criteria for ordering MTP

[tkakin]

We have a procedure that states a massive transfusion is considered a transfusion of greater than 10 units of packed red blood cells in 24 hours.  The ER is confusing GI bleeds with Massive transfusion.  Has anyone found criteria that would be more specific for the Physicians to know when it is appropriate to call a massive transfusion?

 

Thanks

Teresa

[AMcCord]

Funny you should ask....we are just finalizing a new MTP. The section below is the patient identification  portion of our protocol.

 

1. PATIENT IDENTIFICATION:  The adult patient who shows clinical evidence of exsanguinating hemorrhage nearing an 8 unit packed red blood cell requirement qualifies for initiation of the Massive Transfusion Protocol (MTP).  For the child patient, hemorrhage nearing a 25mL/kg packed red blood cell requirement qualifies for initiation 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:

 

a. Hypotension:  Patients with evidence of injury and SBP<80 in an adult or <60 in a child under the age of 15; or SBP from 80-90 that does not respond to a rapid infusion of 30 ml/kg of LR (2L for a 70 kg patient).

 

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

 

c. 3 units RC-LR during resuscitation: and will obviously require additional transfusion

[tbostock]

Our criteria is:

Massive transfusion is defined as the transfusion of 10 or more units of packed red blood cells in less than 12 hours, or the acute administration of more than half of a patient’s estimated blood volume per hour.

Guidelines for Initiation of MTP:

Presence of one or both of the following:

1.Massive blood loss:

a. Adult patient: greater than 4 units of packed red blood cells (PRBC) in the first hour of resuscitation, with a high likelihood of requiring transfusion of greater than 10 PRBC within the first 12 hours.

b. Pediatric patient: greater than 20 mL per Kg of PRBC in the first hour of resuscitation, with a high likelihood of requiring transfusion of greater than 0.1 units of PRBC per Kg within the first 12 hours.

2.Major traumatic injury including:

a. 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.

[Mabel Adams]

Obstetric cases can certainly qualify too--I think the blood loss descriptions above would cover them. Some of the worst hemorrhages I have ever seen were obstetric due to the massive DIC of an amniotic embolism.  

 

Years ago I once had a doctor think he should give plasma because the patient had received 10 units of RBCs--over two weeks!

 

I like the 12 hour definition; it is less likely to catch cases that don't really have the coagulopathy and hypothermia the MTP is trying to correct.

[AMcCord]

Mabel makes a good point. We tend to think that MTP = trauma but it definitely applies to OB, surgery and sometimes ICU.

[rravkin@aol.com]

Tkakin, we have an Exsanguination protocol for massive bleeding, and now I know why, because our massive protocol is the same as yours.

Our exsanguination protocol calls for the ordering of a test, Xsang, which provides fields for filing date/ time and doctor who calls and ends the exsanguination event, along with Type and Screen testing, if able, and emergency release of products.

Edited August 16, 2013 by rravkin@aol.com