Happy Friday!
This week's Wellness POTD will be about what keeps all of us well and alive each and every day: blood! Ok so not as flashy and fun, but hopefully this is a relatively quick and dirty review of massive transfusion protocol (MTP) and OB hemorrhage (OBH) at MMC.
TLDR of MTP
MTP is initiated if there is (1) >4 units of pRBC transfused in 1 hour OR (2) replaced all of the patient's total blood volume in 24 hours OR (3) replaced half the patient's total blood volume in 3 hours OR (4) bleeding faster than 150 ml/min
MTP is un-crossmatched blood
Adult MTP 1st round is 4u pRBC + 4u FFP + 1u platelets, then 2nd round is the same + 10u cryoprecipitate
MTP is activated by an attending physician
Notify the blood bank of MTP activation by calling 3-8400 or 3-7651
TLDR of OBH
OBH is defined as (1) >1000 ml blood loss in any delivery OR (2) >500 ml blood loss in vaginal delivery with sxs of hypovolemia
Call a Code H for concern for OBH
Stage 1 think IV access/fluids/uterotonics, stage 2 think consult MFM, stage 3 think OR, stage 4 think ACLS
Ok now for the longer and more rambly (but hopefully helpful?!) details within our protocol at MMC...
Massive Transfusion Protocol
I will try to summarize the MTP protocol that Dr. Marshall shared via email, which I am also attaching to this email, and will highlight relevant facts for our clinical use in the ED.
Adult MTP Indication
1) Transfused >4 units of pRBC in 1 hour w/ more blood needed
2) Expected to transfuse >50% of a patient's total blood volume in 3 hours (most adults have around 10-12 pints/units of blood in their body)
3) Expected to transfuse >100% of a patient's total blood volume in 24 hours
4) Bleeding faster than 150 ml/min
Pediatric MTP Indication
1) Expected to transfuse >50% of a patient's total blood volume in 3 hours
2) Expected to transfuse >100% of a patient's total blood volume in 24 hours
3) Bleeding faster than 10% total blood volume/min
MTP Initiation/Termination
Activated by an attending physician
Initiate MTP by using the red phone by the North Side charge nurse desk or by calling blood bank at 3-8400 or 3-7651
Information that must be included on the call is name, MRN, sex, DOB, location, diagnosis, and contact physician info
Have a physician fill out the "Emergency Blood Transfusion/Massive Transfusion Request" form, section B, and send it to blood bank by messenger or pneumatic tube
Send a lavender top blood specimen for ABO antibody screening and crossmatching of continued future transfusions
Blood bank does their magic prepping and getting us the blood...
"Crack the fridge" in resus 51 for emergency blood to bridge us while awaiting MTP blood
Charge nurse has the code to the fridge
ED fridge contains 2 whole blood + 8 units O- pRBC + 4 units O+ pRBC + 4 units FFP (no platelets)
The attending physician can decide whole blood vs. components
Use O+ for males and O- for females
Have the attending physician be in close contact with the blood bank to anticipate continued need
Terminate MTP by the attending physician notifying the blood bank OR automatically terminates 4 hours after MTP started
MTP Components
MTP Tips
Try to balance your transfusions by hour 1 or 2 into MTP (1:1:1 ratio of pRBC:FFP:platelets)
The 1 unit of apheresis platelets in MTP is synonymous with ~6 units of individual platelets
Use blood warmers to prevent hypothermia
Consider TXA for trauma
Consider calcium repletion after 3 units of transfusion
OB/Postpartum Hemorrhage
OBH Definition
1) Cumulative blood loss of >1000 ml in c-section or vaginal delivery
2) Cumulative blood loss of >500 ml in vaginal delivery with sxs of hypovolemia
OBH Stages
Stage 1: normal vital signs --> IV, fluids, fundal massage, pitocin, add other uterotonics
Stage 2: normal vital signs but blood loss up to 1500 ml OR pitocin and 2 uterotonics started --> consult MFM, transfuse, add TXA, foley, uterine balloon/packing
Stage 3: abnormal vital signs OR blood loss >1500 ml OR 2 units pRBC transfused --> go to OR, MTP
Stage 4: cardiovascular collapse --> ACLS
"Code H" aka alert the OB troops
Code H is the trigger to get more people involved for any stage OBH. It can be activated by anyone by dialing 33 and stating you have a Code H. The people notified are: OBGYN inside attending, OBGYN outside attending, anesthesia attending, anesthesia resident, chief OB resident, any individual on OB codes list, nursing leadership, blood bank.
OBH Tips
Consider the 4 T's of OBH when treating these patients: Tone (uterine atony), Trauma (laceration, hematoma, inversion, rupture), Tissue (retained products), Thrombin (coagulopathy)
Use the red OB hemorrhage kit in the fridge of resus 52 which has pre-made uterotonic meds and a cheat sheet for when to use each
Get the pitocin running early
Happy transfusing,
Kelsey
Resources:
- MMC MTP and OBH protocol
- Dr. Nicky Chung POTD from 10/8/24
- Dr. Kat Pattee POTD from 5/15/24