Creation, Implementation, and Maturation of a Massive Transfusion Protocol for the Exsanguinating Trauma Patient

Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.
The Journal of trauma (Impact Factor: 2.96). 06/2010; 68(6):1498-505. DOI: 10.1097/TA.0b013e3181d3cc25
Source: PubMed


The majority of trauma patients (>90%) do not require any blood product transfusion and their mortality is <1%. However, 3% to 5% of civilian trauma patients will receive a massive transfusion (MT), defined as >10 units of packed red blood cells (PRBC) in 24 hours. In addition, more than 25% of these patients will arrive to emergency departments with evidence of trauma-associated coagulopathy. With this combination of massive blood loss and coagulopathy, it has become increasingly more common to transfuse early the trauma patients and with a combination of PRBC, plasma, and platelets. Given the inherent uncertainties common early in the care of patients with severe injuries, the efficient administration of massive amounts of PRBC and clotting factors tends to work best in a predefined, protocol driven system. Our purpose here is to (1) define the problem of massive hemorrhage and coagulopathy in the trauma patient, (2) identify which group of patients this type of protocol should be applied, (3) describe the extensive coordination required to implement this multispecialty MT protocol, (4) explain in detail how the MT was developed and implemented, and (5) emphasize the need for a robust performance improvement or quality improvement process to monitor the implementation of such a protocol and to help identify problems and deliver feedback in a "real-time" fashion. The successful implementation of such a complex process can only be accomplished in a multispecialty setting. Input and representation from departments of Trauma, Critical Care, Anesthesiology, Transfusion Medicine, and Emergency Medicine are necessary to successfully formulate (and implement) such a protocol. Once a protocol has been agreed upon, education of the entire nursing and physician staff is equally essential to the success of this effort. Once implemented, this process may lead to improved clinical outcomes and decreased overall blood utilization with extremely small wastage of vital blood products.

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    • "As plasma use and turnover are likely less in these hospitals, we can speculate that they may benefit more from the wastage advantage LP offers. Trauma centers have variable blood product allocation strategies for MTP [3] [5] [7] [8], and very few institutions use LP at their hospitals [31]. With the advent of LP, our institution changed its MTP policy; Table 1. "
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    ABSTRACT: A massive transfusion protocol (MTP) presents a logistical challenge for most blood banks and trauma centers. We compare the ratio of packed red blood cells (PRBC) and plasma transfused over serial time points in those requiring MTP (10-30 U PRBC/24 h) to those requiring "super" MTP (S-MTP; >30 U PRBC/24 h) and test the hypothesis that changes in allocation of blood products with use of readily transfusable liquid plasma (LP) improves the ratio of PRBC and plasma during S-MTP. All transfused trauma patients (n = 1305) from January 01, 2009-April, 03, 2015 were reviewed. PRBC:plasma ratio was compared for MTP (n = 277) and S-MTP (n = 61) patients, before and after the availability of LP at our institution. Data are reported as mean ± standard deviation or median (interquartile range). Age was 41 ± 19 y, 52% blunt mechanism, injury severity score 32 ± 16, and 46.3% mortality. In 24 h, requirements were 17 (14) U PRBC and 10 (11) U plasma, with a PRBC:plasma of 1.6 (0.8). Within the first hour, PRBC:plasma for S-MTP versus MTP was 2.1:1 versus 1.7:1 (P = 0.017). With LP, S-MTP patients received significantly lower PRBC:plasma at the first hour (P < 0.001). Before institutional changes, PRBC:plasma positively correlated with PRBC transfused at hour 1 (r = 0.410, R(2) = 0.168, P < 0.001); after institutional changes and the advent of LP, there was no correlation (r = 0.177, R(2) = 0.031, P = 0.219). Within the first hour of transfusion, units of PRBC transfused positively correlated with PRBC:plasma, and patients receiving S-MTP had higher PRBC:plasma than those receiving MTP. Changes in our institution's MTP protocol to include LP improved the early PRBC:plasma transfused in patients requiring S-MTP. Copyright © 2015 Elsevier Inc. All rights reserved.
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    • "Aggressive and early administration of clotting factors, especially in military studies, has been shown to improve survival among patients requiring massive transfusions [7e10]. However, the proposed 1:1 ratio of FFP/RBCs has recently been scrutinized for its true efficacy and requires additional investigation [11] [12]. Thus, the exsanguinating patient remains a challenge. "
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