ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10030-1427
Panamerican Journal of Trauma, Critical Care & Emergency Surgery
Volume 12 | Issue 03 | Year 2023

Massive Whole Blood Transfusion Protocol: Initial Experience at Hospital de Clínicas, “Dr. Manuel Quintela,” Montevideo, Uruguay


Gabriela Rivas1https://orcid.org/0000-0001-5514-2143, Carolina S Guarneri2https://orcid.org/0000-0001-7680-6164, Marcelo Pontillo3https://orcid.org/0000-0002-6425-6553, Agustin Colombo4https://orcid.org/0000-0002-3812-9286, Jimena Bentos5, Ricardo Robaina6https://orcid.org/0000-0003-3041-272X, Federico Kuster7https://orcid.org/0000-0002-0749-9508, Ismael Rodriguez8https://orcid.org/0000-0002-3361-7117, Fernando Machado9

1,4,5,8Department of Hemotherapy, Hospital de Clinicas, Montevideo, Uruguay

2Department of Emergency, Surgical Clinic A, Hospital de Clinicas, Montevideo, Uruguay

3Department of Emergency, Surgical Clinic F, Hospital de Clinicas, Montevideo, Uruguay

6Department of Statistics, Hospital de Clinicas, Montevideo, Uruguay

7Department of Anesthesiology, Hospital de Clinicas, Montevideo, Uruguay

9Departamento de Emergencia, Universidad de la Republica, Montevideo, Uruguay

Corresponding Author: Carolina S Guarneri, Department of Emergency, Surgical Clinic A, Hospital de Clínicas, Montevideo, Uruguay, Phone: +59895510112, e-mail: carolaguarneri@gmail.com

Received: 12 March 2023; Accepted: 07 August 2023; Published on: 30 December 2023

RESUMEN

Introducción: La hemorragia masiva es la segunda determinante de mortalidad inicial en los enfermos traumatizados. Su tratamiento requiere una reanimación agresiva con sangre o sus componentes Se han postulado nuevos esquemas terapéuticos dentro de los cuales destaca la transfusión masiva.

Objetivo: Analizar la experiencia inicial con la aplicación del protocolo de transfusión masiva en pacientes de trauma, adultos, que ingresaron en el Departamento de Emergencia del Hospital de Clínicas “Dr. Manuel Quintela”.

Material y métodos: Se realizó un estudio retrospectivo, observacional, descriptivo, en el Hospital de Clínicas, en el período comprendido entre el 1 de febrero de 2018 al 1 de febrero de 2020.

Se establecieron criterios de inclusión y exclusión.

Resultados: Si solo incluimos a los pacientes que sufrieron algún tipo de traumatismo, el porcentaje de activación correcta se elevó a 81,6% de los casos.

Al evaluar la mortalidad asociada al uso del protocolo, la misma se mostró ampliamente inferior respecto a aquellos en los que se empleó el protocolo sin indicación clara con un valor p calculado de 0,009. Lo cual refleja que existe asociación entre la necesidad de transfusión masiva y la muerte.

Se demostró una asociación entre el valor del score ABC y la muerte (p = 0,013).

Conclusiones: Disminuye la morbimortalidad en pacientes candidatos a MT. Organiza el grupo de trabajo, asignando roles y terapéuticas establecidas.

Adecua el uso racional de hemocomponentes, un bien finito y escaso en el mundo como es la donación de sangre.

ABSTRACT

Introduction: Massive hemorrhage (MH) is the second determinant of initial mortality in trauma patients. Its treatment requires aggressive resuscitation with blood or its components. New therapeutic schemes have been postulated, within which massive transfusion (MT) stands out.

To analyze the initial experience with the application of the TM protocol in adult trauma patients admitted to the Emergency Department of the Hospital de Clínicas “Dr Manuel Quintela.”

Materials and methods: A retrospective, observational, and descriptive study was carried out at the Hospital de Clínicas in the period from 1st February 2018 to 2020.

Inclusion and exclusion criteria were established.

Results: If we only include patients who suffered some type of trauma, the percentage of correct activation rose to 81.6% of the cases.

When evaluating the mortality associated with the use of the protocol, it was shown to be significantly lower than in those in which the protocol was used without a clear indication, with a calculated p-value of 0.009. This reflects that there is an association between the need for MT and death.

An association was demonstrated between the value of the Assessment of Blood Consumption (ABC) score and death (p = 0.013).

Conclusion: Decreases morbidity and mortality in patients who are candidates for MT. Organizes the work group, assigning roles and establishing therapies.

Appropriate the rational use of blood components, a finite and scarce good in the world such as blood donation.

How to cite this article: Rivas G, Guarneri CS, Pontillo M, et al. Massive Whole Blood Transfusion Protocol: Initial Experience at Hospital de Clínicas, “Dr. Manuel Quintela,” Montevideo, Uruguay. Panam J Trauma Crit Care Emerg Surg 2023;12(3):102–109.

Source of support: Nil

Conflict of interest: None

Palabras Clave: Transfusión masiva, Hemocomponentes, Traumatizado grave, Shock hipovolémico

Keywords: Blood components, Hypovolemic shock, Massive transfusion, Severe trauma

INTRODUCTION

Massive hemorrhage (MH) is the second determinant of initial mortality in traumatized patients, second only to severe brain trauma. Treatment requires aggressive resuscitation with blood or blood components,1,2 usually followed by abbreviated surgery (damage control surgery).

In recent decades, and in an attempt to comply with the precepts of resuscitation with damage control, new therapeutic schemes have been postulated with the aim of increasing the survival of these physiologically devastated patients. These include the early replacement of blood components, such as red blood cells, fresh plasma, and platelets (PLTs), in equivalent ratios (1:1:1 replacement schedules), in addition to the use of prohemostatic drugs, the introduction of tests at the patient’s bedside, and the use of the thromboelastogram.3,4

There are multiple definitions of what we mean by massive bleeding and massive transfusion (MT). The administration of 10 or more blood components (red blood cells, plasma, and PLTs) in the first 24 hours is the traditional conception.5 Other alternative definitions of bleeding exsanguinous are—three units of red blood cells in 1 hour or four blood components in 30 minutes. The latter are more sensitive in identifying patients who need rapid supply of blood components for the treatment of shock and the prevention of death.68

The primary goal of MT is to restore oxygen-carrying capacity and treat acquired coagulopathy.912

Traumatic coagulopathy is present from an early stage after injury, associated with an increase in bleeding, an increased risk of complications, an increase in mortality, an increase in the transfusion requirement, and an increase in hospital stay in intensive care, prioritizing the importance of early diagnosis of this situation and its early and aggressive treatment.1214

Until 2016, we did not have MT protocols in Uruguay. Particularly in our center, in emergency situations that required such intervention, we opted for a classic transfusion of 1:1:1 (red blood cells, fresh plasma, and PLT volumes) initially.

In this context, in 2016, work began with the development of a massive transfusion protocol (MTP) and its implementation through a multidisciplinary and interdisciplinary team at the Hospital de Clínicas “Dr Manuel Quintela,” the largest university hospital in Montevideo. This team, consisting of members from the emergency department, the chair and department of hemotherapy and transfusion medicine, the chair of anesthesiology and resuscitation, the laboratory of emergency clinical pathology, the department of nursing, and the intensive care center, identified the need to unify criteria and create a common action protocol for the treatment of these patients.

One of the difficulties associated with the implementation of MPT has been to find a sufficiently sensitive and specific patient selection criterion as a reliable tool for the activation of the protocol in a timely manner. With this objective, several scales based on clinical, paraclinical, and imaging criteria have been described, with specificities reaching 80–90%. Among them, the Assessment of Blood Consumption (ABC) scale is one of the most used. Although it has been considered that the ABC scale overestimates the need for transfusion, so that many of the activations of MPT could include patients who do not really need it, it has a high detection power for most patients who do require it and has been recognized in multicenter studies as a valid instrument to predict the need for TM early. Following the principles of proactive rather than reactive “resuscitation with damage control,” the supply of crystalloids and/or colloids should be minimized at the expense of immediate administration of blood products. In facilities where the volume of patients is guaranteed, products should ideally be stored refrigerated in the Emergency Department itself.15

The proportion of blood products most appropriate to infuse in the framework of cerebrovascular accident (CVA) has been controversial. Currently, the 1:1:1 ratio (red blood cells, fresh plasma, and PLT volumes) would be supported by prospective and randomized trials16 and is the most accepted ratio in many trauma centers. Initial resuscitation with whole fresh blood has also been evaluated, especially in the context of war medicine. Once the MPT is activated, samples are taken for laboratory analysis by rotational thromboelastometry (ROTEM®). This will allow a specific and real-time diagnosis of bleeding disorders and their correction aimed at the dynamic needs of each patient. Standard thromboelastography (TEG®) can be used for similar purposes. Among the adjuvants for the management of MHs, tranexamic acid inhibits fibrinolysis by inhibiting plasminogen activation and plasmin activity. The CRASH-2 trial showed a significant reduction in mortality in patients who received tranexamic acid within the first 3 hours of trauma without a significant increase in thromboembolic events. In this context, its routine administration has been incorporated into many mass transfusion protocols.

Considering the above, in 2018, the first institutional MPT was generated.

OBJECTIVES

The objective of this study is to analyze the initial experience with the application of MPT in adult trauma patients admitted to the Emergency Department of the Hospital de Clínicas “Dr Manuel Quintela.”

MATERIALS AND METHODS

A retrospective, observational, and descriptive study was conducted based on data obtained from the registry of patients included in the MT protocol of the Hospital de Clínicas for the period from 1st February 2018 to 2020.

Inclusion Criteria

  • Trauma patients over 14 years of age.
  • Severe trauma defined according to the Injury Severity Score (ISS) >15.
  • Assessment of Blood Consumption (ABC) ≥2.

The ABC score assigns a value of 0 or 1 to the presence of any of the following factors: penetrating trauma, positive trauma-directed ultrasound assessment [focused assessment with sonography for trauma (FAST)], systolic blood pressure (SBP) <90 mm Hg, and heart rate (HR) >120 bpm.

Exclusion Criteria

  • Declared deceased.
  • Patient who refuses to be transfused.
  • Patients with incomplete data or facing impossibility of finding data considered relevant in the medical history.

The activation of the protocol was carried out by specific personnel with clear and independent functions: adjunct professors of surgery, medicine or anesthesiology, and assistants of surgery, emergentology or internal medicine.

Incorrect activation was all performed in patients who were not traumatized or who, although they were, did not meet the inclusion criteria.

The MPT generated in 2018 was used, being the first institutional document that would allow mass transfusion to be implemented in selected patients.17

The presence of two or more points of the ABC score was established as an activation criterion. This protocol may be activated from the emergency department, operating room, or other hospital service by the responsible surgeon, emergency physician, emergency physician, or anesthesiologist.

Notice will be given to the Bachelor of Nursing in charge of the resuscitation area of the emergency department, who must manage the call of the response team.

On-call surgeon will be summoned (if the protocol has been activated by the medical team), hemotherapist technician and hemotherapist on call, laboratory doctor, anesthesiologist on call, intensivist, and imaging doctor (conditional to the hemodynamic situation).

The following steps will be carried out successively:

  • Monitoring.
  • Placement of high flow mask at 8 L/minute. The need for intubation and orotracheal tube (IOT) and assist/control mechanical ventilation (ARM) will be assessed.
  • Vascular accesses.
  • Sample extraction for ROTEM®, classification of the ABO/Rh group, multiprofile arterial blood gases [lactate, base excess (BE), ionic calcium], blood count, and crasis [prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, and international normalized ratio (INR)].
  • Thermal control.

Regarding the Initial Management of the Patient

Bleeding control will be performed by tourniquet, compression, and external packing if possible.

Resuscitation will aim for SBP of 80–90 mm Hg until bleeding control is achieved. In patients with severe traumatic brain injury or pregnant women, the goal will be mean arterial pressure >60 mm Hg.

The use of crystalloids will be limited to Ringer-lactate serum (SRL) with a maximum of 1500 mL, and colloids will be restricted.

The target value for hemoglobin in patients without cardiological or central nervous system involvement shall be 7–9 mg/dL. Otherwise, it will be 8–10 mg/dL.

Two units of previously heated whole blood will be used. The use of fresh frozen plasma (FFP) and PLTs in MPT early is recommendation 1B. The dose of FFP will be 10–15 mL/kg, adjusting according to ROTEM® value. PLTs will target 50,000–75,000 or 100,000 in extracorporeal circulation therapy (ECT) or severe bleeding.

Tranexamic acid (1 gm intravenously in 10 minutes) will be administered upon the patient’s arrival at the emergency room (once the protocol has been activated, provided that the traumatic event occurred <3 hours ago), followed by 1 gm in 8 hours per continuous infusion pump.

The use of vasoactives will be indicated in patients where the target pressure is not achieved after the indication of crystalloids. Norepinephrine should be used at doses of 0.05 μg/kg/minute, increasing to 0.3 μg/kg/minute.

Calcium gluconate will be indicated: 2 gm for every four units of blood components and/or by result of calcemia and acidosis will be corrected.

The patient is reassessed every 30 minutes by clinical examination, blood gases with ionogram, and ROTEM®. Reagents intem (intrinsic route), extem (extrinsic route), fibtem (fibrinogen), aptem (hyperfibrinolysis).

Data Collection and Management

Standard operating procedures manuals were developed, and medical and nonmedical personnel from the various areas involved were trained: emergency department, chair and department of hemotherapy and transfusion medicine, emergency clinical pathology laboratory, surgical block, and postanesthetic recovery staff, cardiothoracic intensive care (CTI), and intermediate care.

Data collection was carried out by a trained multidisciplinary team, using a data sheet as an individual record for each patient.

The following were recorded: patronymic data, age, diagnosis on admission and in the surgical block, date and time of the event, arrival at the emergency service, and activation of the protocol, as well as the date, time, and reason for deactivation. In the event of death, the cause was verified and recorded.

The exact times and amounts of the contributions of crystalloids and blood components and infused blood products were recorded, as well as the results obtained from the thromboelastogram (ROTEM®) during direct observation.

For traumatized patients, three trauma severity scores were calculated and correlated: the Revised Trauma Score (RTS) scale, the ISS, and the Trauma Injury Severity Score (TRISS) scores for each of the patients included in the study.

To assess the quantitative variables, we use the mean, variance, and standard deviation. Relative frequency measures were used to assess the qualitative variables. The significance level was 5%. Statistical tests such as Chi-squared and Fisher’s exact test comparing variables were used. Statistical Package for the Social Sciences (SPSS) software was used to perform qualitative data processing.

Informed consent was not requested from the participants because it is a retrospective study, not affecting in any way the medical or surgical treatment carried out. The confidentiality and anonymization of the participants’ personal data were preserved, being handled only by the researchers.

RESULTS

During the study period—1st February 2018 to 2020—the MPT was activated 45 times.

Of the patient population for whom it was activated, 37 (82.2%) were males, and eight (17.8%) were females. The mean age was 35 years (minimum 14 and maximum 73).

The most frequent cause of MPT activation was trauma: 38 out of 45 (84.4%).

The diagnosis on admission was severe polytrauma in 37.8%. Of the severe polytraumatized patients, penetrating trauma corresponded to 55.5%, of which 60% were secondary to a gunshot wound [firearm-associated hemorrhagic phenomena (FAHP)].

Regarding the ABC score for MPT activation, 77.8% had a calculated score ≥2 points, corresponding to 80% correct activation.

The activation was considered correct, that is, MT had a clear indication in 68.9% of cases. However, if we only included patients who suffered some type of trauma, the percentage of correct activation rose to 81.6% of cases.

If we focus on those activated correctly, it stands out that 65.8% had a presumption of internal bleeding, and 15.8% had uncontrolled external bleeding until arrival at the resuscitation area.

The dominant injuries were in the torso: 63%.

Regarding severity, the mean was calculated for the selected scores. In the case of the RTS, the calculated mean was 5.30, for the ISS 34.01, and in the case of the TRISS 40.89 (Table 1).

Table 1: Demographic data of severity in patients in whom the protocolo de transfusión masiva (PTM) was correctly activated
Minimum Maximum Median Deviation type
RTS 0 7.84 5.308611 2.1028146
ISS 2.6 75 34.0167 15.39754
TRISS 1.46 99.7 40.8944 34.3432

The MPT was activated in the resuscitation room in 86.7% of cases, in 8.9% in surgical block, and 4.4% in other areas of the hospital (e.g., tomograph).

Of the total activations in the context of trauma, 66.7% were activated correctly. The overall mortality of the series was 22.1% if only these cases were considered.

When evaluating the mortality associated with the use of MPT, it was much lower (8.3%) compared to those in which the protocol was used without a clear indication (mortality of 50%) with a calculated p-value of 0.009. This reflects that there is an association between the need for mass transfusion and death.

When evaluating mortality in relation to the calculated area under the curve (AUC) score, it was higher in those patients with a score ≥2 points (p = 0.013), demonstrating an association between the value of the AUC score and death (Figs 1 and 2).

Fig. 1: Data recording form used

Fig. 2: Extrapolation and comparison of ST protocol vs 1.1.1 in number of blood components

The use of cryoprecipitates or fibrinogen adjusted to ROTEM® is detailed in Table 2.

Table 2: Blood components used
N Minimum Maximum Median Deviation type
PFC total 37 0 11 1.86 3.011
Cryoprecipitate total 37 0 17 1.54 3.671
Dosis platelet 6 1 3 1.33 0.816
Cryoprecipitate-derived units total 36 0 1 0.06 0.232
Cryoprecipitate and red blood cell total 36 0 28 4.17 6.425
Crios dosis 13 1 3 1.23 0.599
Fibrinogen total 37 0 2 0.05 0.329
Total crystalloid 30 1000 9000 3183.33 1759.523

DISCUSSION

Despite significant advances in the management of severe trauma, uncontrolled bleeding remains a serious problem, becoming the most frequent cause of preventable death.12 It accounts for 30–40% of the causes of death in trauma.12,13

Coagulopathy because of traumatic injury is defined as multifactorial. Multiple factors converge in its genesis: bleeding, tissue hypoperfusion, activation of coagulation pathways and fibrinolysis, inflammatory cascades, and endothelial dysfunction.

Hypothermia, acidosis, hemodilution, and hypocalcemia are added evolutionarily and early if not treated in time.13,14,18,19

Prevention of coagulopathy requires strategies that identify the need for MT early.

Risk factors that increase or predict the need for MT have been described. These include penetrating injury, SBP <100 mm Hg, HR >120 bpm on admission, acute anemia with hemoglobin values below 7 gm/dL, suspected hemoperitoneum, fracture of long or pelvic bones, or baseline deficit <10.19,20

From the recommendations arises the need to create CVA in a consensual manner, in the context of a multidisciplinary team, analyzing its efficacy and safety on a regular basis (recommendation 2C).21 As a component of this protocol, thromboelastography (ROTEM) has been an essential factor in evaluating each stage of coagulation more quickly, guiding its objective management.22

Regarding the scores predicting the need for MT, the trauma-associated severe hemorrhage (TASH) (more complex to calculate) and the AUC stand out, this being the most used for its rapid access, also used by us, not delaying the activation decision.23,24

The implementation of a MPT has been shown to reduce mortality by decreasing the need for unnecessary administration of blood components, thanks to the implementation of thromboelastography (ROTEM®).25

In the present study, we have shown that the vast majority of transfused patients with a clear indication for admission to the MPT (81.6%) have benefited from this resource with a clear decrease in mortality (p, 0.009). Similarly, Consunji et al. report in a systematic review and meta-analysis regarding the implementation of PMT,10 a significant reduction in mortality in patients in whom the protocol was applied.

The implementation of the thromboelastogram as a point-of-care in real time within the MPT generated a reduction in mortality and the rational use of blood components, coinciding with the results obtained in our work.

The international literature shows that in centers where a prehospital mortality and trauma care (PMTC) is used, with a mostly male population, the average ISS is >17.26 In our center, we present the caveat that the mean calculated ISS was 34.01, a fact that reflects the severity of the trauma in the patients of our study.

With regard to hemostatic resuscitation as a cornerstone of damage control, the use of blood components has been described in a 1:1:1 ratio. In the last decade, studies have emerged that propose the use of whole blood, a fact that confers several advantages based on its physiological nature.2729

In the present study, whole blood has been used with favorable results.

Perkins et al.30 described an increase in 24-hour survival in patients treated with whole blood, being a population with a high calculated ISS like TRISS. Nessen et al.31 compared the use of fresh whole blood versus the administration of red blood cell units and plasma alone. The whole blood group was associated with a reduction in mortality risk [odds ratio (OR)—adjusted: 0.096; 95% confidence interval (CI): 0.02–0.53].

Regarding the application of the protocol with whole blood (TS), O Rhesus factor D (RhD) positive with low titer of isohemagglutinins, we can say that it could be implemented with a correct supply of this blood component (45/3), redirecting the needs that would have implied the use of a protocol 1.1.1 to the care of other patients who require it simultaneously. The three activations that did not have TS were due to the coincidence in time of two activations in <24 hours and the next in the same week.

The use of sangre total (ST), prioritized together with ROTEM® the use of cryoprecipitate or fibrinogen early, showing the consumption in most of the patients with TS, deplasmatized blood, fibrinogen, and a minority required PLT concentrates, being these patients those who had replacements greater than 2 volemias.

Platelet (PLT) fragments preserved at 4°C retain their hemostatic capacity, although obviously, the increase in PLT count in the patient is not reflected. It is thus a possible substitute for the PLT concentrate component used by other MPTs.3235

Hypofibrinogenemia in traumatic coagulopathy happens early, and many of the patients arrive at health centers already with an installed coagulopathy due to fibrinogen deficiency, which is a molecule with a half-life of approximately 96 hours, and its replacement becomes imperative.3638

Fibrinogen decreases rapidly in severe bleeding due to its consumption during clot formation; both fibrinolysis and fibrinogenolysis increase fibrinogen consumption. Early treatment with tranexamic acid should protect fibrinogen stores and maintain the ability to form a stable fibrin clot. It is stated that its use should be considered primarily as an intervention to prevent rather than to treat coagulopathy.3639

In addition, tranexamic acid administered within the first 3 hours, or better still in the first hour after trauma, also demonstrates an effect on the reduction and need for transfusion of blood components (red blood cells, fresh plasma, and PLTs), decreasing the incidence of patients requiring TM.40 These findings have several implications for clinical care. Patients with bleeding should receive antifibrinolytics as early as possible, even in the prehospital, for three reasons.

First, most hemorrhage deaths occur within hours of bleeding onset. By reducing bleeding, tranexamic acid has the potential to prevent the hypoxia and acidosis that accompany severe bleeding, but it must be administered before tissue damage is irreversible.

Secondly, the earlier it is supplied, we speak of the prehospital setting, the greater its effectiveness.

Thirdly, there is no evidence of adverse effects associated with tranexamic acid treatment when the patient is with ongoing bleeding, so it can be safely administered as soon as bleeding is suspected. Patients with a history or risk factors predisposing to thromboembolic events and patients with gross hematuria are excepted since they are at risk of developing clot obstructions at the ureteral level. It has been invoked as a cause of acute cortical necrosis with oliguria and renal failure, these being relative contraindications.40

In emergency transfusion, one of the weaknesses linked to blood transfusion without pretransfusion or compatibility tests is the possibility of prior alloimmunization, a fact that only occurred once in our study period. An anti-D antibody developed in a male was identified by previous exposure to blood transfusion in the context of a FAHP.

The proposal of the use of ST O RhD positive from male donors, with isohemagglutinin titer less than one-fiftieth, represents strength in the supply of the protocol, being this blood component only 25% of the units studied. Today it is possible to administer up to four to six units of ST with these characteristics without an increased risk of hemolysis due to differences in the ABO group.

We also emphasize that blood from male donors represents a protective condition for transfusion-related lung injury (TRALI) due to the passive transfer of anti-HLA antibodies present in the female sex due to previous pregnancies.41

With regard to thromboelastometry-guided replacement, it is clear that it is a benefit to the critically ill patient. The replacement is optimized, transfusing objectively according to the patient’s need, being able to discern many times what is a “surgical” bleeding of a coagulopathy.

LIMITATIONS AND STRENGTHS

We highlight as a limitation being a retrospective study in a single center, not having data prior to the protocol that allows us to compare variables. It is important to mention that this project was developed in a university center, with staff in constant training and rotation, so at the beginning of its implementation, there were incorrect activations. This led to reevaluate the protocol, generating changes for later editions of the same adding, among other things, an inactivation item, thus avoiding unnecessary transfusions. We are currently reviewing the results of the next period (2020–2022) to assess whether the modifications made were effective and compare results.

On the other hand, we believe that one of the strengths of the study is to have managed to establish a protocol that has a direct and positive impact on the mortality of these patients, being the first in the country. Protocol generated within the framework of a university environment strictly controlled by professionals of academic excellence is an example that we believe is important to be able to replicate in the rest of the national territory.

ETHICAL ASPECTS

This work has been presented to the Ministry of Public Health, an entity that regulates all health centers in our country, with regard to research projects. It is approved by the institutional ethics committee.

CONCLUSION

The MPT allows to organize the active human resource, assigning roles and preestablished therapeutics. This reduces errors and optimizes time and resources, which translates into the rational use of blood components, a finite and scarce good.

The implementation of an institutional MPT allowed to guide hemostatic resuscitation in real time, reducing mortality in severe trauma patients.

ORCID

Gabriela Rivas https://orcid.org/0000-0001-5514-2143

Carolina S Guarneri https://orcid.org/0000-0001-7680-6164

Marcelo Pontillo https://orcid.org/0000-0002-6425-6553

Agustin Colombo https://orcid.org/0000-0002-3812-9286

Ricardo Robaina https://orcid.org/0000-0003-3041-272X

Federico Kuster https://orcid.org/0000-0002-0749-9508

Ismael Rodriguez https://orcid.org/0000-0002-3361-7117

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