MASSIVE TRANFUSION PROTOCOL

Oleh ERTIGA
DEFINISI
 MT is defined when either
1) Total blood volume is replaced within 24 hours,
2) 50% of total blood volume is replaced within 3 hours, or
3) Rapid bleeding rate is documented or observed. Rapid bleeding
rate in adults can be defined as more than 4 units of red blood
cells (RBCs) transfused within 4 hours with active major bleeding
or more than 150 mL/minute of blood loss

Hsu,Y.,M., Haas,T., 2 Melissa M Cushing,M.,M .,2016, Massive transfusion protocols: current best
practice, International Journal of Clinical Transfusion Medicine Dovepress
Massive transfusion protocols are implemented in cases of
life-threatening hemorrhage after trauma and/or during a
procedure, and are intended to minimize the adverse effects
of hypovolemia and dilutional coagulopathy.

Practice Guidelines for Perioperative Blood Management An Updated Report by the

American Society of Anesthesiologists Task Force on Perioperative Blood Management,
2015, the American Society of Anesthesiologists
Timely MTP activation and deactivation
 MT is a resource-intensive process
 For many trauma centers, the time to issue the first MTP cooler is usually
within 5–10 minutes from protocol activation.
 At the bedside, the clinician who activates the MTP should serve as the
liaison to inform the blood bank about the need for continuing transfusion
support or deactivation of the MT
 Timely deactivation of MTPs not only reduces wastage, but also may
prevent unnecessary adverse events associated with MTP

Hsu,Y.,M., Haas,T., 2 Melissa M Cushing,M.,M .,2016, Massive transfusion protocols: current best
practice, International Journal of Clinical Transfusion Medicine Dovepress
Appropriate product ratios during MT
 Several published retrospective studies have shown that a higher plasma to
RBC ratio in MT is associated with better survival in patients with
traumatic injuries
 Randomized Optimal Platelet and Plasma Ratios study was conducted to
examine the effect of 1:1:1 versus 1:1:2 plasma:platelet:RBC ratio on 24-
hour and 30-day all-cause mortality. The study showed that while there was
no difference in the examined all-cause mortality, there was earlier
hemostasis, lower transfusion requirements, and less death due to
exsanguination at 24 hours in the 1:1:1 ratio group

Practice Guidelines for Perioperative Blood Management An Updated Report by the

American Society of Anesthesiologists Task Force on Perioperative Blood Management,
2015, the American Society of Anesthesiologists
 Practice Guidelines for Perioperative Blood Management An Updated Report by the
American Society of Anesthesiologists Task Force on Perioperative Blood Management,
2015, the American Society of Anesthesiologists
Summary of Recommendations
1. Patient Evaluation
a. Review previous medical records and interview the patient or family
to identify
b. Inform patients of the potential risks versus benefits of blood
transfusion and elicit their preferences
c. Review available laboratory test results including hemoglobin,
hematocrit, and coagulation profiles.
d. Order additional laboratory tests depending on a patient’s medical
condition (e.g., coagulopathy, anemia).
e. Conduct a physical examination of the patient (e.g., ecchymosis,
petechiae, pallor).
f. If possible, perform the preoperative evaluation well enough in
advance (e.g., several days to weeks) to allow for proper patient preparation.

Practice Guidelines for Perioperative Blood Management An Updated Report by the

American Society of Anesthesiologists Task Force on Perioperative Blood Management,
2015, the American Society of Anesthesiologists
2. Preadmission Patient Preparation
 In consultation with an appropriate specialist, discontinue anticoagulation
therapy (e.g., warfarin, anti-Xa drugs, antithrombin agents) for elective
surgery.

 If clinically possible, discontinue nonaspirin antiplatelet agents (e.g.,

thienopyridines such as clopidogrel, ticagrelor, or prasugrel) for a sufficient
time in advance of surgery, except for patients with a history of
percutaneous coronary interventions

 The risk of thrombosis versus the risk of increased bleeding should be

considered when altering anticoagulation status.

 Assure that blood and blood components are available for patients when
significant blood loss or transfusion is expected.
Practice Guidelines for Perioperative Blood Management An Updated Report by the
American Society of Anesthesiologists Task Force on Perioperative Blood Management,
2015, the American Society of Anesthesiologists
3. Preprocedure Preparation
 Multimodal protocols or algorithms may be employed as strategies to reduce the
usage of blood products. However, no single algorithm or protocol can be
recommended at this time.

 The determination of whether hemoglobin concentrations between 6 and 10 g/dl

justify or require red blood cell transfusion should be based on potential or actual
ongoing bleeding (rate and magnitude), intravascular volume status, signs of organ
ischemia, and adequacy of cardiopulmonary reserve.

 Red blood cells should be administered unit-by-unit, when possible, with interval
reevaluation.

 A massive (i.e., hemorrhagic) transfusion protocol may be used when available as a

strategy to optimize the delivery of blood products to massively bleeding patients.

 Use a maximal surgical blood order schedule, when available and in accordance with
your institutional policy, as a strategy to improve the efficiency of blood ordering
practices.
4. Intraoperative and Postoperative
Management of Blood Loss
 Allogeneic Red Blood Cell Transfusion
1. Administer blood without consideration of duration of storage.
2. Leukocyte-reduced blood may be used for transfusion for the purpose of
reducing complications associated with allogeneic blood transfusion.

 Reinfusion of Recovered Red Blood Cells

Reinfuse recovered red blood cells as a blood-sparing intervention in the
intraoperative period, when appropriate

Practice Guidelines for Perioperative Blood Management An Updated Report by the

American Society of Anesthesiologists Task Force on Perioperative Blood Management,
2015, the American Society of Anesthesiologists
 Monitor for perfusion of vital organs using standard ASA monitors (i.e.,
blood pressure, heart rate, oxygen saturation, electrocardiography) in
addition to observing clinical symptoms and physical exam features

 Additional monitoring may include echocardiography, renal monitoring

(urine output), cerebral monitoring (i.e., cerebral oximetry and NIRS (
near-infrared spectroscopy)), analysis of arterial blood gasses, and mixed
venous oxygen saturation.
 If coagulopathy is suspected, obtain standard coagulation tests (e.g., INR,
aPTT, fibrinogen concentration) or viscoelastic assays (e.g.,
thromboelastography [TEG] and ROTEM (rotational trombopelastometry),
if available, as well as platelet count.

 During and after transfusion, periodically check for signs of a transfusion

reaction including hyperthermia, hemoglobinuria, microvascular bleeding,
hypoxemia, respiratory distress, increased peak airway pressure, urticaria,
hypotension and signs of hypocalcemia.
Kesimpulan
 In conclusion, the best practice for MT includes an established institutional
definition of MT, an accurate method for predicting which patients will
require MT so therapy can be promptly initiated and over-utilization can be
avoided, and finally, an established MT protocol with a clear plan for
activation and use of appropriate blood products to maintain hemostasis.

 This can be achieved either by goal-directed therapy with POC testing or,
when point-of-care testing is not available, fixed ratios of blood products
approximating a ratio of 1:1:1, with early initiation of fibrinogen
replacement. Adherence to the established protocol is critical to extract
the full clinical benefit of an MTP for treating either trauma or non-trauma
patients