Everything Nurses Should Know About Massive Transfusion Protocol

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Massive transfusions and massive transfusion protocols are present in many institutions across the United States. Hemorrhage is the most common cause of death in the first hour of arriving to a trauma center (2). More than 80% of deaths in the operating room (OR) and nearly 50% of deaths in the first 24 hours after injury are due to exsanguination and coagulopathy (2). While only 3% of civilian, or non-military, trauma patients will receive a massive transfusion (see definition below) these patients consume an amazing 70% of all blood transfused at a trauma center (2). Knowing the basics about massive transfusions and their associated protocols can help nurses in the emergent care of trauma and other patients.  

Introduction   

Massive transfusions (MT) and massive transfusion protocols (MTPs) are a source of fear for most nurses, and for a good reason. Understanding more about massive transfusion protocols will alleviate your fear and prepare you for the time you may need it most.   

Historically, in wartime, active bleeding from blunt or penetrating injuries was treated by soldier-to-soldier whole blood transfusions (6). This practice is no longer utilized. Management of hemorrhagic shock became the military strategy of “bleeding management” and “damage control resuscitation” in civilians (6).     

Damage control resuscitation has evolved into the creation of massive transfusion protocols starting in the 2000’s.  

In trauma, there is a deadly triad we attempt to control. It consists of:  

• Hypothermia interferes with normal coagulation and platelet function. 
• Acidosis hinders calcium and coagulation factors. 
• Coagulopathy occurs with massive blood loss and is complicated if resuscitation is without coagulation factors or platelets (11). 

The significance and urgency of the triad is that it will ultimately cause death if not stopped. 

Real-life application

You have recently taken a position at a Level 1 Trauma Center and are in orientation. You are excited yet intimidated by all there is to know and learn. As you come into the unit, your preceptor says, “Get ready to move, we have a multiple gunshot wound that was dropped off at the ER door and it’s our patient!”

How do you psychologically prepare for this situation?

How do you handle this type of stress in the workplace?

What past experiences influence your thoughts about this situation?

You and your preceptor enter the trauma bay and see the trauma team feverishly working. On the bed is a young man, profusely bleeding, with one physician inserting a chest tube, the other placing a femoral central line, and a third intubating the patient. Two other nurses appear to help out. Everyone is in full personal protective equipment (PPE); the amount of blood everywhere is daunting. The fellow calls out, “We needed MTP on this patient like yesterday!” 

What is a Massive Transfusion? Massive Transfusion Protocol? 

It is considered a Massive Transfusion (MT) when (6): 

• The patient’s entire blood volume is replaced within 24 hours.  
• Half of the patient’s blood volume is replaced within three hours, or  
• Acute, rapid, unstoppable bleeding is documented or observed.
  

The colossal bleeding in trauma patients is one of the leading causes of death, as many die within six hours of resuscitation (6). This caused the need for a reliable formula or protocol for those requiring massive transfusions in the civilian and military setting (6). Now, there are multiple massive transfusion protocols that predict need and outline treatment for these patients (6).  

Massive transfusion protocols, once created and implemented, have been associated with reduced blood product use and an increase in survival (2). Usually, an institution cannot know when and how many patients will require massive transfusions, but when they do, it requires enormous organization (between Trauma Service, delivery persons or “runners,” the blood bank, emergency room (ER), operating room (OR), intensive care unit (ICU), and embolization suite) (2). 

Real-life application (cont.)

The attending pops in and says, “We’ve got a medical student in here. Let’s review the criteria for an MTP in our center and give me a rundown on this patient.”

The fellow begins, “We’ve got a John Doe about age 20 with multiple gunshot wounds, we haven’t counted. The problem ones are the shots to the right lower chest and abdomen. We are placing a right chest tube before a chest x-ray because we spotted a tracheal deviation indicative of a tension pneumothorax. The belly is actively bleeding; bedside sonography shows almost a liter in there, we already turned him, and there doesn’t appear to be a spinal injury posteriorly and no exit wounds. His heart rate is 140, blood pressure is 60/40 mm Hg. That’s an ABC Score of 4 and a shock index of 2.3; need I say more?” 

What Criteria Decides Who Receives an MTP? 

The assessment of Blood Consumption (ABC) is a simple, validated scoring system (6). Each indicator that is present counts as a score of one (6).  

A score of two or more of these four indicators prompts that an MTP is required (6): 

• Systolic blood pressure less than 90mm Hg 
• Heart rate greater than 120 beats a minute 
• Positive Focused Assessment with Sonography in Trauma (FAST) finding free fluid in the abdomen 
• Penetrating torso injury 

The Shock Index (SI) is the ratio of heart rate to systolic blood pressure and was created to easily recognize shock in patients with seemingly “normal” vital signs (6). A patient is with an SI ≥ 0.9 is considered in shock (6).  

Real-life application (cont.)

The preceptor leans over and tells you, ”With this order, we identify a ‘runner’ to go get the MTP from the blood bank. The charge nurse already checked the order and called the blood bank. The labs I just sent include CBC, type and cross, PT, PTT INR, TEG, platelets, ABG, BUN, Cr, and electrolytes. Let’s prime the rapid infuser and get warmed fluid into this guy; the blood will be here in less than a minute, literally. This is all in the protocol. It took forever to make, and the entire system has to work. The ER, ICU, surgery, interventional radiology, blood bank, trauma, and nursing services all need to be on the same page.” 

Are you comfortable asking questions at work? Why or why not?

How does this level of the organization seem to you? 

Do you appreciate the work that is involved in creating a protocol like this?

How do you best retain information in protocols? 

You ask, “What’s in an MTP?”

Your preceptor responds, “It’s all ratios- packed red blood cells, plasma, platelets all in a 1:1:1 ratio. Our Massive Transfusion Protocol has six units packed red blood cells, six units platelets, one unit plateletpheresis, and we transfuse through a rapid transfuser here that infuses blood up to 750cc a minute and warms the blood. We will keep on getting these MTP’s every fifteen minutes until the fellow calls it.”  

“What do you mean-calls it?” you ask.  

Your preceptor states, “When they go to surgery, and this guy is going soon, they fix the cause of the bleeding, bleeding slows down, and they stop them. It’s in the protocol. The charge nurse is on the phone with the OR now communicating about the MTP, and the runner will follow the patient. Oh, and we give a gram of tranexamic acid to the traumas here to help slow the bleeding.”

Why Massive Transfusion Protocol?

Massive blood transfusion requires packed red blood cells along with select blood products. Studies show that combining packed red blood cells with other blood products (fresh frozen plasma, cryoprecipitate, and platelets) decreases the number of packed red blood cell units required (1). By using massive transfusion protocols, studies indicate that the number of patients receiving ten units of packed red blood cells or more is reduced by 40% (1).  The amount of blood waste is decreased, and the costs associated with transfusion are reduced (1).   

MTP packs should be available immediately once activated and include universally compatible red blood cells (O, Rh-negative, and O Rh-positive) and plasma, and be available in the ER (2).

When a patient bleeds, they not only lose blood, but they also lose coagulation factors. Only whole blood contains coagulation factors and is rarely used in institutions because of storing issues. Packed red blood cells do not contain most coagulation factors, and these factors need to be replaced concurrently during massive transfusions (2).  

The 1:1:1 infusion ratio of plasma, platelets, and packed red blood cells can help prevent exsanguination (2). 

The American College of Surgeons recommends a 1:1 or 1:2 plasma-to-RBC infusion ratio (5).  

The MTP is dispensed from the blood bank and physically transported by the “runner” in a designated cooler with the patient information on it. Blood and blood products require standard two-person verification and documentation prior to infusion. 

Along with blood products, there are non-blood adjuncts used in massive transfusion and the bleeding patient (2, 11).  

1. Tranexamic acid (TXA) or aminocaproic acid is an antifibrinolytic medication used to inhibit plasminogen activation and plasmin activity, stabilizing clotting and decreasing bleeding (2, 11). 

– Tranexamic acid is used in trauma, but also in cardiovascular and orthopedic surgery and in the case of postpartum hemorrhage. Tranexamic acid can be used as part of a protocol in trauma or given when increased fibrinolytic activity is found (2, 11).  

– The recommended dose and frequency of TXA  is 1 gram intravenous over 10 minutes followed by infusion of 1 gram over eight hours in actively bleeding patients within three hours of injury (2, 11). 

2. VIIa, a recombinant activated factor, was made for the treatment of hemophilia (2). Though it has been studied in the setting of trauma and warfarin-created anticoagulation, the role of factor VIIa is not complete in MTPs (2).  

3. Prothrombin complex concentrates (PCC) contain three or four clotting factors (2). PCC is approved for warfarin-induced coagulopathy and in bleeding patients (2). Prothrombin complex concentrates are recommended to use over FFP for warfarin reversal if massive bleeding is present (2). 

Real-life application (cont.)

After infusing the entire contents of the MTP and the arrival of a second MTP to accompany the patient to the OR, the patient is transferred to the OR, accompanied by the trauma surgeons, anesthesia team, and the runner.  

You ask, “When they control the bleeding in surgery and send the patient to the ICU, does the patient stabilize pretty quick?” 

Your preceptor responds, “Our initial treatment and the surgery saves the patient’s life but getting an MTP can cause all sorts of problems that the ICU will have to deal with. They can have hyperkalemia, hypocalcemia, acidosis or alkalosis, hypothermia, thrombocytopenia, and transfusion reactions from all that blood. It doesn’t get better until all that is corrected.” 

Problems Associated with MTP 

There is a range of problems associated with blood product administration and massive transfusions. They generally include thrombocytopenia, acid-base imbalance, electrolyte abnormalities, hypothermia, and transfusion reactions but may be more extensive depending on the individual patient (2).  

Thrombocytopenia

Packed red blood cells do not contain platelets or plasma, making patients at risk for thrombocytopenia (2). Monitor the patient and the lab values for low platelets and notify the provider if present (2). 

Acid/base Imbalance

Metabolic alkalosis may occur because packed red blood cells, platelets, and plasma contain additional acid from storage and the addition of citrate (1). When citrate breaks down, it can lead to increased bicarbonate production, and in turn, metabolic alkalosis (1). Metabolic acidosis may occur, especially if the patient is hypothermic and is part of the deadly triad in trauma. 

Electrolyte Abnormalities

The citrate added to blood binds to calcium, reducing the amount of available calcium and lowering blood calcium concentrations (1). Hypothermia interferes with calcium. Ionized calcium levels are most accurate and should be monitored and reported for calcium replacement (1). 

As blood ages in storing, dead cells release potassium, increasing potassium levels, and increasing the risk for hyperkalemia (1). Hyperkalemia is always a risk in patients with acute or chronic kidney injury, and elevated levels need to be reported and promptly treated (1).  

Hypothermia

Blood and blood products are all stored in refrigerators or freezers. A patient’s temperature can drop precipitately infusion of cold blood products (1). Using a blood warmer helps prevent hypothermia (1). Most written protocols address hypothermia and rewarming strategies. Hypothermia may also be independently present from exposure and blood loss. Hypothermia causes coagulation problems and should be avoided at all costs in the patient receiving an MTP. 

Rewarming strategies in massive transfusion protocols include:  

1. Passive External Rewarming (10) 

• Removing blood-soaked dressings or clothes 

• Increasing the room temperature wherever the patient is  

 2. Active External Rewarming (10) 

• Overhead radiant warmers 

• Fluid/air circulating blankets 

• Head covering 

3. Core Rewarming (10) 

• Heated intravenous fluids  

One of the simplest, most cost effective and clinically effective way to warm is with the use of warmed intravenous fluids and the use of a blood warmer (10). 

Transfusion Reactions 

Because of the high volume of infusions and lack of initial type and cross-match, patients are at risk for transfusion reactions (1,4). Transfusion reactions range from immediately life-threatening (such as hemolytic reactions) to transfusion-associated circulatory overload (TACO) (1, 4). 

Best Massive Transfusion Protocol Practices 

The best practice for MT includes defining an MT, establishing a trigger method for initiating an MT so it can be quickly started, promptly initiated, and an institutional massive transfusion protocol (5). MTPs should use fixed ratios of blood products, approximating a ratio of 1:1:1, including fibrinogen replacement (5).  

The institutional massive transfusion protocol should be accessible to all, and everyone included in the protocol should be familiar with their role in it. A plan for initial training and a way to maintain competency should also be included in the protocol. Simulation of MTP with the interprofessional team involved is an educational best practice (9). The content of MT protocols should be based on the concept of damage control resuscitation.  

Protocols need to include the monitoring and treatment of coagulopathy, acid-base and electrolyte imbalance, and hypothermia (5). Massive transfusion protocols should be written with a set of quality indicators to assess the protocol (12). The Broxton MTP Evaluation Tool is an example of an evidence-based tool an institution may choose to adopt for evaluation purposes (3).  

Currently, there is no evidence of which benchmarks best evaluate the effectiveness (12). Protocol writers should consider short and long-term outcomes to review, especially in light of no current long-term outcome studies (8). The time frame for protocol review will ideally be placed in the plan (5).   

The Multidisciplinary Committee should work collaboratively to develop a massive transfusion protocol. This committee should include representatives from (5): 

• Anesthesia 
• Trauma  
• Nursing  
• ICU 
• Blood bank  
• ER 
• OR 
• Embolization suite 
• Laboratory services 

Specifics the massive transfusion protocol should address (5): 

• MTP product availability, delivery and continuation with the patient from the ER to the ICU and any stop along the way. 
• Transfusion targets and termination points 
• When and how to use adjuncts  
• Quality and performance indicators 

The activation of an MTP should include at least one of the following indicators (5): 

• ABC score of two or more 
• Persistent active bleeding and/or hemodynamic instability 
• Shock Index ≥ 0.9 

Activation of MTP must be performed via concise communication to the blood bank to begin the process as well as ending the process. Communication of worsening patient conditions or crises must be prompt and clear. Closed-loop communication, where the receiver repeats the message for clarity, is used in the MTP process because a clear, concise and quick method of communication is necessary for success (5). 

If MTP triggers are met (2): 

• Infuse blood products instead of crystalloid or colloid solutions to avoid hemodilution and fluid overload. 
• The process should include the automatic delivery of MTP coolers every 15 minutes until the MTP has been stopped. 

Once major bleeding has been controlled (2): 

• MTP triggers for termination are met, the MTP should be terminated, and all notified that no more MTP coolers would be required. 
• Blood and blood product administration should be based on laboratory data or point of care testing 

Once in ICU-driven, data-driven algorithms should be used to guide blood and blood product therapy (2). 

Initial baseline laboratory data should be obtained on arrival and then repeated as indicated and include (7): 

• INR 
• aPTT, PT 
• Fibrinogen level 
• Hemoglobin or hematocrit 
• Platelet count 
• Point-of-care testing/thromboelastometry and rotational thromboelastography (if available) 
• Electrolytes 
• Arterial blood gases 

Collection of quality and performance indicators should be ongoing, and the evaluation of the MTP and process minimally an annual process. 

Real-life application (cont.)

As your preceptor finishes going through the massive transfusion protocol in your institution, they turn to you and ask, “Any questions?”  

You lean back and shake your head yes. Your fingers still slightly shaking from the whole experience, mind overwhelmed with details, you state, “This is going to take a bit to process. I’m going to start with downloading the MTP so I can really have some time to absorb it all. All I can say right now is that I sure am glad I’m on orientation, and I’m also pretty pleased this whole MTP thing was ironed out for me.” 

Conclusion

Massive transfusion protocols are complex protocols that require an interprofessional team to design, create, implement and evaluate. Care of the bleeding patient is an intricate experience that requires a great deal of critical care knowledge to comprehend and deliver. Educating yourself on this topic will allow you to further your understanding of massive transfusion protocols in your practice and better deliver care to the bleeding patient. 

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