Massive Transfusion Protocol

[Nancy L.]

We are a looking at developing a Massive Transfusion Protocol. We are a busy but small (110 bed) hospital. Most of the information I have on MTP's come from larger hospitals and level I trauma centers. Does anyone have any experience with MTP in a smaller setting? Some of the issues we face with trying to implement an RBC:FFP:Platelet ratio are as follows: We do not convert to "thawed plasma". Therefore we do not thaw plasma ahead of time as any FFP thawed and not used within 24 hours is wasted. We do not stock platelets. It takes about 2 hours to get them here from our supplier. We do not stock cryo. We have very few massive transfusions. Probably a couple per year. I look forward to any advice or insights you can share. Thanks!

[Lcsmrz]

Your facility sounds about our size and distance from our supplier. Although we try to use group- and type-compatible units for routine transfusions, we have a liberal trauma policy on using Rh Pos RBCs for males and females > 50yo. We thaw plasma once an order to transfuse if received, and order platelets once the clinician knows it'll take 1-2 hrs to get them. Many of our trauma patients are stabilized only, then transported to "downtown", so we don't overorder.

Our pathologist gets involved in trauma's and makes suggestions, depending on the clinical situation.

[Steven Jeff]

Hi Nancy

There is a set of guidelnes for the management of massive transfusion in the reference section tab, United Kingdom, BCSH tab. These may help you understand the issues.

Regards

Steve

Edited April 26, 2010 by Steven Jeff
spelling again

[vav5325]

Our hospital has ~800 beds and a level 2 trauma center. We have a massive transfusion procedure as well as a " Massive Transfusion Protocol" (MTP). I know they seem one in the same but for our facility there not. The massive transfusion procedure is initiated by the tech and pathologist when a current patient has taken a large amount of products over a short period of time. If the pt is Rh neg and if were low on inventory we obviously switch over to Rh pos. Plasma and Cryo are thawed on demand and Plts given upon request.

Now our MTP is a little different. This is initiated by the physician. They call the blood bank and state that an MTP has been initiated on a PT. We immediately send down 4 O neg PRBCS , 4 "thawed" AB plasma and 1 PLT. This is continued every 30 minutes until the MTP is called off by the physician. PLTs are sent every other round. "Pooled cryo" is thawed on request. If the pt is a Male or a female >50 we give O pos prbcs until we receive a sample. Our pathologist and blood supplier are notified when an MTP is called. Each MTP is reviewed by the Transfusion Committee. Hope this helps.

[David Saikin]

I am from a small hosp (40beds) - MTP calls for 1-1-1 replacement. Rbc - fp- plt. we will give one plt pheresis for every 6u rbc and plasma transfused. Pretty standard protocol. Unless you are a woman less than 50, you will get O+ rbcs, no questions asked unles/until we know the correct type. Only have a large stock of O+/A+ so chances are they will continue to get O+. May even get O+ when small supply of O= runs out. Process is in place, haven't had to use it yet.

We could not support a MT for very long - should be shipped to our referral tertiary care center ASAP.

[bbbirder]

Our hospital is licensed at 240 beds (but I don't know what we really have, I think it is less than that.)

We have a massive transfusion 'protocol' that calls for us to issue 6 RBCs right away (O pos to any male or female over 40... we got our OB staff to agree to 40 vs 50 considering that if this is truly a massive bleed, the patient is likely to die or bleed so much they are not sensitized), and start thawing 2 FFPs (we decided to thaw A's and not AB's because we have covered 85% of the population and if they are bleeding that much we would run out of ABs anyway and they will dilute out quickly) and to issue one PLT apheresis if requested. We keep PLT on hand, but only a maxiumum of 3. We are to assess the PLT inventory and order more ASAP. CRYO is to be thawed as requested (5 random units that are pooled, or one pre-pooled CRYO) and it is suggested that this is thawed if the patient is an OB. We keep CRYO on hand, including pre-pooled CRYO. Most of our CRYO is never used and is discarded as expired. But we need to keep it.

As soon as the above are issued, we get more stuff ready (6 reds, 2 plasmas, 1PLT, Cryo if needed) and continue with that 6:2:1 mix. After 6 Rh neg RBCs have gone out, the next batch is Rh positive. [This is talking about the kind of bleeding where you are shoving it out as fast as you can, not something stretched over 24 hours.] It might be better to give more of the 'yellow stuff' than RBCs, but the clinician can make that call, the time to thaw FFP is somewhat of a limiting factor.

We are 2 hours away from our supplier, so PLTs are a concern.

If you want copies of our procedures, send me a 'private message' and I'll get them to you.

Linda Frederick

[tbostock]

Our MTP also calls for a 1:1:1 ratio, but it sounds like you would not be able to support that at your hospital due to your limited inventory. You can do the plasma. Yes, occasionally you will "waste" a few units in a protocol such as this, but I look at it as all part of the cost of trying to save a massively bleeding patient. You gotta do what you gotta do...

[celbailey]

I am interested in finding out when Blood Bankers are eliminating ; then resuming compatibility testing while your massive transfusion protocol is activated?

[tbostock]

We do immediate spin crossmatches. If a patient has an antibody and needs a Coombs' crossmatch, if time allows, we do it until after 10 units of red cells has gone out the door. Then we discontinue it and just do the immediate spin. At this point, it's not their blood anymore in their body.

And then, of course, we complete all testing after the fact if the physician needs the blood prior to the testing being completed.

[celbailey]

This is basically what we currently do....my last JC surveyor seemed surprised that we still immediate spin after the 10th unit. Thanx so much for the quick response!!!!! Cel

[adiescast]

We are mostly doing electronic crossmatch. When we did immediate spin crossmatch, we eliminated it after 10 units and did not go back to complete it later. If the patient has an antibody (God forbid!), we would go back and do the AHG crossmatch after the emergency to see how much damage we may have done.

[Malcolm Needs ☆]

We are mostly doing electronic crossmatch. When we did immediate spin crossmatch, we eliminated it after 10 units and did not go back to complete it later. If the patient has an antibody (God forbid!), we would go back and do the AHG crossmatch after the emergency to see how much damage we may have done.

Under the circumstances, I would suggest a great deal less than if you had withheld the blood and let the patient bleed to death!

:eek::eek:

[rravkin@aol.com]

We are a looking at developing a Massive Transfusion Protocol. We are a busy but small (110 bed) hospital. Most of the information I have on MTP's come from larger hospitals and level I trauma centers. Does anyone have any experience with MTP in a smaller setting? Some of the issues we face with trying to implement an RBC:FFP:Platelet ratio are as follows: We do not convert to "thawed plasma". Therefore we do not thaw plasma ahead of time as any FFP thawed and not used within 24 hours is wasted. We do not stock platelets. It takes about 2 hours to get them here from our supplier. We do not stock cryo. We have very few massive transfusions. Probably a couple per year. I look forward to any advice or insights you can share. Thanks!

Nancy,

It would be very difficult for you to sequester a set PC's from your limited inventory for two exanguination events per year and with no platletes on hand. The very best thing that you can do is to organize your BB to the max for handling this situation. First, I would suggest filling out prewriten unit tags with as much info as possible without specifying a unit or pt. I would also have emergency release cards presigned by your medical director and BB supplier forms ready and filled out with as much info as possible without designating date, time, type, or number of products. You may want to designate a BB bench specifically for this operation; this bench should be near all of your products. You also should develope a flow chart graffic procedure that would be kept at this designated bench. You may also want to preassign staffing for the three shifts in writing so that each of your staff will pre-know what role, if any, they are to play during this event; and make it clear and consice. Remember the better organized you are and the easier you make the flow chart procedure the more effecient the work will flow. A drill or two per year per shift should work to keep your staff fluent and on the ready. I would set a TAT goal of no longer than ten minutes for the initial PC's to leave the BB. The closer you come to five minutes however the better the prognosis theoretically. Prewriten tags for plasma and platelets should also be at hand. Remember always be ready; it's difficult to do but we have no choice! I hope this helps.

Edited July 18, 2010 by rravkin@aol.com

[Nancy L.]

rravkin,

Thank you for your suggestions. We are, in fact, in the process of doing pretty much as you suggest. I am developing a flow chart procedure and have set up scenarios for techs to "dry practice" to give me feedback for the flowchart. I have also made up "Emergency Release Packets" that contain all the tags, uncrossmatched blood stickers, forms, etc. that would be needed in a massive transfusion or emergency release situation. As much information as possible will be filled out ahead of time. Our current (soon to be previous) procedure is quite thorough and complete and way too cumbersome to be a quick reference. I am trying to make it as easy and as efficient as possible since we all know that these things always happen when the least experienced part time tech is covering blood bank! Once I have the flowchart procedure and packets complete, we will have drills to get everyone comfortable and follow that up with q 6 mos competencies. We meet all requirements now but my goal is to ensure timely competence and efficiency - not just compliance. Thanks everyone for your comments!