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
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