ACS TQIP MASSIVE TRANSFUSION IN TRAUMA GUIDELINES
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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:
zz Transfusion service/blood bank
zz Emergency department
zz Anesthesia
zz 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
zz Triggers for initiating massive
the Assessment of Blood Consumption
transfusion in trauma
(ABC) score. The ABC score consists
zz Resuscitation in the trauma of four variables (pulse >120, SBP
zz Transfuse universal RBC and plasma
Blood Product in a ratio between 1:1 and 1:2 (plasma
to RBC).
Resuscitation in the
Trauma Bay, Operating zz Transfuse one single donor apheresis
or random donor platelet pool for
Room, and Angiography each six units of RBC.
Suite zz 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
zz 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 zz 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
zz 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
zz 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 zz 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
zz 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,
including hypothermia, acidosis, and
hypocalcemia. If massive ongoing
bleeding persists, the patient may require Operational Aspects of
prompt return to the operating room,
particularly if the coagulation status has the Transfusion Service/
been normalized. Blood Bank
An appropriate ICU-driven algorithm A designated trauma center should
should be optimized to use blood have an on-site transfusion service
components for goal-directed therapy. that operates 24 hours a day, seven
days a week and has specific operating
zz Upon arrival in the ICU, baseline
procedures for the rapid early and
laboratory measures should be
continued delivery of blood components
obtained and then repeated as
as dictated by an MTP. The MTP must
needed or at least hourly:
allow adherence to current, standard
INR safe practices for transfusion. During
massive transfusion, timely and precise
aPTT communication between the trauma
Fibrinogen level team, the ED, the operating room,
anesthesia, and the transfusion service
Hemoglobin or hematocrit regarding availability and need for
transfusion products is imperative.
Platelet count
Point-of-care testing/
thromboelastometry and
rotational thromboelastography,
if available
6
The most efficient way to immediately of RBC with short storage times to the
initiate an MTP is to have a blood trauma patient at the expense of other
refrigerator containing universal donor patients. The RECESS and ABLE studies
products in the resuscitation bay. Rapid that are underway in the U.S. and Canada
delivery of subsequent blood coolers may give further guidance in the future.
from the transfusion service to the
For an MTP to be effective, universal
resuscitation bay is best accomplished
thawed plasma should be immediately
by the assignment of a dedicated
available. This step can be accomplished
runner. A process must be in place to
by storing thawed or liquid (never frozen)
rapidly deliver a group and screen to
plasma. The ideal universal plasma is AB
the transfusion service laboratory to
plasma, but unfortunately it is in short
facilitate the availability of crossmatched
supply, as only 4 percent of donors have
RBC. Uncrossmatched (O Rh negative or
this blood type. As a result of increased
O Rh positive RBC) should be available
use of AB plasma in resuscitation,
immediately. Group O Rh negative
shortages of plasma may occur for
RBC should be reserved for women of
patients with AB blood type. However, 40
child-bearing potential (younger than
percent of donors are type A and many
45 to 50 years old). Patients should
of them have low titers of anti-B; this low
be switched to crossmatched RBC as
titer plasma can be safely given to almost
soon as it is available, which should be
everyone. In order to avoid overuse
achievable within one hour for most
or wastage of AB plasma, transfusion
patients (about 97 percent). For a small
services may utilize group A plasma with
number of patients who have a positive
low anti-B titers. This process requires
antibody screen, obtaining crossmatched
determining anti-B titer at the time of
RBC may take hours. Staffing the
donation. Patients should be switched
transfusion service with technologists
to group-specific plasma as soon as
trained in antibody investigations is
the blood group has been determined,
instrumental for providing these patients
which usually takes about 10 minutes.
with compatible RBC. A transfusion
The transfusion service should maintain
medicine specialist should be available to
a sufficient quantity of platelets to
consult with the trauma team regarding
support ratio-based massive transfusion.
compatibility and other issues related to
Additional platelets may be needed to
massive transfusion.
support patients with bleeding disorders
Currently RBC can be safely stored for up or those on antiplatelet therapy. Blood
to six weeks and are released using a first- products should be transported and
in, first-out system to minimize wastage. stored appropriately. RBC and plasma
While there is concern that transfusion of should be delivered and kept in
RBC with longer storage times in trauma temperature-controlled coolers. Platelets
may increase complications, there is no and cryoprecipitate should not be placed
current justification to prioritize the use in coolers. Upon termination of MTP, all
remaining blood products and coolers
should be returned to the transfusion
service promptly.
7
In multicasualty situations, especially zz Special consideration for universal
when patients are poorly identified, the product use should be given only in
transfusion service should be notified multicasualty situations
immediately, and consideration should
be given to exclusive use of universal
donor blood products until stable
identities or aliases can be established. Endpoints of Transfusion
A designated trauma center or its To ensure that the MTP protocol does not
supporting transfusion service needlessly waste scarce resources, it is
should have on hand and available important to determine the criteria and
for immediate release the following: process for termination of the protocol.
Based on guidelines for enrollment in the
At least eight units of universal current Pragmatic, Randomized Optimal
donor, uncrossmatched RBC Platelets and Plasma Ratios (PROPPR)
(for example, four units of O Rh study, criteria for stopping the MTP
negative RBC and four units of should include both anatomic (control
O Rh positive RBC) of bleeding) and physiologic criteria
At least eight units of thawed (normalizing hemodynamic status). The
group AB or low titer anti-B group decision to stop should be made by the
A plasma. Additional plasma trauma surgeon in conjunction with the
should be obtainable from the anesthesiologist, if the patient is still in
transfusion service within 15 the operating room, or the intensivist/
minutes of MTP activation. trauma surgeon if in the ICU.
zz Uncrossmatched blood products In addition, the exact laboratory value
should be delivered until group- endpoints that should be used to guide
matched products are available. further blood product use should
be based on published data and the
Once the transfusion service has extensive clinical experience of those
received a blood specimen for who are caring for the patient.
group matching, group-matched
products should be available zz The ratio-driven massive transfusion
within 10 minutes. may be discontinued or downgraded
to goal-directed transfusion based
Crossmatched RBC should on the laboratory findings if surgical
be available within one hour bleeding has been controlled by the
for most patients. Notable surgeon in the operating room OR
rare exceptions include RBC there is radiographic and physiologic
alloantibody, rare blood group, evidence of bleeding control after
and so on. angioembolization.
8
zz The MTP should be discontinued If rapid TEG is available, the following
when there is recognition that cut-points for transfusion triggers may
further resuscitation is futile. also be used:
zz The following should be used as zz Plasma for ACT >128 seconds
guides to cease therapy with blood
zz Plasma and/or cryoprecipitate
and blood components in a patient
(fibrinogen concentrate) for k-time
who is (1) not actively bleeding and
>2.5 minutes
(2) still in the acute resuscitation
phase: zz Cryoprecipitate (fibrinogen
concentrate) and/or plasma for
zz RBC transfusions for hemoglobin
α-angle 230seconds
zz Cryoprecipitate or fibrinogen
concentrate for fibrinogen level zz Cryoprecipitate (fibrinogen
>180 g/L concentrate) and/or plasma for MCF
fibTEM15
zz Plasma for r-value >9 minutes percent
zz Plasma and/or cryoprecipitate
(fibrinogen concentrate) for
k-time >4 minutes
zz Cryoprecipitate (or fibrinogen
concentrate) and/or plasma for
α-angleFor the purposes of reporting and
documentation in registry and Therapeutic Adjuncts in
databases, hemorrhage control/
hemostasis can be declared when Massive Transfusion
both of the following have been met: There are several adjuncts available for
zz The surgeon declares hemostasis massive transfusion. Antifibrinolytic
based on the absence of bleeding medications, such as tranexemic acid
requiring intervention in the surgical (TXA) or aminocaproic acid, inhibit
field OR resolution of blush after plasminogen activation and plasmin
angioembolization. activity thus stabilizing the clot.
Although available and widely used for
zz The surgeon and/or anesthesiologists many years, it was not until the Clinical
agree that the patient is adequately Randomization of an Antifibrinolytic in
resuscitated based on the following Significant Hemorrhage-2 (CRASH-2)
criteria, if available: trial that the use of TXA in trauma
was examined. Tranexemic acid
Stable or increasing
has been shown to be effective in a
blood pressure, or
variety of surgical settings, including
Stable or decreasing heart rate, or cardiovascular surgery, orthopaedic
Stable or increasing surgery, postpartum hemorrhage, and
urine output, or trauma. In trauma, antifibrinolytic agents
can be used empirically or in response to
Decreasing requirement for
findings of increased fibrinolytic activity
vasopressors to maintain a stable
on POCT.
blood pressure
Frequent communication between Recombinant activated factor VIIa was
the members of the resuscitation initially developed for the treatment of
and surgical teams cannot be hemophilia with inhibitors and is only
overemphasized to guide the licensed by the U.S. Food and Drug
resuscitation, plan for continued need Administration (FDA) for this indication.
for blood products and adjuncts, and However, over the last decade, it has
determination of when to move toward been studied and has been used in
data-based resuscitation and when to the setting of traumatic coagulopathy
end active resuscitation. as well as reversal of warfarin-induced
anticoagulation in serious bleeding. At
this time, the role of factor VIIa is unclear.
It certainly appears to reduce transfusion
requirement, but lack of long-term
mortality benefit and potential increases
in morbidity have placed its position
in the MTP in doubt.
10A variety of prothrombin complex
concentrates are currently available. Monitoring System
These concentrates contain either
three (II, IX and X) or four (II, VII, IX and Performance in Massive
X) clotting factors. Although widely Transfusion
available in Europe and elsewhere for
years, the first FDA-approved four-factor Acute hemorrhage associated with
PCC has just been released in the United traumatic injury places the patient
States. This product is licensed for urgent at risk for a myriad of complications.
reversal of warfarin but is sometimes Review of hemorrhage- and transfusion-
used off-label for management of related complications, along with
trauma-induced coagulopathy in Europe. monitoring of the availability and
management of blood products during
zz TXA 1 gram intravenous over 10 massive transfusion, can help identify
minutes followed by infusion opportunities for improvement in the MT
of 1 gram over eight hours is process.
recommended in all injured patients
who are actively bleeding and are The trauma center should review
within three hours of injury. cases of massive transfusion with the
following complications:
zz PCC is currently only approved for
correction of warfarin-induced zz Coagulopathy
coagulopathy in bleeding patients. zz Thrombotic complications
As such, the American College of
Chest Physicians Guidelines, zz ARDS
9th Edition, recommends use of
zz Other transfusion reactions, including
PCC over FFP for warfarin reversal in
TACO (transfusion-associated volume
the setting of major bleeding.
overload), TRALI (transfusion-related
zz Recombinant VIIa is generally not acute lung injury), and hemolytic
recommended for management of transfusion reaction
refractory hemorrhage in trauma.
zz Over-transfusion of RBC
zz Death
11Performance indicators for the process
of massive transfusion should include:
zz Time from calling MTP to infusion of
first unit RBC
zz Time from calling MTP to infusion of
first unit plasma
zz Adherence to a predetermined ratio
or goal between one to two hours
after initiation of the MTP
zz Informing the transfusion service that
MTP has been terminated within one
hour of termination
zz Wastage rates for blood products
12Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion
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14Expert Panel
H. Gill Cryer, MD, FACS (Chair) Rosemary Kozar, MD, FACS
Professor of Surgery, Trauma/Emergency Surgery Professor of Surgery and Chief of Trauma, Memorial
and Critical Care Program, UCLA, Los Angeles, CA Hermann Hospital, Houston, TX
Avery B. Nathens, MD, FACS Joseph Minei, MD, FACS
Professor of Surgery, University of Toronto, Surgeon Professor of Surgery and Chief, Division of Burn,
in Chief of Department of Surgery, Sunnybrook Trauma, and Critical Care, University of Texas
Hospital, Toronto, ON Southwestern Medical Center, Dallas, TX
Eileen M. Bulger, MD, FACS Katerina Pavenski, MD, FRCPC
Professor of Surgery and Chief of Trauma, University of Assistant Professor, Departments of Medicine and
Washington, Harborview Medical Center, Seattle, WA Laboratory Medicine and Pathology, University of
Toronto, Toronto, ON
J. Forrest Calland, MD, FACS
Assistant Professor of Surgery, University of Virginia Martin Schreiber, MD, FACS
Health System, Charlotte, VA Professor of Surgery and Director of Trauma, Oregon
Health & Science University, Portland, OR
Mitchell J. Cohen, MD, FACS
Assistant Professor of Surgery, Division of General Philip C. Spinella, MD, FCCM
Surgery, University of California, San Francisco, CA Associate Professor of Pediatrics and Director, Critical
Care Translational Research Program, Washington
Bryan A. Cotton, MD, FACS, MPH University, St. Louis, MO
Associate Professor of Surgery, Division of Acute Care
Surgery Department of Surgery, University of Texas, Angela M. Ingraham, MD
Houston, TX Critical Care Medicine Fellow, University of
Pittsburgh, PA
Matthew L. Davis, MD, FACS
Assistant Professor of Surgery, Texas A&M COM, Hunter B. Moore, MD
Trauma Program Director, Scott and White Integrated Research Fellow, University of Colorado
Healthcare System, Temple, TX RAS Liason to ACS Committee on Trauma
Mark R. Hemmila, MD, FACS
Associate Professor of Surgery, University of
Michigan Health Systems, Ann Arbor, MI
John R. Hess, MD, MPH, FACP, FAAAS
Professor of Laboratory Medicine, University of
Washington, Seattle, WA
Randeep Jawa, MD, FACS, FCCM
Visiting Associate Professor of Surgery, Division of
Trauma, Emergency Surgery, and Surgical Critical
Care, Stony Brook University School of Medicine,
Stony Brook, NY
15The intent of the ACS TQIP Best Practices Guidelines is to provide health care professionals
with evidence-based recommendations regarding care of the trauma patient. The Best
Practices Guidelines do not include all potential options for prevention, diagnosis, and
treatment and are not intended as a substitute for the provider’s clinical judgment and
experience. The responsible provider must make all treatment decisions based upon his or
her independent judgment and the patient’s individual clinical presentation. The ACS shall
not be liable for any direct, indirect, special, incidental, or consequential damages related
to the use of the information contained herein. The ACS may modify the TQIP Best Practices
Guidelines at any time without notice.
16Notes
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