Regional West Medical Center

Effective Date: 02/01/2010

4021 Avenue B
Scottsbluff, NE 69361
F:\DATA\DEPTS\LABSHARE\BBK\TRANSFUSION\COMPONENTS\MASSIVE TRANSFUS

MASSIVE TRANSFUSION PROTOCOL ADULT

OR and ICU PROTOCOLS
I.

Purpose
1. To provide Blood/Blood components for massively transfused patients in the
Emergency Department, Operating Room, Intensive Care Unit, on an automatic basis.
2. To facilitate ordering and timely results of clotting and other hematology tests.
3. To facilitate ordering and releasing of blood products.

II.

Definition of Massive Transfusion

1. Replacement of patients entire blood volume within a 24-hr period (10-12 units of
PRBCs)
2. Replacement of 50% of total blood volume within 3 hrs (5-6 units of PRBCs)
3. Need for at least 4 units of PRBCs within 4 hrs with continued major bleeding
4. Blood loss exceeding 150 ml/min

III.

General Aspects of Treatment

1. Hypovolemia results in progressive acidosis impairing hemostasis.
2. Time required to ready blood products must be considered.
3. Notify the Blood Bank early if there is a reasonable expectation of massive
transfusion.
4. All replacement fluids and blood products should be warmed to prevent hypothermiainduced coagulopathy (using a fluid warmer or the Level I infuser-temperature is
preset to 41 C).
5. Blood loss is usually underestimated. Infusion of large numbers of blood products
can dilute lab results suggesting a worsening coagulation status (i.e. 4 units of FFP
and 1 apheresed unit of platelets total volume 1.5L-will dilute the hematocrit).
6. The knowledge of, or the detection of, red cell antibodies may delay release of blood
and blood components.
7. The patient must be wearing a blood bank armband and an adequately labeled blood
bank specimen must be collected as soon as possible.

IV. Standard Notification

The Attending Trauma Physician or designee will:
Make determination: criteria met and noted in medical record.
Direct telephone call to the Blood Bank who will notify the Medical Director of
Blood Bank or designee (ext. 1400).
When applicable, Massive Transfusion Protocol or MTP may be recorded on the
Trauma Lab Order Form, Physician Trauma Admission Orders and/or the Trauma
Standing Orders sheet.

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Regional West Medical Center

Effective Date: 02/01/2010
4021 Avenue B
Scottsbluff, NE 69361
F:\DATA\DEPTS\LABSHARE\BBK\TRANSFUSION\COMPONENTS\MASSIVE TRANSFUS

V. Alternative Notification Procedure

Transfusion service identifies increased use as evident by 6 units of PRBCs
transfused over 3 hours or 4 units of FFP transfused over 2 hours.
The transfusion service notifies surgeon of increased utilization of blood.
The protocol will be initiated with mutual agreement.
VI.

Upon Implementation of the Massive Transfusion Protocol:

1. The Transfusing Trauma Unit: ED, OR, ICU or Interventional Radiology will:
Prepare to collect, receive, and transfuse large volumes of blood and blood
components via multiple accesses simultaneously.
Maintain transfusion records to document actual times of transfusions.
Inform the Blood Bank immediately when need no longer exists.
Arrange for staff to transport units between the blood bank and transfusion location if
necessary.
2. The Blood Bank/Medical Director will:
Confirm/determine volumes based on :
Clinical assessment
Transfusion history
Laboratory test results
Obtain added hematology/coagulation studies as required.
Direct Blood Bank to issue necessary blood and blood components in the appropriate
volumes.
After 10 units of red cells are transfused, the crossmatch may be omitted with the
Blood Bank Medical Directors approval.
3. The blood bank and laboratory will:
Initiate the Massive Transfusion Protocol Verbal Order Form.
Immediately prepare first transfusion package (for both ICU and OR Massive
Tranfusion Protocol). This package will contain:
- Six units RBCs
- Four units FFP
Deliver first package within 35 minutes of the initial order. If type and screen
is not available, transfuse type O uncrossmatched rbcs and AB FFP until type
and screen can be completed. RBCs may be given before all of the package is
available. Determine if patient is being kept on the floor, or will be undergoing
surgery.
- If patient is undergoing surgery: continue with packages (OR massive
transfusion protocol) until patient is in ICU, patient expires, or surgeon
has requested stop of massive transfusion protocol
- If patient is being kept on floor or has been moved from OR to ICU:
follow ICU massive transfusion protocol (see below)

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Regional West Medical Center

Effective Date: 02/01/2010
4021 Avenue B
Scottsbluff, NE 69361
F:\DATA\DEPTS\LABSHARE\BBK\TRANSFUSION\COMPONENTS\MASSIVE TRANSFUS

OR Massive transfusion Protocol

Have second package ready within 35 minutes of issue of first package.
Second package will contain:
- Six units RBCs
- Four units FFP
- One Single Donor Platelet or one six-pack random platelets
Have third package ready within 35 minutes of issue of second package.
- Six units RBCs
- Four units FFP
- One ten-pack pooled Cryoprecipitate
The blood bank will continue making packages every 35 minutes until patient is
moved to ICU, patient expires, or surgeon calls off massive transfusion. All
packages will be delivered within 35 minutes of the last delivered package.
All packages will contain six units RBCs with four units FFP. All even
number packages will also contain a platelet product. All odd number
packages starting with the third package, will contain a ten-pack CRYO pool.
Assess current inventory of platelets and cryoprecipitate.
Obtain two bags of ice and a cooler to be used for transporting RBC units.
If it appears that it may be necessary to use untested platelets during the massive
transfusion protocol, the donor center or blood bank supervisor will be notified to
assess if the untested units were collected from repeat donors.
If necessary, additional products may be ordered from outside suppliers.
If necessary, additional staff may be called in.
If necessary, laboratory couriers may be contacted to transport blood products from
outside suppliers.

ICU Massive Transfusion Protocol

Order HGM, PT, aPTT, and Fibrinogen immediately and q2 hours for the
duration of the massive transfusion event.
Place orders to keep six ahead for RBCs for the duration of the massive
transfusion event.
Place orders to keep two ahead for FFP for the duration of the massive transfusion
event.
Orders will be automatically placed in the system, blood samples obtained, and
testing performed in accordance with this protocol for the duration of the massive
transfusion event.
Testing results will be called to the transfusing location.
Blood bank technologist will determine blood products needed by following
Transfusion Guidelines stated below.
Assess current inventory of platelets and cryoprecipitate. See OR Massive
Transfusion Protocol for steps if platelet or cryoprecipitate inventory is not
adequate.

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Regional West Medical Center

Effective Date: 02/01/2010
4021 Avenue B
Scottsbluff, NE 69361
F:\DATA\DEPTS\LABSHARE\BBK\TRANSFUSION\COMPONENTS\MASSIVE TRANSFUS

VII.

Transfusion Guidelines
1. Plasma Transfusion
a. Consider transfusion when rapid blood loss exceeding 100ml/min continues
after transfusion of crystalloids, colloids and 4u RBCs.
b. After loss of one circulation blood volume when PT, aPTT, and fibrinogen
cannot be obtained in time.
c. Transfuse 10-15 ml/kg rapidly (this corresponds to 1000ml of plasma, or 4
units of FFP).
d. It takes 35 minutes to thaw and transport 4u FFP.
2. Cryoprecipitate Transfusion
a. Fibrinogen deficiency develops early when plasma-poor RBCs used for
replacement.
b. Fibrinogen <50mg/dL strongly associated with microvascular bleeding.
c. If fibrinogen <80-100mg/dl, cryoprecipitate indicated even if bleeding no
longer profuse.
d. Aim for fibrinogen >100mg/dL.
e. Transfuse 1 pack/10kg body weight.
f. It takes 45 minutes to thaw and transport cryoprecipitate.
3. Platelet Transfusion
a. On the achievement of surgical hemostasis, do not let platelets fall below
50,000 mm3 in acutely bleeding patients.
b. Target of 100,000 mm3 recommended for patients with multiple high energy
trauma or CNS injury.
c. Platelet count of 50,000 mm3 can be anticipated when approximately 2 blood
volumes have been replaced with plasma-poor RBCs.
d. Platelets are quickly lost through wounds until surgical hemostasis obtained.
e. Platelets requiring pooling and transport require 45 minutes.
4. Short-term coagulation goals:
Hct>20-24%
Plts >50,000 mm3 (>100,000 for CNS injury or multiple high energy trauma)
Fibrinogen>100mg/dL
APTT<45 sec
PT<18 sec
5. Long-term coagulation goals:
Hct>24%
Plts>100,000mm3
Fibrinogen>150mg/dL
APTT<40 sec
PT<17 sec

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Regional West Medical Center

Effective Date: 02/01/2010
4021 Avenue B
Scottsbluff, NE 69361
F:\DATA\DEPTS\LABSHARE\BBK\TRANSFUSION\COMPONENTS\MASSIVE TRANSFUS

VIII.

Stand Down Procedures

As soon as the physician feels that the acute exsanguination is under control, and the
need for blood will not exceed 2 units per hour, the physician will notify the blood
bank (ext. 1400). This does not mean that there will be no further blood or
component needs, but that the life threatening exsanguination is under control and the
need for system wide activation has lessened. (The number of units of red blood cells
to be kept ahead can be decreased to two).

IX.

References
Stainsby, et al., 2000. Management of massive blood loss: a template guidelines. Br J
Anaesthesia, 85: 487-91.
Hellstern, P and Haubelt, H. 2002. Indication for plasma in massive transfusion.
Thrombosis Research, 107: S19-S22.
Rock, WA Jr, Baugh, Rf, 2000. Acquired bleeding disorders associated with the
character of surgery. Handbook of Hematological Pathology, editors; h. Schumacher,
WA Rock, Jr, SA Stass, Marcel Dekker, New York, pp 655-690.
Massive Transfusion Protocol - Adult, Trauma Policy and Procedure Manual, University
Hospital and Clinics, The University of Mississippi Medical Center, Jackson, Mississippi.

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