Massive Transfusion Protocol Ups RBCs, Plasma
From a meeting on Antepartum and Intrapartum Management
▸ Consider using fluid warmers and forced-air warmers to keep patients from becoming hypothermic and more coagulopathic.
▸ Have rapid infusion pumps or pressure bags available to speed the transfusion.
▸ Prepare for general anesthesia.
▸ Have vasopressors and uterotonics immediately available.
▸ Have a supply of calcium chloride on hand to prevent the low levels of ionized calcium that can occur after rapid transfusion. Citrates in blood products bind with calcium, increasing the risk of extreme hypotension and depressed heart function.
▸ Have a Foley catheter (for measuring urine output) and compression stockings available.
▸ Reserve an ICU bed.
▸ Ask for additional packs of blood products if needed.
▸ Consider giving cryoprecipitate (fibrinogen less than 100 mg/dL).
▸ Consider off-label treatment with recombinant factor VIIa only after the patient has received approximately 10 U of packed RBCs and full factor replacement. “It's not a first-line drug. There's plenty of morbidity and mortality that can occur” with factor VIIa, he noted. “Having said that, I do believe that it is very effective in certain situations.”
▸ Designate someone to tally and record the use of blood products and estimated blood loss.
▸ Bring the “code cart” into the OR early.
▸ Afterward, meet for 3-5 minutes with everyone who worked on the case to review what went well, what didn't, and ideas for improvement.
