ACH Pediatric Massive Transfusion Protocol (MTP) Appropriate Initial Interventions √ Intravenous / intraosseous access→ 2 access points √ Crystalloid→ 3:1 ratio with EBL to max 50 mL/kg √ Labs → T&S, CBC, coagulation, lytes & ionized Ca √ Continuous monitoring → VS, acid/base, Intake/Output √ Aggressive re-warming – including warmed RBC’s and plasma √ Prevent/reverse acidosis √ Correct hypocalcemia →Ca gluconate 20 -50 mg/kg/dose IV slowly (1 ml/min) √ Transfuse with unmatched RBCs on hand √ Complete Tertiary Trauma survey if necessary Other Considerations √ Heparin reversal → Protamine 1 mg IV per 100U of heparin √ Warfarin reversal → Vitamin K 5 mg IV/IM √ CRF & Von Willebrand’s → DDAVP 0.3 mcg/kg IV over 10 mins (max 20 mcg) √ Consider antifibrinolytics: → Tranexamic acid 20 - 50 mg/kg IV load, then 10 mg/kg/hr (max total dose 100 mg/kg) √ Intraoperative cell salvage √ Consider rFVIIa (Niastase RT®) for persistent coagulopathy in consultation with TM physician on call @ 41367. See Niastase RT® Protocol for dosing information √ Surgery Identify & Manage Bleeding √ Angiographic Embolization √ Endoscopy Anticipate replacement of 50% of blood volume (40 mL/kg) in 3 hours OR Estimated blood loss exceeding 0.5 mL/kg/min MD ACTIVATES MTP ASSIGN a clinical team member to activate MTP (MUST be a Nurse – not a Unit Clerk) PHONE Transfusion Medicine (TM) at 52332 PROVIDE Patient name and sex, RHRN, weight, location, ordering physician RECORD Name of TM technologist you are speaking with & fill out evaluation form ARRANGE for pick up of pack (page STAT porter for expedited pick up at 04678) Standard MTP Pack √ 3U RBCs √ 2U FFP RBC’s FFP Platelets THRESHOLD DOSE Aim for Hgb ≥ 100 in bleeding coagulopathic patient Hgb ≥ 70 is sufficint in most stable non-bleeding patients If INR > 1.5 Give 10-15 mL/kg FFP If < 50,000 Cryoprecipitate Fibrinogen less than 1g/L OR evidence of microvascular bleeding Give 5-10 mL/kg Platelets should drip freely and not be transfused using a warmer or pressurized infuser. Give 1U/5 kg √ 1 dose Platelets Or at clinician discretion Q30 Minutes General Pediatric Guidelines for Lab Based Blood Component Replacement PRODUCT Collect Type & Screen STAT Hemostasis & resolution of coagulopathy? Clinical Team member calls TM at 52332 for another MTP pack No MD can adjust pack based on labs prn Yes Repeat CBC, INR, PTT & fibrinogen q1h Stop MTP * Notify TM & return any unused blood ASAP * Resume standard ordering in SCM Repeat ABG, lytes, ionized Ca, serum magnesium q30min NOTE: No order for MTP in SCM – At end of MTP, enter Clinical Communication: MD to Nurse order in SCM to include all blood products transfused during MTP 1 Massive Transfusion Definitions Replacement of 50% of blood volume in 3 hours (40 ml/kg) or blood loss > 2 ml/kg/min or replacement of a blood volume (80 ml/kg) in 24 hours. 2 Protocol based on varying levels of evidence and expert consensus. Developed in conjunction with the Alberta Children’s Hospital Pediatric Trauma Program and Transfusion Medicine CLS form# TSO1304 20110613 DIRECT TELEPHONE DISCUSSION BETWEEN TRANSFUSING PHYSICIAN AND TRANSFUSION MEDICINE TECHNOLOGIST IS ENCOURAGED
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