Massive transfusion protocols (MTP)

[dchz]

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Those of you in level 1 trauma center, what is your MTP protocol? We do 6 pRBC 6 FFP 1 plt ratios.

I think the latest evidence shows that plt through a fluid warmer is ok. specially given how fast it goes in.

Anyone use furosemide? What clinical signs do you use to give you an idea that you need to diurese?

Also what about in pedi? theoretically it should be the same concept, children have more fluid per kg, does that make a difference on how you transfuse?

Theoretical question given today's events.
There is a tendency to over transfuse in MTPs given the nature of the problem. However, if there are other rooms going in a mass casaulty do you try to curb the unnecessary transfusions? How do you even start that conversation?

What about the platelet ratio, do you try to conserve plt as it's the most scarce product in most blood banks?

 

[jwk]

We do 4/4/1, and add a unit of cryo with every other pack. We don't do a huge number of cases under our MTP, perhaps 1-2 a week, with the majority of those being OB hemorrhage cases. Little trauma and no transplants here.

 

[PainDrain]

While it is up to the individual at my place I think most do 4-4-1 protocol. Also throwing in cryo if needed. Vast majority are traumas.

 

[Lecithin5]

We do 4/4/1, and add a unit of cryo with every other pack. We don't do a huge number of cases under our MTP, perhaps 1-2 a week, with the majority of those being OB hemorrhage cases. Little trauma and no transplants here.

Oof! So about 1 OB hemorrhage per week necessitating MTP? You must be in an ob-heavy practice!

 

[Hoya11]

Those of you in level 1 trauma center, what is your MTP protocol? We do 6 pRBC 6 FFP 1 plt ratios.

I think the latest evidence shows that plt through a fluid warmer is ok. specially given how fast it goes in.

Anyone use furosemide? What clinical signs do you use to give you an idea that you need to diurese?

Also what about in pedi? theoretically it should be the same concept, children have more fluid per kg, does that make a difference on how you transfuse?

Theoretical question given today's events.
There is a tendency to over transfuse in MTPs given the nature of the problem. However, if there are other rooms going in a mass casaulty do you try to curb the unnecessary transfusions? How do you even start that conversation?

What about the platelet ratio, do you try to conserve plt as it's the most scarce product in most blood banks?

We do 4/2/1.

Why would I use lasix in a volume depleted patient? Im sure there is a reason that is escaping me..

Are you all using Level 1 or Belmont? i have tried them both and greatly prefer belmont

 

[K31]

We do 6:6:1, plus cryo as indicated based on TEG and fibrinogen.

 

[PainDrain]

Are you all using Level 1 or Belmont? i have tried them both and greatly prefer belmont

The Belmont is amazing. I wouldn’t use the level 1 dinosaur again.

 

[dchz]

Are you all using Level 1 or Belmont? i have tried them both and greatly prefer belmont

Belmont, belmont, belmont....

if i'm being impartial, i'd prefer any rapid infuser.

 

[dchz]

Has anyone ever been a part of a mass casualty where you'd considered sparing platelets or have been rationed blood products given predicted demand?

Anyone out in Vegas in the last month have run into this situation?

 

[Noyac]

I give what is available to me when it arrives.

 

[IlDestriero]

We do 4/4/1, and add a unit of cryo with every other pack.

This is what we do.
Belmont.

--
Il Destriero

 

[fakin' the funk]

Easy for crystalloid creep to happen in big transfusion cases, small dose of lasix might be indicated. wouldnt do it routinely by any means tho.

 

[deleted59964]

our MTP is 4prbcs, 2FFP, 1plt, with instruction to consider cryo if fibrinogen<1g/L

in reality -- we give blood products as per ROTEM ... and it's almost always prbcs and cryo that are required

 

[AdmiralChz]

Has anyone ever been a part of a mass casualty where you'd considered sparing platelets or have been rationed blood products given predicted demand?

No. If you have a situation meriting MTP (multisystem trauma, OB hemorrhage) rationing platelets is exactly the wrong answer. The literature is very clear on this. Unless your institution is being too quick to call MTP, this is inappropriate.

If a hospital has a platelet shortage they should address other areas where they are transfused to conserve. For example, an isolated platelet count of 63K 3 days after a Whipple doesn’t require transfusion in the absence of bleeding. Or a 40K reading in the ER in a psych patient.

 

[Airlife91]

our MTP is 4prbcs, 2FFP, 1plt, with instruction to consider cryo if fibrinogen<1g/L

in reality -- we give blood products as per ROTEM ... and it's almost always prbcs and cryo that are required

Same. If we're on OB and ROTEM shows fibrinogen deficiency, we go with recombinant fibrinogen

 

[dchz]

No. If you have a situation meriting MTP (multisystem trauma, OB hemorrhage) rationing platelets is exactly the wrong answer. The literature is very clear on this. Unless your institution is being too quick to call MTP, this is inappropriate.

If a hospital has a platelet shortage they should address other areas where they are transfused to conserve. For example, an isolated platelet count of 63K 3 days after a Whipple doesn’t require transfusion in the absence of bleeding. Or a 40K reading in the ER in a psych patient.

This is my thoughts as well, but felt like it doesn't hurt to explore the options.

Lastly, we haven't touched on pedi MTPs yet, anyone have any experience? what do yall do different if anything at all?

 

[deleted59964]

Pedi is based on rotem, algorithm considers age and weight

 

[jwk]

This is what we do.
Belmont.

--
Il Destriero

One experience with the Belmont in a real MTP case and anyone will be hooked. It is da bomb!

 

[jwk]

Oof! So about 1 OB hemorrhage per week necessitating MTP? You must be in an ob-heavy practice!

Nah, only about 20,000 deliveries a year. 😉

 

[deleted87051]

Nah, only about 20,000 deliveries a year. 😉

 

[deleted59964]

Same. If we're on OB and ROTEM shows fibrinogen deficiency, we go with recombinant fibrinogen

that'd be nice, but through a quirk of our system we have to use cryo

 

[dchz]

Pedi is based on rotem, algorithm considers age and weight

Does the subspecialty of pedi have an established guideline on this? or is there a weight/height formula that everyone is aware of?

 

[acidbase1]

Is it a sin to transfuse platelets through the Belmont? I’ve heard conflicting information regarding this

 

[deleted87051]

Is it a sin to transfuse platelets through the Belmont? I’ve heard conflicting information regarding this

Stored platelet functionality is not decreased after warming with a fluid warmer. - PubMed - NCBI

Especially if you are blasting them rapidly through a Belmont into a cordis or a RIC, I don’t think there is much risk of cooking them.

 

[dchz]

Is it a sin to transfuse platelets through the Belmont? I’ve heard conflicting information regarding this

I think this is one of the dogmas that's been mentioned many times.

+1 for yes you can put it through fluid warmer to give it.

 

[anbuitachi]

You dump platelets in the belmont with the RBC and FFP?

 

[hankbb02]

You dump platelets in the belmont with the RBC and FFP?

Whole blood koo-laid.

 

[pgg]

I never understood the aversion to putting platelets through a warmer. Aren't they going to get warmed by the inside of the patient anyway?

I totally believe that platelets don't like turbulence and shear forces though, and that they shouldn't be syringed in, piston-pump by hand style.

 

[pgg]

You dump platelets in the belmont with the RBC and FFP?

It's OK to dump whole blood in a Belmont. Those platelets do OK.

 

[thinkorswim]

We did 6/6/1/1 with TXA. The idea behind this is giving all the products in addition to crystalloid, you'll inevitably need the fibrinogen.

Never used the Belmont for MTP in residency, but I have been using it for our post-DHCA bleeders in fellowship and it's a beast.