Implementation of WFB Protocol in Cruise Industry - THOR Meeting, Bergen June 22nd 2016
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Implementation of WFB
Protocol in Cruise Industry
THOR Meeting, Bergen June 22nd 2016
Steve Williams, RN, CEN, CRFN,
Director, Fleet Medical Operations
Royal Caribbean Cruises Ltd.
June 2008 – March 2016
Royal Caribbean Cruises Ltd., ÷ 22 million people will take a cruise in 2016 ÷ 42 cruise ships, visiting 350 ports in 150 countries. ÷ 5 million guests in 2015. ÷ 40,000 crew, 86 physicians, 152 nurses.
Shipboard Medical Center
Cruise Medicine Context
HSevere hemorrhage at sea is a challenging problem.
H3 G’s of bleeding; GI, GU, GYN
H Storing O Negative blood is not practical.
H Safe blood not readily available, universally.
H Plasma expanders of limited value.
H Blood substitutes are not ready for patient use.
H NSAID’s, ASA and anti-coagulants seem to
be making severe GI bleeding more frequent.
H Use of on board blood donors is a solution.
H Possibly combined with anti-fibrinolytic agents.
Royal Caribbean Cruises Ltd - Blood Transfusion Protocol for Shipboard Management of
Catastrophic, Non-Compressible Hemorrhage
Patient presents with active; non-compressible bleeding:
> than 4 hours will elapse till transfer to appropriate shoreside medical facility
Hb < 10.0 grms/d/l
Hemodynamically Stable Hemodynamically Unstable
INITIATE: INITIATE:
ICU level monitoring ICU level monitoring
IV fluid to maintain MAP> 75 mmHg 2 x large bore IV's with IV fluid to maintain MAP > 75 mmHg
(Permissive Hypotension) Alert Captain
4 hrly CBC/FBC/INR / Ionized Calcium Develops
Call Med Ops Hotline
Hemodynamic
Alert Captain 2 hrly CBC/FBC/INR/Lactate / Ionized Calcium
Instability
Consider Tranexamic Acid (TXA) (Note 2) Administer Tranexamic Acid (TXA) (see Note 2 below)
Consider Vitamin K if on warfarin Administer Vitamin K if on warfarin
Complete Eldon card screening of patient Complete Eldon card screening of patient
If later than 17.00 hrs local time call for Call for donors (see Note 3 below)
blood donors (see Note 1 below)
Screen donors and immediately administer first unit of
Routine disembark to shoreside hospital at Group O negative fresh whole blood (FWB)
next port/avoid helicopter use st
RE-ASSESS AFTER 1 UNIT OF FWB
If still Bleeding and/or
Hemodynamically Unstable
Continue ICU level monitoring
Routine Administer further two units of Group O negative FWB as rapidly as patient
Medevac condition can tolerate
Evaluate urgent MEDEVAC options with Captain/MED OPS/Notify CareTeam
Avoid Risk of helicopter transport acceptable -prefer disembark in port
Helicopter
Send 4th unit with patient to run during MEDEVAC process
Urgent Medevac
Risk of Helicopter Acceptable
Medical disembark to hospital with: Note on use of Calcium Chloride
Endoscopy/general surgical capability
ICU level care If serum ionized Calcium is < than 4.2
mg/dl then consider administering IV
Availability of screened, cross matched blood Calcium Chloride 10mls of 10% solution
Notify MedOps/CareTeam of receiving hospital over 30 minutes
Note 1 Note 2 Note 3
Consideration should be A loading dose of Tranexamic Acid Compatible Donor Request Hierarchy
given to ensuring that (Cyklokapron) should be mixed 1 gram in
1. Sexual partners
identified Group O 100 ccs of 0.9% normal saline and administered
2. Male guests with blood donor cards
negative or O positive over 10 minutes. (no faster than 100mgs/min)
3. Male guests without blood donor cards
donors can be contacted If a maintenance infusion is required a further
4. Female donors with blood donor cards
should they be required 1.0 gram is diluted in 100 ccs of 0.9% normal
5. Medical team members
to report to medical saline and administered over 4 hours.
6. Crew
center to donate blood,
without the need for Use of Tranexamic Acid in stable patient Note: blood donated by genetically related family members increases
ship-wide public address requires risk/benefit analysis, i.e. risk of risk of Graft vs Host Disease. Female donors increase risk of
announcements after continuing bleeding vs inducing thrombotic Transfusion Related Acute Lung Injury (TRALI). Only take one unit
21.00 hrs local time. event. from each donor, after ensuring that the donor is not already anemic.
RCCL Clinical guidance ÷ Tranfuse to hemodynamic parameters – not Hb. ÷ Reverse anti-coagulants if possible. ÷ Consider anti-fibrinolytics. ÷ Do not over-resuscitate with fluid. ÷ Concept of “permissive hypotension”. ÷ Avoid helicopter transport if possible. ÷ Transfer to tertiary center, able to treat.
Seven year experience with shipboard
FWB transfusion at RCCL
÷ Patients transfused: 73
÷ Guests: 67 Crew: 6
÷ Hemaglobin range: 3.4 – 10.6 grm/dl
÷ Mean Hb on presentation: 6.31 grm/dl
÷ Units given per patient range: 1 – 6 units
÷ Deaths: 6
÷ Lost to follow up: 4
÷ Sero-conversion at follow-up: 0
÷ Adverse incidents: 2 (Allergic RXN)
÷ Causes: GI, GU, GYN
Training for Transfusion ÷ Heavy focus on training shipboard medical teams. ÷ Goal is annual training for all. ÷ IACSM in September/Shipboard Training. ÷ Provide summary/overview of the biology. ÷ Focus on practical skills. ÷ Critical to provide 24 hour clinical support. ÷ Clinical audit of every case/lessons learned.
RCCL Staff Survey – February 2016 ÷ Used SurveyMonkey and emailed. ÷ Covered a range of staff service 0 – 15 years. ÷ Sent to 250 current physicians and nurses. ÷ 90% response rate… ÷ 224 replied 93 physicians and 131 nurses.
Have Long Have You Been Qualified ?
Please Describe Your Clinical Background
How Long Have You Worked for RCCL ?
How many FWB transfusions have you been involved with?
Do you feel you have been adequately trained and prepared to
participate in the transfusion process?Do you feel the risk of fresh whole blood transfusion at seas is worth the
benefit of lives saved?Case Study: Mr Richard Kearns
÷ 76 year old male with prior Hx of
GI bleed.. Same place !!!
÷ Wife is ICU nurse.
÷ Takes Plavix for ACS/Stent,
& Lopressor for HTN
÷ Presented with active bleed and
initial Hb was 12.2 grms/dl
÷ Given total of 4 units on board.Clinical Summary
B/P Pulse Hb HCT Platelets Rx
19.05 100/60 73 12.2 38.0 241K TXA
20.00 93/62 70 9.9 31.7 265K Fluid
20.30 83/60 72 9.6 31.0 250K PPI
21.00 80/62 100 LOC Blood
22.00 100/62 75 Blood
00.15 108/57 70 10.0 32.3 196K Blood
05.00 104/60 79 7.4 30.7 169K BloodMr Kearns presents to medical facility at 19.00 hrs 1.28.2013
01/28/2013 1900 (ship
�me) – Mr. Kearns at
Medical Facility
01/29/2013 0656 –
Evacua�on from
VesselClosest hospital with emergency gastroscopy: Hospiten Cancun
Oasis of the Seas Patient
÷ 66 year old German female presented with active
upper GI bleed.
÷ BP 60/40, P. 120, pale, clammy, shocked, GCS 12
÷ Initial Hb 7.3 grms/dl
÷ Closest land 246 nm or 13 hours full speed
÷ Given 5 units of blood and 2 grams of TXA
÷ Discharged after 8 days admission to hospital in
Malaga, Spain,
Final DX: Bleeding oesphagel varicesConclusions ÷ WFB transfusion is a useful option for cruise ships. ÷ No hemolytic transfusion RXN using un-titred FWB ÷ Over 7 years, >60 lives have been saved where MEDEVAC was not an option. ÷ Annual training and recurrent training for staff is critical. ÷ Clinical audit and patient follow up is important. ÷ Proposal in 2016 to expand to all cruise ships on voyages > 3 sea days.
Acknowledgements
÷ Anne Bile RN,
Manager, Clinical Training, RCCL
÷ Monica Wuerth, EMT
CARE Team, RCCL
AND of course, RCCL Shipboard medical teamsThank you for your time…. Contact Information: Steve Williams, RN, CEN, CFRN Team Commander Florida Advanced Surgical & Transport Team State Medical Response System, State of Florida, Bureau of Emergency Response Email: command@fast-team.us Cell: 305 970 3005
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