Update on Blood Product Administration and Massive Transfusion

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Update on Blood Product Administration and
Massive Transfusion
 In the Operative Setting
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Objectives

• In this presentation you will
• Define Mass Transfusion Protocol (MTP)
• Identify your role and responsibilities in the
  blood administration process
• Verbalize blood storage return requirements to
  reduce blood wastage

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Rationale

• The activation of a standardized massive
  transfusion protocol (MTP) for large surgical
  bleeds and trauma exsanguinations will provide
  standardized component therapy to avoid
  coagulopathy associated with massive blood loss
• Charge nurse will no longer routinely order
  Trauma Blood
• Outline team responsibilities associated with
  transfusions
• Reduce blood product waste

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Role of Physician and Blood Bank
Initiation of MTP Additional MTP Coolers Ending MTP
Who Attending Anesthesiologist/ Surgeon   Direct Communication to Blood Bank Initiation of MTP Physician Name Patient Name Patient gender MR Location OR Who Attending Anesthesiologist/ Surgeon  Direct Communication to Blood Bank Continue MTP Physician Name Patient Name MR Location OR Who Attending Anesthesiologist/ Surgeon   Direct Communication to Blood Bank Stop MTP for Physician Patient Name MR Location OR  
Blood Bank Confirms Patient Location on E-OR Board   Prepares MTP Cooler 6 units pRBC 4 units Plasma 1 Platelet MTP Cooler Packed Contacts OR Command Center of Ready for Pick up BB call OR Room for Decision of Continue or Cease   Continue MTP Cycle BB Prepares 641 Ratio   MTP Cooler Packed   Contacts OR Command Center of Ready for Pick up  BB to Receive Order by Attending Surgeon or designee No additional MTP cooler picked up   Discontinue MTP cycle BB Anticipates Arrival of MTP Cooler
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Role of Charge nurse Anesthesia provider
Initiation of MTP Additional MTP Coolers Ending MTP
OR Charge Nurse Receives Call From BB for cross check of Patient Patient Gender OR Location Communication of MTP Protocol initiated CN Communicates MTP activation to OR Team Circulator Anesthesia CN deploys runner for MPT cooler pick up To OR to obtain Blue Card or Chart prior to going to Blood Bank Straight to BB for Level 1 trauma if blue card or chart cannot be obtained OR Charge Nurse Prepares for Continuation of MTP Deploys runner for MPT cooler pick up To OR to obtain Blue Card or Chart prior to going to Blood Bank Straight to BB for Level 1 trauma if blue card or chart cannot be obtained Anesthesia Tech Prepares Cooler for Return to BB   Anesthesia Tech transports Cooler to Command Center CN deploys runner to return cooler to Blood Bank
Nurse/Anesthesia Anticipates Arrival of MTP Cooler   Nurse/Anesthesia Follows Blood Administration Check Points Receives call for continuation by BB Nurse /Anesthesia Verifies No Blood Products Remain in OR
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Role of OR Runner
Initiation of MTP Additional MTP Coolers Ending MTP
OR Runner Deployed for MPT cooler pick up To OR to obtain Blue Card or Chart prior to going to Blood Bank Straight to BB for Level 1 trauma if blue card or chart cannot be obtained Returns To OR with cooler if Blue Card or Chart was obtained from OR prior to going to Blood Bank To Command Center if blue card or chart was not obtained for patient location from charge nurse Delivers cooler to designated OR Deployed for MPT cooler pick up To OR to obtain Blue Card or Chart prior to going to Blood Bank Straight to BB for Level 1 trauma if blue card or chart cannot be obtained Returns To OR with cooler if Blue Card or Chart was obtained from OR prior to going to Blood Bank To Command Center if blue card or chart was not obtained for patient location from charge nurse Delivers cooler to designated OR Returns cooler to Blood Bank
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The Circulating Nurse

• Prior to setting up for a case the circulator
  will ensure that No blue cards, patient labels or
  blood boxes from previous cases remain in the
  room.
• On the In-room white board verify
• Patients name
• Procedure, the surgeon,
• Operative site (specifically L or R)
• Number of blood products available.

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Prior to the beginning of the case

• The circulator and anesthesia provider
  individually verify patient identify
• Ask patient to state his/her name when
  appropriate.
• Before patient is moved to the OR table, together
  the caregivers compare
• Stated name to wrist band
• Blue addressograph card, whiteboard and face
  sheet on the chart.
• Names should be identical. Medical record number
  and physician name should also be compared on the
  ID Band, blue card, whiteboard and medical
  record.
• (See Patient Identification Policy 100-32)

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Anesthesia Provider

• In the OR, transfusion is the responsibility of
• Attending Physician
• Resident Physician
• Certified Registered Nurse Anesthetist (CRNA)
• Student Registered Nurse Anesthetist (SRNA)
• Perfusionist
• When blood/blood products are needed
• Circulator is notified
• Circulator orders blood/blood products via Wiz
  Ordering application

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Notification by Blood Bank

• The Blood Bank calls appropriate location when
  blood cooler is ready to be picked up or blood
  products have been tubed.
• The Command Center for the VOR - 22090
• MCE board- 66777
• 4 South/GYN surgery board- 32736
• Hybrid - 22090
• L D - 22255
• If cooler is needed, charge nurse will dispatch a
  runner to the designated OR and obtain the blue
  card or patient chart for the patient needing
  blood as soon as the call is received or patient
  arrives to the OR.
• The runner presents the blue card or patient
  chart to the Blood Bank.

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Blood Bank Technologist

• Blood Bank Technologist
• Requests patient ID from runner
• Confirms transfusion order
• ID presented (current type and screen available)
• All MTP cycles will be type-specific,
  cross-matched blood products.
•  ID is presented (current type screen
  unavailable)
• Trauma blood will be issued.
• ID cannot be obtained
• Trauma blood will be issued.

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Responsibilities of Runner

• Runner has patient chart or blue card
• Returns to the designated OR
• Requested blood
• Patients blue card or patient chart
• OR runner gives blood product to licensed
  practitioner
• Runner does not have patient chart or blue card
• Returns to Command Center for patient location
  from charge nurse
• Delivers cooler to designated OR

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Blood Verification

• Two (2) licensed personnel together verify the
  following information, (only one may be an LPN).
• Patients name and medical record number from the
  wristband/blue card/whiteboard
• Blood product expiration date
• Blood product donor numbers and type
• Verify all information with the Transfusion
  Record

Expiration
Donor number and type
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Blood Product Transfusion Form

• Two licensed personnel sign and date
• Acts as the receipt for the blood product
• Circulator places on the chart
• Becomes part of the permanent record

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Multiple units- Cooler.

• Cooler stays with Anesthesia team
• May take units out to check off (with transfusion
  record, patients name and medical record number
  from the wristband/blue card/whiteboard
• Must return all units back in the cooler under
  ice after verification process
• All units must remain under ice until used and
  lid closed at all times except when removing
  units
• Blood bags kept on top of the ice do not remain
  at proper temperatures
• Do not removed ice from bag
• Keep ice bag closed

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Cooler

• NOTE
• Coolers are returned to Blood Bank as soon as the
  need is over.
• Blood Bank checks the temperature at that time to
  determine if the blood is still the proper
  temperature.
• Do Not place platelets or cryoprecipitate
• in the cooler.

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Ice
Blood Product Reminders
No Ice

• RBCs must be transfused within 30 minutes unless
  in a blood box.
• Plasma must be infused within 4 hours of leaving
  the Blood Bank

• Platelets use immediately
• Cryoprecipitate must be used within 4 hour of
  pooling

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One or Two Units of Blood Tubed to OR

• The Blood Bank calls appropriate location when
  blood products have been tubed.
• The Command Center for the VOR - 22090
• MCE board- 66777
• 4 South/GYN surgery board- 32736
• Hybrid - 22090
• L D - 22255
• Charge Nurse/Runner Responsibilities
• Sends runner to tube station
• Runner returns to Charge Nurse for patient
  location
• Charge Nurse validates patient name on blood
  product
• Charge Nurse sends runner patient blood product
  to OR where patient is located.

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Preventing Blood Wastage

• RBCs Plasma
• If tubed, not needed, return immediately to
  Blood Bank by runner
• In cooler, leave under ice, keep lid closed
• Return cooler as soon as possible

• Platelets
• Never in a cooler!
• Pooled platelets expire in 4 hrs.
• Cryoprecipitate
• Never in a cooler!
• Expires in 4 hours!

Never tube any blood products back to blood bank!
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Unused Products

• Unused products are returned to Blood Bank
• As soon as the MTP is discontinued
• If blood products are tubed not needed
• Patient is transferred to another location (Out
  of OR)
• Return process
• Anesthesia Tech transports cooler to command
  center
• Charge nurse deploys runner to return
• Cooler to blood bank
• Any unused tubed blood products to blood bank

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MTP Review

• Each MTP activation will be reviewed within 24
  hours and feedback provided to the attending as
  well as Transfusion Committee leadership team

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Summary

• MTP provides standardized component therapy to
  avoid coagulopathy associated with massive blood
  loss
• MTP continues until
• Attending anesthesiologist or attending surgeon
  discontinues
• No more coolers are picked up from the Blood Bank
• All unused products are returned to the Blood
  Bank
• As soon as the MTP is discontinued
• If tubed blood products are no longer needed
• If patient transfers to another location (out of
  OR)