SCGH Massive Transfusion Protocol (MTP)

Actual or anticipated 4 units RBC in < 4 hours, + haemodynamically unstable, +/– anticipated ongoing bleeding
Severe thoracic, abdominal, pelvic or multiple long bone trauma, major gastrointestinal, surgical or obstetric bleeding

Senior clinician determines that patient meets criteria for MASSIVE TRANSFUSION PROTOCOL activation

Baseline:
Group & Screen/cross match, full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistry, arterial blood gases.
If using ROTEM order EXTEM & FIBTEM ( If patient is taking heparin order INTEM & HEPTEM)

Notify transfusion laboratory (34018, page 4467.) to:

Activate MASSIVE TRANSFUSION PROTOCOL
Send courier to Transfusion Medicine Unit (TMU) (Ground floor, PP block) to collect Massive Transfusion Pack

Senior clinician Request: ROTEM

NO ROTEM • 4 units Red blood cells ( RBC)
MONITOR • 2 units Fresh Frozen Plasma (FFP) Refer to

(every 30–60 mins): Consider The SCGH ROTEM

Algorithm
full blood count • 1 adult therapeutic dose platelet
coagulation screen for Critical bleeding
• Tranexamic acid in trauma patients within 3hrs for the blood product
ionised calcium
arterial blood gase
Include dosing guide
Page 2 of 3
• 10 units cryoprecipitate if fibrinogen<1.5 g/L
AIM FOR:
• temperature > 350C
• pH > 7.2
• base excess<–6
Bleeding controlled? Special Clinical
• lactate < 4 mmol/L Indications
• Ca2+ > 1.1 mmol/L YES Warfarin, antiplatelet and
• platelets > 50x109/L NO novel oral anticoagulants
• PT/APTT < 1.5 normal (NOACS)
• INR ≤ 1.5
Notify transfusion laboratory to:
Refer to page 3 of 3 for
• fibrinogen > 1.5 g/L Cease Massive Transfusion Protocol by calling 34018 further information
Return unused products to TMU immediately

SCGH Massive Transfusion Protocol and ROTEM algorithm for critical bleeding endorsed by the SCGH blood transfusion committee April 2017, page 1 of 3
 SCGH ROTEM Algorithm for Critical Bleeding

Key Points: This algorithm is for use in patients with CRITICAL BLEEDING only. Only treat abnormal values if active bleeding or at high risk of bleeding.
Repeat ROTEM analysis 10 mins after intervention to assess response.

ABNORMAL CORRECTED
CRITERIA DIAGNOSIS INTERVENTION
ROTEM ROTEM
FIBRINOGEN FIBRINOLYSIS

Early Diagnosis Tranexamic acid 1g

High likelihood of
EXTEM A5≤35mm Consider repeat dose if has lost
excess fibrinolysis
or FIBTEM CT >600s over 1 blood volume
Late Diagnosis since initial dose
Excess fibrinolysis (If no contra-indications)
EXTEM or FIBTEM ML ≥5%

Cryoprecipitate
FIBTEM A5≤10mm Low fibrinogen
(see dosing guide)

EXTEM A5 ≤35mm
Platelets: 1 adult dose
PLATELETS

and Low platelets

(correlate with platelet count)
FIBTEM A5 >10mm
EXTEM A5 ≤25mm
Low platelets Platelets and fibrinogen
and
and Low fibrinogen (correlate with platelet count)
FIBTEM A5 ≤10mm
EXTEM CT 80-140s and Correct fibrinogen
Low fibrinogen
FIBTEM A5 ≤10mm and reassess
FACTORS

EXTEM CT >80s but

Low coagulation factors
FIBTEM A5 >10mm FFP 1-4U or
EXTEM CT >140s and Low fibrinogen and (+ Fibrinogen if indicated)
FIBTEM A5 ≤10mm Low coagulation factors
Fibrinogen Dosing Guide
FIBTEM A5 Target: ≥12mm
FIBTEM A5 Cryoprecipi-
Increase required Cryoprecipitate*
tate*
9-10mm 2-3 mm 10 Units
7-8mm 4-5 mm 15 Units
4-6mm 6-8 mm 20 Units
<4mm ≥9mm 20-25 Units
*Cryoprecipitate dosing is for standard adult units
(Cryo 5 units = Fibtem A5 increase of approx 2mm)

Endorsed by the SCGH Blood Transfusion Committee, Departments of Anaesthesia , Pain Medicine & Haematology January 2017 Adapted from KEMH hospital algorithm with permission page 2 of 3
 PATIENTS ON ANTICOAGULANTS EXPERIENCING CRITICAL BLEEDING - QUICK REFERENCE GUIDE

**FOR GENERAL REFERENCE ONLY - DISCUSS ALL MANAGEMENT WITH HAEMATOLOGIST

Patients on anticoagulants have an underlying predisposition to thrombosis and the decision to use Detect and Exclude other abnormalities
pharmacologic reversal should always be balanced against the risk of precipitating thrombosis. Where Perform ROTEM to detect and treat other
feasible maximise the use of non - pharmacologic treatments such as surgical techniques, embolisation abnormalities that may develop during
or balloon tamponade / packing. Seek advice from the appropriate specialists and Haematology. haemorrhage e.g. low fibrinogen or platelets,
In critical or life threatening haemorrhage urgent reversal may still be required: (see below) hyperfibrinolysis, coagulation factor deficiency.

DIAGNOSTIC TESTS INTERVENTION & REVERSAL

Vitamin K 5-10mg IV
use INR to guide reversal
WARFARIN Prothrombinex VF 25 - 50 U/kg
(*ROTEM is insensitive)
+/- FFP 1-2 units
INTEM CT > 240s and HEPTEM CT / INTEM Cease heparin (short half life)
HEPARIN CT > 0.8 (- indicates reversible heparin Consider protamine 1mg / 100u heparin
(Unfractionated ) effect) Give protamine slowly 10mg/min
APTT > 38s -Maximum dose 50mg
Consider Protamine
(max 50mg):
If < 8hrs: Protamine 1mg /
LMWH Up to 60% of LMWH
INTEM CT > 240s 1mg enoxaparin
(low molecular effect may be reversible
Anti Factor Xa Levels If > 8hrs: Protamine 0.5mg /
weight heparin)” with protamine
1mg enoxaparin
- Give protamine slowly
10mg/min
AGENT - Laboratory Tests / Pro-Haemostatic Drugs
Mechanism of action Antidotes (if no antidote)
Dabigatran - Dabigatran level/ General Advice Discuss with on call
Direct thrombin inhibitor Idarucizumab click here Maximise physical Haematologist
NOACS
Rivaroxaban - measures: In life-threatening bleeding
(Novel Oral
Direct Xa inhibitor Direct pressure when other
Anticoagulants) Rivaroxaban/ Apixaban
Embolisation measures have failed
level
Apixaban - Surgical ligation consider:
No Antidote Available
Direct Xa inhibitor Prothrombinex VF 25-50iu/kg
Tranexamic Acid 1g
Anti-platelets agents (Aspirin & Clopidogrel) Give one adult dose of platelets

Endorsed by the SCGH Blood Transfusion Committee, Departments of Anaesthesia , Pain Medicine & Haematology January 2017 Adapted from KEMH hospital algorithm with permission page 3 of 3