Massive Transfusion Protocol for OB

Claudia S. Cohn, MD, PhD

Medical Director, Blood Bank

September 21, 2021

Malpractice lawsuit nets $4.6 million award

A woman bled to death after giving birth at a hospital in Wright County, MN.

Picture Source: http://www.cnn.com/2011/HEALTH/02/10/ep.conception.truths.myths/index.html

WHO worldwide data

SOURCE: Taking stock of MATERNAL, NEWBORN and CHILD SURVIVAL 2000–2010 decade report, http://www.countdown2015mnch.org/documents/2010report/CountdownReportOnly.pdf

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Maternal Mortality

3

EXAMPLE

PREGNANCY‐RELATED MORTALITY IN THE U.S.

(1987 – 2013)

Source: Creanga et al., 2017

Causes of OB Hemorrhage

Tools for recognizing and dealing with OB hemorrhage

Massive Transfusion Protocol for OB Hemorrhage

• MTP is designed to provide large amounts of red blood cells, plasma and platelets quickly
• Anyone can call blood bank to initiate an MTP – NO EPIC orders

Massive Transfusion Protocol for OB Hemorrhage

• Components arrive in coolers:
• 2 RBC emergency units may be requested at the start – available immediately
• First cooler:
• 2 RBCs; 2 plasma; 1 platelet
• Available within 10’
• Subsequent coolers:
• 4 RBCs; 4 plasma; 1 platelet
• Available within 15’
• Cryoprecipitate arrives in fifth cooler, then every third cooler
• If fibrinogen a concern, cryoprecipitate can be ordered PRN
• Will be available within 15’
• Transfusing the contents of the cooler is like transfusing whole blood
• Avoids a dilutional coagulopathy
• Coolers continue to be prepared in blood bank
• Clinical team needs to send a runner to pick up the next cooler

Blood

Blood

Cellular elements:

• Red Blood Cells
• White Blood Cells
• Platelets

Plasma:

• Soluble Proteins-
• Antibodies

Blood components

Photos courtesy of Dr. Robert Skeate

300-350 mL

250-400 mL

250-350 mL/Unit

Red Blood Cells Unit

Red Blood Cell Unit

• Volume: 250-350 ml
• RBC = 200-250 ml
• Plasma = < 50 ml
• 200-250 mg Iron
• Final hematocrit approximately 55-60%
• Leukoreduced
• Effect of 1 unit Transfusion (for 70 kg adult):
• Hematocrit increase = 3%
• Hemoglobin increase = 1 g/dL
• Universal type = O-

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Red Blood Cell Transfusion

• Can be transfused with:
• Normal Saline (0.9%)
• ABO compatible plasma
• 5% albumin
• Cannot be transfused with:
• Lactated Ringers
• D5W
• 0.45% Normal Saline
• TPN
• Antibiotics

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Blood groups (ABO)

29 Red Cell Blood Group Systems�Over 250 blood group antigens

• 1-4% of multiparous females develop RBC antibodies
• 1% of patients develop RBC antibodies after 1rst transfusion
• Up to 30% of multiply transfused patients develop RBC antibodies

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Antibodies to Minor RBC Antigens and Compatibility

Compatibility testing

• Type and Screen
• Type: ABO/Rh
• Screen: Are there common and clinically relevant antibodies to minor RBC antigens in plasma?

Type and Screen: Screen

Negative Type and Screen: ~30-60 minutes

Positive Type and Screen: 1-4 hours

Type and Screen: Negative Screen

Blood Sent to Blood Bank

Type and Screen Begins

15’

Negative antibody screen

45’

• Patient eligible for electronic cross match
• Blood is available immediately

Type and Screen: Positive Screen

Can take from 1 – 24 hours to obtain compatible units

Emergency RBC units

• Group O- units available immediately for emergencies
• Ordering MD must take responsibility for complications that may result from RBC incompatibility
• These complications are rare
• Patients die faster from anemia than from hemolysis

Fresh Frozen Plasma

Plasma

• Volume: 200 - 250 ml
• 400 mg fibrinogen
• 1 unit/ml all coagulation factors
• Factor 7 has shortest half life = 4 hours
• Dosage:
• 10-20 ml/kg
• 2 units should increase factor levels by 20-30%
• Needs to be type specific
• AB plasma is used in emergencies.

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Plasma cont.

• Indications:
• INR >1.8
• PTT > 45”

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(normal PT at VA Sept 2004)

Dzik . Chap 1. 2005 Mintz. Transf Ther AABB.2005: p 5

Change in INR after Plasma

Holland et al Transfusion 2005;45:1234-5.

INR of Plasma

Holland et al Transfusion 2005;45:1234-5.

Platelets unit

Single donor platelets – apheresis unit

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One donor = 1 adult platelets dose

≥ 3x10¹¹ platelets in ~ 150-350 ml of plasma.

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Gives a ‘bump’ of 30,000 – 50,000 in platelet count

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Platelets unit

• Storage at 20-24C temperature for up to 5 days
• Risks of bacterial contamination from platelets due to storage temperature
• Each dose is 250-400 ml
• Utilization should be based on platelet level and platelet count may not be available

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Platelets

• Target: 50,000 platelet count in actively bleeding patient

Cryoprecipitate

Cold-insoluble portion of a frozen plasma unit that precipitates when the frozen plasma is thawed between 1-6C

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Cryoprecipitate

Cryoprecipitate

• Volume: 15 ml
• Usually pools of 5 or 10 are released at once
• Contents:
• ~250 mg fibrinogen
• Factor VIII
• VonWillebrand’s Factor
• Factor XIII
• Fibronectin
• Indication: Increase fibrinogen level to >150 in actively bleeding patient.

MTP

When to call an MTP?

• Rule of thumb: If you think you need 4 units of RBC in one hour, call an MTP.
• Estimated Blood Loss
• Lab values
• Expectations in a given situation

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Starting an MTP

• Call the blood bank 273-4011
• In the OR: Anesthesia runs it

How to run an MTP?

• Order of components:
1. Correct for anemia first: Transfuse RBC units
2. Coagulation:
• Oozy? Transfuse plasma
• Suspect dilutional coagulopathy: Transfuse plasma
• DIC? Transfuse plasma and call for cryoprecipitate
3. Platelets required to begin a clot.
4. Cryo provides fibrinogen: essential factor at the bottom of the clotting cascade.

Rule of thumb

• Bleeding red give yellow; bleeding yellow give red

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Labs?

• Coolers will have a packet of tubes to order standard labs.
• Laminated cooler cards for guidance
• When possible, draw labs before transfusions begin
• MTP is a dynamic situation. Do not wait for labs to transfuse.

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Complications of Massive Transfusions

• Coagulopathy
• Hypothermia
• Dilutional coagulopathy

Coagulopathy

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• Dilution
• Hypothermia
• DIC
• Anemia
• Metabolic disturbances

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http://upload.wikimedia.org/wikipedia/commons/thumb/b/b6/Coagulation_full.svg/400px-Coagulation_full.svg.png

Hypothermia

The coagulation cascade is an enzymatic process – it is slowed by low temperatures (<35° C)

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Hardy et al. CAN J ANESTH 2004 / 51: 4 / pp 293–310

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Dilution

• Intuitive
• Low factor concentration means less coagulation

Ng KF, Lam CC, Chan LC. Br J Anaesth 2002; 88: 475–80.

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http://library.tedankara.k12.tr/chemistry/vol4/Volumetric%20analysis%20and%20problem%20solving/z23.gif

Transfusion Reactions

• Acute with Fever:
• Acute Hemolytic
• Febrile Non-hemolytic
• Bacterial Contamination
• TRALI
• Acute with no Fever:
• Urticarial
• Anaphylactic
• Circulatory Overload (TACO)

Acute Hemolytic Transfusion Reaction

• Signs/symptoms
• Fever and chills - Most common presenting symptom (>80%)
• Back or infusion site pain
• Hypotension/shock
• DIC/increased bleeding (important in anesthetized patients)
• Hemoglobinuria

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Acute Hemolytic Transfusion Reaction

Septic Transfusion Reaction

• Bacterial contamination is the #1 infectious risk from transfusion
• Platelets most often implicated component
• Signs/symptoms
• Rapid onset high fever
• Rigors
• Abdominal cramping
• Nausea/vomiting
• Shock

Anaphylactic Transfusion Reaction

• Rare
• Presents with shock within the first few drops of the transfusion
• Acute hypotension
• Abdominal distress
• Systemic crash

Transfusion Associated Circulatory Overload (TACO)

• Though underdiagnosed, currently the #1 cause of transfusion-related fatality in the US
• Difficult to distinguish TACO from TRALI
• Patients have risk factors for circulatory overload
• Responds to diuretics (unlike TRALI)

TRALI

• Though underdiagnosed, currently the #2 cause of transfusion-related fatality in the US!
• Acute lung injury which occurs within 6 hours of a transfusion
• Hypoxemia
• Bilateral pleural infiltrates
• Difficult to differentiate from TACO

Some Guidelines

Diagnostic Aid for Assessment

CMQCC OB Hemorrhage Care Guidelines

Thank you

• Questions?
• Claudia Cohn cscohn@umn.edu