What is the term for the administration of whole blood or blood products through the iv route?

Source: Vampire Program: CENTCOM Clinical Operations Protocol-01: Urgent Resuscitation using Blood Products during Tactical Evacuation from Point of Injury

PURPOSE

To provide essential instructions on urgent/life-saving resuscitation procedures using blood products during tactical evacuation (refers to both casualty evacuation and medical evacuation) from the point of injury (POI) for casualties suffering major blood loss/massive hemorrhage. Referred to as the Vampire Program. This guideline supports the Joint Trauma System (JTS) Damage Control Resuscitation Clinical Practice Guideline (CPG), Whole Blood Transfusion CPG, and the Tactical Combat Casualty Care (TCCC) Guidelines.

Guidance applies to medical and non-medical personnel (e.g., flight medic, crew chief, registered nurse, enlisted medical personnel, physician, nurse practitioner, or, physician assistant), assigned/attached or allocated to perform tactical medical response (TCCC) and evacuation (CASEVAC and MEDEVAC) duties that involve direct or indirect patient care.

FIELD INDICATIONS FOR TRANSFUSION DURING TACTICAL EVACUATION

The following are indications for transfusion in the presence of severe traumatic injury:

• Systolic BP <100 or absence of radial pulse; or
• Heart rate >100; or
• Any above knee amputation or double/triple/quadruple amputation (regardless of vital sign indication).

WARNING: The amputation patterns above are the only traumatic injuries that constitute a stand-alone immediate field indicator for transfusion that requires no confirmation with vital sign parameters.

CAUTION: Control external bleeding before or simultaneously with initiation of blood product transfusion.

Traumatic Arrest: patient with exsanguination who had signs of life when received from ground forces and has since become pulseless should receive immediate transfusion (transfusion is more important than chest compressions in cases of exsanguination and should take priority).

Traumatic injuries where early blood transfusions are most likely to be needed:

• Penetrating thoracic/abdominal/junctional (junctional includes axilla/inguinal/cervical) injury.
• Pelvic fracture.
• Multiple injuries.
• Proximal amputations (above knee or elbow). Amputation is defined as any severe trauma to a limb that involves complete or partial loss of the limb (this includes limbs that are severely mangled but not completely severed).

Initiate transfusion with 1 unit of blood product. Give additional units if clinically indicated.  Avoid resuscitation with crystalloid which may increase bleeding, particularly from non-compressible torso hemorrhage.

Refer to Appendix C for list of clinical indicators for hemorrhagic shock.

PROCEDURE

Blood Component Therapy Approved for Transfusion during Tactical Evacuation

Red blood cells (RBCs) increase the recipient’s oxygen-carrying capacity by increasing the mass of circulating red cells. Plasma and platelets work together to improve blood clot formation and clot stability. On average a unit of whole blood (WB) contains a volume of 500-600 mL and a unit of RBC’s contains a volume of 300-400 mL. In an exsanguinating patient, a unit of blood can be given quickly. Ensure good blood flow through IV or IO access before initiating transfusion. Refer to Appendix D for Transfusion Procedures and Appendix F for Pearls for Transfusion.

CAUTION: Rapid infusion against resistance can cause mechanical shearing of RBCs and should be avoided.

1. Blood products will be administered in the following priority depending on availability and according to TCCC Guidelines:

• Cold Stored Low titer Group O whole blood (LTOWB), or, if not available
• Fresh Low titer Group O whole blood (LTOWB), or, if not available
• Plasma, RBCs, and platelets in a 1:1:1 ratio, or, if not available
• Plasma and RBCs in 1:1 ratio, or, if not available
• Reconstituted dried plasma, liquid plasma, or, thawed plasma alone or RBCs alone, or, if not available
• Fresh group O (typed by Eldon card or equivalent) whole blood from unknown titer walking blood bank

NOTE: LTOWB has been screened for anti-A and anti-B antibodies; these units contained a low titer of anti-A and anti-B and are therefore considered a universal donor product that may be given to recipients of any blood type with a minimum risk for a minor ABO incompatibility (typically minor and most often subclinical clinical consequences). The whole blood supplied to MEDEVAC units will be exclusively drawn in the United States from the ASBP-approved sites and distributed in theater by the ASBP blood distribution system. The LTOWB units will be fully tested following FDA current guidelines.

2. POS (either low titer Group O WB or Type O RBCs) is the standard  for transfusion during evacuation.

NOTE: Patients requiring blood can safely receive un-cross matched low titer Group O WB or Type O RBCs until type-specific products are available.

3. If available, use O NEG on females of childbearing potential age <50 years old. Inform receiving facility regarding female given O POS blood for documentation in the medical record. If a minimal amount (just a few milliliters) is given, consider Rhogam therapy. The immunologic consequences of administration of an entire unit of O POS whole blood or RBC to an O NEG female of child-bearing potential cannot safely be reversed with Rhogam. Treatment of exsanguination takes precedence over potential future pregnancy outcomes.

CAUTION: WB collected in theater will NOT be supplied for use onboard MEDEVAC aircraft.

Plasma is recognized as an important component in preventing and treating coagulopathy in trauma. On average a unit contains a volume of 200-250 mL and is transfused rapidly.

1. Type A or AB thawed plasma is the current standard for transfusion during evacuation.
2. Thawed plasma only has a shelf life of 5 days and may not be available for the pre-hospital mission. Liquid plasma (never frozen) has a shelf life of 26 days. Check with issuing facility or blood supply unit for availability.

The recommended mission loads for tactical evacuation are based on operations tempo and determined by the theater or Joint Task Force surgeon. Specific missions may require additional blood products; units will refer to the Joint Blood Program Office.

1. Golden Hour Container (GHC) maximum capacity is 4 units RBC/FFP or 2 units of whole blood.
2. If whole blood or plasma is unavailable, evacuation personnel will fly with RBCs exclusively.
3. Product must finish infusion within 4 hours of spiking the bag. If not complete, then it needs to be stopped and the remainder of the product discarded. If the initiation of transfusion (spiking of the bag) is delayed, then the blood may be returned to storage if it hasn’t exceeded appropriate transport temperature, which is a max of 10C. The only way this can be determined is with use of a Safe-T-Vue sticker on the actual blood bag.
4. Unused blood products (i.e. WB and freeze dried plasma [FDP]) furnished by forward U.S. or Coalition Forces will not be used by evacuation personnel. Recommend products be left with forward forces. Blood products (WB and FDP) spiked by forward forces and transfusing at time of pick up will be continued during evacuation.

Pediatric patients:

1. Emergency transfusion of pediatric patients relies on clinical assessment rather than specific vital signs, since normal heart rate and blood pressure are age-dependent.
2. Clinical signs of shock are the same as in adults (cool, pale, weak or absent radial pulse, delayed capillary refill, decreased mental status).
3. Pediatric fluid resuscitation related to trauma begins with 10 mL/kg of first blood product, then repeat as needed based on response.

Receiving Blood Components from an Issuing Facility (U.S. and Coalition)

U.S. issuing facility personnel from the Blood Support Detachment (BSD), MTF (Role 2/3) or lab will:

1. If requested and available, thaw frozen plasma IAW local procedures and label products (A or AB) with 5 day expiration date.
2. Ensure GHC is properly charged and removed from freezer 25-30 minutes prior to loading blood products.
3. Ensure all blood products issued have a Safe-T-VUE (NSN 6515-08-T00-3056) attached and activated for temperature monitoring (Appendix E). Ensure thawed plasma is at refrigerated temperature (1-6°C) before placing Safe-T-VUE on unit.
4. Evacuation personnel will follow Safe-T-VUE procedures (Appendix E) when required.
5. Document in TMDS the issuance of blood products to an evacuation team (e.g., DUSTOFF; Pararescue; Tactical Critical Care Evacuation Team).
6. Complete appropriate sections of the SF 518 Blood or Blood Component Transfusion Record for issuing blood products; place inside GHC pocket or attach form to each unit of blood product issued.
7. Verify the blood information on the SF 518 against the blood product label with receiving evacuation unit personnel.

Non-U.S. Issuing Facility: When U.S. blood products are to be issued from a Coalition facility, contact the Joint Blood Program Office to coordinate issuing requirements and documentation of units received.

Receiving unit (Evacuation Unit) personnel will:

1. Prior to sealing GHC, ensure each blood product loaded into the GHC has an activated Safe-T-VUE attached (Appendix E) and an SF 518 Form.
2. Accept blood products into receiving unit’s TMDS inventory. If receiving unit is unable to access TMDS, the issuing facility will access account and receive the products under the receiving unit’s TMDS inventory.

Storage, Transportation and Monitoring of Blood Products

1. All blood and blood components must be maintained in a controlled environment and stored under appropriate conditions.
2. Blood products carried outside a BSD/MTF/Lab will only be transported in an approved storage container (e.g., Golden Hour Container NSN 6530-01-505-5301; OCP/5306; Desert) for a maximum of 48 hours.
3. Units will monitor containers and document status (e.g., dry/no leaking noted) at a minimum of every 24 hours.
4. Once loaded and sealed, container will remain closed and intact at all times until blood product is required for patient care.
5. Notify the issuing facility (BSD/MTF/Lab) as soon as possible when blood products have been used.
6. GHC is only approved for 48 hours use; prior to expiration end users will contact issuing facility (BSD/MTF/LAB) to coordinate the return and exchange of a container and blood products per mission requirements.

WARNINGS: -  At no time will container or its contents (blood products) be placed in a refrigerator or other cooling device outside a blood bank. -  Blood products will not be used if container is leaking; or the temperature indicator (Safe-T-VUE) on the blood product is out of standard (refer to Appendix E). -  Notify the issuing facility and return container and products for replacement.

Individual and Unit Training Requirements

1. At a minimum, medical personnel who participate in the administration of blood products during evacuation will be trained in the following topics:
   • Indications for transfusion (Appendix C)
   • Transfusion procedures (Appendix D);
   • Documentation (Appendix G)
   • PEARLS for transfusion (Appendix F)
   • Submission of a patient safety report when required
2. At a minimum, non-medical personnel who assist will be trained in the following:
   • Transfusion procedures
   • Equipment/supplies
   • Documentation requirements for the SF 518
3. Units who implement this CPG will train appropriate personnel on the following:
   • Emergency procedures for in-flight complications.
   • Storage container/blood product exchange requirements.

Essential Items Required for Implementing a Vampire Program

1. Approved blood component transport container.
   • Recommend between 4 and 6 each GHCs for a Vampire Program (NSN 6530-01-505-5301 (OCP)/5306(Desert)).
   • Hemacool (NSN 4110-01-506-0895) or other freezer with temp check to ensure a temperature ≤ to (-) 18°C to support reconditioning of GHC.
2. Safe-T-VUE (NSN 6515-08-T00-3056) for temperature monitoring. (Refer to Appendix E.)
3. Establish Theater Medical Data Store (TMDS) accounts for an issuing facility (BSD/MTF (Role2/3) and LAB); and receiving unit (evacuation unit)

Warming Devices for Blood Transfusion

Use of infusion warming devices is highly recommended. These will be FDA approved for the actual use in transfusion of blood products (examples of devices include: Belmont® Buddy-lite™, EnFlow® or Thermal Angel).

WARNING: Warming devices will have safety mechanisms built in that prevents the output temperature from exceeding 42°C. Unit personnel will be familiar with safety mechanisms for the device used.

Tranexamic Acid (TXA)

Patients receiving blood transfusion within three hours of injury should also receive TXA. Refer to the TCCC guidelines for administration of TXA.

Record Keeping and Documentation Requirements

1. Transfusions will be documented into TMDS by evacuation personnel, or, by issuing facility.
2. Personnel will refer to the Theater Blood Application Training Guide, 02 Jun 2014 for directions on Inventory Management-and for Transfused Products.
3. Complete SF 518 documentation and turn over at the destination MTF for placement in the patient’s medical record.

References

1. Armed Services Blood Program (ASBP), Joint Blood Program Handbook, HQ Departments of the Army, Navy and Air Force (Army Technical Manual 8-227-12, NAVMED P-6530, AFH 44-152-IP), 01 Dec 2011.
2. Central Command Regulation (CCR) 40-1, Quality Management (QM) Programs in Healthcare Operations, 19 Feb 2016.
3. CCR 40-4, Clinical Operations (CLINOPS) Program, Jan 2016.

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