Massive transfusion protocol

[bpkelly]

WE just use separate coolers- we are issuing 5 LPRBC, 5 plasma and a platelet. WE don't generally keep thawed plasma so yes- is goes out after the LPRBC. Our physicians usually tell us not to send the platelets right away. We also issue Factor 7 as part of out massive protocol.

[jkroc]

I was wondering if anyone else out there was getting pressure from the trauma teams to go to a 1:1 ratio of rbc:ffp. There are a couple of articles out there in the journal of trauma that show better survival rates with higher plasma ratios in Iraq battle cases. I am concerned about TRALI, about AB ffp shortages, etc... your thoughts?

[Mabel Adams]

One thing I heard was that some of the data coming out of Iraq may not be applicable to the mechanisms of injury of our non-combat traumas. In the war, the extent of tissue damage is much higher than in your average ruptured spleen from a motorcycle handlebar or horse kick. I think it is wise to move in that direction (swifter provision of plts and FFP) but I wonder if the trend suggesting 1:1 will be found not to apply to all massive bleeds once all the hype settles.

[rcurrie]

Back when I was in the blood banking business, I was a member of our Level 1 trauma team. When the issue was brought up, I said they could have all the type A plasma they wanted, as I was unable to even put a dent in the bucket with AB plasma. They weighed the risk, and agreed. So, we don't automatically supply AB plasma for our traumas- they get type A until proven to be type B or type AB. It sure beats no plasma at all.

BC

[porterl]

We don't advice the physicians when to order other blood components.. BUT.. we do have a massive transfusion policy, so that the Blood Bank Staff can go ahead and prepare the products, without orders, so that there is no delay in thawing plasma or pooling cryo.. etc.

We issue "batches" of products, (6 RBC, 4 FFP, 1 dose platelets and 10 cryo (every other batch)), so the physicians have all products readily available to transfuse when needed.

[scodina]

We try to issue red cells and plasma in equal numbers during a massive transfusion incident. However, we only keep 2 AB thawed plasma on the shelf at all times, so we often do not meet this for the first cooler. That said, we are in the process of creating an objective blood utilization review for patients on the massive transfusion protocol. One thing I have unofficially noted during my reviews is that this plasma often gets transfused even though the INR is 1.2 or less. Therefore, we will likely change this protocol in the future.

As for platelets and cryo, I do not believe the data is there to support giving prophylactic platelet or cryo transfusions even in a massive transfusion situation. As part of our new utilization program, we are proposing that the blood bank attach tubes to every 10th unit or RBCs that is issued. We pre-place a line of fluorescent green tape on the top of the tubes and put them in a colored biohazard bag that is different than all other biohazard bags used in the hospital (both of these are for lab recognition). Clinical staff is expected to draw a platelet count and fibrinogen and send it to the lab super-STAT for testing. The goal of doing this is to remind the physicians to test these parameters. I think that when they are attending to a massively bleeding patient, they are doing all they can to keep the patient alive. It is amazing how quickly time passes when the adreniline is pumping! Even though they know they should be testing these parameters every so often, the every so often goes by quickly and probably does not get done as often as it should. The lab will call results to the clinical location and, if results are abnormal, that will be the flag that tells the physicians to order platelets or cryo. By using this method, the BB wins with utilization (we are not indiscriminately sending products out the door) and the physicians maintain control of the orders.

[Debbie McCaskill]

We are a Level 1 trauma center. We are trying to update our MTP to provide FFP and Platelets as soon as possible. I have asked our supplier to think about providing us with liquid plasma of all types in a limited supply. They are not too keen on this. I like the idea of having thawed type A plasma available and may approach our trauma surgeon with this idea. Thanks for this idea! Does anyone have a supplier that provides pools of cryo in a frozen state? That was a suggestion I recently heard at an AABB teleconference recently.

[scodina]

We purchase our pre-pooled cryo from the American Red Cross. They make pools of 5 cryo, so we generally give out 2 pools as one dose. It is wonderful....especially when you are in a time crunch.

[bloodpumper]

Essentially, having a massive transfusion protocol aids in having the necessary blood components available when needed. Timing is crucial in this setting and the usage of additional PRBC's, autotransfusion salvaged red cells, albumin or normal saline instead of FFP and platelets, only compounds the dilutional coagulopathy and places the patient in a more compromised position of volume overload, pulmonary compromise and multiorgan failure. A 1:1:1 ratio of red cells to FFP to platelets, helps to maintain the balance of oxygen carrying capacity, proteins and coagulation factors necessary to stop this vicious cycle of dilution, coagulopathy, hypothermia and acidosis by reducing the time to hemostasis and thereby reducing the volume of blood products given. The number of actual massive transfusion cases is low and often less severe in nature than in the battlefield of Iraq, but the consequences, mortality and morbidity are equally as high. It has been through the experiences in all of our past armed conflicts that modern trauma centers and the massive transfusion protocol have developed.

Mark Lucas, MPS, CCP

International Board of Blood Management

[BloodBank]

We are level 1 trauma center. We 3 years back developed MTP with Trauma unit and it is working well for BB & Trauma.

Here how it is.

1. Pt. arrives in Trauma, MD assess as hypotensive,tachycardic,<7 base deficit,unstable, planned emergent operative procedure, calls BB to initiate MTP. BB & Trauma assignes MTP coordinator(any tech in BB & RN in Trauma). All communication then on regarding MTP pt. between coordinators. This prevents lot of confusion, duplication, unnecessary phone calls.

2. MD give s pt. name, MR#, location, sex, requesting MD's name.

3. BB dispatches 6 RBCs unxm "O" in a cooler to trauma, obtains pt. sample & return toBB.

4. BB prepares another cooler with 4 unxm "O" to be taken to OR if pt. is on the way to OR.

5. Time Out: Trauma calls BB to continue MTP in OR.

6. BB processes sample, prepares 6FFP(thawed plasma if available), 5 plts, xm 10rbcs (available at 1 hour mark from the time specimen is received).

7. At 1 hour mark BB sends 2 xm rbc, 2 FFP & 5 PLTS to OR via tube system.

8. BB continues to send 2 rbc, 2 ffp every 10 mins. for 30 mins. BB calls everytime product is sent via tube to OR.

9. After 30 mins. BB calls OR whether to continue MTP or not. (2u rbcs q 10 mins, FFP & Plts on request only after 1st 6 FFPs & 5 plts.

10. MTP coordinator calls BB to end MTP or continue till case is over.

We have flow chart posted in BB and Trauma. Trauma surgeons are happy with this because they know once they start the protocol, what is coming and time frame for the products arrival.

If you are interested I can email our policy and flow chart.

[Mabel Adams]

Can you just post the flow-chart and policy here as an attachment to save yourself all that emailing?

[BloodBank]

I will try

[BloodBank]

Arrival of Trauma Patient

Pt assessed as:

Hypotensive

Tachycardic

<-7Base deficit

(unstable per trauma attending)

Planned emergent operative

procedure

MD calls Blood Bank to

Request MTP:

Give pt name, MR #, sex,

Location to send blood and get sample,

requesting MD

TIME OUT

Blood Bank dispatches phlebotomist, 6 units

Uncrossmatched type O RBC in cooler to Trauma (unless noted otherwise)

Blood Bank designates BB MTP Coordinator

Trauma charge Nurse is MTP Coordinator in Trauma unit

Blood Bank prepares additional cooler with 4

Uncrossmatched RBC dispatches to OR when location confirmed. (unless noted otherwise)

Blood Bank Processes sample Prepares 6 FFP,

5 Unpooled PLTs: Crossmatches 10 RBC

(available 1 hr from arrival of sample)

Trauma Team member retrieves blood from Pneumatic tube and returns carriers to BB

BB calls Trauma MTP coordinator

To confirm continuation of MTP (2u PRBC q 10 minutes, FFP on request only) at this time 1 hour after initiating MTP and every

30 minutes there after

(BB documents call)

MTP Coordinator calls BB to update on blood needs

(PLTs must be requested when needed)

Trauma Team calls BB to end MTP

(BB documents call)

MTP Ends

TIME OUT - Trauma MTP Coordinator calls BB to continue MTP protocol in OR

1 Hour Mark……………………………. Primary Numbers to call:

Blood Bank sends 2 crossmatched RBCs, 2 FFP, and PLTs as soon as they are available, via

pneumatic tube. BB calls MTP co-ordinator

to verify location and inform of arriving

blood

Room 15 – x41686

Room 16 – x41685

Blood Bank – x47471

Blood Bank continues to send 2 RBC and

2 FFP every 10 minutes for 30 minutes. BB calls

MTP coordinator to inform of blood arriving and verifies pt location (total of 6 FFP will be sent, additional FFP must be requested as needed)

OR – x42123 – (Internal

control Desk)

[BloodBank]

Flowchart did not come out right. I am not sure how I can attach it with the boxes and arrows. Sorry

[Mabel Adams]

If you use New Reply instead of Quick Reply there is a box at the bottom that says Manage Attachments. Click that and then browse for the file just like attaching to an email.

Even as posted it is useful info. Thanks.

[BloodBank]

Thank you for info. I have attached MTP flow chart. Hope this can be of any help. This works good for our trauma attending staff.

MTP Flowchart.doc

[Antrita]

We have been moving towards using more and more FFP, Cryo and PLP.

Our massive transfusion protocol calls for 1 FFP for every 2 units of packed cells, a platelet after 4 units and then cryo. The success of more FFP early on in Iraq has really influenced our trauma protocol.

Antrita

[kim]

Our blood bank just approved a new massive trx protocol with our trauma team a few weeks ago. The ER will call us telling us that they are implementing the massive trx prot. They then have to send up the Emergency Release request with the massive Trx Products box checked. The products that we release are 6 O RBC's,4 FFP and 1 plt. We then call the Blood Bank resident on call and let them know the situation. We also will not release another set of products until we get a sample or the blood bank resident approves it. We also keep thawed O's and A FFP on the shelf at all times. If we get a request for Emergency Release FFP without a type on the patient we first will give AB's only if we have them thawed if we don't have any thawed we give A's then B's.

[Joanne P. Scannell]

We have a similar protocol ... all in an effort to give them what they need asap and without a thousand phone calls!

Taking the idea away from Burger King/McDonald's/Taco Bell ... we have pre-defined 'Packs' ... and once ordered, we keep making more until they stop coming to get them. This way, we KNOW ahead of time what the needs are and can plan our activities/staff/inventory accordingly AND there are 'no more' phone calls to interrupt and confuse us.

We have 4 'Packs' defined, the contents of which were determined by a collaboration between the Blood Bank and the specific department, eg. ED for Trauma Pack, Birthplace for Obstetrical Crisis Pack, Cardiac Team for Cardiac Crisis Pack.

I have a little color coded chart posted at each station in Blood Bank so that when these packs are ordered, everyone is clear about what they need to prepare.

[Mary**]

Does this only apply if you do not a have a blood type on the patient?

[Joanne P. Scannell]

Yes. If we have no sample, all the stuff goes out 'Emergency Release' until we have a sample and have completed all necessary testing.

[Mabel Adams]

JPCroke, can you please tell us what is in your packs, how frequently you issue them, whether you are a big trauma center and how you adapt the protocol if they don't use all the products in earlier packs.

[gwendamckee]

Our current program is to give 5 RBCs, 5 thawed plasma (FFP) and one apheresis platelet. They believe this is as close to whole blood as we can get and avoids dilutional coagulopathy. Most of ours are L&D patients.

[Joanne P. Scannell]

Yikes! Better review some contemporary literature about massive transfusion ... don't need a 1:1:1 ratio to maintain hemostasis, etc.

[Joanne P. Scannell]

Sure.

Code Yellow STAT Packs: 2 O neg (once)

TRAUMA PACK: First Cooler = 4 RBC Subsequent Cooler = 4 RBC + 2 FFP

Platelets and Cryo are packed when ordered.

OBSTETRICAL CRISIS PACK: Two coolers are set up immediately. One RT with 2 u Plateletpheresis, the other cold with 4 RBC. Subsequently, RT cooler has 1 Cryo (pool) + 2 Platelets. Cold coller has 4 RBC + 4 FFP.

CARDIAC CRISIS PACK: Same as OBSTETRICAL except they didn't want RBCs in subsequent coolers.

Not to say these are right for every hospital ... these combinations were decided upon by the affected groups.

How frequently? The Trauma packs are a few times a week. The others ... may be weeks or months between them. Once they order one though, we keep making them up until they stop coming to get them (effectively staying ahead).

Returns are treated just like any other returns. The temperature of the cooler is taken and if acceptable, the units are returned to inventory.