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Massive Transfusion Protocol

Purpose

Hemorrhage is the leading cause of early death following traumatic injury. Protocol-driven transfusion strategies that approach a 1:1:1 ratio in patients who require massive transfusion improve patient survival, reduce hospital and ICU length of stay, decrease ventilator days, and ultimately reduce patient care costs. 

This guideline is a supplement to and is to be used in conjunction with the organizational policies "Massive Transfusion/Severe Coagulopathy" (TX-36) and "Guidelines for Management of Bleeding in Patients Receiving Anticoagulation" (MP 11).

This guideline standardizes the assessment of coagulopathy including assessment and treatment of acidosis, hypothermia, and hypocalcemia in the trauma patient population. 

Definitions

  1. Massive Transfusion Protocol (MTP): utilized when anticipated blood loss is greater than one blood volume within 24 hours (weight in kilograms x 70 mL), >10 units packed red blood cells (PRBC) within 24 hours of admission, or >4 units PRBC in 1 hour. MTP includes component replacement (thawed plasma, apheresis platelets, and pre-pooled cryoprecipitate).
      • MTP pack 
WeightPacked Red Blood Cells (PRBC)Thawed PlasmaApheresis PlateletsPre-pooled Cryoprecipitate (cryo)
Greater than 50 kg6 (O pos)6 (A)1On pack #3 and every pack thereafter
Less than 50 kg6 (O pos)6 (A)1On pack #3 and every pack thereafter
Infant (less than 10 kg)1 (O neg, irradiated)
1 (irradiated) 
  1. Emergency Release Blood: immediately available blood products for transfusion in which time does not permit compatibility testing (non-MTP or trauma situations)
      1. Emergency Department (ED) trauma bay kiosk refrigerator: 6 O-positive PRBCs, 2 O-negative PRBCs, 3 A thawed plasma
      2. Trauma operating room (OR) kiosk refrigerator: 6 O-positive PRBCs
      3. Blood bank: boxed blood (4 O-negative PRBCs) and limited quantity universally compatible PRBCs, thatwed plasma, platelets and cryo. 

Initiation of MTP

Activation of the massive transfusion protocol is at the discretion of the Trauma Attending or Emergency Medicine physician, in lieu of the trauma attending. The attending should consider activation of MTP if: 

  1. Assessment of blood consumption (ABC) score is two or more:
      • penetrating mechanism of injury (1 pt)
      • systolic blood pressure less than or equal to 90 (1 pt)
      • heart rate greater than or equal to 120 (1 pt)
      • positive FAST exam (1 pt)
  2. Persistent hemodynamic instability (SBP<90) despite two units of emergency release blood
  3. Shock index >1 (SI = HR/SBP)
  4. Active bleeding requiring an operation or angioembolization
  5. Anticipation of transfusing >10 units PRBC in 24 hours or >4 units PRBC in 1 hour. 

Transfusion Goals

  1. Minimize crystalloid or colloid resuscitation to prevent dilutional coagulopathy. Instead, begin early emergency release blood product infusion and initiate MTP based on above triggers. 
  2. Transfuse plasma, PRBC, and platelets in a ratio of 1:1:1 (plasma:PRBC:platelet). Transfuse one apheresis platelet for every 6 units of PRBC and 6 units of plasma. Refer to "Massive Transfusion/Severe Coagulopathy" (TX-36) for children and infant specific ratios. 
  3. Massive transfusion products should be administered rapidly and warmed via a rapid infuser with the exception of platelets. 
  4. Initial rate of transfusion should restore perfusion, but allow permissive hypotension until bleeding has been controlled in the operating room or interventional radiology
  5. Blood product resuscitation should be based on clinical evidence of ongoing bleeding in addition to quantitative data, such as thromboelastography (TEG) when available. 
  6. Utilization of the patient's own blood when safe (use of cell saver, autotransfusion from chest tube, etc.) provides redaily available warm, matched blood. 

Assessment of Coagulopathy and Transfusion Targets

  1. Coagulopathy
      • Initial lab testing: type and screen, CBC, PT/PTT, INR, fibrinogen, and TEG at initiation of MTP.
      • Ongoing lab testing: CBC, PT/PTT, INR, fibrinogen, and TEG every 4 hours during MTP (or more frequently depending on clinical situation) 
  2. Acidosis
      • Goal: Lactic Acid <2.0
      • Goal: Base deficit <4.0
      • Ongoing lab testing: Lactic acid and arterial blood gas (ABG) to obtain a base deficit every six hours during MTP (or more frequently depending on clinical situation)
  3. Hypothermia
      • Goal: 36 degrees Celsius or warmer 
      • All trauma patients should undergo passive external rewarming including warmed blankets and increased ambient room temperature. 
      • Administer warm blood products.
      • Continuously monitor utilizing a core temperature probe. 
  4. Hypocalcemia
      • Goal: Ionized calcium (iCa) >1.0 mmol/L
      • Ongoing testing: iCa should be monitored at initiation of MTP and after completion of each MTP cooler. 
      • After completion of each MTP cooler, 3 grams of calcium chloride IV should be administered. 
  5. Hyperkalemia
      • Goal: Potassium <5.0
      • Ongoing lab testing: Potassium every 6 hrs during MTP (or more frequently depending on clinical situation). 

Therapeutic Adjuncts

  1. Tranexemic Acid (TXA)
      • Should be given within 3 hours of injury
      • Indications (to be ordered at discretion of trauma attending):
          • activation of massive transfusion protocol
          • adult trauma patients with severe hemorrhagic shock 
          • known fibrinolysis by TEG
      • Dosing: 1 gram IV over 10 minutes followed by 1 gram IV infusion over next 8 hours. 
  2. Anticoagulation reversal 
      • This guideline is a supplement to and is to be used in conjunction with the organizational policies "Massive Transfusion/Severe Coagulopathy" (TX-36) and "Guidelines for Management of Bleeding in Patients Receiving Anticoagulation." (MP 11) 

Termination and Endpoints for MTP

Termination and endpoints should be based upon anatomic and physiologic criteria. 

  1.  When surgical bleeding has been controlled or there is radiographic and physiologic evidence of bleeding control after embolization, MTP can be terminated. Resuscitation can then be based on specific, ongoing laboratory testing such as thromboelastography (TEG). 
  2. When resuscitation is futile, MTP can be terminated. 
  3. Resuscitation of any kind (MTP and goal directed based on labs) can be terminated if:
      • no active surgical bleeding
      • hemoglobin greater than or equal to 10, stop PRBC transfusion
      • prothrombin time (PT) <18 seconds, stop plasma transfusion
      • partial thromboplastin time (PTT) <35 seconds, stop plasma transfusion
      • International Normalized Ratio (INR) <1.5, stop plasma transfusion
      • platelet count >150 x 109, stop platelet transfusion
      • fibrinogen level >180, stop cryo transfusion
      • R value <9 on TEG, stop plasma transfusion
      • K-time <4 minutes on TEG, stop plasma and/or cryo transfusion
      • alpha-angle >60 degrees, stop cryo and/or plasma transfusion
      • mA>55 mm, stop platelet transfusion
      • LY30 <7.5%, stop anti-fibrinolytics 

Performance Improvement

All trauma massive transfusion activations will be monitored through the Trauma Performance Improvement Process. Specific indicators include:

  1. time from initiating MTP to infusion of the first unit of PRBCs
  2. time from initiating MTP to infusion of the first unit of plasma
  3. overall ratio of blood product transfusion and at two hours
  4. total blood products used from MTP activation to 24 hours
  5. notifying the blood bank within one hour of MTP termination
  6. blood product wastage rates
  7. use of adjuncts
  8. complications
      • transfusion related adverse reactions
      • coagulopathy
      • thrombotic complications
      • acute respiratory distress syndrome 
      • over-transfusion
      • mortality

References

  1. American College of Surgeons Trauma Quality Improvement Program. (2015) ACS TQIP Massive Transfusion in Trauma Guidelines. Retrieved from https://www.facs.org/~/media/files%20programs/trauma/tqip/massive%20guideline.ashx 
  2. American College of Surgeons Advanced Trauma Life Support, 10th Ed. 2018. 
  3. Callcut RA, Cotton B, Mskat P, Fox EE, Wade CE, Holcomb JB, Robinson RH. (2013) Defining when to initiate massive transfusion (MT): A validation study of individual massive transfusion triggers in PROMMTT patients. J Trauma Acute Care Surg. 74(1), 59-67. 
  4. Schroll R, Swift D, Tatum D, Courch S, Heaney JB, Llado-Farulla M, Zucker S, Gill F, Brown G, Buffin N, Duchesne J. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury. 49(1), 15-19.
  5. Naplitano LM, Cohen MJ, Cotton BA, Schreiber MA, Moore EE (2013). Tranexamic acid in trauma: How should we use it? J Trauma Acute Care Surg, 74(6), 1575-1586. 
  6. Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotten BA. (2009) Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma: Injury, Infection, and Critical Care. 66, 346-352. 
  7. Panteli M, Pountos I, Giannoudis PV (2016). Pharmacological adjuncts to stop bleeding: options and effectiveness. Eur J Trauma and Em Surg. 42, 303-310. 

Last updated:

August, 2019

TX36 Massive Transfusion/Severe Coagulopathy 

MP 11 Guidelines for Management of Bleeding in Patients Receiving Anticoagulation 

 

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