MTP cut-off policy, or Lethal Dose of Blood Products

[jshepherd]

Hello everyone! Controversial topic coming up here: Is there a point in an MTP where the further transfusion of blood products does more harm than good? I know some facilities have published studies on this issue, and some have assigned their own lethal dose, or LD50, to blood products, to say that once a patient is transfused X number of red cells or X number of total products that resuscitation is futile and MTP should be discontinued. We are exploring doing this research ourselves, but I was asked if anyone out there has an actual policy or SOP on this topic. For ethical reasons it gets really touchy, so here's the disclaimer that I'm not trying to rile anyone up, just wondering what everyone else is doing! And......go! 

[Auntie-D]

I have issued 148 units of products to a guy who was cycle vs car massive haemorrhage - he survived. I have issues 120ish units on an obstetric massive haemorrhage (as well as 20 6-packs on the twins) - all 3 survived. I've issued similar on AAA (with eventual bypass) - survival. I think the key is to use TEG to see whether the clotting is screwed - if they are clotting then keep going... In the grand scheme of things blood is cheap

Edited December 13, 2022 by Auntie-D

[Malcolm Needs ☆]

I agree with Auntie-D.  I issued well over 100 units to the police dog handler blown up in the "Harrod's Bomb", and he also survived.

[David Saikin]

I have transfused 400u to 2 patients one night (2 traumatic aneurysms with different etiologies).  Another night a patient w an 8000cc bleed in the OR.  I had never seen folks get so much blood and survive.  All 3 walked out, though one guy was missing 2 limbs.

[Ensis01]

My experience has always been that blood products given during an MTP were a stop gap while the cause(s)of the bleed were dealt with, continuing for as long as it takes. As described above this can involve a huge number of products.

What situations during a MTP can cause more harm than good?

[Auntie-D]

8 hours ago, Ensis01 said:

What situations during a MTP can cause more harm than good?

I think they're probably thinking down the TACO route - which is highly unlikely in an MHP situation. If TACO happens when the MHP is triggered, then it likely wasn't an MHP...

[Neil Blumberg]

There are no data suggesting a particular limit.  Survival is very unusual after 30-50 units of red cells, but everyone has exceptional cases like those mentioned above. We have discussed futility of care many times, and our practitioners are quite amenable and forthcoming.  We have stopped resuscitation in a young man having a liver transplant go badly, when there was no surgical path to hemostasis after about 250 units, but this is unusual too.  Bottom line, a case by case decision as to whether care is futile and/or the patient's needs endanger the well being of other patients needing transfusion.  Those are the key issues in each case to my way of thinking.

[jshepherd]

@Neil Blumberg Exactly. We've all had the odd cases that survive when it doesn't seem they should, and I agree that it's certainly case by case and dependent on hemostasis and coagulation like @Auntie-D said above. We use TEG for coagulation eval as well. I think my trauma surgeons are looking for a prompt to make them aware of how many products they've used, so they can evaluate the futility of continuing versus stopping. Anesthesia is the group transfusing these products, and they can easily lose track as well, so we're looking for an estimate of when the blood bank staff might give them a nudge to let them know they've hit a threshold, and to evaluate the entire picture of the patient with that knowledge, rather than being tunnel visioned into fixing the damage only. I have heard 30-50 units of red cells is the sweet spot as well. We consider more than 30 units of red cells to be a super massive transfusion, so that would jive. 

 

[jayinsat]

On 12/13/2022 at 9:22 AM, jshepherd said:

Hello everyone! Controversial topic coming up here: Is there a point in an MTP where the further transfusion of blood products does more harm than good? I know some facilities have published studies on this issue, and some have assigned their own lethal dose, or LD50, to blood products, to say that once a patient is transfused X number of red cells or X number of total products that resuscitation is futile and MTP should be discontinued. We are exploring doing this research ourselves, but I was asked if anyone out there has an actual policy or SOP on this topic. For ethical reasons it gets really touchy, so here's the disclaimer that I'm not trying to rile anyone up, just wondering what everyone else is doing! And......go! 

We discussed this in our transfusion committee. This was rejected primarily in concern to legal ramifications. Denying a patient life-saving treatment when the treating physician feels more blood is needed opens your medical director up to charges of malpractice and negligence. None of our M.D.'s were willing to stand behind that type of policy. The bottom line was, if the treating physician wanted to use up the entire inventory trying to save a life, we could not deny them the blood, even though it places other patients at risk. 

[Neil Blumberg]

"The bottom line was, if the treating physician wanted to use up the entire inventory trying to save a life, we could not deny them the blood, even though it places other patients at risk. "

I would call this some combination of cowardice and insanity, speaking purely personally.  Taking responsibility for difficult decisions is why physicians get paid well, and avoiding decision making is irresponsible.

[Mabel Adams]

We created a policy to ask at certain stages whether the MTP is likely to go on at the same rate so we can plan for blood ordering since we are several hours' drive from our supplier.  

We have this on the back of our MTP log sheet:

"Assess Futility?

Round 10 cooler has left BB within the first 3 hours of MTP (or inadequate blood supply):

• Evidence shows a much-reduced chance of survival if over 40-50 RBCs have been transfused in an MTP.

• Pathologist can confer with providers regarding the chance of saving the patient with continued transfusion.

• Be prepared to provide pathologist with available blood supply information and expected arrival of more units"

Our rounds contain 4 RBC units plus varying yellow stuff. We are starting the conversation at about 40 RBCs, so we have an answer by 50, we hope.  We don't have other hospitals nearby that we can borrow more than a few units from.

 

[Mabel Adams]

On 12/14/2022 at 7:01 AM, jshepherd said:

@Neil Blumberg Exactly. We've all had the odd cases that survive when it doesn't seem they should, and I agree that it's certainly case by case and dependent on hemostasis and coagulation like @Auntie-D said above. We use TEG for coagulation eval as well. I think my trauma surgeons are looking for a prompt to make them aware of how many products they've used, so they can evaluate the futility of continuing versus stopping. Anesthesia is the group transfusing these products, and they can easily lose track as well, so we're looking for an estimate of when the blood bank staff might give them a nudge to let them know they've hit a threshold, and to evaluate the entire picture of the patient with that knowledge, rather than being tunnel visioned into fixing the damage only. I have heard 30-50 units of red cells is the sweet spot as well. We consider more than 30 units of red cells to be a super massive transfusion, so that would jive. 

 

Here are our "nudge" questions.  See my other post for our rounds etc.