massive transfusion

[Antrita]

Does anyone have a massive transfusion policy that actually works? Ours keeps changing mainly because it doesn't allow for different situations. Right now we are going with "packs" A pack is 3 pack cells, 1 jumbo FFP, and 1 platelet. If they order 2 packs it is considered a massive transfusion and we are to supply additional packs until they say it's over. Every other pack we are suppose to provide pooled cryo and also run DIC panels.

8 hours ago CCU ordered a "probable massive transfusion" They think this patient will hemorrage at any time and they want everything ready to go. I have had FFP and platelets tied up on this patient all day.

I feel like I need different types of massive transfusion procedures, or better yet I think just ordering the packs as needed

Antrita

[David Saikin]

We go by the concepts from the AABB Massive Transfusion Teleconference . . . basically a 1:1 replacement. 1 fp for every rbc with a platelet pheresis for every 5-6 rbcs. It MUST be initiated by the ER/OR docs - doesn't happen automatically from the BB.

[Antrita]

What bothers me is so much time is spent on writing procedures and policies on what is in a pack, how many packs make it a massive transfusion, how often do we do coag tests, etc and then we get a trauma. The traumas are at night of course and the OR wants blood and plasma, not packs. The people that some how never got the training are always the ones in the OR and our protocol falls apart. We have improved though, we are getting them to use more plasma, platelets and cryo but it is just not working right. There has to be a way of getting the right ratio of products without it being so cumbersome that when trauma hits the protocol is the first thing to be tossed aside.

Antrita

[Bill]

Isn't that always the case--not just trauma situations, but mass casuality incidents also. Groups spend hours developing the protocols and some doctor or nurse throws it away without even trying it. I have been in situations when this was done even during a planned drill and the doctor and nurse could not see where they did anything wrong, even though all the planning and purposed test were now worthless.

[jcdayaz]

My experience with massive transfusion protocols refer to massive transfusion as the need for >10 units of blood within a 24 hr period. However, after 6-8 units of blood we would call the DR and "suggest" he/she begin replacing the other products as well. The DR's have always listened to any "suggestion" we have ever made. (In some small portion of their brain, I think they know what they don't know!!)

At 10 units, I would add cryo to the list of necessary products....

[adiescast]

Our massive transfusion protocol runs pretty well. We pack coolers in a set order with a set number of products. We have told the doctors if they call for the massive transfusion protocol that they can't cherry pick from the cooler. If they don't need what's in the cooler, they need to call off the protocol and go back to ordering what they need. They can order over and above the protocol. For example, we send one platelet pheresis with the first cooler and the third cooler, but the doctor can say they want one with the second cooler also or they want 20 cryo instead of the 10 cryo in the protocol.

[Malcolm Needs ☆]

Isn't that always the case--not just trauma situations, but mass casuality incidents also. Groups spend hours developing the protocols and some doctor or nurse throws it away without even trying it. I have been in situations when this was done even during a planned drill and the doctor and nurse could not see where they did anything wrong, even though all the planning and purposed test were now worthless.

At one of the hospitals at which I used to work, we had a rail crash to deal with (needless to say, on a Saturday afternoon).

Something went wrong with the telephone list, and the person on-call for the Blood Bank was never officially informed of the major incident. The first person notified was the Biomedical Scientist on-call for Microbiology!

There may, actually, have been some logic in this. British Rail sandwiches were notorious at the time, and so, perhaps, they were expecting mass cases of food poisoning!!!!!!!!!

:eek::eek:

[Eoin]

We have a Massive Haemmorhage policy PLUS a wall chart which is in all clinical areas. The wallchart directs the traffic (one senior nurse appointed as co-ordinator - who to call - what to do. It is a full flowchart including path testing - frequency of testing and stresses close contact with a Clinical Haematologist specialising in Blood Transfusion. Oh - it also clearly defines what constitutes a massive haemmorhage. The policy clearly defines roles and responsibilities and training is given on it at least yearly to nurses, lab scientists and medicos (if we can get them - including particularly anaesthetists). The policy is reviewed yearly by key members of the hospital transfusion committee.

Cheers

Eoin

If you reply to this, I will not be back in circulation till early Jan 2010 - off to Canada for Christmas today (4hrs & 52 minutes - but who is counting!)

[Malcolm Needs ☆]

Have a good one!

[Scott Hampton]

I am the manger of the BB at Parkland Memorial Hospital in Dallas, TX. Parkland is a level I trauma center and burn unit. I believe that we have a very sucessful plan. Our plan consists of predetermined shipments of blood product and NovoSeven. The plan is the plan. Once the MTP order placed, the BB takes over. We do not deviate unless additional written orders are received. We monitor wastage very closely and review each MTP with our medical directors. We do about 10-15 /month. Contact me if you would like to discuss.

[martha]

Does anyone has a massive transfusion protocol for a Children Hospital?

[Townsend]

I was about to ask the same thing regardiing MTP in pediatrics!

I am the TS Manager from Nationwide Children's Hospital (Columbus, Ohio), a level I trauma/burn center. We have been reviewing our MTP procedure recently and are about to make some changes. The original policy called for red cells/plasma/plts in an approx 1:1:1 ratio based on the patient's dose. Once instituted by the physician, components would be prepared based on patient's weight. The problem is, once we were called, we had a lot of questions - can they wait for us to aliquot the doses, do they need whole units? etc. We will soon be making the change to predetermined "packs" based on patient weight instead of doses/kg:

Patient weight

Red cells per pack

Plasma per pack

Platelets per pack

<10 kg

1 unit

1 ped FFP

1 pheresis

10-40 kg

2 units

1 plasma (FZP or PFP)

1 pheresis

>40 kg

4 units

2 units (FZP or PFP)

1 pheresis

Now the blood bank tech will know exactly what to prepare, and the clinicians will know exactly what to expect once the protocol has been activated. We hope to institute the above packs after the first of the year.

Our only problem now is how to get everyone outside of the blood bank educated. The trauma team is on board and has a great deal of resources for educating their own staff, but we run into problems getting the ICU physicians as well as the OR (esp anesthesiology) educated on the protocol.

Stephanie Townsend, MT(ASCP)SBB:rolleyes:

[Townsend]

Oops, that did not display well, let me try again:

For patients under 10kg: 1 RBC, 1 (pediatric size) PLASMA, 1 PLT PHER

For patients 10-40kg: 2 RBC, 1 PLASMA, 1 PLT PHER

For patients >40kg: 4 RBC, 2 PLASMA, 1 PLT PHER

Sorry about that, cut and paste did not work:p

Stephanie Townsend, MT(ASCP)SBB

[jane tidman]

Hi,

We are a large trauma centre that has been running a massive transfusion protocol since Setember 2008.

Pack 1

4 pks O neg red cells

4 AB FFP

Pack 2

4 pks type specific or cross-matched red cells

4 FFP

I pk platelets

Pk3

As pack 2 plus one adult dose cryopool.(if fibrinogen under 1.0 g/l)

Full blood counts and clotting profiles being performed.

On audit we found only a third of requested units of red cells and FFP were actually used.

Since 1st December 2009 we have put in a preliminary step, before MTP pack 1, of 2 units of O neg red cells.

Since this date not a single MTP has been called!

Hope this helps,

Jane

[MAGNUM]

Our MTP has not been tested to its fullest, but it does work when confronted with a massive hemorhage in the L&D. I have uploaded my policy minus the headers and all.

MASSIVE TRANSFUSION POLICY MTP BB-125 2.doc

[Bill]

BBT--can Magnum's protocol be added to Document Library?

[Antrita]

Part of our problem is we are not a trauma center but we are the only hospital with a population of 90,000. We get cases that we probably shouldn't and we may go months without any major traumas. It seems like after we have one I usually only find out what doesn't work. I like the idea of a wallchart though hopefully it would be read. I have placed tables with what type FFP is compatible with the patient's blood type in 5 places in the blood bank. In this last trauma the patient was O positve the CLS was OK with giving the patient AB plasma but not B, but this is a whole other issue.

Thank you Malcolm for the train story, a laugh always helps.

[tbostock]

I agree with Scott Hampton that the "plan should be the plan". Allowing too much flexibility adds confusion and too much communication. One of the purposes of the MTP is to limit unnecessary communication, so everyone can do their job, thereby limiting error. The tricky part is getting everyone "on board" with the plan and agreeing to let it work without trying to take over.

[Antrita]

I found out Friday that OR has not been informed of all the changes ER has made to the MTP. This information might have been helpful. The powers above wanted to know why we did not release the blood in packs. OR said no to packs, as it turned out, they knew nothing about packs.

Antrita

[kate murphy]

Our extremely busy trauma unit (we call it the knife and gun club) uses much the same plan:

1st cooler - 4 RBC

2nd and subsequent coolers - 4 RBC, 4 FFP, 1 PLT.

Cryo as needed.

Novo7 for blunt trauma and certain head bleeds. One dose only.

Need for lab monitoring andvVery clear goals for INR, Plt and fibrinogen.

Here's a short flow diagram.

When we instituted this 4-5 years ago, products were wasted, as the Emer Dept used it for every trauma coming in. Learning curve, now they are much better, and we average about 6/month and they are real.

MassiveTxflowdiag1.doc

[Malcolm Needs ☆]

Need for lab monitoring andvVery clear goals for INR, Plt and fibrinogen.

.

Kate, do you, or anyone else for that matter, use Thrombelastograpgy (or something similar) in such cases?

There is a theory that this gives are more immediate (and possibly more accurate) measurement of the patient's haemostatic state, on the grounds that the coagulation sample tested in the Laboratory only gives a snap shot of the patient's state when the sample was taken, and is only then as good as the sample taken in the first place?

Having said that, I believe this is used more commonly in the Operating Theatre than in Accident and Emergency, and I also hear a rumour that it is not as good as was first thought (although this could be idle gossip).

:confused::confused: