Massive Transfusion Protocol
Hi – Apologies for recent sluggish activity- I have been a busy Doc lately and working on what I hope are some good posts / resources for you all.
The first Big project I am wanting your feedback on is my “Massive Transfusion Protocol” which you can click here – or I have added as a permanent resource in the “Clinical Resources” section at the bottom of the blog.
Why have I decided to spend hours on this?
I have always found the current published Massive Bleeding Protocols to be either too simplistic or not descriptive enough. There are a few crucial decision points – such as” when to activate” – which are glossed over frequently.
Most protocols deal only with trauma – and in my world, the big bleeding happens on the labour ward, in theatre… etc NOT just in the ED resus bay.
So I have written a protocol for me – one which I can with a click on a page access and remind myself of the steps and “recipes” for resuscitaing in major trauma / bleeding. I have downgraded the role of platelets – because – we do not use them in smaller hospitals and the evidence is not great for empirical use.
I have tried to include some evidence in a ‘hidden’ way to keep it simple in a crisis – or you can read at your leisure later.
Be aware: this protocol relies heavily on your hospital having in place a system-wide approach to this emergency. Your lab have to have a predefined system, your surgeon should be aware of the protocol and the concepts associated with “damage control” operations. This is not the time to get into a territorial dispute, you need to have your chickens all lined up before it happens!
So please read it- this is my draft, I hope to make it more useful with your feedback.
Let me know what you think. Casey
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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
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
- Cut offs vary but commonly used criteria include: > 4 units in first 2 hours, ongoing shock after 2 units, “4 units in 4 hours”
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.
- Crystalloids – aim to minimise the use of crystalloids – they will make your coagulopathy, temp and possibly acidosis worse
- Uncrossmatched (O Rh -) packed red cells – 2 units
- 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
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Recommend invasive monitoring (arterial line) if available
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Send repeat investigations every ~ 30 minutes: FBP, coags, fibrinogen, ABG / lactate, Ca++,
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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
Very useful….and stashing in clinical resources makes it available to all of us if needed.
Trying to set up a MTP in the regional hospital where I’m doing anaesthetics…took some convincing that we need it not just in theatres, but also in ED, labour ward and ICU…amazing how silo-based medicine can be.
Will read and get back to you.