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One in ten patients coming into hospital will require a blood transfusion. Our centre specialises in the transfusion support of trauma patients, haematology and oncology patients, cardiovascular surgery patients and newborns. We have the largest trauma centre in Canada. When trauma patients come in with massive bleeding, they undergo complex testing so we can find out which coagulation factors are missing. If you give a haemorrhaging patient too little blood they will continue to bleed; however, if you give them too much they will go into fluid overload. The most common complication in transfusion which leads to morbidity or death is transfusion-related circulatory overload (TACO). This happens in patients, usually over 60–70 years old, with heart problems or chronic anaemia. TACO causes heart failure and we see that in 1–3% of transfusion cases. We were one of the first hospitals in Canada to drive the use of octaplex®, a prothrombin complex concentrate (PCC) which contains clotting factors II, VII, IX and X. When you are on warfarin anticoagulation therapy, your blood is essentially poisoned so that these clotting factors are low. The goal with warfarin is that you don’t develop blood clots. If you have a bleed, however, you need an antidote to warfarin. PCCs are used to reverse the effects of oral anticoagulation therapy when bleeding occurs.
Before we introduced the use of octaplex® we used fresh frozen plasma (FFP). PCC has been shown to reduce the risk of transfusion reactions, especially TACO, and speed up warfarin reversal time. All our physicians know that we should use PCC instead of FFP; however, on our last audit in 2013 for the Province of Ontario, 10% of our plasma use was still for warfarin reversal despite the availability of a safer alternative. We have now implemented an interceptive process in which, when an order comes in for plasma, the technologists verify if it is an appropriate indication for plasma or for warfarin reversal and, if so, get the physician to change the order to PCCs.
We are currently investigating whether giving fibrinogen concentrate to patients who are bleeding will improve outcomes. Fibrinogen is the first clotting factor and plays a core role in stopping bleeding – it helps your platelets function and is critical to clot formation. In cases of trauma, reduced fibrinogen on arrival increases risk of death. We are trying to determine if the use of fibrinogen concentrates will improve outcomes in severely bleeding trauma patients. We are also investigating if using fibrinogen concentrates after cardiac surgery will result in patients needing fewer red cell transfusions. Fibrinogen concentrate is virally inactivated, unlike cryoprecipitate, and because it is lyophilised rather than frozen it can be used more quickly compared with cryoprecipitate.
I believe that "perfect is the enemy of good". You will never change anything if you get tied up in every minute detail. You have to keep moving forward. Patients should feel confident because there is a massive team of transfusion medicine scientists, technologists, physicians and pharmaceutical partners dedicated to improving bleed management, working very hard every day. There is huge collegiality in this field between different centres and countries. There are thousands of people around the world who are dedicated to driving safety for donors and patients, and passionately working on innovative solutions and improving blood transfusions.