A regional massive hemorrhage protocol developed through a modified Delphi technique

Abstract

assive bleeding is a leading preventable cause of death following trauma, childbirth and surgery. 1-3 There were 5.1 million deaths after traumatic injury worldwide in 2010, mostly affecting young people, accounting for nearly 10% of all deaths. 4 In the United States, it is estimated that up to 20% of such deaths are the direct result of preventable hemorrhage. 4-7 Management of unstable hemorrhagic shock is centred on stabilizing the patient with prompt transfusion of blood components, and rapid identification and treatment of the source of bleeding. Patient outcome is dependent on the availability of rapid definitive surgical intervention, support of a transfusion medicine and clinical laboratory, prompt access to hemostatic agents and care provided by a high-performing interdisciplinary team. 8 In the trauma literature, protocolized delivery of massive transfusion streamlines the complexities

International Forum on the Management of Major Haemorrhage: Responses

“…We list multiple definitions to cover different categories of patients including paediatrics. We do not have separate definitions for major/massive/supra‐massive transfusions.We think that simplifying and unifying the definitions may allow for better compliance with the protocol [2]. National guidelines are available for obstetric haemorrhage and are being developed for other clinical settings.…”

“…We think that simplifying and unifying the definitions may allow for better compliance with the protocol [2].…”

“… The Ontario Massive Haemorrhage Protocol (MHP) does not define major, massive or supra‐massive haemorrhage [1]. The Protocol recommends using one of the following validated published activation criteria: ABC score (trauma only), shock index or resuscitation intensity (>4 units of fluid in first 30 min with ‘1 unit’ defined as any of 1 U RBC, 1 U plasma, 500 ml colloid or 1 L crystalloid).…”

“…Following publication of the Ontario MHP in March 2021 and development of implementation tools (simulation material, checklists, posters, videos and a podcast; www.transfusionontario.org), implementation and harmonization of policies across our province are ongoing. The Ontario MHP detailed 36 recommendations and 8 quality metrics to ensure all massively haemorrhaging patients receive state‐of‐the‐art care in our region [1]. Other regions of Canadian have elected to also implement the Ontario MHP.…”

Protocol for a multicentre, randomised, parallel-control, superiority trial comparing administration of clotting factor concentrates with a standard massive haemorrhage protocol in severely bleeding trauma patients: the FiiRST 2 trial (a 2020 EAST multicentre trial)

“…6 In North America, ATC is typically treated with ratiobased plasma resuscitation, where 1 unit of frozen plasma (FP) is transfused for every 1-2 red blood cell (RBC) units until haemorrhage is controlled and blood components can be administered based on coagulation test results. 7 In contrast, in many European countries, fibrinogen concentrate (FC) and prothrombin complex concentrates (PCCs) are administered instead of FP. 8 The FC +PCC strategy has several potential advantages compared with plasma: simplified logistics by reducing the door-to-needle time (no knowledge of blood group needed, no thawing of FP, convenience of storage at room temperature where needed and ability to safely administer during transport from remote geographic regions), a reduced risk of some transfusion reactions and pathogen transmission (FC and PCC are pathogen-inactivated protecting patients from emerging pathogens) and an elimination of the need for reserving AB plasma for trauma patients.…”