A Massive Transfusion Protocol to Decrease Blood Component Use and Costs

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Hypothesis A massive transfusion protocol (MTP) decreases the use of blood components, as well as turnaround times, costs, and mortality.

Design Retrospective before-and-after cohort study.

Setting Academic level I urban trauma center.

Patients and Methods Blood component use was compared in 132 patients during a 2-year period following the implementation of an MTP; 46 patients who were treated the previous year served as historical control subjects.

Intervention Introduction of an MTP that included recombinant factor VIIa for patients with exsanguinating hemorrhage.

Main Outcome Measures The amount of each blood component transfused, turnaround times, blood bank and hospital charges, and mortality rates.

Results After introduction of the MTP, there was a significant decrease in packed red blood cells, plasma, and platelet use. The turnaround time for the first shipment was less than 10 minutes, and the time between the first and second shipments was reduced from 42 to 18 minutes, compared with historical controls. The decreased use of blood products represented a savings of $2270 per patient or an annual savings of $200 000, despite increased costs for recombinant factor VIIa. There was no difference in mortality in either group; it remained around 50%. Thromboembolic complications did not increase, despite a significant increase in the use of recombinant factor VIIa.

Conclusions The MTP resulted in a reduction in the use of blood components with improved turnaround times and significant savings. Mortality was unaffected. The use of recombinant factor VIIa did not increase thromboembolic complications in these patients.

Massive transfusion is loosely defined as the transfusion of more than 10 units of packed red blood cells (PRBCs) in a 24-hour period.1,2 Although there have been reports of improved survival after massive transfusion during the last decade, it is unclear what factors are responsible.3 There is increasing evidence that the early coagulopathy seen in trauma patients should be treated aggressively during the initial resuscitation, particularly in those patients requiring massive transfusion.4,5 It has been suggested that a protocol designed to give red blood cells and coagulation factors (ie, plasma and platelets) in prespecified ratios can improve outcomes.6,7 Both military and civilian data suggest that a ratio of 1:1 to 1:2 of fresh frozen plasma to PRBCs is needed to adequately treat coagulopathy in patients undergoing massive transfusions.6,8,9

We developed and instituted a massive transfusion protocol (MTP) at Parkland Health and Hospital System, Dallas, Texas, which was mainly designed for trauma patients with severe, active hemorrhage. The protocol includes giving prespecified amounts of PRBCs, thawed plasma (defined in the “Methods” section), cryoprecipitate, and platelets, as well as the recombinant factor VIIa (rFVIIa). The rationale of this protocol was to improve turnaround time, ie, the time between when the order for the products was received in the blood bank and when the products left the blood bank, as well as to provide component therapy in a more clearly defined proportion to prevent and treat coagulopathy and to reduce the waste that occurred with random product ordering.

We sought to examine our experience and outcomes among patients treated using this protocol. We hypothesized that an MTP would improve turnaround times, reduce the use of blood products and associated charges, and possibly decrease mortality.