Effects of a Massive Transfusion Protocol in Obstetric and Gynecologic Population

Background:

Large volume blood loss management is vital to survival especially in obstetric and gynecological surgery in women of childbearing age.  For this reason a protocol was developed to assure availability of blood products for transfusion during acute blood loss in this patient population.

Case:

After a failed trial of labor, A.D. consented to a cesarean section which resulted in the loss of one liter of blood after the delivery of her baby.  In the recovery room A.D. voiced concerns about increasing abdominal pain from her right pelvis to her right upper quadrant.  As her blood pressure decreased, the team quickly moved to stablize her and she was moved back to the OR for exploration.  A Massive Transfusion Protocol I was initiated at 2354 because of a large hemoperitoneum (blood collection in the abdomen) of 3.5 liters (total EBL 4.5 L). Surgical repair of a right cervicovaginal laceration was performed as 8 units of PRBC, 2 units of FFP, and a pack of platelets were transfused. The patient remained on mechanical ventilation and was admitted to the WICU where she remained intubated overnight. A review of labs revealed a decrease in hemoglobin from 10.7 mg/dl  on admission to 6.5  mg/dl,  with a return to 11.6 mg/dl by 0338 the day following these interventions.  A.D. had the breathing tube removed that same day and was discharged home on day 6 after the MTP was initiated.

 Conclusion:

The Massive Transfusion Protocol (MTP) was initiated in 2010 along with a Maternal Urgent Surgical Team (MUST) to manage this complex population. Each cooler from the blood bank contains 6 units of packed red blood cells (PRBC), 6 units of fresh frozen plasma (FFP), and pack of platelets. During the MTP, the blood bank will release a cooler every 20 minutes until the MTP leader terminates the MTP.

Forty-three protocols (MTP I: 22; MTP II: 21) were utilized in obstetric and gynecologic patients from December 2010 - December 2012. Estimated blood loss (EBL) averaged 2.8, 3.4, and 3.0 liters respectively. The ratio of RBC to FFP transfusion ranged from 1: 0.54 to 0.66, mean patient age of 33.6 years.  Average length of stay (LOS) from time of MTP to patient discharge was 4.3 to 5 days with a mean LOS in ICU of 2.3 days. Exemplary practice and quality outcomes are a direct result of this collaborative effort in patient-first care.

Keywords: massive-transfusion protocol, postpartum hemorrhage, blood administration,