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Massive Transfusion Protocol


Kathyang

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I was wondering what kind of protocol other Blood Banks use for Massive Transfusion. I work in a 100 bed hospital and we don't get trauma cases. Our protocol says to switch to uncrossmatched after 10 units in a 24 hour period.

We had a doctor at the Transfusion Commitee meeting that wants to have the amount of FFP, platelets and cryo needed in the procedure. He is worried about a healthy female after a C-Secion bleeding and needs an emergency hysterectomy. This got into a discussion saying that if the patient is a normal , FFP wouldn't necessarily be needed, etc. They would like information for our Dec meeting.

If anyone has any information on this, it would be helpful.

Thanks,

Kathy

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Hi Kathy,

I run the blood bank of a large hosiptal (around 500 beds) but we are not a level 1 trauma center - we have around 1-2 massive transfusion cases a month so keep this in mind -for your facility, but our center has a protocol that states if more than 6 units of packed cells have been transfused in a short period of time (2-3 hours is defined as short) OR greater than 10 packed cells transfused in 24 hours than the MTP should be initiated (by blood bank or by OR,etc) - this is how many hospitals decide to define an MTP. The protocol on what makes up the MTP package would then be up to the blood bank and the potential users of the MTP - so if your L&D services wants to use it or your emergency service - they should be involved also. Our facility goes with a 6,6,6,10 pack = 6 red cells (many times the first round would be O neg uncrossmatched), 6 FFP , 6 plts (either a pool, SD pheresis or prepooled acrodose that we always have on hand) and 10 pk of prepooled cryo. We do not have FFP or cryo prethawed so we would send up the red cells and plts first while thawing the FFP and cryo. Then the cycle repeats until they say STOP! We had a discussion about MTPs at our annual blood bank meeting for the state and found that smaller hospitals may not have a plt on hand, or many go with 4 pk cells and 4 FFP and maybe add a plt of some sort in the next package depending on how far they were from their blood supplier. So that will all depend on your system.

Also we try to crossmatch (we do not do electronic XM) all red cells even if 10 or more have been given and even if they are a different type as much as possible, but if the need is greater for products we will use O neg or type specific un crossmatched at any time point during the MTP - it just depends on the need of each case - and for that we have strong communication with a dedicated RN for the bleeding pt - it's a specific role of someone on the trauma team so the BB talks to them directly. We also get our medical director or a pathologist on call involved early! They too can help assess the situation and contact the blood supplier if more blood is needed etc. :) Hope this helps.

Megan

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We are a 260 bed level 2 trauma center. We get 3-5 MTPs a month.

In order to get certified as a T2, we had to have everything worked out at all levels--Lab, OR, ER, Trauma-- and all of the P&Ps for all of the associates and docs involved. This took several months. We have a protocol to follow in BB when a MTP is started and follow it until it is called off. An MTP is usually started by ER or OR. Once begun, we look at lab values and usage to decide what needs to be set up next.

Having said that, you may need to see if you can get a trauma surgeon or ER doc to take the lead in deciding what is needed for your facility. It needs to be a multi-diciplinary process so that everybody is on the same page when the time comes. But I think, even in a smaller facility, someone has to take the lead in coordinating the process to establish P&Ps for all concerned.

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If someone initiates the MHP we automatically issue them with 6 units group specific (they should in theory have had 4 flying squad to be going on with until we get a group), 4 FFP and 2 cryo. As soon as someone initiates the massive haemorrhage protocol we order 4 platelets as we are 3 hours away from our nearest blood centre.

We ensure that they have a designated 'runner' - usually one of the junior docs as they are able to communicate better the potential need for more products (other places have used porters as runners but this can create confusion IME).

We keep issuing 6,4,2 (and 2 platelets) until they tell us to stop.

After the first 10 units (if given within a 24 hour period) we issue uncrossmatched and don't retrospectievly crossmatch - with such a fluid loss...

One thing our wards have found invaluable, with us being such a small centre, is a 4 monthly 'dummy run'. We do it every 4 months due to the doctor's rotation - they seem to find it quite helpful for their training in how to cope in a crisis :)

We recently had a RTA - biker vs car - and the patient had a ruptured spleen and liver. We used 31 red cells, 16 FFP, 8 cryo and 4 platelets and the patient survived! It was eeirily calm taking the blood to theatre. Noone got confused, noone flapped, everyone knew their roles, the medical team knew that we were going to keep the blood coming, you would have barely known it was a crisis!

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I haven't worked in a hospital laboratory for years now, but I have recently been at a plethora of lectures on this subject.

In each and every case, the take home message was that it is far better to prevent a coagulation problem by giving prophylactic FFP, cryo and platelets, than to try to catch up with it afterwards with gallons of FFP, cryo and platelets.

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Most MTPs require component replacement at a 1:1:1 ratio (rbc:fp:plt). As Malcolm intimates, it is better to keep pace with the products than giving large boluses (boli?) after the fact. The August issue of the Journal of Trauma Medicine (or some such) abounds with excellent articles on MT and how to deal with them.

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There has just been a paper published in Brit J Haem too.

Davenport R, Khan S. Management of major trauma haemorrhage: treatment priorities and controversies. British Journal of Haematology 2011; 155 (5): 537-548.

Unfortunately, for copyright reasons, I cannot post it here.

Edited by Malcolm Needs
Unforgivably, the "B" in "British" was not in italics!!!
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Contact your blood supplier. Their medical director may be able to help you with suggestions that fit your specific patient load, blood product stock levels and location (rural, urban, or otherwise).

I've been having discussions with the assistant medical director of our blood supplier and she has a wealth of information. It helps that she worked in a hospital setting prior to working for the blood center, so she knows what it's like to be on the receiving end for mass transfusion cases. She is also available for presentations at my facility, so the docs here can be educated and ask questions.

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There was an article in Transfusion a couple of years ago in the "How we do it" theme on massive obstetric transfusion that might be helpful. Your medical library can help you get it unless someone here can post a copy.

Is this it Mabel?

How we treat: Transfusion medicine support of obstetric services Transfusion Lawrence T. Goodnough, Kay Daniels, Amy E. Wong, Maurene Viele, Magali F. Fontaine and Alexander J. Butwick

Article first published online : 4 MAY 2011

Edited by Liz
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I was wondering what kind of protocol other Blood Banks use for Massive Transfusion. I work in a 100 bed hospital and we don't get trauma cases. Our protocol says to switch to uncrossmatched after 10 units in a 24 hour period.

We had a doctor at the Transfusion Commitee meeting that wants to have the amount of FFP, platelets and cryo needed in the procedure. He is worried about a healthy female after a C-Secion bleeding and needs an emergency hysterectomy. This got into a discussion saying that if the patient is a normal , FFP wouldn't necessarily be needed, etc. They would like information for our Dec meeting.

If anyone has any information on this, it would be helpful.

Thanks,

Kathy

Have him order a type and screen,to rule out any antibodies,this will allow a units to be added on if needed.

In regards to FFP,cryo,plts this sounds like DIC not a C-section.Anyways if he insists thaw 2 AB FFP and have plts a phone call away.The cryo thaw as needed-low fibrinogen or low angle read on a TEG.Did you mean type specific blood after 10 units of Oneg prbc's? Good luck:DHappy Thanksgiving!

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We've had an MTP in operation for a little over a year. The majority of our cases have been patients where at least a type and screen was done or just finishing when the MTP is called. When an MTP is initiated we send a pack of 4 RBCs, 1 platelet dose (apheresis or pool), and 2 FFP (depends on patient's blood group). We keep 2 group A and 2 group O thawed plasma on hand at all times. We try to keep 4 uncommitted platelet doses available at all times. As soon as that pack leaves lab another similar pack is prepared. We then play leap frog. Pack 2 leaves and we prepare pack 3, etc. We will add cryo pools as they are thawed and become available. The ratios can change as products become available (more plasma thawed, more platelets received, etc.).

Our Blood Bank pathologist spearheaded this protocol with the able assistance from anesthesia, EROPD and our trauma and cardiac surgeons. It was a joint effort.

We do crossmatch -- eventually -- all RBCs given to the patient. I guess we always thought that was a requirement as long as we had sufficient patient sample available. No electronic crossmatches as this time so we program them on our ProVue.

We have noticed that even though we are sending FFP and Cryo some has been returned. They use the RBCs and platelets but not the other two and it's not because the patient expired. So we're working on some education and MTP drills to make sure all involved parties know the products available.

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We have noticed that even though we are sending FFP and Cryo some has been returned. They use the RBCs and platelets but not the other two and it's not because the patient expired. So we're working on some education and MTP drills to make sure all involved parties know the products available.

Give them all the references you can find about FFP/cryo being better for the patient than colloids. Once we educated them about this (and told them that we are more than happy to issue lots of the product - as we have lots of it) they started following our MHP to the letter. Patients really do seem to recover more quickly, and less red cells seem needed when you treat volume loss with FFP rtaher than colloids. It's just easier to stick a bag off colloids up though than request, and sign for a bag of FFP...

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It seems to be a bit overl-response to start throwing so much FFP/ PLTs for such a small amount of pc (6-10 units). Is this evedince supported for the clinical safety of the patient? Does anyone have good references? I am interested in updating our massive transfusion procedure. Though I am not convinced that giving automatic ffp and plts for every patient is what is best. I have read where massive transfusion patients do not often do well and have increased deaths so are there clinical studies showing where doing all this reduces these deaths or is this just a theory at this time?

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If someone initiates the MHP we automatically issue them with 6 units group specific (they should in theory have had 4 flying squad to be going on with until we get a group), 4 FFP and 2 cryo.

We keep issuing 6,4,2 (and 2 platelets) until they tell us to stop." Eend Quote

By 2 CRYO, do you mean 2 singles or 2 pools of 10? or 2 pre-pooled of 5 by supplier?

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It seems to be a bit overl-response to start throwing so much FFP/ PLTs for such a small amount of pc (6-10 units). Is this evedince supported for the clinical safety of the patient?

Don't think of it in terms of red cells given, think of it in terms of red cells lost. They are not going to be returning their Hb to 'normal' they will be aiming for 10 or so once the bleeding has stopped. 6 units might not sound like a lot but if they transfuse 6, it's more than likely that the patient has lost more than 10. If someone has lost their whole volume of red cells, they are going to have also lost their whole volume of clotting factors. 6 units doesn't sound like much but for me that would be all of my blood!

tients in terms of volume replacement than colloids. Fluid replacement by colloids, to maintain BP, has been show to reduce the clotting factors and seriously increase the time bleeding. By relacing fluids with FFP and cryo we are replacing the clotting factors, as well as the fluid loss.

educed. There is no evidence that giving platelets for someone with a platelet count over 50 shows any benefit.

Barabarakym - our Cryo is 5 donor pooled.

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Have a look at _Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma_ by de Biasi, et. al. Transfusion, Vol 51, No 9, Sep 2011, p. 1925. There's even CME available for the article.

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Here are a couple more references:

  • Creation, Implementation, and maturation of a Massive Transfusion Protocol for the Exsanguinating Trauma Patient. Journal of Trauma, Volume 68, Number 6, June, 2010
  • Improvements in Early Mortality and Coagulopathy are Sustained Better in Patients With Blunt Trauma After Institution of a Massive Transfusion Protocol In a Civilian Level I Trauma Center. Journal of Trauma. 2009; 66:1616-1624.

The other 2 AABB presentations were in the Oral Abstract sessions and I don't think that you can get to them online anymore.

9323-TC Blood Ordering and Transfusion Support in Obstetrics from 2011, they discuss MTPs in reference to post-partum hemorrhage

9106-TC Massive Transfusion Protocols: A Workshop in 2009

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