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What in your MTP?

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Our current MTP states that the first immediate cooler will be 2 RBC/2 FFP, second cooler is 4 RBC/2 FFP/1 SDP and all subsequent coolers will contain 6 RBC/4 FFP/1 SDP.  One of our trauma surgeons wants to move the first platelet pack to the first cooler.  My medical director is very hesitant to do so for several reasons.  We only keep 2 platelets in house and about 60% of the cases that are called MTP actually end up using minimal amounts of blood products.  When do other facilities include in each MTP pack?

P.S. We are a level 2 trauma center that gets about 1-2 MTP activations a month.

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First, I would educate the trauma team on the differences between an actual MTP (in terms of products prepared, and the fact its >10 products in 24hrs), and regular emergency release. That's not to say to ever deny them a protocol if they call for one, but from firsthand experience when I receive a call asking for the phrase "Massive Transfusion Protocol," and I verify what products they will be getting, they don't actually want the sheer number of rounds/number of products listed in our MTP. These areas just know an MTP will deliver products stat, and with relative ease. So, in that case, having pamphlets, posters, what have you, in their areas would be beneficial, as well as explaining about regular old emergency release options (i.e. maybe they only want RBCs, but they only know about MTPs, so they call for that). Just explaining to them that this is an option may reduce the amount of products you're issuing compared to the products they end up using.

That being said, our MTP states our first round is 6:6:1, and then a subsequent round is set up after that, and additional rounds in the same 6:6:1 ratio as needed. We are also a Trauma I center, so our numbers might be higher than yours. However, there have been studies, particularly driven by the US Army, about the "optimal" ratio of RBC:plasma:platelets. If you're worried about platelet wastage, that is an honest concern, but in true MTPs, massively bleeding is still massively bleeding; in which case the products may just dribble out. At the end of the day, it's about pluggin' holes and treating the underlying coagulopathy.

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Agree with Ward's points, above.  Any change in policy will involve discussion with ER, Surgery, etc.  that includes education once a decision is made.

When we became a level 2 truma center a few years ago, we had a rather elaborate MTP process that included things like Coag and CBC results.

We have two different orders for emergent situations: An "Initial Resusitation Cooler" order (2 RBCs, 2FFP), and an "MTP Protocol" order (5 RBCs, 5 FFPs, 1 5-pk platelets).  We repeat the MTP order until it is called off.

In addition, individual orders for uncross matched products can also be made.

Scott
 

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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.  

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3 hours ago, Neil Blumberg said:

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.  

This! I don't think consulting a hematologist is even on the care team's mind in terms of these bleeders, which is unfortunate, because if there is an underlying coagulopathy that isn't being treated the products will just run right in and out of the patient with little to no benefit. I guess in terms of traumas, doctors assess the needs for blood and know that's how to save them at that point. Obviously send them RBCs first, but after using x amount of products, what about tranexamic acid!!

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20 hours ago, John C. Staley said:

I think I missed something.  Did you really imply that you are putting platelets in the same cooler as the RBCs??  :coffeecup:

They are in an MTP cooler that has a separate RT platelet storage box. 

Although we occasionally get them back in the cold part of the cooler.  They claim it's just easier to put them in there.  SIIIIIIIIGH!!!

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1 hour ago, slsmith said:

6 rbc/6plasma(usually liquid)/1 pphl every 15 minutes(we try). If it is a OB one of the rounds also gets a pooled cryo.

What is pphl?

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We send out whatever is ready first and maintain a 1-1-1 ratio. For us that generally means 2 RBC and 2 FP to begin and then Platelets in the second round of 2 RBC- 2 FP, then 2 RBCs, 2 FP to finish out a 1-1- ratio and then repeat. Cryo on separate order if indicated (Fib <150 or on FibTem.)  We keep 2 FP thawed at all times. We are also a Level II Trauma center but have 2-3 times more activations, depending on the month.  We have a Trauma Order that includes 2 RBCs and 2 FP if indicated. I would agree that we often do not make it to the platelets either. Evidence supports 1-1-1, but not platelets earlier than that necessarily.

If we could support the cost, and use before expiration, we would go to whole blood for the first two coolers of MTP. Unfortunately we cannot justify the doubled cost and wastage.

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We are also a level II Trauma center.  Our adult MTP 1st pack is 6 FFP, 6 PC and 1 PLTPH.  Initially, we issue 2 PC and 1 PLTPH because we already have the 2 PCs ready for emergency issue.  The assigned runner returns to pick up the other 4 PCs and then the 6 FFP once they are thawed.  We are going to be stocking liquid plasma as soon as we can arrange for that from our blood supplier.  After that, we will issue 4 units of liquid plasma at the beginning of an MTP.  We felt that whole blood was too costly, but we think the liquid plasma will work well for us.

The second pack includes 2 pooled cryo with the 6 FFP, 6 PC, and 1 PLTPH -- and we alternate contents as the MTP continues.

We have also defined 2 pediatric MTP packs, based on the weight of the patient.

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