Massive transfusion protocol

[CTWRUBEL]

I'm getting conflicting info from two sources. Our trauma service is asking us to update our massive transfusion protocol and to consider adding in guidelines for when physicians should start adding in components like thawed plasma and platelets, i.e. when X number of red cells are issued give Y units of thawed plasma and Z number of platelets. One of our Blood Bank physicians is reluctant to do this saying the trend is to get away from specific numbers.

As far as the trauma service is concerned their patients are usually not in the ED for very long so for the most part they just transfuse red cells to keep the patient alive till he/she reaches the OR. Then the surgical team takes over and deals with proper component ordering.

But as far as massive transfusion goes, have I been missing the boat? What is the current thinking/practice out there?

[Cliff]

My opinion is that physicians need to order all products. Med techs should never order blood products. If you were to have a protocol such as you describe, who would be the ordering physician for the plasma and platelet products?

[bmarotto]

The BB technologist would not be ordering the products; the trauma physicians would. What they want is something in the massive transfusion policy (this policy is in both the Blood Bank and Trauma Program SOP manual) that would assist in determining when it is "time" to order other components. My concern is once guidelines are written in this shared SOP, the physicians may assume it is the responsibility of the BB tech to keep track of what has been issued and to alert them when it is time to think about ordering other products. This is not a position I want my techs to be put in.

My opinion is the decision to order plasma or platelets must be based on the clinical situation, laboratory results, and a knowledge of dilutional coagulopathy. I vote for physician education instead of writing specific details in an SOP. A Blood Bank physician is always available for consultation if the attending physician needs additional guidance.

[Seveets]

My opinion is the decision to order plasma or platelets must be based on the clinical situation, laboratory results, and a knowledge of dilutional coagulopathy. I vote for physician education instead of writing specific details in an SOP. A Blood Bank physician is always available for consultation if the attending physician needs additional guidance.

Hear, hear

Unfourtanely our policy states that after the first 5 units of packed cells are transfused and more are ordered, we (blood bank) thaw 2 units of FFP and order pheresis platelets (we do not carry a supply of them) and deliver them ASAP. We will be notified when the crisis has passed.

[donellda]

I received a letter from the trauma physicians at my hospital last week because a trauma patient did not get his FFP fast enough. We are technically supposed to thaw 4 AB FFP as soon as they come for "the red chest" which is a cooler with 6 O neg uncrossed RBCs. This plasma generally gets wasted so we often will thaw 2 to start and once we get a specimen, we thaw ABO compatible.

I researched the trauma that they spoke of. It was on midnight shift with only one tech working. He gave out the first 6 O neg RBCs at 1130PM and received a specimen 15 minutes later. They came for a second chest at 1202 at which time the tech was able to give type specific. An order for 4 FFP and 10 platelets came at 1240AM and these were issued 30 minutes later along with more packed RBCs. In less than 2 hours, this one tech prepared and issued 39 units of blood, 4 units of FFP and 10 units of platelets, which he pH tested and did 2 pools of 5 platelets. I thought that was pretty good work.

The trauma physicians asked if we needed to revise the policy because of the "delay". I told them everything I just wrote out here and I said "no". I then put up a help aid on the window where we keep our units pre-prepared for emergency release, reminding the techs to thaw 4 units of FFP as soon as the "red chest" issued. I made sure that they knew that the tech did an impressive job and being by himself was just trying to get all the work out for their patient.

[Cliff]

We switched from thawed FFP to thawed plasma a couple of years ago. We keep a small amount thawed at all times. It really helps with the outdating of products, and with emergencies.

[donellda]

We convert our expired thawed FFPs to thawed plasma also. It does help with our expired products but we only use them for traumas and open hearts or if the physician agrees to use the product. If we have AB thawed plasma, we do throw them in the "red chest" with the uncrossed blood but we don't always have them available.

[Eagle Eye]

We keep 2O, 2B, 4A FFP thawed all the time. Once we get a specimen we type the patient and issue type specific/compatible FFP. We have MTP written but not implemented yet. (need signature from so many directors!!!). Our Trauma surgeons are aware of the fact that if the patient is AB, they will not be able to get FFP right away, all other type they can start with 2 and then we can thaw more FFP as needed.

We give 5 day expiration to our FFP once its thawed. Most of our AB FFP are pheresis unit so we can not give 5 day expiration and AB is always emergency release.

[Scott Hampton]

Our facility (level I trauma) has an MTP that is acitivated and blood products are supplied in shipments based upon predetermined quantities. This protocol went through various physician and nursing groups. We have had very good success.

[kate murphy]

We do a LOT of traumas - our massive transfusion protocol does NOT include recommendations for other products. Our ER/trauma surgeons believe strongly that it is their responsibility to monitor and order products. Like Cliff, however, we keep a thawed inventory of 5 day plasma ready at all times.

[bpkelly]

We are a level one trauma center and we have a standard protocol for preparations of products although not all of them wind up being issued.

For every 10 LPRBCs, we thaw 2 FFP and hold one apheresis platelet. We are in the process of building factor 7 doses into the protocol as well.

[rcurrie]

My massive transfusion protocol is quite simple. It is a keep-ahead order for 6 RBC, 4 FFP, and 1 SDP. Whenever anything is picked up, we automatically set something up to replace it. We have 2 or 3 massive transfusions a week and average 5 level 1 traumas a day, which really isn't that much when you get down to it. We also have about 5-10 level 2 traumas a day (blood not needed). We have an MTP bucket ready to hand out the window. We thaw A plasma, and that covers 85% of the population. We also use 5-day Thawed Plasma routinely.

BC

[MJDrew]

In spite of what your trauma docs may tell you, NO ONE dies because of a "delay" in receiving FFP!

We have found it immensely helpful to have thawed, 5 day plasma of multiple types on hand for situations like these. Once a specimen is typed, plasma can then be immediately available.

The last time I remember a "formula" used for massive transfusion was when I was a resident. Back then (not saying when! ) once a patient had received 6 RBCs, we thawed and released 2 FFP whether they were asked for or not. I haven't worked for a facility with a policy like this for many years now. Most of the time the patient is not in the ER long enough for FFP to be thawed if their condition is really precarious; they are whisked directly up to surgery.

Our only massive transfusion protocol is dispensing with crossmatching once the patient has received 10 units of RBCs. By that time it's all donor blood circulating anyway. We just save a segment and send the type specific uncrossmatched units until things cool down...

MJ:cool:

[rcurrie]

The only reason we have a massive transfusion protocol is because the trauma inspectors wanted to see one in place. My protocol puts the responsibility for massive transfusion right where it should be- with the physician. All we do is make X amount of certain products continually available until someone says Stop. We (the Blood Bank) make no recommendations whatsoever as to what should be transfused and when. That's what they have point of care analyzers for.

BC

[Eagle Eye]

We have trauma protocol where we supply pack with certain number of component every 15 minutes from the time we get specimen. We continue to do that until they stop the MTP. Our pack one is 4 Thawed plasma(RBC if requested) but if they want to add SDP physician need to tell us that. THey have the same protocol so they make changes according to their need otherwise we continue to send new pack.

LOts of communication needed to make sure we do not waste the product and receive all the paperwork in timely manner. We review each protocol to see where improvement is needed.

[Mabel Adams]

For the historical record: They used to always order plts and FFP after 8-10 units of red cells. Then that went out of fashion and they were supposed to only order components based on coag and plt count results. More recently (there was a really interesting teleconference on it last year) they are saying the worst trauma patients can't wait for the test results to get back and they need to start the FFP and plts earlier. Coagulopathy of trauma including the effects of hypothermia etc, I think.

[Eagle Eye]

Mabel, Our trauma surgeon said almost same thing that they couldn't wait for 30 min to thaw FFP that's when we started 5 day plasma and started to keep inventory of thawed plasma (O, A & so we can issue plasma within 15 min of receiving the specimen.

[rcurrie]

We don't even wait for a specimen. We just pass A plasma out the window. We used to thaw AB plasma when the blood type was unknown, but that stuff is just too precious.

BC

[MJDrew]

Good idea with A plasma!

I still maintain that no one will die from a 5-15 minute wait for thawed plasma. I've been busy lately dishing out statistics on TRALI and other reactions when we have a case with borderline coags and a desire to keep FFP flowing like water. Correcting the numbers is often impossible and attempts to do so can cause a multitude of other problems, the most common being fluid overload. Yes, this can happen even in a trauma patient losing blood by the bucketful. Surgery & anesthesia staff have a unique talent for transfusing folks into cardiac failure to "correct" coag values that won't budge one iota for the duration of the calamity.

BP, I would be really careful with the Factor VIIa before making this part of a trauma protocol. AABB has recently had a couple of articles in its daily mailings (Smart Briefs, I think??) regarding venous thromboses, pulmonary and cerebral emboli in troops in Iraq given Factor VIIa for bleeding, or, scarily, in anticipation of bleeding. Many trauma docs in the US are backing away from the enthusiasm they had about this product when it first was being used for this "off label indication".

[bloodpumper]

Massive transfusion protocols (MSP) are not going by the wayside. We just completed a MSP and put it into motion for our hospital. It is just a means to prevent bleeding disorders from depleted coagulation factors and platelets in a trauma patient. Many drugs also require adequate serum protein levels to facilitate transport and function. In a trauma situation, not everyone is thinking about maintaining these variables and it then falls on the blood bank to help provide a failsafe. I've seen situations in trauma where the hematocrit is greater than 40%, but the patelets are less than 20K and all of the coagulation tests were extremely abnormal with considerable bleeding, including cerebral hemorrhage. The patient remained in the trauma room for hours just because of the bleeding and then required massive amounts of platelets, Cryo, FFP and Factor VII to get dry enough to be transferred to the intensive care unit. The patient's lungs and kidneys then shutdown and the results were not positive. Had they maintained a better ratio of blood products, they may have potentially not seen this outcome. Often times clear fluids are given along with PRBC's which exaccerbates the edema and further dilutes the platelets and coagulation factors, and also compounds the bleeding. There is a catch 22 in these situations because you need to maintain an adequate circulating blood volume to sustain life, so anesthesia gives more clear fluid which lowers blood pressure and causes more bleeding by diluting coagulation factors so more fluid needs to be given. FFP can be infused almost as fast and it helps maintain oncotic pressure in the blood reducing hypotension which is how anesthesia gauges how much fluid to give. Platelets can be given more slowly. You have to maintain hemostasis during and after repair of the torn or damaged bones and tissues to prevent further problems.

[Mabel Adams]

My transfusion committee is asking for better guidelines relating to blood usage review. If a trauma patient gets 6 units of blood in one day, is it justified for the doc to give plts and 2 units of plasma? This doesn't fit my view of a massive transfusion, but the doc may have ordered the products early on when he thought it was going to be worse. How do we make blood utilization criteria jive with the newer thinking on traumas? We are a level 2 trauma center that probably gives uncrossmatched blood about 4 times per year, so it doesn't make sense for us to keep thawed FFP hanging around and our docs may get overly excited when they do get a badly bleeding patient. Any suggestion on where I can get current blood utilization guidelines including for trauma patients would be appreciated.

[bbbirder]

For those of you who regularly deal with several traumas with high blood use, I'd like to get ideas on ways to improve our issue process for blood in these circumstances.

We don't get many traumas or surgery patients with high blood use, and when it happens, some of the techs seem to be a little too slow in getting the blood out the door, while others can get it out quickly. I'd like the speedy ones to be an example to others, but would like ideas from other facilities as well.

When you are issuing 5-6 units of RBCs at once, how much checking of patient ID and unit numbers are you doing and still fulfilling the standards requirements for the checks at time of issue?

Any suggestions or ideas are welcomed.

Linda Frederick

[bloodpumper]

Hey Linda,

We are a level one trauma center and even if it is a dire emergency we always check the blood before issue. The minimum is patient identification for uncross matched universal donor and the full Monty for cross matched. The problem you may be having is due to the low number of cases you get. Let your techs watch a trauma case to see the importance of speed and accuracy. Checking does slow things down a bit, but being prepared ahead of time when a trauma is on the way sure helps.

Mark

[rcurrie]

If you have the inventory to do so, have a massive transfusion bucket set aside in your refrigerator. Have a form with each unit number and product code already completed so that all you have to do is write the patient info on the form along with the issue info (who, when, where). It takes us less than 2 minutes to issue a bucket 'o blood, including the final inspection.

BC

[Mabel Adams]

Has anyone with the newer Massive Transfusion Protocols that include plts and FFP with the red cells as soon as possible found a reasonable way to issue their "bucket-o-blood products"? We won't have pre-thawed FFP so it will likely go out a little later than the red cells and plts. It seems like it would be good to keep it all together but we have temperature issues between red cells and plts and even freshly thawed FFP might be too warm to put in with red cells. So, any creative coolers out there?