Chin Victoria, Cope Stephanie, Yeh Calvin Hsiung, Thompson Troy, Nascimento Barto, Pavenski Katerina, Callum Jeannie
Sunnybrook Health Sciences Centre, Toronto, Canada.
Ontario Regional Blood Coordinating Network, Toronto, Canada.
Injury. 2019 Jan;50(1):46-53. doi: 10.1016/j.injury.2018.11.026. Epub 2018 Nov 12.
Massive hemorrhage protocols (MHP) are critical to standardized delivery of timely, safe, and resource-effective coordinated care for patients with life-threatening bleeding.
A standardized MHP survey was sent to all hospitals (n = 150) in Ontario with a transfusion service. This study aim was to determine the proportion of hospitals with an MHP and assess for variability.
The overall survey completion rate was 133 of 150 hospitals (89%) (remaining 17 providing negative affirmation that they did not have an MHP). An MHP was in place at 97 of 150 (65%) hospitals (60% of small (<5000 red cell units/year) vs. 91% of medium/large). A total of 10 different names of protocols were reported, with "Massive Transfusion Protocol" (68%) predominating. Activation criteria were present in 82 of 97 (85%); commonly activated based on volume of blood loss (70%). Blood work was drawn at the discretion of the physician (37%) or at predefined intervals (31%; majority every 60 min). Common routine laboratory tests performed were CBC (87%) and INR (84%). Fibrinogen testing was available at 88 (66%) of 133 reporting hospitals and part of the standard testing at 73 of 97 (75%) hospitals with an MHP. Median targets of hemostatic resuscitations, stated in the protocol at 49% of hospitals with an MHP, were: platelets >50 × 10/L, INR < 1.8, fibrinogen >1.5 g/L, and hemoglobin >70 g/L. Protocol required patient temperature monitoring in 65% and specified a reversal plan for patients on anticoagulants in 59%. At 36% of sites all patients are initially managed with O RhD negative blood. Overall, 61% of sites issue blood in predefined packs (vs. on demand). Hemostatic agents in protocols included: tranexamic acid (70%), prothombin complex concentrate (14%), fibrinogen concentrate (13%), and recombinant FVIIa (4%). Quality metrics were tracked in 32% of hospitals.
A third of hospitals lack formal MHPs, with the majority lacking in smaller hospitals. The survey results indicate that there is marked variability in all key aspects of the reported MHPs. This may be due to differences in hospital resources and personnel, lack of supporting evidence to dictate requirements, and differences in knowledge base of the individuals involved in protocol setting.
大出血预案（MHP）对于为危及生命的出血患者及时、安全且资源高效地提供标准化协调护理至关重要。
向安大略省所有设有输血服务的医院（n = 150）发送了一份标准化的MHP调查问卷。本研究旨在确定设有MHP的医院比例，并评估其变异性。
150家医院中有133家（89%）完成了总体调查（其余17家明确表示没有MHP）。150家医院中有97家（65%）设有MHP（年红细胞输注量<5000单位的小型医院占60%，中型/大型医院占91%）。共报告了10种不同的预案名称，其中“大量输血预案”占主导（68%）。97家设有MHP的医院中有82家（85%）有激活标准；通常根据失血量激活（70%）。血液检查由医生酌情进行（37%）或按预定间隔进行（31%；多数为每60分钟一次）。常见的常规实验室检查包括全血细胞计数（87%）和国际标准化比值（INR）（84%）。133家报告医院中有88家（66%）可进行纤维蛋白原检测，97家设有MHP的医院中有73家（75%）将其作为标准检测的一部分。49%设有MHP的医院在预案中规定的止血复苏中位数目标为：血小板>50×10⁹/L、INR<1.8、纤维蛋白原>1.5g/L、血红蛋白>70g/L。65%的预案要求对患者体温进行监测，59%的预案为服用抗凝剂的患者制定了逆转计划。36%的机构最初对所有患者采用O型RhD阴性血进行处理。总体而言，61%的机构按预定包装发放血液（而非按需发放）。预案中的止血剂包括：氨甲环酸（70%）、凝血酶原复合物浓缩剂（14%）、纤维蛋白原浓缩剂（13%）和重组凝血因子VIIa（4%）。32%的医院跟踪质量指标。
三分之一的医院缺乏正式的MHP，其中大多数是小型医院。调查结果表明，所报告的MHP在所有关键方面存在显著差异。这可能是由于医院资源和人员的差异、缺乏规定要求的支持性证据以及参与预案制定的人员知识基础的差异所致。
