I'm pretty sure the 1:1:1 ratio is using random plts not pheresis. For pheresis, it would be more like 6:6:1 for RBCs, FFP & plts. This is certainly the trend we are hearing about.

We are a very busy level II trauma center. We have a predetermined "recipe" that was approved by the trauma surgeons...based on the criteria used by the major trauma centers. We use a 1:1 ratio of red cells to plasma, with an apheresis platelet every 6 red cells/6 plasma units, and a batch of cryo after 12/12. Works great, and of course, if the trauma surgeon wants to alter that due to a patient's condition, etc, we would comply.

Now that the education is going out about using FFP earlier in massive transfusion cases, I am wondering how others are applying this concept to scheduled surgery cases that end up using > 10 units of red cells. (Our recent case was a back surgery.) I think these differ from traumas in that they should lack the tissue damage and hypovolemic shock of the trauma massive transfusions, but I don't know enough to know what we should suggest in these cases. 1. Ignore it and let the docs decide if they think the bleeding is sufficiently out of control to require the massive protocol. 2. Urge them to move promptly into the MTP after 6, 8 or 10 units and start giving FFP & plts then. 3. Urge them after 6 units transfused to order a coag screen and give FFP etc. based on the results. We are not a big trauma center nor a big teaching hospital so we have a wide range of knowledge (and misinformation) among our docs regarding MTP.

Does anyone know how these patients would differ in their clinical needs from those in the "vicious bloody cycle" of traumatic injury? Does anyone have a sensible approach that doesn't cause docs to use FFP inappropriately jsut because they have a surface knowledge of massive transfusion protocols? Should we use different approaches for vascular surgery gone bad than for orthopedic?

Mabel, my thoughts on this has always been that a massive transfusion is a massive transfusion regardless of the reason behind it. A patient with a AAA or a ruptured uterus can bleed out as quickly and one with a bullett wound or a ruptured liver due to a car wreck. Treat them all the same.

I agree with John. We have used our MTP with traumas, and just recently with a massive bleed from an arterial bleed in OR that was not anticipated. The protocol is the same, we leave it up to the trauma surgeon or the anesthesiologist to initiate the MTP, but if we see red cells start to fly out to the door in rapid succession, we will "suggest" the MTP and they usually go for it.

Another wrinkle to this topic. Some patients are using blood salvage and others aren't. Six units issued from the blood bank are not equal in determining a "massive transfusion" in these 2 cases, are they?

Mabel, you're correct about the cell salvage; that does make it difficult to estimate. One of our recent traumas did not "convert" to an MTP until the patient was in OR for awhile. Then we found that they had already returned over a liter of red cells by cell saver. So we had to quickly readjust our products to start with plasma and platelets to prevent coagulopathy.

Massive bleeding is same in case of trauma, AAA, open heart gone bad.... We have a protocol and we trained OR, OB, critical care units, cardiac care unit and of caurse trauma department. Surgeon can initiate the protocol and we send products every 15 mins...we evaluate each case and compile STAT everymonth.

I agree with John, comming from a major metropolitan transfusion service, I would say that the earlier it is called the better for bb, the docs, and the pt. we have a standard kit ready to go in a cooler, 8 rbc, 2ffp. Once one cooler is out the door, we start getting the next ready. A lot of doc's forget about the ffp when they get a big bleed, thats why having a standard of how many units you can use before you have to use the ffp is helpful. in any case other than a MT, we require coag studies after 4 units. After 8 units, you can quit typing and crossmatching.

LABRAT1169: have you investigated going to a 1:1 ratio of red cells to plasma? There a lot of studies to support it.

Could I please aks for a copy of all ya'lls policies? We are having a major problem with our Anesthesiologists.

Thanks anorris@georgetownhospitalsystem.org

Alicia

FYI to all: there is a great website that has CE presentations on coagulation issues with patients. It's www.hemostasiscme.org

They had a Coagulopathy in Trauma one that was great; not sure if it is still available.

Terri -

This looks like an interesting site. I'm going to pass the info on to our tech who teaches Coag to our Clinical Laboratory Scientist students. Thanks!

Donna

Our trauma team wants us to keep thawed FFP available at all times. Unfortunately, AB FFP is in short supply and as stated previously is apheresis FFP that cannot be converted to 5 day plasma. If you are a level 1 trauma center, please advise me on how I can possibly accomodate these physicians. They are wanting the 1:1:1 ratio as recommended by other trauma centers.

Debbie -

You might check out the thread titled "5 day plasma - the debate still rages" on this website. There was a lot of discussion from several trauma hospitals about how they were handling this topic.

ANORRIS--Check the early pages of this thread. There are links to several protocols.