Cryoprecipitate wastage: An unintended consequence of introduction of a massive transfusion protocol

Introduction: Massive Transfusion Protocols (MTPs) have become routine in level I and II trauma centers. When executed well, an MTPhasthe potential to save lives and resources, however, the MTP could also be responsible for excessive losses of scarce blood products. We hypothesized that the introduction of a MTP in our institution would be associated with improved outcomes, and efficient use of of blood products. Methods: We retrospectively studied all trauma patients requiring massive blood transfusions over a six year period (June 2006-June 2012). This was dichotomized into the three years before and after the institution of our MTP in June 2009. Pre-MTP Patients with a transfusion requirement of over ten units of blood products were identified retrospectively from the blood bank database. In phase one of the MTP implementation the cryoprecipitate was in the first cooler, phase two it was in the second cooler and in the third phase it was removed from the protocol. Statistical testing was done with Chi-square, student,s t test and ANOVA where appropriaite. Results: We identified 234 patients who met inclusion criteria, 84 before the introduction of the MTP, and 150 patients after the implementation of the MTP. The patients were predominantly male (75.0% vs 79.3%, P=0.44), suffered blunt trauma (64.3% vs. 57.3%, P=0.3), had high injury severity (ISS 34 vs. 29, p=0.01) and the median age was 40 years in both groups. Analyzing only the 174 patients who received more than 10 units of PRBCs, (84 pre and 90 post-MTP introduction), mean PRBC and FFP use was not significantly different between groups (Table). Platelet use was similar, but there was increased cryoprecipitate use. Cryoprecipitate wastage also increased with implementation of the MTP (<1 unit vs 5.5 units, P=0.001). Following the introduction of the MTP, we noted this increased cryo wastage (14.2 units of cryo wasted per patient), therefore it was moved to a later shipment (12.4 units of cryo wasted per patient) before finally being eliminated altogether (22.5 units of cryo wasted per patient). Mortality overall in patients with MTP activation was similar in the pre and post implementation groups 58.3% vs. 56.7% (P=0.81). Mortality in patients receiving ten units or greater was 58.3% vs. 68.7%(P=0.15). The cost of wasted blood products increased with implementation of the MTP, $70,485 vs. $149,396. Conclusions: The introduction of a MTP is not without its challenges; in our institution, this led to increased wastage of cryoprecipitate, without a significant improvements in clinical outcomes. Despite increases in tranfusion we did not see improvment in mortality. We question if cryoprecipitate is a necessary component of an MTP, and suggest that this should be prospectively studied in a multicenter trial. (Table presented).