ACS TQIP MASSIVE TRANSFUSION IN TRAUMA GUIDELINES Released October 2014 Table of Contents Introduction .............................................................................................................................................. 3 Development of a Massive Transfusion Protocol: Engagement and Scope ....................................................................................................................... 3 Triggers for Initiating Massive Transfusion ..................................................................................... 4 Blood Product Resuscitation in the Trauma Bay, Operating Room, and Angiography Suite ...................................................................................... 5 Massive Transfusion in the Intensive Care Unit ........................................................................... 6 Operational Aspects of the Transfusion Service/Blood Bank .................................................. 6 Endpoints of Transfusion ...................................................................................................................... 8 Therapeutic Adjuncts in Massive Transfusion .............................................................................10 Monitoring System Performance in Massive Transfusion ....................................................... 11 Bibliography ........................................................................................................................................... 13 Expert Panel ............................................................................................................................................15 Disclaimer .................................................................................................................................................16 2 Introduction Development of a Hemorrhage is the most common cause Massive Transfusion of death within the first hour of arrival to Protocol: Engagement a trauma center. More than 80 percent of deaths in the operating room (OR) and Scope and nearly 50 percent of deaths in the An MTP should be a written document, first 24 hours after injury are due to accessible to all, and adopted by the exsanguination and coagulopathy. While center. All staff should be familiar only 3 percent of civilian trauma patients with the procedures. Initial training will receive a massive transfusion (>10 and subsequent regular drills are units red blood cells [RBC] in 24 hours), recommended to maintain competency. these patients consume 70 percent of This process is especially important in all blood transfused at a trauma center. trauma centers where MTP initiations are Because massive transfusions are rare, for example, smaller centers. The unplanned and require the processing content of MT protocols should be based and delivery of large amounts of blood on the principles of damage control products rapidly for a sustained period resuscitation. As such, they should of time, significant preplanning and provide for ratio-based blood products coordination between the blood bank, that are empirically delivered (hemostatic the emergency department, the OR, resuscitation) and have a process for and delivery personnel is required. The the immediate availability of RBC, development and implementation of plasma, and platelets. Protocols should massive transfusion protocols (MTPs) also include standardization of the have been associated with a reduction assessment of coagulopathy and include in mortality and overall blood product assessment and treatment of acidosis, use in trauma centers. The purpose of hypothermia, and hypocalcemia. the following guidelines is to identify the necessary components of an MTP Massive transfusion protocols should and address key issues involved in be developed by a multidisciplinary developing an MTP for trauma. committee that includes, at a minimum, representatives from: z Transfusion service/blood bank z Emergency department z Anesthesia z Trauma service 3 The massive transfusion protocol respectively, with specificities that range should address: between 80 percent and 90 percent. One well-validated scoring system is z Triggers for initiating massive the Assessment of Blood Consumption transfusion in trauma (ABC) score. The ABC score consists z Resuscitation in the trauma of four variables (pulse >120, SBP<90, bay, including: + FAST, and penetrating torso injury), each assigned one point. A score of two MTP product availability or more warrants MTP activation. The MTP product delivery ABC score overestimates the need for transfusion, with a positive predictive MTP blood product transfusion value of 50 percent to 55 percent, z Continuing MTP in the OR, meaning that 45 percent to 50 percent angiography suite, and intensive of patients in whom MTP is activated will care unit not need a massive transfusion. However, the ABC score is excellent at identifying z Transfusion service processes for who will not need massive transfusion, delivery of blood products with a negative predictive value of less z Transfusion targets than 5 percent, meaning it identifies more than 95 percent of all patients z The use of adjuncts for massive who will need a massive transfusion. transfusion patients Other prediction scores have been developed and all include the presence z Termination of the MTP of severe tissue injury and hemorrhagic z Performance improvement shock as important risk factors. monitoring Criteria to trigger the activation of an MTP should include one or more of the following: Triggers for Initiating z ABC score of two or more Massive Transfusion z Persistent hemodynamic instability Predicting the need for MT is difficult. z Mortality is improved with rapid Active bleeding requiring activation of a massive transfusion operation or angioembolization protocol, but complications are increased z Blood transfusion in the trauma bay if patients have unnecessary exposure to blood products. Prediction tools for MT in adult trauma patients have been developed for both military and civilian trauma patients with injuries from penetrating or blunt trauma, 4 z Transfuse universal RBC and plasma Blood Product in a ratio between 1:1 and 1:2 (plasma Resuscitation in the to RBC). Trauma Bay, Operating z Transfuse one single donor apheresis or random donor platelet pool for Room, and Angiography each six units of RBC. Suite z Blood products should be Universally compatible RBC (O Rh- automatically sent by the transfusion negative and O Rh-positive) and service in established ratios. thawed plasma should be immediately z Subsequent coolers should be available and ideally stored in the delivered at 15-minute intervals until emergency department (ED). Centers the MTP has been terminated. that have used thawed plasma early in resuscitation have seen reductions z The goal is to keep at least one MTP in blood product utilization and cooler ahead for the duration of the product wastage. In areas where the MTP activation. transfusion service is unable to provide When the patient is moved from the adequate stores of AB plasma, low resuscitation suite to the operating (anti-B) titer A plasma may be utilized. room or the angiography suite it is For maximum effectiveness, damage important that this is communicated to control resuscitation (DCR) principles the Transfusion Service so that blood suggest that RBC and plasma should product delivery can continue to the site be delivered by a rapid transfuser and of patient care. During the procedure through a blood warmer. Initial rate of rapid delivery and transfusion of transfusion should restore perfusion but products should continue in appropriate allow for permissive hypotension until ratios and at a rate to keep maintain the operation or angioembolization to adequate blood volume while the patient stop the bleeding has begun. Platelets is actively bleeding. Once major bleeding and cryoprecipitate should not be has been controlled and the rate of administered through a blood warmer. transfusion has slowed it is appropriate to switch to a laboratory-or point of z Universal blood products should be care (POCT)-based transfusion. For immediately available on patient performance improvement purposes the arrival to support ratio-based ratio of blood product transfusion should transfusion. be assessed at the time of bleeding If MTP triggers are met: cessation and not necessarily at a specific time point or at the end of an operation z Begin universal blood product or angioembolization. infusion rather than crystalloid or colloid solutions. 5 Ionized calcium Massive Transfusion in Blood gas analysis, including the Intensive Care Unit base deficit Trauma patients for whom a massive z Use of empiric fixed ratios of blood transfusion protocol is activated most products should be followed in the frequently require intensive care. ICU until bleeding is controlled and/ Arrival of these patients to the intensive or specific laboratory and POCT data care unit (ICU) marks an important are available. These products should checkpoint, including a systematic be delivered in a ratio between 1:1 review of the patient’s prior resuscitative and 1:2 (plasma:RBC). efforts. The ICU accepting team should z Once laboratory data are available, anticipate arrival of these patients with resuscitation should be goal directed the necessary equipment to continue based on the laboratory findings rapidly infusing blood products. and clinical evidence of ongoing Attention should be paid to correcting bleeding. factors that exacerbate coagulopathy,