Major Haemorrhage Protocol (MHP)

WAHT-HAE-008 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet

Major Haemorrhage Protocol

WAHT-HAE-008 of 15 Version 4

Major Haemorrhage Protocol (MHP)

This protocol does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation

with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this protocol.

Introduction This protocol outlines the steps to follow during massive blood loss defined as:

50% blood volume loss within three hours

or 100% within 24hrs (70 ml/kg, >5 litres in a 70kg adult)

or a rate of blood loss in excess of 150 ml/min Successful treatment depends on

prompt action

good communication

involvement from senior clinicians with the necessary expertise

THERE IS A SEPARATE POLICY FOR HAEMORRHAGE RELATING TO OBSTETRICS

Antepartum Haemorrhage Including Massive Obstetric Haemorrhage WAHT-OBS-014

This protocol is for use by the following staff groups: All medical and nursing staff Blood Transfusion Staff

Lead Clinician(s)

Dr.T. Skibbe (Chair of Blood Transfusion Committee) Consultant Haematologist

Gillian Godding Phillippa Cheshire

Lead Transfusion Practitioner County Wide Blood Bank manager

Document approved by trust transfusion team meeting on: This protocol should not be used after end of:

21st January 2015 21st January 2017

Key amendments to this Document:

Date Amendment By: Jan 2012 Guideline reviewed & minor changes made. G Godding

March 2013

Section added about the reversal of anti-coagulant drugs. G Godding

March 2014

Changes with regard to emergency transportation of blood cross county Name changed to Major Haemorrhage Protocol Addition of an algorithm for procedural responsibilities

G Godding P Weaver

January 2015

Revision due to introduction of regional/national guidelines G Godding P Cheshire

http://nww.worcsacute.nhs.uk/EasysiteWeb/getresource.axd?AssetID=11847&type=full&servicetype=Attachment





Index

Title Page

1.0 Introduction 3

2.0 Staff Competencies 3

3.0 Patients covered 3

4.0 Activation of the protocol 4

5.0 Immediate Clinical Response 4

6.0 Major Haemorrhage Pack 1 5

7.0 Aims for therapy 6

8.0 Major Haemorrhage Pack 2 6

9.0 Stand down 7

10.0 Satellite sites 7

11.0 Complications 8

12.0 Audit 8

13.0 Flowchart: Adult 9

14.0 Flowchart: Paediatric 10

15.0 Monitoring Tool 11

16.0 References 12

17.0 Contribution / Circulation lists 13

18.0 Equality Impact Assessment 14

19.0 Financial Impact Assessment 15





1.0 Introduction: [ back to Index ] The aim of this protocol is to provide a clear management structure for massive blood loss to enable the provision of blood/blood components to be available as quickly as possible as required.

2.0 Staff competencies: All staff involved in the process of transfusion must have undertaken mandatory training and competency assessment relevant to their role.

3.0 Patients covered: [ back to Index ] All patients (except obstetrics) experiencing blood loss as defined by:

50% blood volume loss within three hours

or 100% within 24hrs (70 ml/kg, >5 litres in a 70kg adult)

or a rate of blood loss in excess of 150 ml/min All patients MUST wear an identity band. The identification of the patient must adhere to the blood transfusion policy WAHT-HAE-001 and related procedural documents. The NHS number MUST be used as the primary identifier except if the patient is unconscious and/or unidentifiable when an A&E number can be used. It may be difficult to assess the amount of blood loss, but consideration of lost circulating volume may be useful in guiding transfusion management. The table below is a classification of hypovolaemic shock according to percentage blood loss, and the associated clinical signs. Red cell transfusion is indicated in Class III, massive transfusion is indicated in Class IV.

Class I Class II Class III Class IV

Blood loss mls 750ml 750 – 1500ml 1500 – 2000ml >2000ml

Blood loss % < 15%

15 – 30%

30 – 40%

>40%

Pulse rate

<100 >100 >120 >140

Blood pressure Normal

Normal Reduced Low

Pulse pressure

Normal Decreased Decreased Decreased

Capillary refill: Normal

Slow Slow Slow

Respiratory rate :

14-20 20-30 30-40 >35

Urinary output ml/hr

>30

30-20 20-10 10-0

Mental state: Alert Anxious

Confused Lethargic

Extremities: normal Pale Pale/Cool Pale /Clammy

Classification of hypovolaemic shock according to blood loss (P. Freeman, March 2000)




4.0 Activation of the Protocol A consultant must make the decision to trigger the major haemorrhage protocol (MHP). When a patient meets the above criteria, one person in the clinical area should take responsibility for communication between the transfusion laboratory and the clinical area. This person should act as the “coordinator” to avoid miscommunication and facilitate the speedy delivery of blood components. The coordinator should phone 2222 and state massive haemorrhage, the location and site. The switch board will notify the emergency response team including the blood transfusion laboratory, consultant anaesthetist on call and the porters. The laboratory will contact the area and ask for:

The patients full identification details

Clinical condition that has caused the haemorrhage,

The telephone number that the coordinator will be working from

Indication of the timescale within which blood components are required

Request samples for XM, FBC, PT, APTT, fibrinogen, UE & CA2+

The coordinator must contact the haematology consultant on call for advice, this is essential when the patient is on anticoagulant therapy or the haemorrhage does not subside after administration of pack 1. They can be bleeped via switchboard and will advise on the use of haemostatic agents including Vitamin K, Prothrombin Complex Concentrate, Factor VII and Fibrinogen Concentrate.

Antiplatelet drugs (Aspirin, Clopidogrel etc)

Platelet transfusion should be given as soon as possible Vitamin K-antagonists (Warfarin and similar)

give Vitamin K10mg IV and Prothrombin complex concentrate (Beriplex) dose calculated based on INR and estimated body weight

Rivaroxaban:

Prothrombin complex concentrate: (Beriplex) can be used if the last dose was given within the last 24 hours - give 50 units / kg body weight max 5000 units IV

Dabigatran:

if the last dose was given within the last 24 hours and conventional methods to stop bleeding fail consider Recombinant Factor VIIa at a dose of 80 mcg/kg max 14.4mg

Consider activated charcoal for patients taking dabigatran and apixaban if ingested in the last 4 hours

After discussion with a consultant haematologist give prothrombin complex concentrate (Beriplex) 25iU/kg (max dose 2500iU)

If no improvement with prothrombin complex consider recombinant FVIIa (NovoSeven) 90 mcg/kg (rounded DOWN to the nearest 1000mcg), consideration should be given to a second dose 1 hour later if no response or loss of response.




5.0 Immediate clinical response STOP THE BLEEDING & RESUSITATE PATIENT

1) Maintain Airway, Breathing and Circulation. 2) Apply direct pressure / tourniquet if appropriate 3) The clinical team must administer Tranexamic Acid; this should be given by bolus as

soon a major haemorrhage is identified. 4) Stabilise fractures 5) Consider surgical intervention including cell salvage, interventional radiology and

endoscopic techniques 6) Prevent hypothermia by using fluid warming device and forced air warming blanket.

When blood loss exceeds 150ml/minute then emergency O Rh D negative red cells can be used to support the patient whilst waiting for the haemorrhage pack. Take all the samples prior to transfusion if possible. Emergency O Rh D negative red cells are available from:

Blood Issue Fridge WRH- 2 units Blood Issue Fridge Alex- 2 units Blood Issue Fridge KTC- 6 units Blood Fridge Evesham- 2 units

6.0 Major Haemorrhage Pack 1: [ back to Index ] The response of the laboratory to the activation of this protocol is to provide a standardised set of blood components that meets the immediate need of the patient. The aim is to make blood components accessible within the time limit according to the clinical situation. When a consultant activates the MHP the local transfusion laboratory will provide: Adult Major Haemorrhage Pack 1(MHP1)

4 units of red cells

4 units of fresh frozen plasma The ratio of FFP: RBC should be 1:2 to 1:1. Paediatric MHP 1

Weight Red cells FFP

<5kg 2 paediatric units (80-100ml)

2 ‘neonatal’ units methylene blue (MB) treated FFP (100ml) or 1 unit Octaplas

5-10.9kg

1 adult unit (250ml) , will require LVT unit if <12 months old

1 unit MB FFP (225ml)or 1 unit Octaplas

11-20kg 2 adult units (500ml) or 2 LVT if <12 months old

2 units MB FFP (450ml)or 2 units Octaplas




> 20 kg 4 adult units (1000ml)


LVT: large volume red cell pack suitable for neonates and children 12 months or less

NB MB treated Group AB cryoprecipitate is not routinely available: for group AB patients first choice is Group A and second choice is Group B

Time to receive at this clinical area WRH/ Alex:

• Electronic Issue red cells 5 minutes • Group specific red cells 10 minutes • FFP 30 minutes

At KTC and Evesham the supply will be via ambulance arranged by laboratory (see section 10.0) The laboratory will phone the clinical area to let them know when the components are available. The clinical area must send a porter or theatre assistant to collect the components, either from the laboratory (WRH & ALEX) or ambulance drop off point. It is important for the clinical area to liaise closely with the transfusion laboratory to avoid miscommunication and to ensure that the appropriate components are issued in a timely way

7.0 Aims for Therapy[ back to Index ] Reassess patient after giving pack 1 by repeating the FBC, PT, APTT, fibrinogen, UE & CA2+. The aim is to maintain the following parameters:

Haemoglobin 80-100g/L

Platelets >75 x 109

/L

PT ratio < 1.5

APTT ratio <1.5

Fibrinogen >1.5g/L

Ca2+

>1 mmol/L (give 10 mls Calcium chloride (10%) over 10 minutes after pack 1. Repeat if necessary)

Temperature > 36o

C

pH > 7.35 (on ABG) Monitor for hyperkalaemia

If haemorrhage is continuing then order massive haemorrhage pack 2

8.0 Major Haemorrhage Pack 2 (MHP2) [ back to Index ] Adult MHP2 This pack will contain:

Red cells 4 units

FFP 4 units

Platelets 1 dose (ATD)




Give 2 packs of Cryoprecipitate if fibrinogen <1.5g/l (< 2g/L for obstetric haemorrhage) Once administered, repeat the FBC, PT, APTT, fibrinogen, UE & CA2+. Paediatric MHP2

Weight Red cells FFP Cryoprecipitate Platelets

<5kg 2 paediatric units (80-100ml)

2 ‘neonatal’ units methylene blue treated (MB) FFP (100ml)or 1 unit Octaplas

1 single MB donor unit (40ml)

1 paediatric pack of platelets (50ml)

5-10kg 1 adult unit (250ml), will require LVT if < 12 months old

1 unit MB FFP (225ml)or 1 unit Octaplas

2 single MB donor units (80ml)

2 paediatric packs of platelets (100ml)

11-20kg 2 adult units (500ml) will require LVT if less than 12 months old .



1 adult apheresis pack (200ml)

> 20 kg 4 adult units (1000ml)



1 adult apheresis pack (200ml)

Further components will need authorisation from the consultant haematologist.

9.0 Stand Down [ back to Index ] When massive haemorrhage has subsided the clinical coordinator must ensure that:

The laboratory is informed

Any used components are returned

All documentation is completed including traceability Once patient stable thromboprophylaxis should be considered.

10.0 Satellite sites [ back to Index ] It is the coordinator’s responsibility to liaise with the laboratory to ensure that both parties know who is to organise transport. The ambulance service will be contacted by the laboratory for emergency transportation of blood. The A&E department will act as the collection point, it is essential that the drop off point is clearly identified by the coordinator (remember to consider access restrictions).




Major haemorrhage protocol is activated by surgeon responsible for patients care

A member of clinical staff will be allocated to act as coordinator

The clinical area will inform the ambulance service if a member of personnel is to

accompany the blood for example: Vascular surgeon

Laboratory will issue the components requested and contact emergency blood porter

on bleep 432 at WRH to transport components/products to A+E, the bleep number

for Alex blood porter is 0208.

If group specific red cells have been issued a retrospective group and cross match

will be performed whist the blood is in transit providing a current specimen is

available.

Laboratory staff will pack up components and seal transit boxes.

Transportation box to be taken to the A&E department for collect by the nominated

ambulance driver

Once cross match is complete the laboratory will inform clinical area if cross matched

units are compatible for the patient

Should further units require transportation then a taxi should be ordered via Alex

switchboard

11.0 Complications [ back to Index ] Disseminated Intravascular Coagulation in acute bleeding is rare outside obstetric practice – treatment is with platelets, FFP and cryoprecipitate given ‘sooner rather than later’. Hypothermia may induce coagulopathy therefore both the patient and the blood should be warmed Transfusion of large volumes of red cells and other intravenous fluids that contain no coagulation factors or platelets causes dilutional coagulopathy. Major traumatic haemorrhage is often associated with activation of the coagulation and fibrinolytic systems and plasma fibrinogen predictably falls to sub-haemostatic levels (<1.5 g/L). Coagulation is also impaired by hypothermia, acidosis and reduced ionised calcium (Ca2+) concentration. TACO is defined as acute or worsening pulmonary oedema within 6 hours of transfusion. Typical features include acute respiratory distress, tachycardia, raised blood pressure and evidence of positive fluid balance. Poor pre-transfusion clinical assessment and inadequate monitoring during transfusion is a common feature of reported cases. The treatment of TACO involves stopping the transfusion and administering oxygen and diuretic therapy with careful monitoring and critical care support if required Toxic effects from citrates, changes in electrolytes and plasma pH

12.0 Audit [ back to Index ] Audit is important to assess adverse events, timeliness of blood component support, patient outcome and component wastage. There should be multidisciplinary review of cases that trigger the major blood loss protocol to ensure it is being applied appropriately and effectively. All cases will be reviewed at the Hospital Transfusion Committee.




15.0 Monitoring Tool [ back to Index ]

STANDARDS % CLINICAL EXCEPTIONS

During a massive blood loss episode blood components will be provided within: Red cells - 10 minutes FFP- 30 minutes Platelets -30 minutes

100% Red cells - Patients with irregular antibodies or special requests If platelets not onsite – within 2 hours

Traceability documentation done for all blood components

100% None

Page/ Section of Key Document

Key control:

Checks to be carried out to confirm compliance with the policy:

How often the check will be carried out:

Responsible for carrying out the check:

Results of check reported to: (Responsible for also ensuring actions are developed to address any areas of non-compliance)

Frequency of reporting:

WHAT? HOW? WHEN? WHO? WHERE? WHEN?

Patients having major haemorrhage receive blood within the required time scale

Monitor when major haemorrhage protocol is activated

At each activation of the major haemorrhage protocol

Transfusion practitioners

The transfusion practitioners will report back to the trust transfusion team TTT/committee TTC should there be deviations from the protocol

TTT – 10 times per year TTC – 3 times per year

Traceability All slips to be returned to the laboratory If there are units unaccounted for the transfusion practitioners will find and record the evidence of transfusion

After the transfusion episode

Staff involved in the episode and transfusion practitioners

The transfusion team will feed back non compliance to the TTT and escalate to the TTC if necessary

TTT – 10 times per year TTC – 3 times per year




16.0 References [ back to Index ]

Baskett, P.J.F. Management of hypovolaemic shock BMJ 1990, 300: 1453 - 1457.

Handbook of Transfusion Medicine 5th Edition, The Stationary Office 2013

Johansson PI, Stensballe J: Haemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets – a review of the current literature. Transfusion, 2010 Mar;50(3): 701-10

Klein H., Anstee D: Blood Transfusion in Clinical Medicine – Mollinsons 22nd Ed. 2005

Levi M et al.: Safety of Recombinant Activated Factor VII in Randomized Clinical Trials. N Engl J Med 2010; 363:1791-1800

Management of major haemorrhage - Midlands Trauma Networks Ref: 14 Reviewed: Oct 13 Next Review: Jan 2015 Source: MHP Group

Massive haemorrhage toolkit http://www.transfusionguidelines.org.uk/uk-transfusion-committees/regional-transfusion-committees/north-west/policies/massive-haemorrhage-toolkit accessed 14/1/14 16:10

National Blood Service Midlands & South West Zone Clinical Policy Group Guidelines for the Clinical Use of Red Cell Transfusions March 1999

Serious Hazards of Transfusion Annual report (2013)

Stainsby et el - Guidelines on the management of massive blood loss: British Committee for Standards in Haematology – British Journal of Haematology August 2006 135,634-642

Stainsby D, MacLennan S, Hamilton P, Management of massive blood loss: a template guideline British Journal of Anaesthesia 85 (3): 487 – 91 (2000)

http://www.transfusionguidelines.org.uk/uk-transfusion-committees/regional-transfusion-committees/north-west/policies/massive-haemorrhage-toolkit%20accessed%2014/1/14






17.0 Contribution List [ back to Index ]

Key individuals involved in developing the document

Name Designation

Dr. T. Skibbe Consultant Haematologist

Phillippa Cheshire Countywide Transfusion laboratory Manager

Gill Godding Lead Transfusion Practitioner

Circulated to the following Divisional / Clinical heads of department for comment

Name Dr Tony Scriven Director Medical Director - Medicine

Dr Nick Hudson Clinical Director – Medicine

Dr Rosa Johnson Clinical Director – A&E, MAU, AMU,

Dr Aldulaimi Clinical Director – Stoke, Gastro, elderly med

Mr Graham James Divisional Medical Director - Surgery

Mr Anthony Perry Clinical Director – Upper GI

Mr Steve Pandey Clinical Director – lower GI

Dr Andrew Short Divisional Medical Director -Women and Children

Dr Andrew Gallagher Clinical Director – Paeds and neonates

Mr Samson Agwu Clinical Director – Obs and Gynae

Dr Julian Berlet Divisional medical Director -Theatres, ambulatory

Mr Nick Hickey Clinical Director – Daycase KTC, Evesham DTC

Dr Chris Catchpole Divisional Medical Director – Clinical support

Dr Mark Crowther Clinical Director- Pathology

Ann Digby Theatre manager

Shelley Goodyear Matron Critical Care

Amanda Moore Matron Day case and ambulatory care

Clare Bush Matron A&E WRH

Mark Tarrant Matron A&E ALEX




18.0 Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval.

If you have identified a potential discriminatory impact of this key document, please refer it to Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Human Resources

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

No

Race No

Ethnic origins (including gypsies and travellers)

No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

No

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? No

6. What alternatives are there to achieving the policy/guidance without the impact?

No

7. Can we reduce the impact by taking different action?

No




19.0 Supporting Document 2 – Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval.

Title of document: Yes/No

1. Does the implementation of this document require any additional Capital resources

No

2. Does the implementation of this document require additional revenue

No

3. Does the implementation of this document require additional manpower

No

4. Does the implementation of this document release any manpower costs through a change in practice

No

5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff

No

Other comments:

No

If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval

Major Haemorrhage Protocol (MHP)

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