Massive Transfusion Protocol

Car Crash MTP
MTPs can be activated in severe trauma from a car accident
Massive transfusion protocol (MTP) is a critical medical intervention used in emergency situations to save the lives of patients with severe bleeding. This protocol is a set of guidelines developed by healthcare professionals that facilitate the rapid administration of large quantities of blood products, including red blood cells, plasma, and platelets. Studies have shown that early implementation of MTPs can improve patient survival rates and decrease the incidence of complications such as multiple organ failure, sepsis, and respiratory distress syndrome. By providing blood products in a targeted and timely manner, MTPs can help to replenish the patient's blood volume, restore normal clotting function, and improve tissue oxygenation.

We will discuss what MTP is, how it works, and why it is essential in emergency medical situations. We will also provide some insights on how MTP is initiated and what factors influence its success.

What is Massive Transfusion Protocol?

Massive Transfusion Protocol (MTP) is a pre-established set of procedures and guidelines for the administration of large volumes of blood products in trauma patients who have sustained significant blood loss. MTP is initiated in patients who have lost over 50% of their total blood volume, typically as a result of a severe injury or surgical procedure.

The goal of MTP is to rapidly replace the lost blood volume and maintain appropriate levels of oxygen delivery to the body's vital organs, including the brain, heart, and lungs.

How Does The Massive Transfusion Protocol Work?

MTP is a coordinated effort involving healthcare professionals from different specialties, including emergency medicine, critical care, hematology, transfusion medicine, and pharmacy. The protocol is typically initiated by the trauma team leader, who assesses the patient's condition and determines whether MTP is necessary.

Once the decision to activate MTP has been made, blood bank staff prepares and delivers a predetermined amount of blood products, including red blood cells, plasma, and platelets, to the patient's bedside. The blood products are then administered based on the patient's specific needs, as determined by laboratory tests and ongoing clinical assessments. MTPs are most successful when a 1:1 ratio of Red Blood Cells and Plasma is followed. So, for example, each MTP cooler may contain 6 RBCs and 6 units of plasma. Platelets and cryoprecipitate may also be prepared at specific intervals. 

Factors Influencing the Success of MTP

The success of MTP is influenced by several factors, including timely activation, appropriate selection of blood products, and effective monitoring of the patient's response to transfusion. The early initiation of MTP is critical, as it ensures that the patient receives blood products promptly, which can improve survival rates.

Another essential factor in the success of MTP is the selection of appropriate blood products. Red blood cells are typically administered first, followed by plasma and platelets in a predetermined ratio (usually 1:1). This approach ensures that the patient receives the necessary clotting factors to stop the bleeding.

Finally, effective monitoring of the patient's response to transfusion is essential. The patient's vital signs, laboratory values, and overall clinical condition must be continuously assessed to ensure that the transfusions are providing the intended benefit.

Why is MTP Important?

MTP is critical in emergency medical situations, as it can save the lives of patients with severe bleeding. Without MTP, patients who have lost significant amounts of blood may not receive the necessary blood products in a timely fashion, leading to poor outcomes and high mortality rates.

MTP has been shown to improve survival rates in trauma patients with severe bleeding, reducing the risk of death from bleeding by up to 70%. Additionally, MTP has been associated with a reduction in hospital length of stay and ICU admissions, leading to lower healthcare costs.

What are the negatives of activating an MTP?

While MTP can be life-saving, it is not without complications. Some potential complications of MTP include:

  • Transfusion reactions: Blood transfusions can trigger immune reactions in the recipient, leading to symptoms such as fever, chills, itching, hives, and difficulty breathing. These reactions can be mild to life-threatening.

  • Fluid overload: Rapid transfusion of large amounts of blood products can lead to fluid overload, which can cause edema, shortness of breath, and heart failure.

  • Coagulopathy: Patients who have lost a large amount of blood may also have impaired blood clotting function, which can be exacerbated by transfusions. This can lead to bleeding complications and make it difficult to control bleeding.

  • Hypothermia: Blood products that are stored at cold temperatures can cause hypothermia when rapidly infused into a patient. Hypothermia can cause a variety of complications, including cardiac arrhythmias and impaired coagulation function.

  • Transmission of infectious diseases: While blood products are tested for infectious diseases, there is still a risk of transmission of viruses, bacteria, or other pathogens.

  • Cost: MTP can be expensive due to the large amount of blood products used, which can strain healthcare budgets and resources.

  • Blood Wastage: Ocassionally, MTPs might be activated inappropriately, and thus blood products, especially thawed FFP, might be wasted. MTPs must only be called in true exsanguination emergencies. 

Ionized Calcium and Massive Transfusion

What is Ionized Calcium? Ionized calcium refers to the calcium in one's serum that isn't bound to proteins or other molecules. It plays a crucial role in various bodily functions, including blood clotting, heart function, and muscle contractions.

Challenges During Massive Transfusions: During massive blood transfusions, ionized calcium levels can drop due to several factors:

  • Dilutional Effect: Transfusing large volumes of blood products, which typically contain low levels of ionized calcium, can dilute the patient's ionized calcium concentration.

  • Citrate Anticoagulant: Blood products are preserved with citrate to prevent clotting. Citrate binds to calcium ions, reducing available ionized calcium. Although the liver metabolizes citrate, releasing calcium back into the blood, rapid transfusions can overwhelm this process.

  • Acidosis: Massive transfusions can increase blood acidity, leading to more calcium binding with proteins and less free ionized calcium.

Consequences of Ionized Calcium Depletion: A drop in ionized calcium during massive transfusions can lead to complications such as:

  • Impaired clotting function
  • Cardiac arrhythmias
  • Muscle cramps

Managing Calcium Levels: To counteract ionized calcium depletion, healthcare providers may administer calcium supplements like calcium gluconate or calcium chloride during and after the transfusion process. This intervention helps maintain essential physiological functions and prevent the complications associated with low ionized calcium levels.

This approach underscores the importance of monitoring and managing ionized calcium levels during massive blood transfusions to ensure patient safety and treatment efficacy.

How Do You Administer Blood Rapidly for an MTP?

The Belmont Rapid Infuser System: A Crucial Tool in Emergency Care

Overview of the Belmont Rapid Infuser: The Belmont Rapid Infuser is an advanced medical device designed for the rapid and efficient delivery of large volumes of fluids, including blood products, directly to patients. It's especially crucial in emergency situations where quick fluid replacement is essential.

How It Works:

  • Fluid Warming: The device can warm fluids to body temperature, ensuring patients receive fluids that match their physiological conditions.
  • Disposable Cassette System: Utilizes a unique cassette system with a built-in heating element and pump. Fluids, such as blood, are loaded into the cassette, warmed, and then infused at high speed.
  • Rapid Infusion Capabilities: Capable of infusing up to 1 liter of fluid in less than a minute, it's invaluable during massive transfusions required in trauma cases or surgical procedures.

Safety Features:

  • Air Embolism Prevention: Designed to minimize the risk of air embolism, a dangerous condition where air enters the bloodstream. It includes air detection sensors that halt infusion if air is detected, enhancing patient safety during rapid infusion.

The Role in Emergency Care: The Belmont Rapid Infuser is a vital component in the management of emergencies requiring fast fluid replacement. Its ability to quickly warm and infuse large volumes of fluids makes it a key device in trauma care and surgical settings, helping to save lives by stabilizing critical patients rapidly.