fibrinogen > 2.5g / L. • Normal fibrinogen concentration during pregnancy is 5g/L. FFP has 1-2g/L of fibrinogen and

will thus dilute patient fibrinogen. Use Apheresis Cryo or Riastap as per urgency and dosing table.

Head Injury • Target platelets > 100 x 109 / L. • Target MAP>80, SBP > 110 mmHg (no permissive hypotension).




Adjunctive Therapies Tranexamic Acid • For trauma / Obstetric patients. • Any bleeding patient when ROTEM indicates hyperfibrinolysis. • Should be given within 3 hours of injury / start of bleeding. • Loading dose: 1gm (in 50ml Normal Saline) over 10 minutes. Paed 15mg / kg. • Maintenance: 1gm (in 100ml Normal Saline) over 8 hours. Paed 15mg / kg over 8 h. • Caution: In renal failure, consider using loading dose only. Rapid Infuser (Level One) • Two rapid infuser machines are available in the hospital. One is kept in ED, the other in

theatre. Circuits are attached to each machine. • The rapid infuser should be primed whenever there is a likely or actual massive

haemorrhage. All patients to whom this protocol applies should have access to this. The rapid infuser will also function as a blood warmer.

• The rapid infuser should be attached to a short, wide-bore IV cannula. It should NOT be attached to a standard central line, as the length and small bore make the resistance too high. Immediate attempts should be made to seek an alternative (e.g. a vascath, rapid infuser device (RIC), Swan Ganz introducer sheath or 14G peripheral cannula).

• These access devices are available in the MHR box (ED / OT / ICU). Cell Saver The red cell saver is located in theatre. Its use requires someone specifically trained for this purpose. Contact the Anaesthetic Consultant on – 5372. The cell saver is useful when bleeding is occurring from a sterile site (e.g. massive bleeding from an intercostal drain) but cannot be contaminated (eg with faecal soiling etc). See WPI for intra operative cell salvage (C-PRO 422 V1.0).

Extreme Blood Usage Related to Massive Transfusion On some occasions resources will be exhausted in the Mackay laboratory. The Health Practitioner liaising with the Consultant will activate an Emergency Procedure

whereby supplies from other laboratories are activated. The following information may be helpful; RSQ = Retrieval Services Queensland = Phone Number: 1300 799 127 Error! Hyperlink reference not valid.http://qheps.health.qld.gov.au/rts/home.htm QCC = QEMS Clinical Coordination = Queensland Emergency Medical System Clinical Coordination http://qheps.health.qld.gov.au/rts/home.htm Supply of Blood for Retrieval Teams Queensland Pathology Protocol QIS 29181: http://qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=29181&DocumentInstanceID=83571


http://qheps.health.qld.gov.au/rts/home.htm

http://qheps.health.qld.gov.au/rts/home.htm

http://qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=29181&DocumentInstanceID=83571

http://qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=29181&DocumentInstanceID=83571



4. Supporting Documents The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition (2016). Rossaint et al. Critical Care (2016)20:100. Australian Red Cross Blood Service [Online]. 13 Sep 2012Available from: URL: http://www.transfusion.com.au/disease_therapeutics/transfusion National Blood Authority. Patient Blood Management Guidelines. Critical bleeding / Massive transfusion, module 1 (2011) Queensland Health Lady Cilento Children’s Hospital Paediatric Massive Transfusion Protocol (12/2014). 5. References Suggested Reading Queensland Health Royal Brisbane Women’s Hospital V3.1 (August 2013) Massive Transfusion Policy. Queensland Health Gold Coast University Hospital Massive Transfusion policy (26/09/2014). NHMRC/ASBT Clinical Practice Guidelines on the use of blood components (2012). Hagemo et al. Critical Care (2015)19:97. Detection of acute traumatic coagulopathy and massive transfusion requirements by means of rotational thromboelastometry: an international prospective validation study. Khan, Davenport, Raza et al. Intensive Care Medicine (2015)41:239-247. Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma haemorrhage. Gorlinger, Dirkman, Solomon et al. British Journal of Anaesthesia. (2013) 110 (2): 222-230. Fast interpretation of thromboelastometry in non-cardiac surgery: reliability in patients with hypo-, normo-, and hypercoagulability. Khan, S., Allard, S., Weaver, A., Barber, C., Davenport, R., & Brohi, K. (2013). A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion. Injury, 44(5), 587-592. doi:10.1016/j.injury.2012.09.029. Callcut, R., Cotton, B., Muskat, P., Fox, E., Wade, C., Holcomb, J., & ... Robinson, B. (2013). Defining when to initiate massive transfusion: a validation study of individual massive transfusion triggers in PROMMTT patients. The Journal Trauma And Acute Care Surgery, 74(1), 59. doi:10.1097/TA.0b013e3182788b34. Inaba, K., Karamanos, E., Lustenberger, T., Schöchl, H., Shulman, I., Nelson, J., & ... Demetriades, D. (2013). Impact of fibrinogen levels on outcomes after acute injury in patients requiring a massive transfusion. Journal Of The American College Of Surgeons, 216(2), 290-297. doi:10.1016/j.jamcollsurg.2012.10.017. 6. Consultation The Critical Care Protocol Committee


http://www.transfusion.com.au/disease_therapeutics/transfusion



7. Procedure Revision and Approval History Date Amendment Authorised by

Dr R Van Raalte Critical Care Protocol Committee

October 2013

Amendments Page 1 - definition added. Acidosis - Page 2 Severe thoracic abdominal pelvic or long bone trauma. Major obstetric gastrointestinal or surgical bleeding Page 2 Activation >4 units of blood. Page 5 pH.7.2 base excess <6lactate<4mmol/L. Page 6 - The routine use of Factor VIIa in trauma patient with critical bleeding requiring massive transfusion is not recommended because of its lack of effect on mortality and variable effect on morbidity. Page 6 Tranexamic Acid • For trauma / Obstetric patients • Must be given within 3 hours of injury for cases

requiring blood products • Loading dose: 1gm (in 100ml Normal Saline) over

10 minutes • Maintenance: 1gm (in 100ml Normal Saline) over 8

hours • Caution: In renal failure, consider using loading dose

only Page 6 Warfarin. Add Vitamin K, IV 5-10mg and Fresh Frozen Plasma 1bag (150-300mg) and Prothrombinex 25-50 U/kg. References Updated. Blood emergency numbers added after critical event whereby emergency supplies were required and had to be transferred from other centres.

Dr Neeraj Bhadange

Aug 2014 ELP added to document.

Aug 2016 Major revision of content and structure. Update following the new European guidelines of major bleeding and coagulopathy in trauma. Significant addition the early use of fibrinogen. ROTEM use in context of MTP. Rotem guided and non rotem guided pathways. Paediatric algorithm. Addition of a feedback form.

Dr Anni Paasilahti

Nov 2016 Fibrinogen ampoule incorrect changes to 1g/ml. Dr Anni Paasilahti

Jan 2017 Appendix Two reviewed and changed and feedback form updated.

Dr Anni Paasilahti




November 2017

Name change from Massive transfusion protocol to Massive Haemorrhage Response protocol. ROTEM targets changed from A10 to A5. Fibrinogen dosing table updated to reflect current stock of apheresis cryo.

Dr Anni Paasilahti

January 2018

Novoseven removed from document Dr Anni Paasilahti and Ron Nightingale

8. Audit Strategy Level of risk High if not followed. Audit strategy Review adverse events, RiskMan, documentation. New

Feedback form for auditing protocol and blood usage. Audit tool attached Yes. Audit date Continuous. Audit responsibility Haemovigilance committee and all clinical staff (prime).

Pathology for blood usage auditing. Key Elements / Indicators /Outcomes

Early detection and appropriate management of adverse events.




9. Appendices Appendix One – Massive Haemorrhage Response Algorithm




Appendix Two – Rotem Algorithm MBH Critical Bleeding – ROTEM Blood Product Management Algorithm Criteria: patients with haemorrage and haemodynamic instability for whom a MTP (massive transfusion protocol) is activated e.g. major trauma, ruptured AAA, obstetric haemorrhage. Sample collection: Blue top citrate tube (labelled) delivered to pathology (not Lamsoned).

Repeat ROTEM test 10 minutes after each step if blood products given.

FIBRINOGEN DOSING GUIDE FIBTEM A5 TARGET >12mmFIBTEM A5 Required AC* or Riastap9-11mm 2-3mm 3-5IU 1-2 g7-8mm 4-5mm 6-8 IU 3g4-6mm 6-8mm 9-12IU 4g<4mm >9mm 15 IU 5g* AC= Apheresis CryoCryoprecipitate 5 units= Apheresis Cryo 3 units

Repeat ROTEM test 10 minutes after each step if blood products given Heparin (CT long in INTEM and normal in HEPTEM) –> protamine ROTEM is not used to detect or monitor direct thrombin inhibitors, warfarin, LMWH, von Willebrands disease, GpIIb/IIIa or other platelet inhibitors (e.g. aspirin) due to low sensitivity to these agents.

Treat the patient, not the temogram!

Transfusion not necessary unless clinically significant bleeding

Physiological targets: temp ≥ 36 pH ≥ 7.2 iCa ≥ 1mmolL Hb >70g/L

1. INDICATION: patients with haemorrhage and

haemodynamic instability for whom a MHR is activated

major trauma, ruptured AAA, obstetric bleed

2. SAMPLE: Blue top citrate tube (labelled) delivered to

pathology (not Lamsoned).

3. ORDERING: call pathology 7316 (not on iEMR):

pt details, location, ordering Dr.




ROTEM ANALYSIS

CT (clotting time in sec): time from start of measurement until initiation of clotting (clot initiation, thrombin formation, start of clot polymerisation) – initiation phase CFT (clot formation time in sec): time from initiation of clotting (2mm) until a clot firmness of 20mm is detected (fibrin polymerisation, stabilisation of clot with platelets and FXIII) – propagation phase MCF (maximum clot firmness in mm): firmness of clot (increasing stabilisation of the clot by the polymerised fibrin, platelets and FXIII) – clot generation A10 (clot firmness in mm at 10 minutes post CT): early assessment of clot firmness – clot generation ML (maximum lysis): reduction of clot firmness after MCF in relation to the MCF (stability of the clot (ML <15%) or fibrinolysis (ML >15%) within 1h) – clot lysis phase.Channel Normal

values Explanation

FIBTEM Fibrinogen concentration

A5: 7 – 23mm A10: 10 – 23mm

EXTEM activation with platelet inhibition. Amplitude influenced by fibrinogen concentration and function. A10>25mm can lead to not detecting reduced platelet effect on EXTEM.

EXTEM Extrinsic pathway Platelet/fibrinogen interaction

CT: 38 – 79 sec A10: 43 – 65 mm ML: 0 – 15%

Clotting time sensitive to factor deficiency (if levels <30% normal) but not to heparin. Amplitude & CFT influenced by fibrinogen & platelets.

INTEM Intrinsic pathway

CT: 100 – 204sec A10: 44 – 66mm ML: 0 – 15%

Clotting time sensitive to heparin and factor deficiency (if levels <30% normal). Amplitude & CFT influenced by fibrinogen & platelets.

APTEM Fibrinolysis

Compare ML to EXTEM

EXTEM activation with inhibited fibrinolysis (normal with hyperfibrinolysis)


Procedure: Massive Transfusion


Appendix Three – MTP Feedback Form Please see below “sample only”, these forms are available on QHEPS at this link; http://qheps.health.qld.gov.au/mackay/docs/non-clinical-forms/mtp-fbck-form.pdf.


http://qheps.health.qld.gov.au/mackay/docs/non-clinical-forms/mtp-fbck-form.pdf



Appendix Four - Extended Life Plasma Extended Life Plasma Product Description and Clinical Notes Fresh Frozen Plasma (FFP) • Is prepared from anti coagulated whole blood. • Contains all coagulation factors. • Is frozen to -25°C within 18 hours of collection. • Shelf life of thawed FFP currently 24 hrs – if product not able to be transfused within

that time it is discarded or it can be considered for conversion to extended life plasma. Indications • Urgent warfarin reversal (use of Vitamin K and Prothrombinex is preferred). • Bleeding due to coagulation factor deficiencies (massive transfusion, liver dysfunction,

hereditary deficiencies); o Where no specific factor concentrate is available.

Extended Life Plasma (ELP) • Approved for laboratory inventories by the Australia and New Zealand Society of Blood

Transfusion (ANZSBT). • Is thawed FFP (not used within 24hrs);

o Product is relabelled “ELP” and refrigerated (2-6°C). o Shelf life extended to 4 days. o ‘30 minute’ rule applies (if infusion cannot be started within 30 minutes of collection

the product should be returned to transfusion Department for placement into controlled storage).

Indications / Contraindications ELP is considered clinically equivalent to FFP and may be utilised for the same clinical indications except in: • Patients with congenital factor V and VIII deficiencies. • Neonates. • Acute DIC (FFP is preferred for non urgent requests). Plasma Requests as the products are considered clinically equivalent; • Allocation will be based on inventory management practice and documented clinical

indication. • Transfusion scientist will allocate thawed ELP if available or thaw FFP.




Medical • Medical Officers must request plasma utilising the Pathology Queensland Transfusion

Request Form as per current Hospital and Health Service (HHS) policy with documented: o Clinical indication. o Relevant pathology results (INR). o Date / time required.

• Medical Officers should prescribe ‘plasma’ on the Intravenous and Subcutaneous Fluid Oder Form.

• Fresh plasma components are generally inappropriate at INR’s ≤ 1.5 and request will be vetted accordingly.

Nursing • Administration of ELP is the same as for FFP (standard blood giving set with inline

170-200um filter). • Administration times are unchanged (30 minutes per unit for non-critical indications). • Checking procedures, clinical observation and documentation for ELP remain

unchanged. Pathology As the products are considered clinically equivalent: • Transfusion scientist will allocate either FFP or ELP depending on inventory and

clinical indication. • ELP may be held in reserve for urgent trauma or massive transfusion cases (will result

in immediate product availability – saved thawing time). Reference Australian and New Zealand Society of Blood Transfusion Inc. (2013). Extended Life Plasma (ELP): A Framework for Preparation, Storage and Usage. (2nd Ed). Sydney, August 2013.


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