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Mon Jul 23 23:38:32 BST 2007

Hi Karim,

Response from a "lurker" down under.

We do have a massive transfusion protocol, but  have developed an "exsanguination' protocol for those with uncontrolled bleeding and shock also, and give blood products differently to those. The old definitions of "massive" nowadays seem a bit  like a normal day at the office.

In answer to your questions then

Do we have a protocol YES, two Massive (M) and Exsanguination (E)

FFP delivery:  according to TEG or coag results (M) or 1:1 with red cells (E)
platelet delivery: according to Platelet count or TEG (M) or 1:5 with red cells (E)
cryo if fibrinogen < 1 g/L (M)

We add 100 mcg/kg of VIIa after 10 units of RBCs (aiming for a HB > 7 g/dl), repeated once if bleeding is uncontrolled. We do it at any temp, but raise the pH above 7.2 with HCO3  (I know)

Labs. 

We sat down and did a time and motion study with Labs. If you look at processing a Hb, platelet count, PR  APTT, fibrinogen, it takes them 12 mins to do one once the serum is in the lab. The Hb and platelet is ready in 3 mins. We have a sucker tube to get blood specs to them and electronic delivery of results to the operating room. The request form is orange and thus once it arrives in labs it gets first priority. With all that the average draw to result time is 25 mins. I don't think we could get it down much more.

We have looked at the istat and coaguchek for POC coag results in trauma and liver transplant and the results didn't agree with labs. Both give you quick results but are not accurate for PT and APPT. The istat Hb under reads in massive blood loss.

We have found TEG the best in massive trauma and exsanguination. We have it in all our operating rooms.

Our protocol is wait for TEG or coags in massive transfusion, but in exsanguination do them (every 30 min) but just treat empirically until you get control. The results essentially are a retrospective audit.

Cheers

Kerry
Dr Kerry Gunn MBChB DA(UK) FANZCA
Department of Anaesthesia and Perioperative Medicine
Auckland City Hospital
Auckland, New Zealand
ph +64 9 3797440 ext 7505
fax+64 9 3072814
mob +64 21 427626

Message: 6
Date: Sun, 22 Jul 2007 22:37:24 +0100
From: "Karim Brohi" <karim at trauma.org>
Subject: Massive Transfusion Protocol: What's in YOUR pack?
To: "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
Message-ID: <03a301c7cca8$7f2e20d0$0300a8c0 at brohid9700a65d>
Content-Type: text/plain;       charset="us-ascii"

Dear All,

A straw poll if you don't mind on massive transfusion protocols for
traumatic haemorrhage.  Please base your answers on your current practice or
your institution's current practice, not latest research / hearsay etc:

A. If you HAVE a massive transfusion protocol in your hospital:

        1. Are you given packs of FFP according to how many units of blood
have been administered?
                (eg. 2 units of FFP after every 6 units of blood)

        2. How much FFP after how much blood?

        3. If your answer to (1) was NO, what's the make-up of your packs

B. If you have just administered 6 units of blood:

        1. Do you always give a certain amount of FFP or do you wait for
labs? Which labs?

        2. If you give FFP, how much for those 6 units would you consider
standard?

        3. What is the minimum that should be given (0 is an acceptable
answer)

C. Labs:

        1. You send a PT/PTT from the ED or Operating room.  How soon do you
get it back? (really)

        2. Do you have point of care testing for PT/PTT in the ED & OR?

        3. Do you do thromboelastometry routinely on bleeding trauma
patients in the ED and OR?

There are no right or wrong answers, as practice varies so widely.  I'm just
trying to see the breadth of responses. So as many replies as possible
please - even from the lurkers :-)

Karim

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