Massive Transfusion Protocol for Pediatrics

[Mabel Adams]

Does anyone have a massive transfusion protocol for trauma packs for children of various sizes?  I want to add it to the Broselow tape that the ED uses for various size children so they don't have to try to calculate amounts of product in the heat of the moment.  See the chart at the end of the attached document.

 

 

Broselow tape and blood products.pdf

Edited October 1, 2014 by Mabel Adams

[tbostock]

See attached for an article about pediatric MTP.  Also we added these points in our policy; I would attache our whole policy but it isn't quite finished yet:

 

Differences in pediatric massive transfusion:

• Transfusions are weight based.
• Coagulopathy in pediatric trauma is more common than in adults.
• Rapid infusion is NOT recommended; blood warmer is recommended for red cells and plasma (FFP).
• Irradiated red cells are contraindicated (except in neonates) due to higher potassium levels.
• Fresher red cells are warranted, to limit excess potassium.
• Frequent potassium levels are recommended to prevent hyperkalemia and cardiac arrest.
• Frequent monitoring to prevent hypocalcemia.
• Intravenous access by weight:
  • 1-5 kg: 22-24 gauge
  • 6-10 kg: 20-24 gauge
  • 11-25 kg: 18-22 gauge
  • 25-50 kg: 16-20 gauge

[Mabel Adams]

Thanks, Terri.

 

I can't begin to figure out how to put platelets into packs for small peds MTP when all we have are apheresis.  Would they have enough lines in a 12 lb. kid to just keep platelets dripping continuously from early in the massive transfusion?  It seems like that would help treat the coagulopathy (as long as they aren't PAS plts) plus spread the plts out over more than one blood volume replacement with RBCs.

[tbostock]

We have a sterile tube welder where we could sterile dock a syringe or pedi-pak on the apheresis and take out portions.  If you don't have that capability and/or if you will only be doing this on an exceedingly rare basis, then I would recommend having them put the apheresis unit on a pump and give it slowly.  They could discard what volume they didn't use and document that appropriately.

[Townsend]

Nationwide Childrens Hosp MTP Policy AUG 2014.pdfOur MTP started out as a 1:1:1 dose by patient weight. There were two factors that lead to us changing our protocol a few years ago: 1)Aliquoting of products to account for weight (like we do for our routine transfusions) was just too time consuming in a true MTP situation, and 2)Product usage was more like 2rbc:1plas:1plt dose at our facility.

This is what is in our current policy, which also states the standard doses we have defined at our facility as an aid (this is in chart form, but it didn't paste very well, so I've attached the actual policy) :

Patient weight Red cells per pack Plasma per pack Platelets per pack

<10 kg 1 unit 1 pediatric unit 1 plateletpheresis unit

10-40 kg 2 units 1 unit 1 plateletpheresis unit

>40 kg 4 units 2 units 1 plateletpheresis unit

Standard doses: 10 – 15ml/kg 10ml/kg 5ml/kg

There is also a multi-center, prospective data collection IRB underway for detailed MTP statistics in pediatrics. This information will be used to determine targets for future randomized controlled patient trials for use of MTP in children. Hopefully we will get some evidence-based guidelines out of these studies as to the best treatment for our bleeding pediatric patients!

Stephanie Townsend, MT(ASCP)SBB

[Kathy H]

Our policy is as follows:

 

Up to 19 kg:  1 prbc, 1 FFP, 1 plt per batch

 

20 kg - 50 kg: 2 prbc, 2 FFP, 2 plt per batch

 

50 kg and above: 5 prbc, 5 FFP, 1 apheresis platelet pack per batch

[DeeMc]

^{I have attached what we use... the formatting of the tables did not work well in the post}

MTP for pediatric patients.doc

Edited October 2, 2014 by DeeMc

[Mabel Adams]

Terri, we can sterile dock but don't want to take the time for that in a massive transfusion.  Also, we usually put the product into syringes and I am not sure the ED would be transfusing a peds patient using a syringe pump. I don't want to cause delay while they hunt downt the pump.  Also, we issue our aliquots to the NICU already filtered so that might be a process difference in the ED.  No harm if they filter it again, I guess.

 

Thanks for all of your examples.  I think I will be able to cobble something together.

 

Useful tidbit I just learned: our ED and OR beds have scales built into them so they always know patient weight.

[cthherbal ☆]

Interesting discussion, thanks all. I am taking a look at our MTP now and possibly making changes for Peds.

 

We only use blood warmers for RBCs and no other components.