Participant Self-Guided Mode
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68-year-old male admitted for new-onset atrial fibrillation with RVR. Started on heparin infusion 6 hours ago — therapeutic aPTT achieved. Now reporting sudden coffee-ground emesis with frank blood visible. Abdomen distended.
Two large-bore IVs in place. Covering APP is at bedside.
Clinical indicators: Hypotension (SBP < 90), tachycardia, altered LOC (GCS 13), signs of active bleeding. This patient meets multiple shock criteria in the context of active GI hemorrhage.
- MTP trigger: ongoing hemorrhage with hemodynamic instability
- Assessment of Shock Index (HR/SBP): 128/88 = 1.45 — significantly elevated
- Volume replacement alone is insufficient — blood product therapy is indicated
Immediate: Stop heparin infusion now. Document time of discontinuation.
Reversal discussion (protamine):
- Protamine 1 mg per 100 units heparin received in past 2–3 hours (max 50 mg IV slowly)
- Risk/benefit: Protamine reversal has cardiac risks (hypotension, bradycardia, anaphylaxis) — weigh against bleeding severity
- AFib consideration: Reversing anticoagulation may increase thromboembolic risk — decision made by provider
- Nurse role: Hold infusion immediately; anticipate protamine order; do not administer without explicit order
At Thompson: a nurse can activate adult MTP when hemorrhagic shock is assessed. Provider blood product administration orders and documentation still need to be completed, but they are not what starts the MTP workflow.
- Nurse role: Recognize hemorrhagic shock, stop/hold heparin per provider direction, notify charge/provider, activate MTP, and call Blood Bank
- Provider role: place blood product administration orders and document activation in eRecord
- Do not wait for lab confirmation — activation is a clinical decision
- Call Blood Bank at x6544 to activate MTP
Blood Bank cannot issue type-specific products without a Type & Screen. If not already done:
- Order T&S stat in eRecord immediately
- Draw in the correct pink-top tube with patient label, handwritten date/time, and collector initials
- Runner delivers directly to Blood Bank — time matters
- Until type-specific available: O-negative (male: O-positive acceptable) can be emergency-released
- CRITICAL SAFETY: If no historical blood type on file, an initial AND confirmatory T&S specimen must be collected at DIFFERENT times. Collecting specimens at different times reduces the risk of mislabeled specimens with incorrect patient information. This type of error could result in the death of a patient.
MTP gets moving through the activation workflow and the Blood Bank call. The provider still needs to enter blood product administration orders and document activation, but the room should not wait on an order before calling when criteria are met.
- Activate the workflow and call Blood Bank when criteria are met
- Provider places needed blood product administration orders in eRecord and documents MTP activation as required
- Blood product orders support documentation and product tracking; they do not replace Blood Bank communication
Call Blood Bank at x6544 to activate MTP. Provide:
- Patient full name
- Date of birth
- MRN
- Location (unit name, room number)
- Unit phone number (for Blood Bank to call back when ready)
Blood Bank will confirm receipt and advise on T&S status and product readiness.
- Primary RN: Notify Charge RN, confirm T&S is ordered/resulted, prep IV lines and warmer for transfusion
- Charge RN: Notify nursing supervisor, assign runner for Blood Bank transport
- APP/Attending: Place blood product administration orders in eRecord, document MTP activation as required, notify GI for urgent consultation
- Runner/designee: Label specimens at bedside → deliver directly to Blood Bank → await products
MTP activated. Heparin is stopped, the patient remains on the monitor in AFib, and products are being prepared. Charge RN has contacted the nursing supervisor. Runner/designee is headed to Blood Bank with a label. The provider team is completing blood product orders/documentation and notifying GI.
Patient on continuous monitoring — remains in AFib. First shipment en route.
- Blood Bank completes emergency release paperwork
- Prepares initial shipment of products
- Notifies American Red Cross of ongoing MTP per policy
- Contacts unit phone when cooler is ready for pickup
Blood Bank calls the unit when products are ready — do not send runner prematurely.
- Nursing supervisor coordinates runner to retrieve cooler
- Runner goes directly to Blood Bank — no stops
- Runner returns cooler directly to bedside team
- Cooler temperature must be verified upon arrival (acceptable range: 1–10°C; cannot exceed 10°C)
- Check cooler temp before adding new PRBC units — if approaching 10°C, contact Blood Bank (x6544) immediately; coolants must be changed
Standard first MTP release pattern:
- 4 units Packed Red Blood Cells (PRBC) — in cooler (1–10°C)
- 4 units Fresh Frozen Plasma (FFP) — thawed at 37°C and released separately/as available, often 2 at a time; thawed FFP should NOT be placed in the MTP cooler because it can make PRBCs/CSP unusable
- 1 dose platelets — cold-stored platelets travel in the cooler; SDP platelets do not
Cryoprecipitate AHF is thawed and issued after 4 units FFP have been released. It comes as 1 dose (2 pre-pooled bags), is stored at room temperature, does NOT go in the cooler, and must NOT be run through a warmer or rapid infuser.
Platelets should be administered through standard blood tubing with a blood product filter and should NOT go through a warmer or rapid infuser. Read the label; do not identify products by appearance.
Subsequent coolers dispatched on request or per protocol. All products require Blood Bank emergency release paperwork.
PRBC + FFP: Administer via blood warmer. May use rapid infuser if rate dictates.
Rate consideration: This patient has AFib and underlying cardiac history — discuss with provider before using maximum rapid infusion rates. Fluid overload risk is real.
- Use clinical judgment and provider orders to guide infusion rate
- Monitor for signs of fluid overload: increasing respiratory distress, SpO₂ decline
- Balance resuscitation with cardiac risk
Per Thompson MTP policy, vital signs are documented every 15 minutes during active transfusion phase.
- Set monitor alarms appropriately
- Document in eRecord with product unit numbers and start/stop times
- Notify provider of any significant hemodynamic changes
Two-RN verification required before hanging each unit:
- Two-patient identifiers: name + DOB (or MRN)
- Blood product tag signed by verifying nurses
- Emergency release paperwork signed by provider before administration
- Product matches order in eRecord
- Inspect product for abnormal color, clots, or damage
Do not rush verification — shortcuts here create patient safety risk.
4 units PRBC and 2 FFP administered. BP improved to 96/60, still in AFib HR 110. Attending orders first dose of platelets via rapid infuser. The room also has a separate blood warmer available.
Next 2 FFP are in transit from Blood Bank.
Next 2 FFP arrive. Cooler temperature reads 12°C. Proceed to Complication 2.
Facilitator: Return to scenario. Correct the order and continue. Next 2 FFP arrive. Cooler temperature reads 12°C. Proceed to Complication 2.
Discuss: Time implications of discarded products during active hemorrhage. Who is responsible for verifying cooler temp? What does this reveal about the handoff workflow?
Attending asks: "Should we reverse anticoagulation?"
Discussion points — by agent:
- Heparin → Protamine: Decision authority is provider only. Dosing: 1 mg per 100 units heparin in the last 2–3 hours; max 50 mg IV slowly over 10 min. Adverse reactions: hypotension, bradycardia, anaphylaxis (fish allergy / prior exposure) — resuscitation equipment at bedside. Nurse role: anticipate order; know where protamine is stocked.
- Warfarin or DOACs: Consider emergency reversal agents per provider order (e.g., vitamin K, 4-factor PCC, andexanet alfa, idarucizumab — agent-dependent). Nurse role: confirm agent, dose, and route; have pharmacy involved early.
- Aspirin: Provider may request additional plasma or platelets to compensate for platelet dysfunction. No direct reversal agent exists.
- AFib risk (all agents): Reversing anticoagulation increases thromboembolic risk — ongoing clinical conversation between provider, cardiology, and patient/family.
- Documentation: Time of administration, dose, patient response, any adverse effects for all reversal agents.
After 8 units PRBC, 6 FFP, 1 dose platelets — patient stabilized:
Emesis resolved. Attending discontinues MTP. Patient remains in ICU. 1 unit FFP still infusing.
Provider OR designee must call Blood Bank (x6544) to discontinue MTP as soon as possible. Blood Bank continues preparing and issuing products until notified — delay costs resources and product.
- Provider or designee calls x6544 to notify Blood Bank of discontinuation
- Provider also closes related blood product orders/documentation in eRecord as appropriate
- 1 unit FFP currently infusing may be completed — confirm with provider
- No additional products are released after Blood Bank is notified
- All remaining products and the cooler must be returned to Blood Bank
Document in eRecord:
- Total units by product type: 8 PRBC, 6 FFP, 1 platelet dose
- Duration: MTP start time to discontinuation time
- Vital signs at time of discontinuation
- Any adverse events or reactions
- Provider who ordered discontinuation and time
All unused products and the cooler must be returned to Blood Bank immediately upon MTP discontinuation.
- Do not store unused products on the unit
- Runner returns cooler, products, and paperwork to Blood Bank
- Blood Bank documents receipt and disposition of returned products
The MTP paper record (emergency release paperwork, product tags, cooler log) is sent to medical records per Thompson policy.
- Primary RN ensures all paper documentation is complete before submission
- Do not discard any MTP-related paperwork
Post-MTP monitoring priorities:
- Repeat CBC and coagulation studies (per provider orders)
- Continuous cardiac monitoring — patient remains in AFib; watch for rate changes and rhythm shifts with volume shifts
- Reassess anticoagulation plan: GI bleed vs. AFib thromboembolic risk — cardiology consultation recommended
- GI follow-up: scope planning, source control
- Monitor for transfusion reactions (delayed hemolytic, TACO, TRALI)
Use these questions to guide the team discussion. In self-guided mode, reflect on each question before moving on.
How confident were you in your ability to manage an MTP in the ICU?
How confident do you feel now in your ability to manage an MTP in the ICU?
Thank you!
Your reflection is complete.
Thompson Health Education Team