SPECIAL REPORT :: TRANSFUSIONS Other non-blood product factors
Besides blood products themselves, other factors like use of hemostatic agents, and the availability of point- of-care testing (POCT) may contribute to overall MTP effectiveness.
Most institutions regularly activate MTPs for trauma and non-trauma indications, however, few use validated scoring systems for MTP activation.17 Although traditional protime (PT) and partial throm- boplastin time (PTT) laboratory tests can help guide resuscitation therapy, trauma institutions in particular have used thromboelastography (TEG) as a point-of- care mechanism in or nearby the operating room, as a rapid alternative.
McDaniel discusses the use of hemostatic agents in MTPs, as well as the inherent waste and inefficiency that happens as more institutions expand trauma- center based protocols to non-trauma hospital set- tings.16
Some trauma institutions have incorporated tranexamic acid, an inexpensive, antifibrinolytic pharmaceutical agent, within three hours of injury into their protocol due to its reduction in mortality in massive hemorrhage.16
The lack of consistent practices
underscores the need for outcome-based studies to guide transfusion practices, which are lacking in current literature.
Who will bleed?
In the U.S., there is no established scoring system to predict whether patients may massively bleed in the first place. One trauma-center evaluated MTP acti- vations for one year after implementing their MTP program. Their goal was to determine if patients were missed in that an MTP should have been activated, but for whatever reason, was not. The four criteria where patients were included for an MTP activation, whether activated or not, were:
1) Patient required uncrossmatched blood transfusions; 2) patient required tranexamic acid;
3) transfusion of four or more RBCs in one hour; and 4) transfusion of ten or more RBCs in 24 hours. Patients who met these four criteria were included in the study, which showed that there were more deaths in the non-MTP group than in the MTP group.22
Transfusion medicine role
In order to provide the blood products for immediate patient care, the transfusion service, or hospital labo- ratory blood bank, plays a key role in the execution of an MTP. The blood bank is comprised of hospital staff members who prepare and dispense blood prod- ucts to all patients who require transfusion therapy as prescribed by their physician, including the subset of patients involved in an MTP. To have an efficient MTP, a consistent process must be followed, by all staff, 24 hours a day, 365 days per year. Hospital blood banks must maximize patient outcomes by helping to establish MTPs based on evidence-based research, however limited it may be.13 Three areas of blood-bank related areas will be reviewed in this discussion: 1) Timing;
2) amount of products dispensed; and 3) the use of liquid plasma.
1. Timing Timing is everything for patients who are exanguinat- ing. Just how fast can an MTP be prepared? One article in the literature review discussed timing of the initial cooler of blood products provided in a trauma-center and offered a target level of ten minutes.18
This time
frame may seem reasonable to accomplish in most hospitals. There are several key factors that may impact being able to get blood to the patient’s bedside this quickly, however. For example, the location proximity of the blood bank to the patient’s location at time of MTP could be a five-minute walk, not to mention the time it takes for the blood issue (dispense) process, and any required checks prior to handing off the products. In addition, many hospitals have just enough blood product for a limited amount of time (a few days or one week), and therefore an MTP could quickly deplete all stock of a particular patient’s blood type). Further, the resources available in the patient’s loca- tion, in the lab, or both, may not be sufficient to be able to allow for a ten-minute or less turnaround time (TAT).
Some of the questions to consider when developing or fine-tuning the MTP with respect to blood-bank opera- tions are: Does initiation of an MTP require an electronic order or is the request placed by phone call? What is required (paperwork, etc.) to pick up the blood? If there is no sample in the blood bank, is there a separate process to be followed if uncrossmatched (Emergency Release) RBCs vs type specific (compatible) RBCs are dispensed? What is required for the dispense step? What is required for the delivery process to the patient location? Does the person assigned to pick up (or deliver) the blood products know the exact location of the patient (or blood bank)?
2. Product amount
The amount of blood products contained in an MTP, regardless if the patient is trauma or non-trauma, is essentially the same.13
This information is helpful so
that the hospital transfusion service can ensure that all staff are trained and knowledgeable on a single process with regard to the number of products prepared and dispensed for an MTP. A standardized approach used by all blood bank staff can streamline operations and help to maximize patient outcomes.
3. Liquid plasma use The use of liquid plasma can help the transfusion service streamline the MTP process for quicker patient care. Liquid plasma is plasma that is never frozen and expires 26 days after collection from a volunteer blood donor. Gaining popularity in the U.S. in recent years, liquid plasma has been proven beneficial in order to more rapidly meet the quick TAT, at least in the initial round of MTP products.2
This is because the product
requires no manipulation (thawing) prior to transfu- sion, and is therefore readily available, as opposed to most plasma in the frozen state, which must be thawed prior to transfusion.
In addition, liquid plasma availability has helped transfusion services minimize plasma outdating. Blood centers may typically supply group AB (universal plasma type) or group A liquid plasma, which has been proven to be safely transfused to any adult patient in an emergency,
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