1. Massive Transfusion Protocol
K. Pavenski, MD FRCPC
Head, Div. Transfusion Medicine
October 31, 2013

2. Outline What is massive hemorrhage/massive transfusion?
Massive Transfusion Protocol (MTP)
Team
Activation criteria
Initiation
Blood products
Transfusion goals
Termination
Common errors and adverse events

3. Introduction
There is no universal definition of massive hemorrhage (MH) or transfusion (MT)
Commonly used definition is a requirement for more than 6 units of red blood cells (RBC) in 4 hours
Rate of bleeding and likelihood of rapidly achieving hemostasis are important considerations
MH is a rare, complex and high stress medical scenario
MH is associated with a high mortality rate

4. Introduction
Massive hemorrhage and massive transfusion may occur in the following clinical contexts:
Trauma
Post-partum hemorrhage
Cardiovascular complication (ex. ruptured abdominal aortic aneurysm)
Acute upper GI bleeding
Post surgery

5. Introduction
MTP is an algorithm for management of a patient with a massive hemorrhage
MTPs have been shown to
Improve patient outcomes
Reduce patient mortality
Reduce wastage of blood products
St. Michael’s MTP can be found on CPPS

6. MSICU MTP Stats 62 MTP activations per year at SMH 5 in MSICU GIB – 3
Bleeding due to drug overdose – 1
Bleeding kidney mass - 1

7. Principles of MT management
Early recognition of blood loss
Maintenance of tissue perfusion and oxygenation by restoration of blood volume and haemoglobin
Control of bleeding with early surgical, endoscopic or radiological intervention – “damage control surgery”
Early management of coagulopathy
Early administration of antifibrinolytics (ex. Tranexamic acid)
Maintenance of normothermia and normal calcium levels
Reversal of anticoagulant and/or antiplatelet medications if applicable
Monitoring for and management of complications of massive transfusion

8. MTP Activation Criteria: General
In a bleeding patient, recognized need for uncrossmatched RBC
Actual substantial blood loss
estimated 1500cc of blood lost OR at least 6 RBC transfused with anticipated ongoing hemorrhage
Anticipated substantial blood loss requiring transfusion of at least 6 RBC within minutes to hours

9. MTP Activation Criteria: Specific
Trauma:
Penetrating trauma AND persistent hypotension (2 measurements of SBP< 90 mmHg taken 5 min apart).
Blunt trauma AND persistent hypotension AND one of the following:
Massive haemothorax
Positive FAST scan
Pelvic fracture

10. MTP Activation Criteria: Specific
Post partum haemorrhage (PPH):
>500 cc vaginal blood loss AND hypotension not responding to crystalloid bolus
>1000 cc blood loss following caesarean section AND hypotension not responding to crystalloid bolus
Suspected bleeding AND hypotension not responding to crystalloid bolus in a post-partum patient.
Bleeding in cardiovascular patients:
Known/suspected ruptured or leaking abdominal aortic aneurysm
Postoperative chest tube drainage >1000 cc in 30 minutes or less
Cardiac or aortic rupture
Atrial leak

11. MTP Activation: Where
MTP may be administered in the following clinical areas:
Emergency Department
Operating Rooms
Intensive Care Units
If the need for MTP arises in any other area, initiate MTP and transfer the patient as soon as practically possible to an appropriate location for further resuscitation

12. MTP: Team MTP lead Is a physician in charge of patient care during MTP
In ER, ER physician or Trauma Team Leader
In OR, anaesthesiologist
In ICU, staff physician or clinical fellow
In all other areas, staff anaesthesiologist assumes the role of MTP lead

13. MTP: Team MTP assist RN, RRT, or perfusionist
Administers IV fluids, medications, blood products, monitors patient’s vital signs, charts
Nurse assigned to the patient will become MTP assist

14. MTP: Team Transfusion Medicine (TM)
One technologist is usually designated to assist with MTP and will keep track of what products are issued and when
TM performs compatibility testing and prepares blood products for transfusion
TM regularly communicates with the team at patient’s bedside
TM may provide recommendations on optimal transfusion therapy

15. MTP: Team Additional resources may be necessary Respiratory therapist
Assists with airway and oxygen therapy
Administers IV fluids and blood products
Perfusionist
Sets up cell salvage if appropriate
Porter
Delivers laboratory samples to the laboratory and blood products from TM to the patient
Returns empty coolers and untransfused blood products to TM

16. MTP: Activation
MD assesses the patient and makes a decision to activate MTP
MD (or delegate) calls Transfusion Medicine Laboratory (ext 5084) and requests to activate MTP

17. MTP: Activation
MD (or delegate) is to provide the following information to TM:
Patient location and contact telephone number
Patient’s name and MRN
If patient’s identity is not known, state MRN, gender and approximate age
Name of the MD who will lead MTP
State whether the patient is/appears to be pregnant
May require CMV negative RBC and platelets
May need to activate CODE OB

18. MTP: Activation Assemble team Designate MTP lead, assistants (RN, RRT)
Call locating if additional resources are necessary
Anaesthesia, porter, perfusionist, etc.
Porter
If your area has a porter or CA and he/she is available to assist, do not call portering services
Outside of ED/OR/ICU, call CCRT or Code Blue

19. MTP: Initial Patient Management
Secure airway and provide oxygen
Obtain appropriate vascular access
2xG14-16 i.v. or central line
Start IV fluids
Note: only 0.9% NaCl solution is compatible with blood products
Set up rapid infuser/blood warmer
Administer tranexamic acid if appropriate
Keep core temperature >35C
Place patient on continuous monitoring

20. MTP: Initial Patient Management
For information on administration of tranexamic acid in trauma, refer to Protocol for intravenous administration of tranexamic acid (Cyclokapron) during trauma resuscitation (Pharmacy)

21. MTP: Initial Laboratory Investigations
Send off laboratory investigations:
Group and screen (2 pink top tubes)
CBC (1 lavender top tube)
INR, aPTT, Fibrinogen (1 blue top tube)
Electrolytes, ionized calcium, creatinine (2 yellow top tubes)
Lactate (1 grey top tube)
VBG (syringe)
Place labeled specimens into a red plastic STAT bag and deliver to the labs as soon as possible

22. MTP: Patient Monitoring
Clinical
BP, HR, SatO2, RR, temperature
Input and output
Laboratory
Send CBC, INR, fibrinogen every 1 h
ABG/VBG every min
Creatinine/Magnesium/Lactate every 4h

23. MTP: Transfusion
Follow the policy on Administration of Blood Products (CPPS)
Use blood warmer for RBC and plasma
Refer to Use of rapid infusion and blood warming devices for infusion of blood products and resuscitating fluids (CPPS)
Do not transfuse platelets and cryoprecipitate through a blood warmer
RBC and plasma will be transported and stored in a cooler during MTP
Platelets and cryoprecipitate should be kept at room temperature; do NOT place in the cooler

24. MTP: Transfusion of RBC
RBC must be ABO compatible and crossmatch compatible
Following initiation of MTP, red blood cells (RBC) are immediately available for pick-up
If patient’s compatibility testing (group & screen, crossmatch) has not been completed, you will receive uncrossmatched RBC
If patient has RBC already crossmatched, you will receive crossmatch compatible RBC

25. MTP: Transfusion of RBC
Notes:
For a new patient, it will take at least 45 minutes to obtain crossmatch compatible RBC from the time of specimen arrival in TM
For a patient with an in-date group and screen (with no crossmatched units available), time to compatible RBC will depend on whether the patient has RBC antibodies (5 min to few hours)
Patient will be switched to crossmatch compatible RBC as soon as they are available

26. Time to Availability of RBC
RBC Product
Turn-Around Time
Comments
Uncrossmatched blood
(O Rh pos or O Rh neg)
<5 minutes
Only in emergencies (when risk of delaying transfusion is higher than the risk of acute hemolysis*)
Group-specific, uncrossmatched RBCs
10 minutes (to perform group)
As above; superior, because matching for ABO and RhD preserves O-Neg stock
Crossmatched RBCs
45 minutes to hrs (to perform group and screen, antibody investigation if appropriate, crossmatch)
Preferred choice, as the serologically cleared product is the safest product available
O Rh neg reserved for females of childbearing age
* 1% risk 26

27. MTP: Three approaches to transfusion
Transfusion management of a massively bleeding patient may be:
Lab-based
Ratio-based (1:1 frozen plasma to RBC)
Point-of-care testing driven
Our protocol utilizes ratio-based resuscitation to guide plasma transfusion and lab-based approach to guide transfusion of platelets and cryoprecipitate

28. MTP: Transfusion of Plasma
Administered during MTP at a 1:1 ratio RBC to plasma:
1st cooler: 4 units
2nd and subsequent coolers: 4 units
Must be ABO compatible
Thawing plasma takes about 20 minutes
Upon initiation of MTP, plasma should be ready in 20 minutes
If patient blood group is not available, AB plasma will be issued
Patient will be switched to group specific plasma once patient’s blood group has been determined

29. MTP: Transfusion of Platelets
During MTP, administer if platelet count is <100 for CNS/spinal cord bleeding or traumatic brain injury; <50 for all others OR at any count if platelet dysfunction is suspected (ex. post-bypass)
Dose is “1 adult dose”
Available immediately
Note: For patients with PPH, platelets
will be offered with the 1st cooler

30. MTP: Transfusion of Cryoprecipitate
During MTP, administer if fibrinogen level is <1.5g/L
Dose is 10 units
Must be ABO compatible
Thawing and pooling cryoprecipitate takes 30 minutes
Note: For patients with PPH, cryoprecipitate will be offered with the 1st cooler

31. MTP: What is in the shipment?
1st shipment
Cooler with 6 units of RBC
4 unit of plasma will be issued separately in the next 20 minutes
For PPH OR upon request
1 adult dose of platelets (available immediately)
10 units of cryoprecipitate (available in 20 minutes)
2nd shipment and subsequent shipments
Cooler with 4 units of RBC, 4 units of plasma
Will be prepared every 30 minutes
Platelets and cryoprecipitate must be ordered as per clinical situation and laboratory results
These will be issued in a clear plastic bag

32. MTP: Transfusion Goals
The following should be used as a guideline only and not replace clinical judgment
Transfuse RBC to maintain Hgb>80g/L
Transfuse plasma at a 1:1 to 1:2 RBC to plasma ratio or maintain INR<1.5 and/or aPTT<1.5x upper limit of normal
Transfuse cryoprecipitate to maintain Fibrinogen >1.5 g/L
Transfuse platelets to maintain platelet count of 100x109/L for CNS/spinal cord bleeding or traumatic brain injury; platelet count for 50x109/L for all other bleeding patients
Note: If platelet dysfunction is suspected, transfuse platelets regardless of platelet count

33. MTP: Supportive measures
The principal aim is to achieve either surgical or medical haemostasis
Other potentially useful interventions:
Maintain normothermia
Replace calcium
Consider cell salvage
Consider tranexamic acid (TXA): 1 g loading dose over 10 minutes followed by 1g over 8 hours
Use of recombinant Factor VIIa (rFVIIa) is not recommended in the management of MT

34. MTP: Termination Termination criteria
bleeding is controlled or patient is deceased
Note: Re-assess need for ongoing MTP every 30 minutes; if transfusion requirements have decreased, consider terminating MTP and provide transfusions as necessary
Inform TM (ext 5084) that MTP has been terminated
Return MTP cooler(s) and any untransfused blood products as soon as possible to avoid wastage

35. MTP: Common errors Consistently identified weaknesses during MTP:
Poor planning
Poor communication
Delay in activation of MTP
Failure to monitor laboratory parameters during MTP
Failure to monitor for and manage hypothermia
Failure to administer blood products as per MTP
Failure to administer cryoprecipitate
Delay in termination of MTP

36. MTP: Adverse Events Hypothermia Citrate toxicity
Volume overload, abdominal compartment syndrome
Transfusion Reactions
Acute hemolytic transfusion reaction (ex. ABO incompatible transfusion due to clerical error)
Transfusion related acute lung injury (TRALI)
Transfusion associated cardiac overload (TACO)
Major allergic reaction

37. Concluding Remarks Be prepared – know the protocol
Practice - participate in mock MTP
During MTP, communicate with all members of the team, including those in TM
Re-assess need for ongoing MTP frequently
Return coolers and untransfused products ASAP