Update Course Rewind: Massive Transfusion Protocol 2023

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm M. Goudi, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held past August. In this video series, we'll recap the sessions and share the main highlights with you. In this video, Doctors Mira Godagal and Katie Russell are sharing their guidelines and the updates in Massive Transfusion Protocols, or MTPs. All right guys, here's our next scenario. So this is an 8-year-old who's got a gunshot wound to the abdomen. He was playing with his 4-year-old brother and he was unintentionally shot. He's hypotensive, despite already getting a bolus of crystalloid in the field. And he's now gotten 20 ml per kilo of blood. Our question is, when should we activate a massive transfusion protocol? And you've got the cooler in front of you. Now, what product are you going to give first? So we would often get to 40 per kilo of blood and then go to a 1-1-1. So, I don't have great data for this, but I actually start with FFP. I think there is adult data to support that. Yeah. Absolutely. The data on 1-1-1 resuscitation, I think is really important. We do have plasma in our original trauma cooler that comes to the bay and then we get more. Dr. Godagal also mentioned that they don't have platelets in their original trauma cooler. So in order to get platelets, they have to activate MTP, or order platelets separately. I don't know the answer of when is the time, and I don't know if it's the same everywhere for when you call. I would always do it just because of gestalt. I'd be like, okay, I gave blood, I'm going to call MTP. I think that's like the actually the take home point. So, we're going to show some new studies, but if you're in the trauma bay and you're giving blood, you need to activate it. It's go time. Blood equals MTP. Yes. That's its phrase to remember. If you get blood, call MTP. Is that standard or is that your opinion at your hospital? This is actually a new paper. There are these blood investigators. They're part of the MATIC trial, looking at whole blood versus component therapy. But they wrote a bunch of papers out of the first iteration of this trial, and after 20 per kilo of blood within an hour, you should activate the MTP. And what is what gets destroyed or ruined when you call an MTP and don't use it? It's resources. So, what about blood? So usually no, unless you spike the bag, the blood can be returned to the blood. When do you give something other than packed red blood cells and what do you give? Bad trauma coming in, not normal at all. Whole blood would be the best. I think, personally. So we have not been able to get our blood bank to make whole blood for kids because it needs to be irradiated. Okay. We want to aim for 1-1-1. For sure. And definitely FFP should be what you give after you give blood. It most of the time an original trauma cooler that comes to the bay in most hospitals does not have platelets. The MTP helps you get platelets or you can call for platelets. This paper basically is the definition for an MTP. People have different definitions for what massive transfusion kids actually is, but I think the best one is, 40 of any blood product over 24 hours. So, do you agree with that? I would. And I think it's worth clarifying that activating your MTP and your threshold for doing that is different than massive transfusion. According to this paper, anytime you give kids 40 ml per kilo or more blood, you should consider it as a massive transfusion. When you decide to activate your massive transfusion protocol, which is going to bring you lots of blood, is a different question. Yeah. Next paper, this is the paper about 1-1-1, right? And in this paper, they looked at a balanced resuscitation. The main idea is, the more fresh frozen plasma, or FFP you give, the lower your mortality is. The closer you are 1-1-1 is better and these guys have shown this in kids. So it's not just adult data at this point. And I think there's great pediatric data on whole blood. So in the event that you can't, balance resuscitation is really important because kids bleed whole blood. And then last paper, so this is, you're in the trauma bay, you are actively transfusing. They've gotten 20 per kilo and they're still not stable. So this is new data. Our protocol is next. We're doing 40 as of now, but I think that it's certainly an area for improvement. This is a low frequency, high equity event and every now and then there'll be a GI bleeding or a bad liver transplant. So sometimes it is just useful to have a second set of hands. We recently created an MTP team that responds anywhere in the hospital to try to help run these resuscitations. And so all they're in charge of is giving the blood. Primary physicians can take care of dealing with what the underlying medical problem is and then we just go and give blood. Who's on your team? The trauma APP is running the team and then we bring an ER nurse who knows how to run the Belmont. That's like the core team, and they go with the blood to the bedside, give the blood, and they say, we got to get the labs and check back in. What we showed is that we changed our balance resuscitations. Our balance resuscitation used to be 25% and then after activating this team, we're now up to 85% on our balance resuscitation. Do you do pre-hospital transfusion? Recently lead a visual abstract about this and I don't have it available in Chile but I'm guessing if you do, it could even reduce mortality. The data definitely supports that we will have patients who may get blood started at an outside hospital, but our EMS does not. And Dr. Godagal shares her experience from a hospital that they partnered with in the Netherlands. Their trauma program and they have an incredibly cool system. They have a helicopter based team. They actually rendezvous in the field, so they ECMO cannulate in the middle of a Tulip field. And they will take their team to meet the patient in the ambulance and then transport so that they're actually starting their resuscitation in the field with an anesthesiologist and a nursing support. Blows my mind they actually cannulate. Like if they need to for ECMO kids, they cannulate in the field, which is incredible. Can you comment on pre-hospital TXA? Yeah, we are not routinely doing it, but I think there is evidence to support its use. I, I do encourage them for people that are using TXA and MTP to get a Rotem or a Teg as fast as you can because it's going to be a delay a little bit. If you have rapid Teg is great, but if it's a Rotem takes a little longer, but as soon as you can directly target your goals for resuscitation, you will highly improve the outcomes in terms of lungs. If the patient ends up intubated, if you guys have access to it, just get it as soon as you can. In summary, in this video, we focused on the Massive Transfusion Protocol for trauma patients. When a patient remains hypotensive after receiving a significant amount of blood, activating MTP is crucial. Immediate blood transfusion is paramount, followed by FFP, aiming for a balance 1-1-1 ratio. Guidelines suggests MTP activation after administering 20 ml per kilo of blood within an hour. Early pre-hospital transfusion might reduce mortality. Lastly, using tranexamic acid or TXA in MTP, combined with rapid resuscitation goal targeting is important. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.