Massive transfusion protocol: the reason it is necessary

Objective. The purpose of this study is to identify problems of emergency transfu-sion at the bedside and to determine need for massive transfusion protocol. Methods. We included patients who met the criteria for “trauma team activation” and were admitted to division of trauma. The amount of blood product transfused in each unit was investigated for balanced transfusion. We also investigated the com-pliance with assessment of blood con-sumption score. The correlation between the time elapsed from patient visit to first transfusion order and time elapsed from first transfusion order to transfusion start was analyzed. Finally, we investigated vari-ous factors which serve to influence the decision-making process regarding early transfusion order. 

Results. Ratio of packed Red blood cells (pRBC): Fresh frozen plasma (FFP) was well-balanced, but platelet transfusion done was much lower than pRBC and FFP in emergency room. The application of emergency blood release did not match the criteria of assessment of blood consump-tion (ABC) score. The time from the first transfusion order to the transfusion start was found to be constant irrespective of time from patient visit to first transfusion order. And, the time from the first transfu-sion order to transfusion start did not dif-fer significantly among patients with early transfusion order and delayed transfusion order. Only systolic blood pressure of < 90 mmHg was identified as a major predictor for early transfusion order. 

Conclusion. Balanced transfusion is not easy and emergency transfusion could be delayed at the bedside. Integrated and sys-tematic structures for massive transfusion protocol would be invaluable and indis-pensable.

transfusion, emergency, protocol

1. Demetriades D, Murray J, Charalambides K, Alo K, Velmahos G, Rhee P, et al. Trauma fatalities: time and location of hospital deaths. J Am Coll Surg 2004; 198(1): 20-6.

2. Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63: 805–13.

3. Pidcoke HF, Aden JK, Mora AG, Borgman MA, Spinella PC, Dubick MA, et al. Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: increased plasma and platelet use correlates with improved survival. J Trauma Acute Care Surg 2012; 73: S445–52.

4. Spinella PC, Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev 2009; 23(6): 231-40.

5. Sinha R, Roxby D. Change in transfusion practice in massively bleeding patients. Transfus Apher Sci 2011; 45: 171–4.

6. O’Keeffe T, Refaai M, Tchorz K, Forestner JE, Sarode R. A massive transfusion protocol to decrease blood component use and costs. Arch Surg 2008; 143: 686–90.

7. Schuster KM, Davis KA, Lui FY, Maerz LL, Kaplan LJ. The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion? Transfusion 2010; 50: 1545–51.

8. Young PP, Cotton BA, Goodnough LT. Massive transfusion protocols for patients with substantial hemorrhage. Transfus Med Rev 2011; 25: 293–303.

9. Fox EE, Holcomb JB, Wade CE, Bulger EM, Tilley BC; PROPPR Study Group. Earlier endpoints are required for hemorrhagic shock trials among severely injured patients. Shock 2017; 47(5): 567-73.

10. Oyeniyi BT, Fox EE, Scerbo M, Tomasek JS, Wade CE, Holcomb JB. Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care. Injury 2017; 48: 5-12.

11. Johnson JJ, Garwe T, Albrecht RM, Adeseye A, Bishop D, Fails RB, et al. Initial inferior vena cava diameter on computed tomographic scan independently predicts mortality in severely injured trauma patients. J Trauma Acute Care Surg 2013; 74: 741–5

12. Hagiwara A, Kushimoto S, Kato H, Sasaki J, Ogura H, Matsuoka T, et al. Can early aggressive administration of fresh frozen plasma improve outcomes in patients with severe blunt trauma?- a report by the Japanese Association for the Surgery of Trauma. Shock 2016; 45: 495–501.

13. Odell DD, Liao K. Superior vena cava and innominate vein reconstruction in thoracic malignancies: double-vein reconstruction. Semin Thorac Cardiovasc Surg 2011; 23: 326–9.

14. Baumann Kreuziger LM, Morton CT, Subramanian AT, Anderson CP, Dries DJ. Not only in trauma patients: hospital-wide imple-mentation of a massive transfusion protocol. Transfus Med 2014; 24: 162–8.

15. Neal MD, Marsh A, Marino R, Kautza B, Raval JS, Forsythe RM, et al. Massive transfusion: an evidence-based review of recent developments. Arch Surg 2012; 147: 563–71.

16. Phan HH, Wisner DH. Should we increase the ratio of plasma/platelets to red blood cells in massive transfusion: what is the evi-dence? Vox Sang 2010; 98: 395–402.

17. Elmer J, Wilcox SR, Raja AS. Massive transfusion in traumatic shock. J Emerg Med 2013; 44: 829–38.

18. Kashuk JL, Moore EE, Johnson JL, Haenel J, Wilson M, Moore JB, et al. Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer? J Trauma 2008; 65(2):261-70; discussion 270-1

19. Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 2007; 62: 112–9.

20. Gunter OL Jr, Au BK, Isbell JM, Mowery NT, Young PP, Cotton BA. Optimizing outcomes in damage control resuscitation: identify-ing blood product ratios associated with improved survival. J Trauma 2008; 65:527–34.

21. Dente CJ, Shaz BH, Nicholas JM, Harris RS, Wyrzykowski AD, Patel S, et al. Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center. J Trauma 2009; 66: 1616–24.

22. Dzik WH, Blajchman MA, Fergusson D, Hameed M, Henry B, Kirkpatrick AW, et al. Clinical review: Canadian National Advisory Committee on Blood and Blood Products – massive transfusion consensus conference 2011: report of the panel. Crit Care 2011; 15(6): 242.

23. Cotton BA, Gunter OL, Isbell J, Au BK, Robertson AM, Morris JA Jr, et al. Damage control hematology: the impact of a trauma ex-sanguination protocol on survival and blood product utilization. J Trauma 2008; 64(5): 1177-82; discussion 1182-3.

24. Cotton BA1, Au BK, Nunez TC, Gunter OL, Robertson AM, Young PP. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009; 66: 41–8; discussion 48-9.

25. Zaydfudim V, Dutton WD, Feurer ID, Au BK, Pinson CW, Cotton BA. Exsanguination protocol improves survival after major hepatic trauma. Injury 2010; 41: 30–4.

26. Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, et al, The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg 2013; 148(2): 127-36.

27. Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: sim-ple as ABC (assessment of blood consumption)? J Trauma 2009; 66(2): 346-52.

28. Cho D. Development of Standard Operation Manual for Emergency and Massive transfusion at Hospitals. Osong: Korea Centers for Disease Control and Prevention; 2017.