MTP - Major Transfusion Protocol CUH

Algorithm

Give 30mL 10% calcium gluconate IV with each MTP "pack", then check serum Ca⁺⁺
An emergency supply of Fibrinogen is available in the drug fridge in anaesthetic Room 3 in CUMH for massive obstetric haemorrhage
Please note: Plasma will take 20 mins to thaw and platelets need to ordered from the IBTS so all products will be available for collection as they become available, rather than in a single delivery

Procedure

Alert key personnel to the possibility of a massive haemorrhage:

EM consultant
Blood Transfusion Laboratory CUH Ext 22537, (OOH bleep 199)
Consultant haematologist

Communication

An experienced clinician (registrar or above) should assume overall responsibility for immediate management of the patient.

The senior clinician nominates a named individual (liaison person), who is familiar with the clinical details, to take responsibility for:

Communication with the blood transfusion lab. and
Documentation of all aspects of the massive haemorrhage management from time of initiation to stand down, including the status of blood product support
He/she should have appropriate documented training in haemovigilance

The named liaison person:

Notifies the blood transfusion laboratory that a 'massive haemorrhage' has been diagnosed by the named senior clinician
Provides identification details of the patient affected
Provides their own name and contact details to enable effective communication between the lab. and the clinical area
Checks that a transfusion sample is available in the laboratory or
Arranges for a transfusion sample to be sent urgently to the lab
Arranges for urgent FBC, coag. screen, fibrinogen to go to the haem. lab
Informs the lab. if the emergency O Rh (D) negative blood has been used and is required to be replaced
Advises the laboratory whether emergency uncrossmatched, group specific or fully crossmatched blood is required

General Mx

Identify and control (± surgery) cause of bleeding
Send baseline FBC, PT, APPT, Fibrinogen, Biochem
Consider TXA if trauma
Hourly VBG (lactate)
IV crystalloid (not colloid) as required
Beware hypothermia
Beware DIC (at risk):
- Prolonged hypovolaemia or tissue hypoxia
- Extensive tissue damage
- Hypothermia
- Penetrating head injury
- Obstetric complications e.g. placental abruption, uterine rupture, amniotic fluid embolism, pre-eclampsia, sepsis

Indication by blood loss	Degree of Urgency	Transfuse within
≥2.5L, no response to resuscitation	Emergency	15 mins Use Emergency O Neg
1-1.5L + active bleeding 1.5-2.5L	Very Urgent	30mins 6 units type specific and/or uncrossmatched
1-1.5L + loss controlled	Urgent	1 Hour Urgent Crossmatch
0.5-1L	Normal	Standard

Red cells

Start blood component therapy
Use a blood warmer and/or rapid infusion device
The choice of red cells depends on the degree of urgency
The presence of antibodies will delay the provision of compatible blood
Note: For ♂s and ♀s beyond child-bearing age it may be necessary to give Rh positive cells

Platelets

Anticipate platelet count <50 x 10⁹/L after 1.5–2 x blood vol. replacement
Request via Blood Transfusion Laboratory CUH Ext 22537, (out of hours bleep 199) and send Blood Product Requisition Form to Blood Transfusion Laboratory CUH
One unit is the standard adult dose. 10ml /kg for a small child or neonate
More on paediatric MTP
Further doses should be guided by platelet count and/or clinical condition
Allow time for platelet collection and delivery
Allow margin of safety to ensure platelet count >50 x 10⁹/L
Keep platelet count >100 x 10⁹/L if platelet function abnormal e.g. if patient taking aspirin or other antiplatelet agents
Head injury – aim for platelets > 100 x 10⁹/L

SD Plasma (OCTAPLAS LG)

Anticipate need for SD plasma after 1-1.5 x blood volume replacement
Give SD plasma (solvent detergent treated pooled plasma –‘Octaplas’) 15-20 ml/kg (Usual dose is 4-6 units)
Base further dosing on coagulation results- aim for PT and APTT <1.5 mean control
Order from Blood Transfusion Laboratory CUH using Blood Product Requisition Form (allow 20 min thawing time)
PT/APTT >1.5 x mean normal value correlates with increased micro-vascular bleeding

Fibrinogen

Anticipate need for fibrinogen after 1-1.5 blood volume replacement and give Fibrinogen 1-2g IV
Base further dosing on coagulation results- aim for fibrinogen >1.5 g/L (for obstetric patients maintain at >2.0 g/L in the event of ongoing haemorrhage)
Order from Blood Transfusion Laboratory CUH using Blood Product Requisition Form. Reconstitute at bedside
Fibrinogen < 0.6 – 0.8 g/L strongly associated with micro-vascular bleeding

Further Management

Initial doses of platelets, SD Plasma and fibrinogen can be administered before platelet or coagulation results are available
Repeat Hb, platelet count, PT, APTT and fibrinogen every 2-4 hrs or after administration of initial blood component/product support are necessary to assess the response to blood component therapy and facilitate ongoing management of the patient
As soon as the second set of results (Hb, platelet count and coagulation screen) are available, the haematology registrar/consultant covering the blood transfusion laboratory should be asked for advice on further blood product support
Continue to repeat Hb, platelet count, PT, APTT and fibrinogen every 4 hours or after second order of blood components/products have been transfused to assess the response to blood component therapy and guide further therapy

Factor VIIa

Circumstances where patients with massive haemorrhage may benefit from Factor VIIa include:

Ongoing clinically significant haemorrhage, despite appropriate attempts to achieve surgical control of bleeding and full correction of other clotting factor/platelet deficiencies
Severe obstetric haemorrhage requiring consideration of internal iliac artery ligation, uterine artery embolisation or hysterectomy in the setting of optimal blood product support
Severe haemorrhage, refractory to local control, in patient who refuses/would refuse blood products, but would accept recombinant blood factors. Administration in these patients may need to be earlier in the course of events, because transfusion is prohibited

All use of VIIa requires authorisation by consultant haematologist.

Special Circumstances

Warfarin – add Vitamin K, Prothrombin complex concentrate.

Obstetric haemorrhage – early DIC often present, consider increased use of fibrinogen.

Head injury – aim for platelets > 100 x 10⁹/ L

Stand down

The transfusion laboratory should be notified when the massive haemorrhage is controlled and the patient is haemodynamically stable or if the patient has been transferred to another hospital/site within the network.

Major Transfusion Protocol CUH (Adult)