MTP-sectors-presentation-massive transfusion protocol.pdf

massive transfusion

1. Massive Transfusion Protocol
Vimlesh Dhir
Area Transfusion lead
NSWHP-SWSLHD
2023

2. Standards and protocols
•National Blood Authority-Module 1 Critical
Bleeding/Massive Transfusion
•ANZSBT-S4 -use of blood products in specific clinical
situations
•NPAAC-Critical bleeding/emergency transfusion
•RCPA-including college of Physician/surgeons
•ACHS-Standard 7
•Local PBM committee-establish local procedures
and protocol

3. Criteria for Activation
Source: NBA- Critical Bleeding Massive Transfusion

4. How is MTP activated?
Medical officer or NUM activates MTP via a phone call:
•After assessing Life- threatening haemorrhage
•Expected replacement of blood volume in 24 hours
•On-going bleeding after rapid blood loss
Laboratory Activated MTP
•5
th
Unit within 2 hours
Blood Staff:
Remain calm and take all available patient details: Name or Alias
MRN/DOB and if patient is Male or Female
Key Word- MTP or Code Crimson (LIV Only)

5. Triad of Death
Massive blood loss causes tissue hypo -perfusion
•Hypo-perfusionleads to Acidosis(as cells switch to anaerobic metabolism)
•Acidosis can reduce cardiac output, further reducing perfusion
•Reduced cardiac output leads to Hypothermia (contributed to by cool fluids,
extended down time & theatre time)
•Hypothermia causes further Coagulopathy•Coagulopathy leads to continued blood loss, and further hypoperfusion
•Leads to Multiple organ failure
Image:Matthew Keane Published1 September 2016: Medicine Emergency nurse :
the journal of the RCN Accident and Emergency Nursing Association

6. Critical indicators in MTP:
•Temperature < 35°C
•pH < 7.2, base excess > –6, lactate > 4 mmol/L
•ionised calcium < 1.1 mmol/L
•Platelet count < 50 × 109 /L
•PT > 1.5 × normal
•INR > 1.5
•APTT > 1.5 × normal
•Fibrinogen level < 1.0 g/L

7. Coagulation cascade
Image: www.learnhaem.com/courses/coagulation/lessons/normal- haemostasis/topic/the-
revised-coagulation-cascade

8. MTP Flowchart

9. What happens in Blood Bank?
•Patients details are checked in LIS for a Valid G&S or
Historical Blood group.
•First Shipment- 4 RBC +4 ELP
•Start defrosting the ELP immediately based on
history or Group AB / A low titre for unknown Blood
groups (KPI-FFP dispensed with 20 mins of
activation)
•Prepare the red cells for the MTP-Cross -matched or
Uncross-matched
(KPI-5 mins of activation)

10. FFP /CRYO

11. Selection Of Alternative Groups- MTP
•Platelets- any Platelets can be given
•Plasma- group specific or for Unknown AB/A low
titre
•Cryoprecipitate - same as ELP
•Red Cells
-unknown male >18 (and female >50)- O Pos
- unknown Female <50 (and male <18)- O Neg

12. Use of uncross- matched O Negative
NBA released National statement for the emergency
use of group o red blood cells
•Maximum of 6 Units of uncross-matched O negative
RBC to be released (2021) for:
Males <18 yrs. and Females <50 yrs. With no valid
G/H
•Further reduction: up to 4 units of O negative RBC in
May 2023
•Patients with Allo Anti-D should continue to receive
Rh Negative RBC
Ref: https://
www.blood.gov.au/group-o-negative-red-blood-cell-management

13. Valid Sample/ Unknown Patients
Valid Sample
XM-Leave Open
Historical Group
Red Cells: Group O
BUT Plts, Plasma, Cppt:
use Historical Group
Red Cells: Group O
Plasma/Cppt Group AB/A
Platelets: Any ABO group

14. Emergency Dispense
If cross matched blood is not available, Dispense Red Cells (using
patient MRN) or as Unknown Male or Unknown Female (if no
MRN)

15. 1
st
Shipment
•Prepare 1
st
shipment (4 red cells + 4 FFP)
•Sector and Regional Lab?: Call in help if alone (Haem &
Chemistry tests is vital in managing MTP)
•Check red cell inventory + order plts (Liv/ Lifeblood)
•Provide photocopy of tally sheet with every
shipment

16. MTP Tally Sheet

18. Use MTP Tally Sheet
•Gives a snapshot to Laboratory and clinicians where they
are during an MTP
•Fill all required sections
•Blood bank will document patient details and doctor
activating MTP (with contact details)
•Attach valid accession (once received) and order MTP
(DOE) as a separate accession (no need for individual
product orders)
•If at a Sector Lab – Fax tally sheet to Liverpool
•MTP tally sheet guides relevant required fields
▫Sample Accession
▫Activation Details
▫Blood group and requirements
▫Haem Registrar Notified (after 2
nd
shipment taken)

19. 2
nd
Shipment
•Must start as soon as possible
▫Keep one shipment ahead
•Haem. Registrar must be notified once the 2
nd
shipment is
collected from laboratory.
•FEIBA, Praxbind and Novoseven request needs Haematology
registrar approval.

20. MTP Entry

21. Patients with Antibodies
•Provide antigen negative units if no time for serological cross
match. (Dispense as uncross matched units)
•Other requirements such as CMV- and Irradiated can be
dropped in consultation with haematologist.
•Switching Rh status should be conceded earlier in MTP (for
males with known Rh Neg blood group)
•Females of child bearing age should be given K- neg units
where possible.

22. Neo-natal and Paediatrics MTP
< 4 months old
NEONATAL MTP
Shipment 1 Shipment 2
1x RBC, 1x FFP, 1 x Platelet1x RBC, 1 x Platelet, 1 x CPT
< 15kg Paediatric
MTP
Shipment 1 Shipment 2
1x RBC, 1x FFP, 1 x Platelet1x RBC, 1 x FFP, 1 x CPT
15–30kg Paediatric
MTP
Shipment 1 Shipment 2
2 x RBC, 2 x FFP, 1x Platelet2 x RBC, 2 x FFP, 2 x CPT
30–50kg Paediatric
MTP Shipment 1 Shipment 2
3 x RBC, 3x FFP, 1x Platelet3x RBC, 3x FFP, 3x CPT

23. Use of by- pass agents:
•Use of Novoseven (activated Factor VIIa) in MTP-
NovoSeven
®
is recombinant human coagulation Factor VIIa (rFVIIa), intended for
promoting haemostasis by activating the extrinsic pathway of the coagulation
cascade.
•Must be approved by Haematologist or Haematology Registrar
•Suitable product in managing bleeding patients who refuse use of Blood and
blood product.

24. Rotemor TEG Guided MTP
•Rotational Thromboelastometry (ROTEM)
•Thromboelastogram (TEG)
•Clinicians using ROTEM guided MTP
Image: litfl.com/wp-content/uploads/2019/01/TEG

25. TEG Guided MTP

26. ROTEM Algorithms- MTP

27. Deactivation of MTP
•Clinical team should contact Blood Bank to deactivate MTP.
(Maybe a different person if Pt was transferred)
•Record clinicians name and time deactivation was requested.
•Doctors can re-activate the MTP if required.
•After Deactivation tally sheet is used to determine how many
products was used during MTP.
•MTP's that have not been active for 3 hours may be
deactivated by laboratory.

28. RTP- Off site MTP
•Retrieval Transfusion Procedure (RTP) applies to patients who
are pre-hospital, in the care of NSW Ambulance specialist
medical teams, and who are in need of off- site MTP.
•Treat RTP as Unknown Trauma
•Blood transport organised by Ambulance Control Centre
•NSW ambulance specialist will call the lab to request products
required.

29. Preparing Products
•Once the order is taken, NSW Ambulance will give you an ETA
of when the product will be collected.
•Takes around 10 mins to prepare red cells and 25 mins to
prepare and pack ELP
•Blood Bank keeps photocopies of dispense sheets, to update
Cerner with patient details if provided.
•If no details provided (allow 48hrs), unit details will be
discarded in Cerner and FATED in blood Net.

30. Off-Site MTP- RTP
Separate box for each product
•Red cells: 2- 6
0
C
•FFP thawed: 2- 6
0
C
•Plts/Cryo: room temp
All blood products are to be packed in accordance with
Australian Red Cross Customer guidelines.
•Label outside of the box with an RTP form
•Clearly indicate what products are inside, for example, “O Neg
Red Blood Cells”. Clear labelling mitigates confusion and unnecessary breaks in the cold chain

32. Code Crimson- ED Trauma
•Severely injured pre-hospital trauma patient
requiring surgical interventions
•Hemodynamically unstable and unresponsive to IV
fluids and Blood transfusions
•Code is used to streamline patient’s access to OT
•Early pre-hospital activation allows trauma team to
assemble, and to activate the MTP before the patient
arrives in hospital

33. Communication to Blood Bank
•Trauma Blood coordinator contacts Blood Bank
•Code Crimson patient are pre-registered with an
assigned emergency identification name/MRN at the
time of Blood Bank contact.
•products are available quickly for pickup to ED or
operating theatre.

34. Case Study
•Unknown, Alpha Twelve Female MRN 1688225, age
40 yr. old. Trauma involving multiple injuries-
Shattered Femur, fractured Pelvis-Pt intubated
•PH 6.9-CO2 -73.2 Lac-9.4
•BP-86/61 HR 143
•Preparing for OT

35. Timelines
Code Crimson activated 1825hrs
Shipment 1: 4 RBC- 18304 ELP ready 1840
Shipment 2:4 RBC 1909
4 ELP 1910 5Cryo 1910 1PLT-1905
Shipment 3: 4 RBC-20104 ELP2015 5Cryo 2010
Shipment 4: 4 RBC-20344 ELP2034 15Cryo 2034 1PLT
2034 (ROTEM)
Shipment 5: 4 RBC-22004 ELP2200 5Cryo 2200