Massive Transfusion Protocol

Question 1

reference- IBCC

What is the rationale for MTP?

Answer 1

Patients with severe hemorrhage can develop refractory haemorrhage due to:
* Dilution of clotting factors (incl. platelets)
* Hypothermia
* Acidosis
.Hypocalcemia

Labs would not return fast enough to guide initial resuscitation - hence the protocol based resusc.

MTP gives balanced resuscitation with PRBC, platelets, FFP to avoid dilutional coagulopathy.

Question 2

When should you initiate MTP?

Answer 2

Based on clinical judgment +:
* Hemodynamic instability
* Bleeding not responding to fluids/blood
* Rapidity of bleed
* Expected trajectory of ongoing bleeding
* Clinical condition of the patient

Hb level alone is not useful for MTP decision.

Question 3

What is MTP used for?

Answer 3

• Initially validated for traumatic hemorrhage
• Now used broadly: GI bleed, obstetric bleed, intraoperative bleeding, etc.

Question 4

What is the definition of Massive Transfusion?

Answer 4

• ≥10 units PRBC in 24 hrs
• ≥4 units in 1 hr
• Whole blood ≥1 volume in 24 hrs (≈70 mL/kg)
• 50% of blood volume lost in 3 hrs

vs MTP- administration of large amounts of blood products-at least 6units of PRBC in a fixed ratio-1:1:1 with an aim to prevent dilutional coagulopathy.

Question 5

What does MTP typically involve administering?

Answer 5

Rapid delivery of RBCs, FFP, platelets in fixed ratios (e.g., 1:1:1), aiming to reverse hemorrhagic shock.

Question 6

Next 9 slides- outline steps in MTP

Points to be considered during MTP

Answer 6

1. Avoid excessive crystaloid resus
2. 1:1:1RBC, Platelet,FFP
3. Reversal of other coagulopathies
4. consider Fibrinogen
5. TXA
6. Calcium
7. Avoid Hypothermia
8. Avoid Acidosis
9. Haemodynamic Mx
10. Source control
11. Post MTP care

Question 7

Avoid excessive crystalloid resusc

Answer 7

1. Dilutes coagulation factors, no O2 carrying capacity
2. Where possible resuscitate haemorhagic shock with blood/ blood products-avoid dilutional coagulopathy

Question 8

Fibrinogen supp

Answer 8

• Hypofibrinogenemia during MTP - mainly dilutional
• Replace with cryo/fibrinogen concentrate
• 1 adult dose of cryo supp. as 10units gives 3-4gm of Fibrinogen
• Aim fibrinogen level-1.5 to 2.0

Question 9

Tranexamic acid

Answer 9

• Proven benefit in obstetric haemorrhage(Woman trial) and early in major trauma(CRASH2)
• 1gm immediately foll by 1gm over 8hrs

Question 10

Reversal of Coagulopathy

Answer 10

• MTP- designed to prevent dilutional coagulopathy - other coagulopathies need to be treated- eg:
• Warfarin- PCC
• Doacs- specific reversal agent or PCC
• Antiplatelets of uremic platelet dysfunction- Desmopressin-21mcg

Question 11

Calcium

Answer 11

• Hypocalcemia - due to chelation
  by citrate in blood products
  *keep Ionised Ca- >1.0-
• 1-2 gm of cacl2 or 3-6gm of ca gluconate.

Question 12

Avoid Acidosis

Answer 12

• Aim Ph>7.2
• If ventilated- mild hyperventilation
• If NAGMA/uremia- may improve foll. citrated blood products/ sod bi carb
• Lactic/Ketoacidosis- Tt underlying cause

Question 13

Prevent Hypothermia

Answer 13

• Warmed blood products
• Pre emptive surface warming- with heated blankets/bier huggers
• Warm inhaled gases if possible
• Extracorporeal rewarming

Question 14

Haemodynamic Mx-

Answer 14

• Maintain low normal BP- MAP-60-65mmhg till haemostasis achieved EXCEPT_ in TBI where CPP needs to be maintained
  
  • High CVP- increases venous ooze
  • High arterial BP- dislodgement of clot

Question 15

Source control

Answer 15

• Paramount importance
• Should be done ASAP
• Quickest possible method- eg Damage control sx/ interventional radiology. Definitive Sx can be done at a later stage.

Question 16

Post MTP care

Answer 16

*Labs
Electrolytes, including ionized calcium
Complete blood count
INR, PTT, fibrinogen
*Set Targets
1. temperature>36
2. Platelets>50,000
3. INR <2.0
4. Fibrinogen>1.5 g/l
5. Ca ionised>1.0 mmol/l
6. Monitor with ROTEM

Question 17

Quick check list

Answer 17

MTP – Quick Checklist

1). Initial Setup
* Establish large bore IV access
* Send initial labs:
-ABG/VBG
-Blood group & crossmatch
-CBC, electrolytes
-Coagulation profile
-ROTEM/TEG

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2). Activate MTP
* Order Massive Transfusion Protocol
* Begin invasive monitoring
* Initiate 1:1:1 transfusion: PRBC, FFP, platelets

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3). Medications and Supportive Care
* Administer fibrinogen (especially in obstetric hemorrhage)
* Replace calcium (aim ionised Ca > 1.0 mmol/L)
* Give TXA (tranexamic acid) early
* Consider DDAVP if platelet dysfunction suspected

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4). Additional Key Steps
* Review anticoagulant medications
* Avoid acidosis
* Avoid hypothermia
* Set resuscitation targets (e.g. MAP 60-65, fibrinogen > 1.5, platelets > 50k)