Parkview Health / Clinical Practice Manual
Policy & Procedure Title: Massive Transfusion Protocol: Pediatrics
Category:Patient Care
Parkview Hospital Randallia (PVH) / Parkview Huntington Hospital (PHH)
ParkviewLaGrangeHospital (PLH) / Parkview Noble Hospital (PNH)
Parkview Behavioral health (PBH) / Parkview Orthopedic Hospital (POH)
Parkview Whitley Hospital (PWH) / X Parkview Regional Medical Center (PRMC)

I.POLICY STATEMENT:

This protocol provides a standard for efficient and effective procurement and delivery of blood products for hemodynamically unstable pediatric patients needing rapid transfusion. The patient may also be coagulopathic, or become coagulopathic, due to rapid red blood cell transfusion with lack of replacement of coagulation factors. Children >=50 kg should be transfused using the adult Massive Transfusion Protocol.

The goals of the protocol are to:

A.Prevent or reverse hemodynamic instability and dilutional coagulopathy.

B.Anticipate and provide for the blood product needs of these patients.

C.Avoid wastage of blood products via coordination with the blood bank/transfusion service.

D.Provide a standardized protocol

E.Improve patient outcome.

II.DEFINITIONS:

  1. Massive Transfusion: a transfusion approximating or exceeding the patient’s blood volume within a 24 hour interval.
  1. Dilutional coagulopathy: is coagulopathy ascribed to dilution of platelets and clotting factors, occurring as patients receive multiple red blood cell transfusions and lose hemostatically active blood.
  1. Hemodynamically Unstable- Low blood pressure that provides inadequate tissue perfusion. “Shock” describes a more extreme state of hemodynamic instability.
  1. Massive Transfusion Panel: Laboratory panel including INR, APTT, Fibrinogen,CBC, Calcium and Potassium.
  1. Pediatric: Child <50 kg.

III.PROCEDURE FOR ORDERING MTP

  1. The protocol may be initiated by the Surgeon, Emergency Medicine physician or designee, Anesthesiologist, Intensivist or Transfusion Services at PRMC, for ED, ICU and Surgery,, and in FBC surgery.
  2. To initiate the MTP the treatment area must call blood bank, 266-1555. Blood bank will request the following information-

1.Patient full name and MRN

2Treatment location

3.Patient approximate age and weight is needed.

  1. The Physician Order for Emergency Release of Uncrossmatched Blood Products will be provided in the first MTP cooler and must be completed and signed by the physician. The white copy will be charted and the yellow copy should be returned to the laboratory.

IV.MTP PROCEDURE:

  1. Refer to Pediatric MTP tracking form. .The Tracking form will be included in the first MTP at delivery to the treatment area.
  2. The Blood Bank will prepare coolers with the following blood products and supplies:

Children <20 kg

All Odd Numbered Shipments / All Even Numbered Shipments
1 Packed Red Blood Cells / 1 Packed Red Blood Cells
1 Units Fresh Frozen Plasma / 1 Units Fresh Frozen Plasma
1 Unit Apheresed Platelets
Tubes and requisition required for MTP panel
* / *

Children 20-49 kg

All Odd Numbered Shipments / All Even Numbered Shipments
3 Packed Red Blood Cells / 3 Packed Red Blood Cells
2 Units Fresh Frozen Plasma / 2 Units Fresh Frozen Plasma
1 Unit Apheresed Platelets
Tubes and requisition required for MTP panel
* / *

*Cryo may be included in any cooler when indicated by a fibrinogen test result < 100 mg/dL

  1. The Blood Bank will make every effort to deliver the shipments. If this becomes impossible, the unit ordering the shipment will be notified.
  2. The first shipment will be taken to the patient location immediately.
  3. Nursing staff will coordinate the transfusion of the products in the order listed on the Massive Transfusion Protocol Tracking Form.
  4. An X will be marked through the product on the Tracking Form after it is given.
  5. Nursing staff will verify with physician the need to continue the protocol prior to each shipment.
  6. Each even numbered cooler will contain a laboratory requisition and tubes for the following tests: CBC with no differential, PT/INR, APTT, Fibrinogen, Ca, K+.
  7. Nursing staff will collect these tubes, complete the requisition and send to the lab with the empty cooler.
  8. A caregiver will call 266-1555 to notify the Blood Bank when the next shipment will be needed within 10 minutes, and verify the patient location.
  9. At the time of delivery, a patient caregiver will meet the lab co-worker with the previous cooler, a form of patient identification and filled blood tubes with requisition, if applicable. Blood samples and test requisition may also be tubed to the lab directly to expedite testing.
  10. At the time of delivery, the Blood Bank will confirm that the next shipment should be prepared by asking, “What is the name of the physician continuing the MTP?”
  11. If the results of any Fibrinogen < 100 mg/dL, the Blood Bank will add 5 units of pooled Cryoprecipitate to the next shipment.
  12. The Blood Bank will be called immediately when the physician cancels the MTP, or the patient RHC’s, to decrease wasted blood products.

V.TRIGGERS FOR TRANSFUSION SERVICE:

  1. If 2 units of packed cells have been transfused within 1 hour, the Blood Bank will call the patient care area to question if a MTP should be initiated.
  2. Nursing staff are encouraged to question the need for a MTP any time a large number of blood products has been transfused.
  3. If at any time during the MTP, the physician deviates from the MTP order set, the Blood Bank will discontinue the MTP and notify the ordering department.
  4. If a shipment has not been requested for 1 hour, the Blood Bank will discontinue the MTP without notification.

VI.References

  1. Parkview Health Trauma Multidisciplinary Performance Improvement Subcommittee
  2. Journal of TRAUMA, Injury, Infection and Critical Care: An FFP:PRBC Transfusion Ratio ≥1:1.5 is Associated with a Lower Risk of Mortality after MTP. Nov. 2008
  3. Journal of TRAUMA, Injury, Infection and Critical Care:Impact of Platelet Transfusion in Massively Transfused Trauma Patients. Nov. 2010
  4. Parkland Health and Hospital System, Dallas TX Department of Pathology: Massive Transfusion Protocol(MTP) procedure 122.2 May, 2004
  5. Ben Taub General Hospital Department of Pathology SOP Manual: Massive Transfusion Protocol and Transfusion of RBCs in Massive Transfusion, TS40.0 Aug. 2011.
  6. Wishard Health Services: Massive Transfusion, Dec. 2011.

Origination Date:11-6-2012 / Original Source:Trauma Multidisciplinary Performance Improvement Committee
Revision Source:
Review/Revision Date: / Authorized By:
PHH – Linda Prus, Director of Patient Services
PLH – Jordi Disler, VP Patient Care
PNH – Cathy Byrd, VP Patient Care
POH –Laura Ferrell, DON
PWH – Bridget Johnson, VP Patient Care
9/12 / PRMC/PVH - Judy Boerger, Sr. VP, CNO
PBH – Sally Boyce, Director of Nursing