Massive Transfusion Protocol

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 MTPs

Ionized Calcium is the free calcium within ones serum that is not bound to other proteins or molecules.

During a massive transfusion, ionized calcium levels can become depleted due to a number of factors.

One of the main reasons for this is that blood products, such as stored red blood cells and plasma, have low levels of ionized calcium. When large volumes of these products are transfused into a patient, it can cause a dilutional effect, reducing the concentration of ionized calcium in the bloodstream.

In addition, the citrate anticoagulant that is added to blood products to prevent clotting can also chelate (bind) calcium ions in the blood, further depleting ionized calcium levels. Citrate works by binding to calcium ions, which is necessary to prevent clotting in the blood bag during storage. When blood products are transfused, citrate is rapidly metabolized by the liver, leading to the release of ionized calcium into the bloodstream.

The rapid infusion of large volumes of blood products can also cause an increase in acidity in the blood (metabolic acidosis), which can further reduce the levels of ionized calcium. This occurs because acidosis can cause an increase in the binding of calcium to proteins and other molecules in the blood, reducing the amount of free ionized calcium.

Overall, the depletion of ionized calcium during massive transfusion can lead to a variety of complications, including impaired blood clotting function, cardiac arrhythmias, and muscle cramps. To prevent or manage these complications, healthcare providers may administer calcium supplements, such as calcium gluconate or calcium chloride, during and after transfusion to help restore ionized calcium levels to normal. 

How Do You Administer Blood Rapidly for an MTP?

Many systems will use the Belmont Rapid Infuser System. The Belmont Rapid Infuser is a medical device used to rapidly and efficiently administer large volumes of fluids, including blood products, to patients in emergency situations. It is a type of fluid warmer that can warm fluids to body temperature as they are being infused into the patient.

The Belmont Rapid Infuser works by using a disposable cassette system that incorporates a heating element and a pump. The cassette is filled with the fluid to be infused, such as blood products, and is then placed into the Belmont device. The device warms the fluid to body temperature and then rapidly infuses it into the patient using a high-pressure pump.

The device can infuse up to 1 liter of fluid in less than one minute, making it particularly useful in situations where patients require large volumes of fluids or blood products quickly, such as during massive transfusions for trauma or surgery.

The Belmont Rapid Infuser is designed to minimize the risk of air embolism, which can occur when air enters the patient's bloodstream during infusion. The device is equipped with air detection sensors that can automatically stop the infusion if air is detected in the tubing.