Massive Transfusion

[scodina]

Are any of you auditing massive transfusions for appropriateness? Currently, or BB medical director does a quick review of massive transfusions to ensure that coags/CBCs were drawn and she lists patient outcome, but she finds it difficult to do any more retroactively. Hospital administration has asked us to do a more comprehensive, objective review as part of our blood utilization review. We are not sure where to go with this.

Also, does anyone have a separate massive transfusion protocol for pediatric patients? We are currently using our standard "adult" massive transfusion protocol for everyone, but our pediatric trauma numbers have reached a point where we probably need a policy adapted to pediatric transfusion. There is not a lot in the literature, but the physicians have suggested breaking this into either age or weight groups. Any help will be greatly appreciated.

[Marilyn Plett]

The most recent AABB audioconference was about managing massive transfusion. The participants discussed their protocols. You might get some good ideas from that. The AABB also published Guidelines to Massive Transfusion in 2005.

[jhaig]

We get massive transfusions so rarely that any type of review wouldn't be feasible. However, our protocol states that, after every 10th units of packed cells transfused, the patient is to be drawn for coag profile (PT, APTT, FIB, platelet count), K+, and ionized CA. A full summary of the incident, including chart review, is to be done by the blood bank supervisor, reviewed and signed by the pathologist, and reviewed at the next transfusion committee meeting.

[Likewine99]

Our network trauma team devised our massive tx protocol, based on literature they reviewed relating to trauma. It lays out the guidelines as to what tests to be done after units of RBC's, FFP, and plts are given.

BB keeps track of what has been given and notifies ED/OR/ICU of which labs to draw. We haven't been asked to retrospectively monitor this, it only happens about 3 or 4 times a year at our place.

[adiescast]

We recently instituted a massive transfusion protocol with specific product numbers in a designated order. The OR medical director is doing a retrospective review on the patients we have had. He is looking at time of arrival to time of first unit, injury score, volume of crystylloids/colloids infused, vital signs on arrival, INR, time to OR, and outcome.

We started this policy because there were reports of better survival in patients who received plasma instead of saline. So far we have not observed any improvement in survival. One thing the reviewer is doing is to determine whether the protocol was run correctly by the physician and whether the patient had any chance of survival on arrival.

[kate murphy]

We do a lot of traumas, and lots of massive transfusions. To activate the protocol, the ER doc needs to tell us - write MASSIVE TX on the emergency release form. We do 4 FFP and 1 dose plts for every 8 RBC. Cryo is based on fibrinogen.

CBC, INR, PTT, Fib, ABG with ionized Ca is drawn every hour, until the protocol is closed. Usually when the pt is post-op and the bleeding is controlled. Most go 8-10 hours.

We are currently training OB for this.

We do not have a separate pedi protocol as yet.

[mewilde]

Children's Hospital in Detroit, MI has a policy for Massive Transfusion in pediatric patients. They tweaked the adult policy to "fit" smaller people. Let me know B/C if you want a contact and I'll supply you with the information.

[jtmtascp]

We have implemented MTP at our facility and have had some that were of questionable utility. It seems that some of the MTP's were called simply because the department did not want to send someone to courier the products and since our protocol requires that the lab deliver the products they have taken advantage of the protocol.

Since then, because of waste, our Utilization Review committee has begun reviewing all MTP's although I believe the review to be somewhat cursory in nature.

[Eoin]

We have adapted the National Blood Users Group of Ireland protocol for our use. There is a clinical flowchart. it even spells out what constitutes a MT. Early FBC Coag, Bio and gases , followed every four hours or after every 1/3 blood volume replacement. Anticipate low coag factors after 1.5 x pt blood vol replacement. FFP & platelets given as result of lab results. aim for PT aPTT <1.5 x mean control. Cryo as result of low Fib. Aim for Fib > 1.0g/L. repeat as necessary. Losses are scaled down for paeds. Same component/product triggers but plats 10-20ml/Kg body weight. FFP 15mls/kg body weight. Cryo 1 - 1.5 packs / 10kg body weight. Same aims of treatment as above for adult. The flowchart tells users exactly what to do (including appointing a coordinator) and we insist on a Haematology Consult.

[scodina]

Thank you to everyone who replied to this message. I have been out of the office for a few weeks and have been very bad about checking the thread while away. I found everyone's response very helpful and I would love the contact information from Detroit if you would be willing to provide that. My e-mail address is stephanie.L.codina@healthpartners.com.

I am glad to see that may of you indicate your MTP dictates when coags, platelet counts, etc need to be drawn. I think that is what we have decided to do.....essentially let the lab results indicate when cryo and platelets should be given. We give rbc's and plasma out in equal numbers based on the military's research suggesting that this ratio demonstrates improved patient survival. However, we often run into the scenario where the red cells are given and the plasma is returned. I was able to discuss this with Anesthesia lately and received a valid reply. Essentially, they stated that they recognize that red cells and plasma should be given in a 1:1 ratio during an MTP. However, these patients generally have a dramatically reduced oxygen carrying capacity. When they are pushing products in as fast as they can, they are forced to make the choice between blood and plasma. Increasing the oxygen-carrying capacity trumps the coagulation parameters every time.