Tag Archives: MTP

Resuscitation

Massive Transfusion Cooler Etiquette

The Massive Transfusion Protocol (MTP) is one of the key life-saving tools that trauma professionals can utilize in their trauma centers. These are complex processes with specific triggers and logistics that vary by trauma center level, location, and volume. Because of this complexity, it is impossible to create a cookbook for designing your protocol.

However, there is one constant across all trauma centers regarding their MTP. I call it MTP cooler etiquette. This cooler is the center focus of the entire protocol, and the patient relies on good manners in its use for their life. Here are my thoughts about how to properly handle the MTP cooler.

  • Decide who carries it to and from the trauma bay / OR  ICU. At a few centers, blood bank personnel are responsible for bringing the coolers to the required location. However, the majority do not have enough spare lab techs to run coolers all around the hospital. Each center will need to decide who is best suited. Frequently, this falls to personnel from the ED or OR. However, in large medical complexes, it may be preferable to have security personnel handle this, as they are very familiar with the hospital layout.
  • Ensure the cooler is visible in the area it is used at all times. It is critically important that the cooler not be hidden in a corner or behind other equipment. This can lead to it being forgotten and to the wastage of the blood products inside. In the trauma bay, it should be located next to the team leader. In the operating room, it should be adjacent to anesthesia personnel. In the ICU, it should be located just inside the patient room door. This guarantees that everybody who enters and leaves the area can see it and will not forget to send it back when it’s no longer needed.
  • Place clear signage on the cooler to remind all personnel to call the blood bank when the MTP is over.
  • When moving the patient from area to area, place the cooler on the bed next to them. Placing it under the bed is a recipe for forgetfulness.
  • Empower everyone in the room to bring up the question of whether the cooler is no longer needed. Don’t wait until there are cobwebs on it and the blood products are at room temperature. Once the question is asked, call the blood bank immediately and let them know it is being deactivated.
  • Finally, decide who has the task of taking it back to the blood bank. Typically, this is someone from the area where it was last used. Anyone assigned to this task should recognize the importance of a timely return to the blood bank. Blood is a precious product and should be handled accordingly.

If you have some good suggestions on blood bank etiquette, please leave them in the comments below.

Guidelines

Best Practice: The MTP Coordinator

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Every trauma center has a massive transfusion protocol (MTP). But every trauma center also does it entirely differently. Ideally, an MTP is designed with the resources available at the hospital in mind. These may include whole blood, the use of O- vs. O+ blood, the number of units of each product per cooler, the different products in different coolers, and personnel available to move those coolers to the correct locations.

In my experience, one of the areas with the greatest variability is the person or persons who are actually directing the blood resuscitation, hanging the units, and doing the paperwork. Frequently, this is split across several people. In the ED, the surgeon is usually directing it. However, nurses typically hang the products and do the paperwork.

Often, though, the surgeon may be up to their elbows in a resuscitative thoracotomy and may be unable to direct their full attention to figuring out if more products are needed. In the OR, the anesthesiologist can frequently take over this task while the surgeon is busy in a body cavity. But sometimes, the resuscitation needs may overwhelm even their ability to concentrate on the MTP.

The Solution

The solution to this problem borrows from the team leader concept in trauma resuscitation. It is best if the team leader has minimal clinical responsibilities during the resuscitation. Once they move in and touch the patient, their area of attention collapses to that one spot, and they cannot fully concentrate on all of the big-picture issues going on in the room.

This is where the MTP coordinator comes in. This is a dedicated person who only has one job: to deal with the MTP.  They have no other responsibilities in the room.

Here is a list of tasks that they can offload from the other nurses and physicians in the ED/OR:

  • Call for the next cooler to be sent from the blood bank, taking into account the transit time
  • Ensure required labs are being sent for crossmatch and TEG/ROTEM, if used
  • Order and hang TXA on appropriate patients
  • Transfuse products in the appropriate order
  • Fill out all required transfusion records
  • Ensure 1:1:1 transfusion ratios
  • Regularly inform the surgeon of the current product counts
  • Order calcium and cryoprecipitate when appropriate, according to your protocol
  • Inform the blood bank when the patient moves to a new area (e.g. ED to OR) and follow along with the patient
  • As the resuscitation winds down, interpret TEG/ROTEM and modify transfused products as indicated
  • Notify the blood bank when the MTP is terminated
  • Ensure all final paperwork is complete

This seems like a lot! But we are normally asking numerous people in the trauma bay to do it. Assigning it to one person and one person only creates a much more reliable and efficient system.

Who should it be assigned to? Generally, not one of the usual ED nurses. This is a specialized position that requires additional training and practice. Some trauma programs have dedicated trauma nurses for trauma resuscitation, and they may be a good choice. However, they are frequently the only nurses assigned to resuscitations, and making them the MTP coordinator takes them off all other duties. This may not be practical.

In my opinion, the best candidate is an ICU nurse who has received training for this duty. Ideally, it would be the ICU nurse who would be receiving and taking care of that patient in the ICU if they survive. They will be very familiar with their patient once they arrive there.

If you have an MTP coordinator at your center, please take a moment to leave comments or suggestions below! Let us know how you do it.

Resuscitation

MTP And The Blood Availability Trap In Trauma Team Activations

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Early availability of blood is a key component in the successful resuscitation of severely injured trauma patients. All trauma centers have implemented massive transfusion protocols (MTP) to ensure rapid delivery of blood products to the trauma bay.

Unfortunately, locating the blood bank in some remote corner of the basement is common practice, as far from the trauma bay as possible. This guarantees a delivery delay once the MTP is activated. To offset this, many centers have implemented policies to make a limited quantity of blood products available in the trauma bay.

This supply can be located in a blood refrigerator located nearby. Or it may be a practice of calling for emergency release blood if the trauma professionals believe it might be necessary. Some trauma centers have codified this so that highest-level activations automatically have a cooler of blood products delivered, hopefully before patient arrival.

However, I have observed while visiting numerous centers that this often causes an unintended consequence. It can actually slow MTP activation!

How can that be, you say? It’s simple. Critically injured patients result in an intense and highly charged trauma activation. The surgeon is concentrating on keeping the patient alive and orders the emergency release blood to be hung. The resuscitation continues. “Hang another unit.” And so on.

Eventually, the temporary supply runs out. Then everybody looks at each other and does a facepalm. Nobody thought to activate the MTP!

How can this be avoided? The key is to do everything possible to activate it from the very start. Here are some tips:

  • Use an objective scoring system to trigger MTP. The two most common ones are the ABC score and the Shock Index. Both are easy to calculate, and can frequently be used based on the prehospital report. This means the MTP can be activated before the patient even arrives.
  • If you open the blood refrigerator or touch the emergency release blood, activate the MTP. This will give you two to four units to buy time for the first MTP cooler to arrive.
  • Empower everyone in the trauma bay to speak up. Make sure everyone knows the rules listed above, and encourage them to speak up if they see that any of them are met. “Team leader, should we activate the MTP?”
  • Don’t be shy! If you only transfuse one unit of refrigerator blood and stop, no harm, no foul. The unopened MTP cooler can be sent back to the blood bank with no risk of waste.

Bottom line: Don’t get suckered into forgetting to activate the MTP just because it looks like you have blood available. Automate the process so you never run out again.

Resuscitation

MTP Activation Criteria For Pediatric Patients

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Early resuscitation, particularly with blood products in patients with hemorrhage, is literally a lifesaver.  As each minute ticks by, survival slowly diminishes. To facilitate this, massive transfusion protocols (MTP) have been designed to rapidly deliver sizable quantities of blood products to the trauma resuscitation bay.

One of the recurring issues I see at trauma centers is the lack of a reliable way of activating the MTP. Many centers publish what I consider “psychic criteria.” These promote criteria that involve the amount of blood loss over four or twenty-four hours. Who even knows?

Delays in activating the MTP frequently occur because no one thinks about it when a critically injured patient arrives. All of the trauma professionals are busy with the patient and are rudely surprised when they ask for the first unit of blood.

Objective MTP activation criteria have been developed and are well-supported by the literature. The ABC score and the shock index are two of the more common methods. Both are based on observations made upon patient arrival (and possibly before if a prehospital report is received).

The ABC score uses four criteria:

  • Heart rate > 120
  • Systolic blood pressure < 90
  • FAST positive
  • Penetrating mechanism

If any two of these are present, there is a 50% chance that massive transfusion is warranted.

The Shock Index (SI) uses the initial vital signs to perform a quick and dirty calculation by dividing the heart rate by the systolic blood pressure.  A score greater than or equal to one predicts at least a 2x higher need for blood. Of the two, SI is more easily calculated and gives a marginally more accurate result.

But what about children? The ABC score was evaluated in pediatric patients and was found to be much less sensitive than in adults. Combining the ABC score with an age-adjusted Shock Index improved the accuracy only slightly. This was named the ABC-S score.

Several adult and pediatric trauma centers in the Denver area collaborated to test a new score using the ABC-S score in combination with serum lactate and base deficit. This was termed the ABC-D score. Clever.

Here are the factoids:

  • A retrospective review of patients aged 1-18 from a single trauma registry who had received a blood transfusion during their initial care
  • The study included 211 children, of whom 66 required massive transfusion
  • The three methods listed above were compared, and the ABC-D score was found to be the most predictive of MTP
  • ABC-D was 77% sensitive and 79% specific
  • The authors showed that the accuracy and balance between sensitivity and specificity improved for each point increase in the ABC-D score.
  • They concluded that ABC-D may be a useful tool to expedite the delivery of blood products during a trauma resuscitation.

Bottom line: Hmm. The system that they developed and the analysis of their experience appears to be sound. But unfortunately, it fails the practicality test. Here’s the sticking point. How long does it take to obtain that initial blood specimen, send it to your lab, and then return stat results to your trauma bay? Once you receive the results, you then activate the MTP and wait another 5-10 minutes for the first cooler to arrive!

That’s an awful long time to wait for blood while you watch a child hemorrhaging in front of you. So what to do? For now, use one of the existing systems to make a rapid decision. And always err on the side of activation. You can always send the blood back if you don’t need it!

Reference:  The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients. J Pediatr Surg. 2020 Feb;55(2):331-334. doi: 10.1016/j.jpedsurg.2019.10.008. Epub 2019 Nov 1. PMID: 31718872.

General

Crafting And Refining Your Massive Transfusion Protocol – Part 4

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It’s more on the massive transfusion protocol (MTP). I’ll continue today with MTP activation triggers.

What criteria should trigger your massive transfusion protocol? Sometimes, it’s obvious. The EMS report indicates that your incoming patient is in shock. Or there was notable blood loss at the scene. Or they have a mangled extremity and will need blood products in the OR, if not sooner.

But sometimes the need for ongoing and large quantities of blood sneaks up on you. The patient is doing well but has an unexplained pressure dip. And it happens again. You give one of your  uncrossmatched units of blood. It happens again. At some point, you come to the realization that you’ve given six units of blood and no plasma or other products! Ouch!

Many trauma centers have adopted MTP criteria like:

  • More than 4 units given over 4 hours
  • More that 10 units to be given over 24 hours
  • Loss of half a blood volume over 24 hours

I call these the “psychic power” criteria, because one must surely be prescient to know this information just shortly after the patient arrives. Don’t include criteria like these at your center!

Instead use some sort of objective criteria. A simple one is the use of any of your blood refrigerator products or emergency release blood, or a calculated score such as the ABC score or shock index (SI).

ABC score is the Assessment of Blood Consumption score and gives one point each for a heart rate > 120, SBP < 90, positive FAST, penetrating mechanism.  ACS score > 2 was predictive of requiring MTP with sensitivity and specificity of about 85%. Overtriage was about 15%.

Shock index (SI) is defined as the heart rate divided by the SBP. Normal values are in the range of 0.5 to 0.7. Need for MTP was found to increase to 2x for SI of 0.9, 4x with an SI of 1.1, and 7x with SI 1.3.

One paper compared these two systems retrospectively on 645 trauma activations over a 5-year period. They found that they both worked well with the following results:

  • Shock index > 1 – 68% sensitive 81% specific
  • ABC > 2 – 47% sensitive, 90% specific

The study suggests that shock index is more sensitive, and takes less technical skill to calculate. Bottom line: just pick the some objective criterion you are most comfortable with and use it!

Reference: Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury 49(1): 15-19, 2018

Well folks, that’s it for the MTP series! Hope you enjoyed it. Feel free to email or leave a comment with any questions or suggestions!