Guidelines for initiating MTP

[Mabel Adams]

Does anyone have good guidelines for telling docs that maybe don't deal with massive transfusion that much--say OBs--how to know when they should call a massive transfusion? Obviously, we can't wait till we've already given 10 units of RBCs. I was thinking that if they thought they were likely to give over 4 (or 6?) units RBCs in an hour it would be reasonable to initiate a massive. Or maybe estimated blood loss?

I am trying to help our smaller hospital (we crossmatch remotely for them) devise a quick and dirty system for the very rare occasions when they might have to keep a massive transfusion patient to stabilize. One of the biggest problems will be communication including knowing whether this is a Massive Transfusion. If that lab can ask a simple few questions of the nurses that might be an effective way to know to initiate an MTP. I just need help in devising the questions.

[tbostock]

From our MTP policy:

Guidelines for Initiation of a MTP

1. The MTP should be initiated when the Trauma Surgeon or Anesthesiologist anticipates a transfusion requirement of greater than 6 units of red cells within 4 hours of hospital admission for the following patients:

a. Major torso trauma: defined as injury of two or more abdominal organs, two or more long bone fractures, complex pelvic fractures, massive hemothorax, or major vascular injury.

b. Metabolic acidosis: defined as a base deficit equal to or greater than 6 meq/L within 12 hours of admission.

c. Age: a patient 65 years or older with two of the above criteria.

2. The Blood Bank will be contacted immediately to initiate the MTP.

[jalomahe]

We just implemented a new MTP in our lab to include scenarios where MDsor departments may be unfimiliar with the process.

If we have given 5-6 pRBC in under an hour the tech will ask if the MD wishes to call an MTP. If the answer is 'no' then the tech will notifiy the Transfusion Service Medical Director (or pathologist covering) to inform them of the situation. That way the can intervene MD-to-MD if necessary.

Our problem in the past is that nursing/MDs don't like it when we start asking them questions. They want us to just keep throwing product at them without knowing what's going on. Putting the med director/pathologist in the loop helps alleviate this.

Also when we instituted the new policy we did short presentations to various nursing departments during some of their mandatory education sessions. This allowed them to ask question of us and find out that we really do have a need to know and that we can help them get ahead of the patient's bleeding to help stabilize the situation, instead of always playing catch up.

[BSIPHERD]

This is from our Massive Transfusion Protocol procedure:

1.3 Patient criteria: Patients who show clinical evidence of exsanguinating hemorrhage require activation of the MTP. This may include category I trauma patients, aortic rupture, surgical misadventures, etc. Patients likely to require large volumes of fluid and blood should be considered for inclusion in this protocol as soon as one of the following is evident:

No.

Criteria

1

Hypotension: Patients with evidence of injury and systolic blood pressure (SBP) < 80 in an adult or < 60 in a child under the age of 12; or SBP from 80-90 that does not respond to a rapid infusion of 30 ml/kg of Lactated Ringers (2L for a 70 kg patient).

2

Major obvious blood loss: >700 mL immediately out through a chest tube, multiple long bone and/or pelvic fractures, heavily blood soaked clothing, etc.

3

3 units of Red Cells during resuscitation: and will obviously require additional transfusion.