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We are persuaded that sending plasma and platelets in a first cooler harms more patients than it helps. We actually wait to provide plasma and platelets/cryo until we are told this is a massively bleeding patient or 8 red cells have been sent. First cooler is 4 red cells. Second cooler is 4 red cells, if needed. Almost all the time, none or few of them are used. We are the only level I trauma center within 70-80 miles. Thus including plasma and platelets, which are highly toxic products, associated with nosocomial infection, multi-organ failure, thrombosis and mortality, will likely lead to the occasional patient receiving them along with one or a few red cells. A recipe for increased harm with no benefit. I realize this goes against the grain of what is being recommended, but the experts in surgical trauma are resolutely unaware or in denial about the risks of transfusion in patients in whom transfusions are not life saving. Reasonable, to my way of thinking, to reserve plasma/platelets and cryo for patients who are truly massively bleeding and will die without transfusion. Even then, I'd recommend tranexamic acid and/or DDAVP, and possibly fibrinogen concentrate (or cryo) long before transfusing plasma and platelets to bleeding patients, based upon randomized trial evidence to date. Remember that early use of plasma and platelets has never been tested against these other modalities in randomized trials. Platelet transfusion in particular, has promoted bleeding and mortality in randomized trials to date, and should be avoided if possible. Particularly ABO non-identical transfusions which almost certainly make bleeding worse, not better.

i ended up finding a reference that actually provided the half-life of rhogam, which is the product we use, and the minimum blood concentration needed to prevent immunization. it's the math behind the 28 week dose covering up to 40 weeks comes from, i dont know why neither I nor my BB manager learned this during our training! i also pinged a senior OB I trust about this stuff, and he said she's very likely covered by what she's already got, but can redose if so desired. So since we gave her 300 mcgs a week ago, we advised that she is very likely completely covered (she should still have almost the full dose in her system just one week out), but that OB can dose again if she feels squirrely about it. D. Salkin, thanks for your input! sounds about like what i ended up with.

I wholeheartedly agree with all the above comments for you to determine the surgeons expectations. One other thing we found VERY useful was asking if the patient has had prior heart surgeries, i.e. how much scar tissue was on/around the heart. We found that the more scar tissue the patient had the more products, especially RBC, would be needed.

FYI: the draft guidance was implemented 9/30/19 and we have 18 months to comply.