massive transfusion protocol

Massive Transfusion Protocols in Trauma

VictimsDR SHADAB KAMAL

Patient Presentation to ER• 64 Year old male, passenger, suffered Motor Vehicle

Crash with high-speed rollover presented to ER with

drowsiness, SBP 60 and tachypnea.

• Crystalloid fluid resuscitation initiated for hemorrhagic

shock.

• Airway control to avoid hypoxemia and Emergent

Endotracheal intubation was done in ED.

• Blood (PRBC, FFP) transfusion initiated for hypotension

and hemorrhagic shock.

Patient Presentation to ER

• On physical exam Severe Flail chest was found along

with Bilateral hemo-pneumothorax.

• Bilateral closed tube thoracostomy(ICTD) was done.

• Transient responder to blood transfusion.

• FAST – Positive for hemoperitoneum

• Pelvic fracture (unstable) was found on X ray of pelvis

• Plan: To Operating Room for emergent laparotomy

Management of Injuries in OR (DCS)

• Laparotomy was done and splenectomy, repair of diaphragmatic injury, repair of liver lacerations, abdominal packs, Vaccum Assisted Closure of abdominal wall done.

• Blood pressure normalized after abdominal hemorrhage controlled, liver & pelvis packed.

• 18 Unit of PRBCs, 15 Unit of FFP, 3-5pk Platelets, 2 Cryoprecipate was transfused to the patient

• Patient shifted to angiography for pelvis fractures, then to CT head and then ICU.

• Chest CT scan obtained postop to evaluate intra- thoracic injuries

Time Arterial pH

pCO2 pO2 HCO3 Hct iCa++ Lactate

0712am 7.04 22 351 6 24 0.46 11.9

0805am 7.29 29 413 14 29 0.58 9.3

0849am 7.28 32 332 14 30 0.65 8.4

0712am Hb 6.9Platelet 90000/mm3PT 17.4 secINR 1.8 secPTT 77.8 sec

Patient investigations

Hospital Course

• Persistent need for mechanical ventilation with the risk of ARDS, VAP

• Need for further operation for removal of abdominal packs, transgastric

jejunostomy for enteral nutrition and abdominal wall closure

• ECHO confirmed blunt myocardial injury.

• Tracheostomy was done

• ICU Length Of Stay > 3 weeks

• Eventual full recovery.

Massive transfusion: Introduction

• MT are needed in trauma, obstetrics, and major surgery.

• According to CDC >120 000 deaths in 2010 due to trauma

• About 40% of trauma-related mortality is due to uncontrolled

bleeding.

• Among the injured patients admitted to trauma centres, up to 10%

of military and up to 5% of civilian patients require MT. • In general, injury severity and transfusion requirement are associated

with mortality. Most (99%) of the patients receiving <10 RBC units within the first 24 h survived, whereas only 60% of patients who received >10 RBC units within the first 24 h survived.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Prehospital First 24 hours After 24 hours

Per

cent

age

of d

eath

s

Hemorrhage CNS Other

Hemorrhagic Mortality

• While bleeding is the #2 cause of mortality, hemorrhage is the #1 reversible cause for mortality

• Almost all mortality from hemorrhage occurs within 1st 24 hours

Massive Blood Transfusuin

Transfusion of ≥10 red blood cell (RBC) units, which approximates the total blood volume (TBV) of an average adult patient, within 24 h,

Transfusion of >4 RBC units in 1 h with anticipation of continued need for blood product support

Replacement of >50% of the TBV by blood products within 3 h.

Transfusion support to loss of blood >150ml/min

In Paediatric pts

Transfusion of >100% TBV within 24 h,

Transfusion support to replace ongoing haemorrhage of >10% TBV /min

Replacement of>50% TBV by blood products within 3 h.

Definition of Massive Transfusion

Trauma Resuscitation• Determine severity of hemorrhagic shock (admission arterial

lactate)• Expedite control of hemorrhage• Damage Control Surgery• Early blood and blood product resuscitation• Blood product resuscitation ratio – PRBCs/FFP/platelets, 1:1:1• Minimize crystalloid (prevent coagulopathy, thrombocytopenia)• SBP 80-100 mm Hg• Frequent labs (Type & Crossmatch, CBC, Plts, Coagulation profile,

INR, PT, PTT, Fibrinogen, Electrolytes, BUN/Creatinine, ionized calcium, Lactate, TEG if available)

• Consider TXA and additional coagulation factors (rFVIIa etc)

Predictor of massive transfusion

Trauma Associated Severe Hemorrhage (TASH)-score incorporated seven clinical and laboratory variables into a composite score to predict the need for MT.

• Haemoglobin, • Base excess, • Systolic arterial pressure, • Heart rate, • Presence of free intra-abdominal

fluid and/or• Complex fractures, and• Gender

Nunez and colleagues demonstrated that simple parameters also appears to be as good as other more complex scoring systems to predict MT.

• Presence of penetrating trauma, • Systolic arterial pressure <90 mm Hg, • Heart rate >120 beats min, and• a positive focused abdominal

sonography for trauma, • If any two of the above four

parameters are positive, the patient is likely going to require MT.

Early trauma induced coagulopathy (ETIC) or Acute coagulopathy of Trauma

Historically, Early Trauma Induced Coagulopathy or acute coagulopathy of trauma was attributed to crystalloid and RBC transfusion without administration of platelets, plasma, or both.

However, subsequent studies in both adult and paediatric trauma patients demonstrated that ETIC was present in 24%, and up to 56% in severely injured patients, usually within 30 min of injury, even before receiving RBC and fluid resuscitation.

Breaking the “Bloody Vicious Cycle”

Control hemorrhage Use best possible

resuscitation products

Prevent hypothermia Prevent

hemodilution

Treat coagulopathy

• In the past, trauma patients were given colloid or crystalloid fluid initially.

• Blood products were administered after 2 litre of fluid resuscitation, usually guided by laboratory results to keep haemoglobin >10 g/dl, platelet count >50000, and INR ≤1.5.

• Using these guidelines, blood loss continued because of delay in laboratory turn around time and dilutional coagulopathy.

• Recent studies with consideration of resuscitation, and better understanding the pathophysiology of ETIC has led to early use of RBCs, plasma, and platelets and reduced crystalloid use in resuscitation.

J TRAUMA 2010

• Current component therapies in the USA suggested that when administering RBC, plasma, and platelets in a 1:1:1 ratio, this 630-650 ml product has a haematocrit of 29%, coagulation factor activity of 65%, and a platelet count of 90000/mm3.

• With storage defects taken into account, this mixed product would have a haematocrit of 26%, coagulation factor activity of 40–50%, and platelet count of 90000/mm3

• Furthermore, any attempt to increase the concentration of one component would lead to dilution of the other two.

• The administration of RBC:plasma:platelets at 1:1:1 ratio was first

proposed by the US military and subsequently supported by military and

then civilian studies. The rationale for the 1:1:1 ratio is that it more

closely resembles whole blood, which would help to treat and prevent

ETIC.

• A retrospective review of patients receiving MT at a US combat hospital

demonstrated reduced mortality from 66% to 19% when the RBC:Plasma

ratio decreased from 8:1 to 2:1.38

Ann of Surg 2008; 248:447-458.

Resuscitation with a 1:1:1 ratio of RBCs, plasma, and platelets is the recommendation of the Army Surgeon General and his Trauma Consultant.

However, these studies, and multiple others, are retrospective, and are affected by survival bias which is resulting from the fact that surviving patients are more likely to receive more plasma and platelets in relation to RBCs compared with nonsurviving patients because they lived long enough to receive those blood products.

• In June 2011, the Canadian National Advisory Committee on Blood and Blood Products determined that the retrospective evidence available at the time was insufficient to recommend a RBC:Plasma:Platelet transfusion ratio of 1:1:1 as the standard of care for MT.

• They also stated that subsequent retrospective studies would be unlikely to overcome survivorship bias and would not be able to make further contributions to the determination of the most effective ratio.

• Recently, the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study examined the association between mortality rates in trauma patients and transfusion ratios; this cohort study demonstrated improved in-hospital mortality with RBC:plasma and RBC:platelet ratios <2:1 in the first 6 h.

•In the first 6 hours, patients with ratio < 1:2 were 3 to 4 times more likely to die than patients with ratios of 1:1 or higher.

•After 24 hours, plasma and platelet ratios were unassociated with mortality, when non-hemorrhagic causes prevailed.

1 July 2009 - 15 Oct 2010

• The follow-up Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial is a randomized trial to evaluate ratios, MT patients receive either a 1:1:1 (higher ratio) or a 2:1:1 (lower ratio) RBC: Plasma: Platelet with primary outcome of survival, and also complications and length of hospital stay.

• The results of this study should further elucidate the optimal ratios of blood product administration during MT.

8/2012 – 8/2015

..extensive lab analysis will be done to evaluate the influence of fluid resuscitation on traumatic induced coagulopathy.

What is MTP?

MTP is a way to coordinate the care for patients requiring MT, to facilitate communication between different services (trauma, nursing, transfusion medicine, and other laboratories), avoid delay in clinical care, laboratory testing and blood product transfusion, and nursing care.

MTP is a way to assure good patient care by having a standard protocol on specific actions to take for each service involved.

MTPs have demonstrated improved patients survival and reduced rates of organ failure and post-trauma complications.

Component of MTP(i) When and who should initiate MTP.

(ii) Notification of the transfusion service and laboratory regarding

start and stop of MTP.

(iii) Laboratory testing algorithm [prothrombin time (PT), activated

partial thromboplastin time (aPTT), fibrinogen level, blood gas, and

complete blood count], and thromboelastography if available.

(iv) Blood product preparation and delivery (i.e. predetermined

transfusion packages).

(v) Other patient care needs (such as blood warmers, nursing care).

• MTPs can include preparation and administration of blood

products based on laboratory test results, predetermined

transfusion packages

• Although the number and timing of blood component delivery,

laboratory testing algorithms, and other aspects of the MTPs

varies between institutions, most current MTPs use

predetermined transfusion packages.

• MTPs vary in their predetermined transfusion packages, but all

include platelet and plasma units with RBC units.

43 Cotton BA,GuyJS, MorrisJAJr,AbumradNN.Thecellular,metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006; 26: 115–2145 Dente CJ, Shaz BH, Nicholas JM, et al. Improvements in early mortalityandcoagulopathyare sustained better in patients with bluntTrauma after institution of amassive transfusion protocol in acivilian level I trauma center. J Trauma 2009; 66: 1616–2446 Nunez TC, Young PP, Holcomb JB, Cotton BA. Creation, implementation, and maturation of a massive transfusion protocol for theexsanguinating trauma patient. J Trauma 2010; 68: 1498–505 47 O’Keeffe T, Refaai M, Tchorz K, Forestner JE, Sarode R. A massive transfusion protocol to decrease blood component use and costs. Arch Surg 2008; 143: 686–90; discussion 90–148 Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortalityreduction. J Am Coll Surg 2009; 209: 198–205

Whole Blood vs Blood components

• In the recent military experiences in Iraq and Afghanistan, whole blood

transfusion compared with RBC, plasma, and apheresis platelet use

reduced pulmonary and tissue oedema, which decreased the ventilation

time and also allowed closure of the abdomen with minimal delay.

• Furthermore, retrospective analysis suggested that patients who

received both fresh whole blood and component therapy had better

clinical outcomes compared with those who received only component

therapy.

• However, concern for transfusion transmitted infections and

transfusion-associated graft vs host disease remains.

Paediatric MTPs

• The data on paediatric MTPs are limited, and thus practices vary significantly among institutions.

• In the majority of institutions, a single MTP is used for both adult and paediatric patients.

• Published studies on paediatric MTPs did not show improvement in mortality in the group receiving blood products according to the institutional MTP compared with the historical control or the group receiving blood products at physician discretion.

• Despite obtaining null results in both studies, probably due to small sample sizes, it was suggested that implementation of MTP to increase the Plasma: RBC ratio is feasible in paediatric patients.

Considerations in MTP

• Group O RBCs and AB plasma products should be given until the patient’s blood type can be determined.

• Use of D-positive products in D-negative or D-unknown patients• Thawed plasma units• Prothrombin complex concentrate (PCC)• fibrinogen concentrate• Tranexamic acid (TXA) given early in the resuscitation process (<3

h from injury to treatment, preferably within 1 h from injury).• When to consider rFVIIa?

Blood Product until result of Type and Crossmatch

• In many trauma situations, there is excessive blood loss, and transfusion is needed before the ability to perform pre transfusion testing. In these cases, group O RBCs and AB plasma products should be given until the patient’s blood type can be determined.

• It is important to obtain and test a patient sample as soon as possible after admission so that type-specific products can be administered when available.

• This helps to preserve the inventory of group O RBCs and AB plasma, and minimizing potential for ABO typing discrepancies when a patient has received multiple units of group O RBCs and AB plasma.

Use of D-positive products in D-negative or D-unknown patients

• Each institution should have a policy determining the use of D-positive products in D-negative or D-unknown patients, including the use of D-positive products for men and women past childbearing age (usually >50 yr old), and after a set number of D-negative RBC units.

• The frequency of anti-D formation after transfusion of D-positive blood products to a D-negative patient is about 20% for RBCs and ,4% for platelets (likely lower for apheresis platelets).

• It is especially important to prevent anti-D formation in females of childbearing potential because anti-D can cause haemolytic disease of the fetus and newborn in future pregnancies.

• Therefore, females of childbearing potential should receive D-negative RBCs.

Thawed plasma units

• Thawed plasma units are not available for patients requiring MT. It takes about 20 min to thaw frozen plasma.

• Hence, in order to facilitate early transfusion of plasma in the resuscitation process, many institutions keep some units of thawed plasma available for immediate issue.

• Many trauma patients arrive in the trauma bay with unknown blood type; thus, AB plasma is prepared since it is the universal donor type.

• However, AB plasma is rare since only 4% of the population is group AB. Once plasma is thawed, it can only be kept for 5 days.

• Therefore, maintaining an inventory of thawed AB plasma at all times might be a challenge.

Prothrombin complex concentrate (PCC)

• used to treat congenital coagulation disorders and for warfarin reversal in patients with active bleeding or undergoing urgent procedures.

• PCC contains factors II, VII, IX, and X, and proteins C and S, • PCC can be three-factor, such as Profilnine SD (lacking factor VII), or

four-factor, such as Kcentra.• To date, there has not been any prospective randomized controlled

trial to evaluate the efficacy and safety of PCC in massively bleeding patients.

• Hence, risks and benefits of using PCC as an adjunctive therapy should be discussed in any institutional MTP and it is recommended that PCC usage should be continually evaluated.

Fibrinogen concentrate

• Fibrinogen concentrate has been shown to reduce peri-operative bleeding and transfusion requirement.

• Fibrinogen concentrates, in conjunction with PCC, also have been shown in a few prospective studies to decrease the transfusion requirements and mortality in trauma patients.

• It has not been approved to be used as an adjunctive therapy in patients requiring MT.

• Therefore, it is recommended to discuss the risk and benefit of using fibrinogen concentrate as part of the MTP in any institution.

• Tranexamic acid (TXA), were demonstrated to reduce mortality in trauma patients in both civilian and military settings, especially if given early in the resuscitation process (<3 h from injury to treatment, preferably within 1 h from injury).

• In the military setting, the MATTERs study, mortality in the TXA group was lower than in the group not receiving TXA.

J Trauma Acute Care Surg 2013;75(6):1575-1586

Conclusion:Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study.

On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients.

But…No difference in blood transfusion rates.

Lancet 2010;376:23‐32

• Moreover, TXA was also shown to be a cost-effective therapy in all low-, middle-, and high-income countries using data from the randomized controlled CRASH-2 trial done in a civilian population.

• TXA should be part of the early resuscitation process.

Boffard KD et al. J Trauma 2005 Jul;59(1):8-15

Conclusion:In blunt trauma, RBC transfusion was significantly reduced with rFVIIa (estimated reduction 2.6 RBC units, p=0.02) and the need for massive transfusion was reduced (14% vs. 33% of patients, p=0.03)

Lab monitoring in MTP

• MTP requires adequate laboratory support to oxygen-carrying capacity, haemostasis, and metabolic status in order to address and correct abnormalities.

• In addition, laboratory results can be used retrospectively to assess the need for MTP adjustment.

• For example, if all patients have low fibrinogen values upon ICU admission, increased cryoprecipitate or fibrinogen concentrate use is indicated during MTP. A metabolic panel should be used to monitor metabolic abnormalities during MT, such as hyperkalaemia and hypocalcaemia.

• Point-of-care ABG measurement is helpful in monitoring oxygenation.

Conventional coagulation assay vs TEG/ROTEM

• Monitoring haemostasis in patients with MT is challenging because there is no validated coagulation assay that can detect accurately the coagulopathies in massively bleeding patients in a timely manner.

• Conventional coagulation assays, such as PT, aPTT, and fibrinogen levels, are likely not available in real-time fashion.

• In addition, these tests do not detect some haemostatic abnormalities, such as platelet dysfunction, hyperfibrinolysis, and factor XIII deficiency.

• They also do not quantify the relative contribution of pro-coagulant and anti-coagulant factors.

• These conventional coagulation assays do not predict the future need for MTP.

TEG/ROTEM

• Recently, it has been suggested that such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), might be better at assessing coagulopathy inpatients requiring MT.

• These assays offer clinicians a graphic representation of the coagulation process

• In addition, the parameters obtained from TEG/ROTEM could provide a quantitative measure of individual components of the haemostatic process in adult patients.

• Hence, the use of TEG/ROTEM can provide information to guide blood component therapies in a more timely manner.

Advantages of using TEG/ROTEM• Turn around time for these assays is shorter compared with

conventional assays (15–30 min); thus, they can be used in combination with clinical assessment for the decision-making process.

• These assays can detect hyperfibrinolysis, an important component of haemostatic abnormalities in patients with MT that cannot be detected by PT and aPTT assays.

• Unlike the PT and aPTT that can only test secondary haemostasis, TEG/ROTEM assess all phases of coagulation, such as the contribution of platelets to primary haemostasis and factor XIII to cross-linking the fibrin clot.

• TEG/ROTEM can be performed at the patient’s true temperature, which makes it more sensitive for detection of coagulopathy due to hypothermia.

Plasma Transfusion

• a. Consider transfusion when rapid blood loss exceeding 100ml/min continues after transfusion of crystalloids, colloids and 4u RBC’s.

• b. After loss of one circulation blood volume when PT, aPTT, and fibrinogen cannot be obtained in time.

• c. Transfuse 10-15 ml/kg rapidly (this corresponds to 1000ml of plasma, or 4 units of FFP).

• d. It takes 20 minutes to thaw and transport 4u FFP.

Platelet Transfusion • a. On the achievement of surgical hemostasis, do not let platelets

fall below 50,000 mm3 in acutely bleeding patients. • b. Target of 100,000 mm3 recommended for patients with multiple

high energy trauma or CNS injury. • c. Platelet count of 50,000 mm3 can be anticipated when

approximately 2 blood volumes have been replaced with plasma-poor RBC’s.

• d. Platelets are quickly lost through wounds until surgical hemostasis obtained.

Short-term coagulation goals:

• Hct>20-24%• Plts >50,000 mm3 (>100,000

for CNS injury or multiple high energy trauma)

• Fibrinogen>100mg/dL• APTT<45 sec• PT<18 sec

Long-term coagulation goals:

• Hct>24%• Plts>100,000mm3• Fibrinogen>150mg/dL• APTT<40 sec• PT<17 sec

Although the number and timing of blood component delivery,

laboratory testing algorithms, and other aspects of the MTPs varies

between institutions, most current MTPs use predetermined

transfusion packages.

MTPs vary in their predetermined transfusion packages, but all include

platelet and plasma units with RBC units.

Massive Transfusion Protocol (MTP)

• Intravenous access – 2 large bore IVs and CVC• Crystalloid -3:1/colloid- 1:1 ratio with Expected blood loss• Limited crystalloid - avoid dilutional coagulopathy• Labs: Type & Crossmatch, CBC, Platelets, INR, PT, PTT, Fibrinogen,

Electrolytes, BUN/Creatinine, ionized calcium• Continuous monitoring: Volume Status, U/O, Acid-base status• Aggressive re-warming.• Prevent / Reverse acidosis• Correct hypocalcemia: Calcium Gluconate or Calcium Chloride: 1 gm iv

10 slowly(Target goal ionized calcium 1.2 – 1.3)• Transfuse with unmatched group O RBCs on hand. • Repeat lab testing to evaluate coagulopathy

Appropriate Initial Interventions:

Other considerations:

• Heparin reversal: Protamine 1mg IV/100 U heparin• Warfarin reversal: Vitamin K 10 mg IV; Consider PCC(prothrombin

complex concentrate)• Consider antifibrinolytics: by Tranexamic acid 10 mg/kg IV or

Amicar(EACA) 5 gm IV bolus then 1 gm/hr IV infusion• Intraoperative RBC salvage techniques

General Guidelines for Lab-based BloodComponent Replacement in Adults:

Components Thershold Dose

RBCs No Thershold Physician Discretion

FFP INR>1.5 4 Units FFP

Platelets <100000 5- Pack Platelets

Cryoprecipate Fibrinogen<100 Two 5-pack Cryoprecipate

Identify and Manage bleeding(Surgery, angiographic embolization, endoscopy)

4 unit RBCs in <4 hour and ongoing uncontrolled Bleeding

Clinical team activates MTP and designates clinical contactClinical contact phones blood bank(BB) and:• Provides name of clinical contact person to BB• Provides MR#, sex, name, location of patient• Records name of BB contact, calls if location/contact information changes• Ensures that MTP protocol electronic order is entered in CareLink

BB Prepares MTP Pack; Transfuse as 1:1:1 RatioMTP Pack: 6U RBCs; 4U FFP ; One (1) 5-pack Platelets

Stop MTPNotify BB & return any unused blood ASAP Resume standard ordersD/C MTP Electronic order

BB Prepares MTP Pack; Transfuse as 1:1:1 RatioMTP Pack: 6U RBCs; 4U FFP ; One (1) 5-pack

Platelets

Hemostasis & resolution of coagulopathy?

Repeat Labs

• CBC, plts• INR, PT, PTT• Fibrinogen• Ionized Calcium• Consider rapid

coagulation tests

Consider rFVIIa, If persistent coagulopathy

• 40 to 100 ug/kg dose

• Round up to 1, 2, 5 mg vial size

Clinical designate contacts Blood Bank for another MTP pack ** emergency physician can adjust pack based on labs PRN

No

Yes

Transfusion reactions:

• Allergic: Range from simple urticarial to anaphylaxis, Steroid and diphenhydramine might be given to patients with allergic transfusion

• Haemolytic transfusion reaction (acute and delayed): Might be reduced by giving group O RBCs and AB plasma for emergency release of blood products

• Febrile non-haemolytic transfusion reaction: Diagnosis of exclusion

Complication of Massive Transfusion

Immunological reactions:• Transfusion-related acute lung injury (TRALI): Incidence can be

reduced by transfusing male-only plasma• Transfusion-related immunomodulation (TRIM): Might be

responsible for increased risk of bacterial infection• Transfusion-associated graft vs host disease (Ta-GVHD):

Irradiation of cellular blood products in patients at risk (such as neonates and immunosuppressed patients) to prevent Ta-GVHD

• Post-transfusion purpura (PTP): Can be treated with IVIg infusion, steroid, or plasma exchange

Metabolic complications• Hypocalcaemia: Because of citrate overload from rapid

transfusion of blood products. (Each unit PRBCs – approx 3gm citrate)

• Healthy adult liver metabolizes 3gm citrate every 5 minutes. Transfusion rates higher than 1 unit every 5 minutes or impaired liver function may lead to hypocalcemia (Manifest by transient hypotension or tetany).

• Neonates and patients with pre-existing liver disease are at risk for hypocalcemia. Monitor ionized calcium level and correct if necessary

• Hypomagnesaemia: Because of large volume of magnesium-poor fluid and citrate overload. Monitor ionized magnesium level and correct if necessary

• Hyperkalaemia: Because of haemolysis of RBC from storage, irradiation, or both.

• Neonates and patients with pre-exisiting cardiac and renal diseases are at risk for hyperkalaemia.

• Monitor potassium level and correct if necessary. • Fresh RBCs (<5–10 days old), irradiated<24 hbefore transfusion or

washing may decrease risk• Hypokalaemia: Because of re-entry into transfused RBCs, release

of stress hormones, or metabolic alkalosis. Monitor potassium level and correct if necessary

• Metabolic alkalosis: Because of citrate overload. Monitor acid–base status

• Acidosis: Because of hypoperfusion, liver dysfunction, and citrate overload. Monitor acid–base status

• Hypothermia: Because of infusion of cold fluid and blood products, opening of body cavities, decrease heat production, and impaired thermal control. Neonates and infants are at increased risk. Blood warmer should be used

• Other: infections

WeightRed cells FFP

<5kg 2 paediatric units(80-100ml)

2 ‘neonatal’ units methylene blue (MB) treated FFP (100ml) or 1 unit Octaplas

5-10.9kg 1 adult unit (250ml) , will require LVT unit if <12 months old

1 unit MB FFP (225ml)or 1 unit Octaplas

11-20kg 2 adult units (500ml) or 2 LVT if <12 months old

2 units MB FFP (450ml)or 2 units Octaplas

> 20 kg 4 adult units (1000ml)

4 units MB FFP (900ml)or 4 units Octaplas

Weight

Red cells FFP Cryoprecipitate

Platelets

<5kg 2 paediatric units(80-100ml)

2 ‘neonatal’ units methylene blue treated (MB) FFP (100ml)or 1 unit Octaplas

1 single MB donor unit (40ml)

1 paediatric pack of platelets (50ml)

5-10kg 1 adult unit (250ml), will require LVT if < 12 months old

1 unit MB FFP (225ml)or 1 unit Octaplas

2 single MB donor units (80ml)

2 paediatric packs of platelets (100ml)

11-20kg

2 adult units (500ml) will require LVT if less than 12 months old .

2 units MB FFP (450ml)or 2 units Octaplas

5 single MB donor units (200ml)

1 adult apheresis pack (200ml)

> 20 kg 4 adult units (1000ml)

4 units MB FFP (900ml)or 4 units Octaplas

10 single MB donor units (400ml)

1 adult apheresis pack (200ml)

Senior clinician

• Request:a

o 4 units RBC

o 2 units FFP

• Consider:a

o 1 adult therapeutic dose platelets

o tranexamic acid in trauma patients

• Include:a

o cryoprecipitate if fibrinogen < 1 g/L

a Or locally agreed configuration

Massive transfusion protocol (MTP) template

Senior clinician determines that patient meets criteria for MTP activation

Baseline:

Full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistry,

arterial blood gases

Notify transfusion laboratory (insert contact no.) to:

‘Activate MTP’

Bleeding controlled?

Laboratory staff

• Notify haematologist/transfusion specialist

• Prepare and issue blood components

as requested

• Anticipate repeat testing and

blood component requirements

• Minimise test turnaround times

• Consider staff resources

Haematologist/transfusion

specialist

• Liaise regularly with laboratory

and clinical team

• Assist in interpretation of results, and

advise on blood component supportNOYES

Notify transfusion laboratory to:

‘Cease MTP’

OPTIMISE:

• oxygenation

• cardiac output

• tissue perfusion

• metabolic state

MONITOR

(every 30–60 mins):

• full blood count

• coagulation screen

• ionised calcium

• arterial blood gases

AIM FOR:

• temperature > 350C

• pH > 7.2

• base excess < –6

• lactate < 4 mmol/L

• Ca2+

> 1.1 mmol/L

• platelets > 50 × 109/L

• PT/APTT < 1.5 × normal

• INR ≤ 1.5

• fibrinogen > 1.0 g/L

The information below, developed by consensus, broadly covers areas that should be included in a local MTP. This

template can be used to develop an MTP to meet the needs of the local institution's patient population and resources

The routine use of rFVIIa in trauma patients is not recommended due to

its lack of effect on mortality (Grade B) and variable effect on morbidity

(Grade C). Institutions may choose to develop a process for the use of

rFVIIa where there is:

• uncontrolled haemorrhage in salvageable patient, and•

failed surgical or radiological measures to control bleeding, and•

adequate blood component replacement, and•

pH > 7.2, temperature > 340C.

Discuss dose with haematologist/transfusion specialist

b rFVIIa is not licensed for use in this situation; all use must be part of practice review.

• Warfarin:

• add vitamin K, prothrombinex/FFP

• Obstetric haemorrhage:

• early DIC often present; consider cryoprecipitate

• Head injury:

• aim for platelet count > 100 × 10

9/L

• permissive hypotension contraindicated

• Avoid hypothermia, institute active warming

• Avoid excessive crystalloid

• Tolerate permissive hypotension (BP 80–100 mmHg systolic)

until active bleeding controlled

• Do not use haemoglobin alone as a transfusion trigger

• Identify cause

• Initial measures:

- compression

- tourniquet

- packing

• Surgical assessment:

- early surgery or angiography to stop bleeding

• If significant physiological derangement, consider

damage control surgery or angiography

• Consider use of cell salvage where appropriate

•

Actual or anticipated 4 units RBC in < 4 hrs, + haemodynamically unstable, +/– anticipated ongoing bleeding•

Severe thoracic, abdominal, pelvic or multiple long bone trauma•

Major obstetric, gastrointestinal or surgical bleeding

Specific surgical considerations

ResuscitationInitial management of bleeding

Dosage

Cell salvage

Considerations for use of rFVIIab

Special clinical situations

Suggested criteria for activation of MTP

ABG arterial blood gas FFP fresh frozen plasma APTT activated partial thromboplastin timeINR international normalised ratio BP blood pressure MTP massive transfusion protocolDIC disseminated intravascular coagulation PT prothrombin time FBC full blood countRBC red blood cell rFVlla activated recombinant factor VII

Platelet count < 50 x 109/L 1 adult therapeutic dose

INR > 1.5 FFP 15 mL/kga

Fibrinogen < 1.0 g/L cryoprecipitate 3–4 ga

Tranexamic acid loading dose 1 g over 10 min, then infusion of 1 g over 8 hrs

a Local transfusion laboratory to advise on number of units needed to provide this dose

Hemorrhagic shock requiring Massive transfusion is associated with high mortality.

Massive transfusion protocols are associated with improved outcomes.Early blood product tranfusion with plasma:platelet:RBC ratio close to 1:1:1 is associated with reduced 6-hour mortality

Goal-directed transfusion with TEG/TEM is feasible.Fibrinogen concentrates, PCC and other factor concentrates require further study.

When hemorrhage control is complete, stop transfusion.

Summary

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