A transfusion medicine physician in Colorado would like to know if others use "automatic" protocols for dealing with massive transfusion. For example, how do you define 'massive transfusion' and at what point is the trigger to initiate a massive transfusion protocol? Does any institution use a 'formula' for determining how many platelets and/or plasma products are issued per unit of RBCs transfused in the massive transfusion setting? For those reporting on their massive transfusion protocol, please comment on the scientific basis (evidence) for establishing the protocol?

The following responses have been received.

ADDENDA July 23, 2004

1. A blood banker in Colorado reports that her facility defines massive transfusion as transfusing 10 or more units of RBC's within a 24-hour period. When they decide to initiate the Massive Transfusion Protocol, they document it in the computer on the accession number for the original order and notify the physician or nurse. They do not have a fixed formula for platelets and other plasma products.

2. A transfusion medicine physician in the Pacific Northwest reports that over the last 3 years she has worked closely with the trauma hospital in Seattle (reportedly the 2nd largest trauma center in the nation). She is aware that the scientific literature does not support the use of "ratios" (5 FFP for every 8 units of red cells, etc) in transfusion medicine. They set up a protocol for perhaps a more practical reason, after collecting data on their own trauma patients for a few months.

By analyzing data on the time of admission of the patient, time to first sample draw, and time to get coagulation results back and order blood components based on those results, they recognized that the patient could be well into the resuscitation phase before any components besides red cells were ordered. For some of these patients, the fibrinogen was extremely low or became low within 30 minutes of arrival into the ER. Their rational with a "massive transfusion pack" (MTP) was to get the correct components quickly to the patient, in hopes of stabilizing the coagulation parameters and using fewer components in the long run. And with the "golden hour" for a trauma patient, to get the patient components before he/she became cold or too acidotic for the components to be effective.

The basics of the protocol are as follows:

• For those patients where the anticipated blood loss is 10 red cells in 2 hours, an MTP can be ordered
• The Blood center will send 1 cryopool, 4 FFP, and 1 apheresis platelet
• After this, it is expected that blood components will be ordered based on results of coagulation tests. (NOTE: The hospital's coag lab will turn results around for PT/INR, fibrinogen and platelet count in 15 minutes if the specific order is given.)
• The agreement between the hospital and the blood center was that the hospital transfusion committee would audit the ordering of MTPs to ensure compliance with the agreed-upon criteria. To date, the use of the MTP appears to be working well for both institutions.

ADDENDA July 26, 2004

3. A colleague in the Pacific Northwest reports that her institution employs an automatic protocol that is activated by the patient's physician. They define massive transfusion as replacement of 1 blood volume over 1-3 hours. Once activated, the protocol requires a baseline blood sample to be collected for PT, PTT, fibrinogen, platelet count, hemoglobin and hematocrit. Followup samples are sent on a regular basis (every 30 minutes) over the duration of the protocol. Results of baseline and followup testing are first reported to the blood bank (and then to the attending physicians) within 15 minutes of sample receipt, and no more that 30 minutes from sample collection time. The blood bank then prepares blood products for issuance based on pre-set transfusion triggers:

• 2 FFP for an INR of 1.5
• 4 FFP for an INR of 2.0
• 1 prepooled cryo (pool of 6) for a fibrinogen of 100 or less
• 1 apheresis plt for a count of 100,000 or less

The blood products are sent immediately to the Operating Room (or to the patient's site) via dedicated runner who is focused on product and sample delivery. In the blood bank one tech is assigned the responsibility of preparing plasma/cryo/platelet for issuance and another technologist focuses on crossmatching 4 units every 15 minutes. They issue 4 units of red cells without interruption every 15 minutes while this level of support is needed. Other blood components, if needed based on documented followup lab values (reported every 30 minutes) are issued in addition to the red cells. After results are called to blood bank they are then called to the attending physician or if the patient is in surgery the results are called to the anesthesiologist. According to their local protocol, their blood bank is informed first of the test results so that they can start processing the frozen products literally within minutes of result receipt. They use apheresis platelets and prepooled cryo so the TAT for these products is 15 minutes or less. The blood bank communicates frequently with the patient care area to ensure that red cells do not stockpile and to ensure the plasma-containing products are transfused immediately upon receipt.

The day after the massive transfusion episode ('when the dust has settled') the blood bank staff and clinicians discuss the case to determine what worked well, what did not work and how the protocol might be improved. This is important in her institution because they have only about fifteen massive transfusion protocol activations per year, so it is important for them to learn as much as they can from each protocol activation. A summary of each post-protocol discussion is prepared and distributed to all areas that could potentially activate a massive transfusion protocol (ED, ICU, CCU, OR and Family Birth Center). They have 6 'drills' in the laboratory each year, 2 on each shift to keep the techs proficient with the protocol. At first it was difficult for surgeons , anesthesiologists and other clinicians to trust the protocol. However, it has been 2 years since implementation and the majority of the clinicians are reportedly comfortable with this protocol. WHEN COMPARED TO THEIR PREVIOUS PROTOCOL WHICH WAS BASED ON AN EMPIRIC FORMULA, THE CURRENT PROTOCOL SHOWS A DECREASE IN THE AVERAGE TRANSFUSION OF RED CELLS AND COMPONENTS, DECREASED DURATION OF THE MASSIVE BLEED AND AN INCREASE IN THE NUMBER OF JUSTIFIED TRANSFUSIONS. She concludes that the blood bank techs like this approach because they know exactly what to do in a massive transfusion situation.

ADDENDA Aug. 2, 2004

4. The director of a transfusion service at a large trauma hospital in New York City agrees with the sentiment expressed by others that emphasis should be on the patient's clinical presentation and lab values, and not on formulas. However, he does believe that formulas do have their place in guiding expectations, and in his experience one should expect to issue FFP after one blood volume (10 to 12 units) of red cells. Platelets may also be required, but in his opinion cryo almost never is indicated at that point, particularly with a trauma patient who started off reasonably healthy, and who is receiving the indicated FFP. In his experience, fibrinogen levels below 100 mg/dL are not usually seen until the patient has been transfused with the equivalent of two blood volumes. This is sometimes a hard sell to surgeons who are of the opinion that cryo is useful in stopping brisk hemorrhage. The responding physician has seen surgeons 'waste precious time fussing over getting and transfusing the cryo'. The obstetricians also seem to insist on cryo if their patient is on the third or fourth red cell unit and has moderately elevated PT/PTT ("DIC"), despite the fact that fibrinogen could still be over 300 mg/dL!! The New York director has had to 'sell them on the better marginal utility of sticking with FFP in these patients'. He concludes by saying that he is interested in the experiences and opinions of other blood bank physicians in this regard.

ADDENDA Aug. 4, 2004

5. A Professor and Chairman of a Department of Anesthesiology in Canada comments that as acknowledged by several colleagues, transfusion protocols are not supported by the literature. Recently, along with European colleagues from the Perioperative Hemostasis Interest Group (Groupe d’Intérêt en Hémostase Périopératoire - GIHP), they published a review article on the topic of massive transfusion and coagulopathy (Can J Anesth 2004;51:293-310). In this article, they contrast massive transfusion in the elective surgical setting with that in the trauma situation. They also contrast the situation when whole blood or modified whole blood was available with that for contemporary blood component therapy. Very briefly, with blood component therapy, a deficit in coagulation factors (specially fibrinogen) is more likely to be the primary cause of defective hemostasis secondary to massive transfusion during elective surgery. In the trauma setting, the situation is more complex and the available data do not support definitive conclusions. Case series suggest that the transfusion of large volumes of platelets may be associated with higher survival rates in this context. Their approach is to recommend transfusion therapy based on the results of coagulation testing. In order to expedite therapy, the simultaneous ordering of hemostatic blood products and tests of hemostasis will allow clinicians to transfuse the most appropriate components at the moment they receive the results of coagulation testing (or to look for other causes of bleeding should the tests be normal). However, they recognize that this approach may not always be possible and that the urgent, “blind” transfusion of hemostatic blood products may be warranted.

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Ira A. Shulman, MD
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