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Massive Transfusion Protocol

MASSIVE TRANSFUSION PROTOCOL

STEP 1: Bleeding control

Control of bleeding is the single most important intervention.

  • Minimise time between arrival and surgery if indicated – “Damage Control Surgery”
  • This may require early Evacuation planning
  • Use torniquets to control peripheral bleeding vessels
  • Tamponade techniques: eg. pelvic binders, direct pressure, suture head lacs
  • Intrauterine balloon devices for PPH, manual compression, oxytocic agents

STEP 2: Identify the  need for Massive Transfusion

The problem with most “massive transfusion protocols” – they don’t specify who is likely to benefit, whom should activate it and upon which patient. Most of the identifiers of Massive transfusion say things like “after 6 units in 4 hours” or “after a whole blood volume equivalent”, the problem being it might be a bit late to correct some of the pathophysiology – it is better to anticipate and activate, rather than wait and see.

A:  Use a clinical prediction rule to stratify the need for MTP:

  • The ABC score: 4 points = penetrating injury,   positive FAST exam,   HR > 120/min,   systolic BP < 90   [no lab results - purely clinical]
    • 0/4 = 1% risk of MTP,       1/4 = 10% risk,      2/4 = 41% risk,       3/4 = 48% risk,      4 /4= 100%  [Activate MTP if 3 + criteria met]
  • The TASH score (diagram): 6 point scale = syst BP < 100,  HR > 120,   Hb < 70,   positive FAST,   femur or pelvic fracture,   base Excess <  -10,   INR > 1.5,   male gender

B:  Identify massive trauma / bleed on purely clinical basis – “the Crashing Patient” – this remains a subjective call based on a senior clinician’s suspicion of likely MTP requirement:

  • Multitrauma with multiple system injuries and unstable haemodynamics
  • Massive post-partum haemorrhage with measured blood loss > 1500 mls
  • Post-surgical bleeding from major vessels
  • GI bleeding with shock
C:  After initial resuscitation – based on volume requirements:
  • Cut offs vary but commonly used criteria include:  > 4 units in first 2 hours,  ongoing shock after 2 units,  “4 units in 4 hours”

These systems allow you to ‘triage’ the patient and anticipate the probability of needing a massive transfusion. Why is this important? Well – giving all that blood, plasma and factors to the patient who didn’t need it has serious consequences – namely a risk of sepsis, ARDS and organ dysfunction – Inaba et al showed the main villain was the plasma volume trasfused. So MTP is good if you need it, but might be bad if you were not needing it – so we need to exercise some restraint.

 STEP 3:Activate Hospital Massive Transfusion system

  • Lab team need to know early – they will need to prep products and process your incoming blood samples AQAP
  • Early thawing of 2 units FFP if large volumes are expected.
  • Dedicated nurse / team member to run the rapid infusion device
  • Orderly to run samples and bloods to the lab for processing
  • Scribe to document the products / volumes and response

STEP 4: Initial Empirical Resuscitation (first 15 – 30 minutes)

Take bloods for URGENT processing: FBP, cross match, coag profile (INR, APTT, fibrinogen), ABG (VBG)

Request immediately available blood products.

  1. Crystalloids – aim to minimise the use of crystalloids – they will make your coagulopathy, temp and possibly acidosis worse
  2. Uncrossmatched (O Rh -) packed red cells – 2 units
  3. Fresh frozen plasma (ABO Rh spec) – 2 bags.   [recommend 1:1 ratio where possible]  NOTE: thawing FFP takes ~ 30 minutes – so you need to alert the lab to this possibility early

STEP 5:  Continue Volume Resuscitation / Monitoring

A:  Continue  PRBCs and FFP in 1:1 ratio – target MAP is 65 – 70 mmHg (prior to definitive intervention)  NB:  target MAP is 90 – 100 in patients with traumatic brain injury / raised ICP suspected

B :  Monitoring – establish early and use to titrate specific agents / interventions

  • Recommend invasive monitoring (arterial line) if available
  • Send repeat investigations every ~ 30 minutes: FBP, coags, fibrinogen, ABG / lactate, Ca++,
  • Frequent / continuous temperature monitoring

STEP 6:  Consider other agents for prevention / limitation of coagulopathy

  • Warfarinised / known coagulopathy : give Vit K 10 mg,  Prothrombinex (25 iu/kg = ~ 4 vials for 80 kg pt)
  • Dabigatran / thrombin inhibitor: call Haematology.  PCC and recomb. factor VII have some evidence in healthy subjects
  • Obstetric haemorrhage: early use of cryoprecipitate is recommended (Reference 1,   Reference 2)
  • Platelets: only recommended in thrombocytopenia < 50.  (Notify incoming team if required)
  • Discuss specific clinical scenarios with on-call Haematologist
  • Tranexamic acid:  give 1 g loading dose (over 10 mins)  as early as possible in traumatic bleeding

 STEP 7:Target therapy to results / clinical parameters

  • Target BP - MAP = 65 mmHg                           Give fluid volume:  ideally RBCs / FFP
  • IF Hb <  80 g/l                                                       THEN  Give RBCs
  • if  INR > 1.5  OR  APPT > 50 sec                      Give 2u FFP  consider Prothrombinex
  • if fibrinogen < 1.0 g/l                                          Give 8 units of cryoprecipitate
  • if ion. Calcium  is < 1.1 mmol                            Give 1 amp of  Ca-gluc 1g/10mls
  • Optimise acidosis                                                  Consider intubation / ventilation => normocapnea
  • Maintain patient  T > 35 deg                             IV fluid warmer, airblanket, limit exposure & operation time

**The use of recomb. factor VII (NovoSeven) remains controversial – this should only be used in consultation with Haematologist and once other reversible causes of coagulopathy have been addressed / targets reached

 STEP 8:  Evacuation planning

  • In smaller centres the early evacuation planning should commence as soon as the patient is received
  • In the absence of a definitive surgical service – evacuation should be expediated to such a centre
  • The retrieval team should be made aware of the product availability and stock so they can plan to bring further agents for the ongoing resuscitation / transfer.
  • Suggest early liason with RFDS, receiving hospital ED / surgeon and clinical Haematologist

Comments

  1. Useful….have you done a test at 3am with skeleton staff.

    Been involved in a few MTPs in past fortnight. Medicine side not too hard…but getting enough theatre staff,, porters/runners, backup for lab staff,and clear lines of communicqtion have been weak points

    How is your MTP activated? Single phone call to switch to ‘activate’ and then a downstream cascade to anaes/surgeon/nurse manager/theatre team/lab tech/oncalll lab staff/porter(s) etc ?

    Dont want phone lines jammed up with calls…ditto calls to notify results or ask for more products. Making anaesthetic reg the key go to person seems to work…

    Also, we’ve incorporated a tally sheet of products received from the lab, as well as those used…useful when patients are moved from labour suite to theatre to ICU and products/tallies may trail behind them….this is on flip side of a sheet used for documenting results as they are phoned through, to keep a timeline of resus goals and products used….in addition to the anaes chart, espec useful when moving from place to place. Gives the campus nurse manager something to keep them occupied too…

    Make any sense?

  2. Just to clarify…we activate and run team like a MET or trauma team call out.

    Code Crimson is the call..

  3. Great stuff!
    Thanks for sharing it
    Carlo

  4. Looking good Casey. I think this protocol would benefit from convincing the blood bank folks to get some fibrinogen concentrate to sub for plt and cryo.

  5. Minh Le Cong says:

    good stuff ,Casey. ONly thing I can add is a suggestion to have some advice about the patient on dabigatran as FFP and Vit K do not work at all. You already mention TXA and Novoseven but not specifically in relation to dabigatran.

  6. Does anyone know what to do about dabigatran?

    My plan involves lots of swearing, a lot of voodoo and perhaps haemodialysis on ICU or else trying to do best can until the evil shit has worn off.

    I always said i’d never want to be on warfarin…but I reckon dabigatran is less attractive still!

  7. Casey

    Very good stuff.

    I have worked in a few towns with no packed cells and no FFP etc. But we did have a “Donor Bank”. So we had donor’s who were pre-screened and we would use them if required. Thankfully a rare event. A once every decade event apparently.

    What are your thoughts in more remote locations or with a primary response from RFDS?

    I was thinking:

    Preplanning:

    What resources do you have?

    Packed cells usually 2-4 units most of the small towns with blood supplys
    Usually No FFP

    Is there a donor bank in place?

    Donor banks -- Hard to implement but life saving

    Clotting Factors:

    Fibrinogen concentrate
    Prothrominex (II,IX and X)
    Albumin
    Hypertonic saline -- Small volume resus
    Transxemic acid preferably IV but would be interested to see if we could use oral transxemic acid if IV not available??

    Treating this as a septic shock state

    As you said Early advanced airway intervention
    keeping the energy expenditure from Breathing to a minimum
    Torniquets use
    Damage control as required

    What are your thoughts??

    • Casey Parker says:

      Hi Ray
      Nice ideas -- I did consider long-and-hard how much to put in for the really small places with no blood bank to speak of…. it is tough to make a protocol for all hospitals. So I decided to do one for a Broome-sized place, and you can modify it to suit your place.

      The powder / concentrate are a good option for small places -- they keep well and are storable.

      There is quite abit of evidence re: hypertonic saline, whole blood (walking bank) out of the US military in the Iraq / Afghani wars -- Scott W has a great lecture on Emcrit if you want the cool 45 minute version. However, it is basically too hard in a small, civilian population in Australia I fear..

      Tranexamic acid costs ~A$60 IV per amp -- so you can give it with the resus in a small place. I am not sure the literature supports it as a “life saver” in the immediate sense though, still needed same blood volume etc. Cannot imagine a scenario where i need to use it PO -- ie. always need a drip in place -- so I can at least get the initual bolus dose in early.

      As you allude to -- the most important aspect of this protocol concept is to have a plan that works in your hospital and a clearly defined system in place before the poo hits the fan

      Cheers
      Casey

  8. Casey Parker says:

    Thanks for all of your input -- great points
    I am trying to put extra info and links into the Protocol to answer the queries and provide data. So keep checking the Protocol for updates -- added Dabigatran stuff yesterday…
    I am hoping to put up a single page “simple” version that could go on the wall of your Resus room as an aide memoir
    Casey

  9. I am Pretty sure that platelets are the appropriate treatment for patients on dabigitran, but in the absence of this product, I think you are in a position where you must use factor 7 concentrate. If the patient survives, the next problem is managing the hypercoag state caused by factor 7--it can thrombosis off all sorts of parts of these patients, so watch out!

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