10/12/2016
Massive Transfusion Protocol
Scott Koepsell MD PhD
Medical Director, Division of Transfusion and Transplantation Services
Nebraska Medicine
Agenda
• Transfusion history/components
• Trauma/hemorrhage
• Evidence based recommendations
• Questions/Discussion
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10/12/2016
Blood Bank History
• 1936 Chicago’s Cook County Hospital
• 1941 Irwin Memorial Blood Bank, SF
• WWII
• Returning surgeons demanded blood
• Initially whole blood in glass bottles, but also lyophilized plasma as well
• 1970s – component blood products
• 2000’s – renewed interest in whole blood in trauma resuscitation
• Warm Fresh Whole Blood (WFWB) has been shown to increase survival with
combat-related injuries
J Trauma 2009:6(S4):S69-76
Blood Components
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Blood Components
=
The amount of platelets in an apheresis platelet unit = the amount of platelets in 6 bags of whole blood
Plasma can
be
manufactured
into cryo
Severely Injured or Trauma Patients
• Many hospitals have adopted a massive transfusion protocol (MTP) that includes
plasma and platelets along with RBCs and possibly cryoprecipitate
• The purpose of an MTP is to prevent a dilutional coagulopathy
• Crystalloids and RBCs do not contain clotting factors or platelets
• What type and amount of blood products are provided to prevent a dilutional coagulopathy?
• MTP is not a hemorrhage protocol
• Proper calcium, pH, and temperature are required to form a clot
• Key components of an MTP
• What to include
• Logistics
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MTP: What to include
• Early administration of plasma in trauma likely lowers mortality
Reviewed in Hematology 2013: 656-659
• PROPPR trial
• Resuscitation of a patient with 1:1:1 (plasma:platelets:RBCs) versus or 1:1:2
had equivalent mortality at 24 hours and at 30 days
JAMA 2015: 313(5):471-482
• Many hospitals do not routinely stock platelets
MTP: What to include
• Nebraska Medicine, Nebraska Medical Center
• Emergency release refrigerator with 2 O-neg RBCs, 6 O-pos RBCs, 3 A plasma
• MTP Pack (1:1:1)
• 6 O-positive RBCs
• 6 A-plasma
• 1 apheresis platelet
• Cryo (5 units) every 3rd pack
• Keep two MTP packs ready to go at all times
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MTP: What to include
• Nebraska Medicine, Bellevue Medical Center
• Emergency release 3 Group O RBCs
• MTP Pack (1:1)
• 4 O-positive RBCs
• 4 A-plasma or AB-plasma
• Plasma has to be thawed (~15 minutes)
MTP: What to include
• Uncrossmatched RBCs, Group O
• 0.4% chance of acute hemolytic reaction
• 2.6% chance of delayed hemolytic reaction
AJCP 2010;134:202-206
• O-positive RBCs for males and woman >50 usually ok
• O-negative RBCs are in short supply and giving Rh-positive RBCs is
perfectly acceptable to prevent life-threatening anemia
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10/12/2016
MTP: What to include
• Plasma – AB or A
• Group A plasma usually has low anti-B
• Only about 10% of population is Group B or AB
• Group A plasma is likely safe for all adult patients
J Trauma Acute Care Surg 2012; 74:69-75
• Platelets or cryoprecipitate – Any type
MTP: Logistics
• Equally as important as what to include as part of your MTP
• Who can initiate an MTP?
• Designate one person to interact with the blood bank
• What phone number?
• How to deliver MTP pack
• Clerk/tech, RN, blood bank staff, someone else
• How to prevent wastage
• Who is in charge of MTP pack
• How to order additional MTP packs
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MTP: Logistics
• Vascular access
• Rapid infusion systems
• Platelets often cannot be used
• Co-administration of drugs or LR
• How to document transfusion of a blood product (Required)
• What to do in case of a transfusion reaction
• How to stop an MTP
MTP: Logistics
• MTPs can be somewhat rare events so drills are an excellent idea
• OB hemorrhage drill at BMC
• Discovered the care tech assigned to get MTP pack did not have access to the
blood bank hallway
• Benchmarked expected times for blood delivery
• Practiced assigning roles and communicating with the blood bank
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MTP: Summary
• Large blood volume resuscitation depletes coagulation factors and
platelets – so called dilutional coagulopathy
• Massive transfusion protocols can be developed to provide blood
product support to combat dilutional coagulopathy and support
hemorrhage protocols
• Risks of massive transfusion include uncrossmatched RBCs
• Logistics of activating, delivering, infusing, documenting, monitoring,
and stopping an MTP event are key to success
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