Massive transfusion: a question of timing, detail, a golden ratio

Here it was, the kind of massive postpartum hemorrhage case for which the team at Duke University Medical Center had spent months preparing. The multidisciplinary group had agreed on which laboratory tests would be done in such a case, determined which blood products would be delivered, and decided which members of the OB team would be sent racing to retrieve the potentially life-saving package.

For the two labor-and-delivery nurses designated as runners, the quickest way to get down to the blood bank was the elevator. The elevator was working, but the nurses’ badges did not allow them access to it.

“They had to run all the way down the hall, then all the way down the stairs. It took much longer,” says Evelyn Lockhart, MD, a pathologist who specializes in transfusion medicine and led the Duke team in implementing a massive transfusion protocol for postpartum hemorrhage.

“It was a surprise to us all,” Dr. Lockhart says. Fortunately, the only harm associated with the inaccessible elevator was a couple of winded nurses. That is because the elevator flap came as part of a simulation, and no woman’s life was in danger. It turned out that access to the elevator was restricted to emergency department personnel. That changed soon enough, before any real-life obstetric massive transfusion protocols, or MTPs, were initiated.

The story illustrates an essential truth in the world of massive transfusion, experts tell CAP TODAY. While a randomized clinical trial likely to be published could help answer persistent questions about which blood component ratio can best reduce the mortality rate in massive transfusion cases, experts say that fine-tuning the timely communication, processing, and delivery elements of the MTP are just as essential as determining what “golden ratio” of blood products to prepare.

My cover story from the December issue of CAP TODAY. Read the whole shebang.