UTMB Health Angleton Danbury Campus
132 E. Hospital Drive
Angleton, TX 77515
POLICY NO. 240
ED/TRAUMA
POLICY AND PROCEDURE
SUBJECT: Massive Transfusion Protocol
DATE: 02/05
REVISED: 10/05, 10/08, 11/08, 9/10
REVIEWED: 05/05, 10/05, 02/07, 10/08,
11/08, 9/10, 3/13, 5/14
_______________________________________
Director of Trauma and Emergency Services
Associate Administrator of Patient Services/CNO
UTMB respects the diverse culture needs, preferences, and expectations of the patients and families it
serves to the extent reasonably possible while appropriately managing available resources and without
compromising the quality of health care delivery.
PURPOSE
1. To provide consistent expectations for assessment, communication and intervention for patients
who require large blood volume replacement and treatment of coagulopathy.
2. To define a mechanism of treatment for those patients who meet these criteria.
3. To define thresholds for immediate Massive Transfusion intervention.
4. To define continuous monitoring indicators of patient status/response.
5. To minimize unnecessary component transfusions.
6. To identify necessary personnel resources to activate Massive Transfusion
DEFINITIONS:
1. Level I: The highest level of response to patient condition (e.g. Massive blood loss
accompanied by hemorrhagic shock and/ or metabolic acidosis/base deficit). Upon initiation of
intervention/protocol, blood products will be provided according to protocol without requiring
specific physician order.
2. Level II: Intermediate level of response to patient condition (e.g. need for administration of 1
estimated blood volume, decreasing H&H with continued blood loss or a coagulopathy. Blood
products will be administered according to physician order, based on the patient’s clinical
condition. The Blood Bank will “keep ahead” on red cell products, if requested.
*KEYPOINT: The Blood Bank will not provide blood products automatically.
*KEYPOINT: Patient may move between levels of Massive Transfusion Protocol based on clinical
condition.
3. Massive Transfusionist: RN, anesthesiologist, or CRNA trained in massive transfusion protocol.
4. Massive Transfusion Pack: 4 units PRBC’s , 2 -4 Units of FFP,
PROTOCOL
1. Massive Transfusion is initiated and terminated by the physician.
2. Indications for Massive Transfusion include but are not limited to:
a. Administration of one estimated blood volume (approximately 10 units of blood in 24 hours in
an adult; 80ml/kg for pediatric patients) and continuing need for transfusion.
b. Massive blood loss with profound hemorrhagic/hypovolemic shock
c. In cases of trauma, surgical or obstetrical emergency consider:
1) Prolonged PT (INR > 1.5), decreased fibrinogen levels (<100mg/dl) or platelet count
(<100,000/ml), accompanied by hemorrhage.
2) A clinical presentation that suggests profound or continued microvascular bleeding in the
absence of abnormal lab values.
3. Blood and blood product administration will be based on the clinical
condition and the results of laboratory tests. This will require tests to be done
frequently with rapid turnaround to support timely assessment and treatment.
4. Massive Transfusion will continue until the physician determines that it is unnecessary.
A INITIATION OF PROTOCOL
1. Physician initiates Massive Transfusion
2. Initiate Level I Response if patient demonstrates massive blood loss accompanied by
hemorrhagic shock and/or metabolic acidosis/base deficit.
3. Initiate Level II Response if the patient demonstrates a need for the administration of 1
estimated blood volume (10 units/24 hours or 80 ml/kg peds), decreasing H&H with continued
blood loss or a coagulopathy.
B LEVEL I MASSIVE TRANSFUSION RESPONSE
1. Call Blood Bank to activate Massive Transfusion Level I Response. Provide the
following information:
a. Advise you are calling for a Level 1 Massive Transfusion Response
b. Name
c. Medical Record Number, DOB, or SSN
d. Gender (if known)
e. Specific location of patient intervention
f. Verify coagulation studies have been drawn
2. Identify a massive transfusionist. Massive Transfusionist is responsible for:
a. Administration of blood and blood products
b. Obtaining necessary lab specimens
c. Monitoring and recording of all intake and output data
3. Arrange for transport for Massive Transfusion Packs from the Blood Bank to the patient location
and provide the transporter with necessary patient identification to release blood from Blood Bank.
4. Obtain IV access to facilitate monitoring, access for labs, rapid transfusion of blood, blood
products and fluids
a. Large bore peripheral lines and/or,
b. Central venous access and/or
c. Arterial line
5. Monitor and document the following:
a. Continuous VS, arterial or Non-invasive BP
b. Temp
*KEYPOINT: Hypothermia contributes to coagulopathy. Use the warmers when administering large
volumes of blood products and fluids.
c. Lab data, coagulation studies, chemistry and blood gas profiles. See Table 2.
d. Record times and volumes of colloids, crystalloids and drugs infused
e. Record output from all tubes and ongoing estimated blood loss from all sources
6. Recommended equipment:
a. Blood warmers
b. Rapid Infuser (Level 1)
c. Lab tubes
d. Blood bank arm band.
e. Syringes
f. Blood administration tubing
7. Administer Massive Transfusion Packs every 30 minutes or as indicated by patient status.
*KEYPOINT: Additional preparation time is needed when blood products are doubled or aliquoted, or
deviation from protocol occurs.
a. All packed cells will be administered with an appropriate filter using a blood-warming device.
Refer to Policy and Procedure “Transfusing Blood and Blood Components.”
b. Rapid Infuser (Level 1) can be used when increased flow is needed.
c. Packed cells and fresh frozen plasma not immediately transfused will be held under wet ice at
the patient’s bedside until administered.
d. Platelets; and cryo should be kept at room temperature.
e. Transfuse with type specific or cross-matched blood whenever possible.
f. Transfuse with uncross-matched blood if cross-match will unnecessarily delay transfusion, Onegative for all females under age 50 and O-positive blood if O-negative is unavailable.
* KEYPOINT: If there is gross evidence of microvascular bleeding/DIC that is not reflected in the most
recent coagulations studies, the transfusionist will consult with the physician and order
a full Massive Transfusion Pack
POLICY NO. 240
8. Monitor lab data.
a. Draw necessary blood samples for coagulation, hematology and chemistry profiles. (See
Table 2).
b. Reassess need to continue at current level of support every 30 minutes.
* KEYPOINT: Ongoing communication with the Blood Bank is important to determine continued need.
Products may be held in the Blood Bank for patient with ongoing need. See Table 1
9. Blood Bank responsibilities – Level I response.
a. Massive Transfusion packs will be prepared in the blood bank. Required components will be
based on testing results and thresholds (Table 1).
b. Include component products in the Massive Transfusion pack if test results are unavailable or if
requested by the transfusionist or physician.
c. If initial dose does not correct deficit or abnormal values, products are doubled until deficit is
corrected.
Table 1 BLOOD AND BLOOD COMPONENT REPLACEMENT IN MTP
Component
Threshold
Adult
Peds (< 40 kg)
PRC
(on blood warmer)
Frozen Plasma
(FP)
None
4 units
10ml/kg
INR > 1.5 = 2
FP
INR > 2.0 = 4
FP
Platelets
<100,000
> 2 units
10ml/kg
> 6 units
(1 apheresis unit
= 6 units of
platelets)
> 10 units
(1 pre- pooled
unit = 5 units
cryo)
10ml/kg
Platelets
Cryoprecipitate
Fibrinogen <
100
1 button/ 10kg
minimum 2
buttons
10. Cessation of Level I Response
* KEYPOINT: Promptly return all unneeded units to the Blood Bank.
a. The Massive Transfusionist will promptly notify the Blood Bank of Massive Transfusion
Level I cessation.
b. Once Level I Massive Transfusion is discontinued the Blood Bank will no longer
automatically supply blood or products.
POLICY NO. 240
C LEVEL II MASSIVE TRANSFUSION RESPONSE
1. Call Blood Bank to clarify level of support when moving from Level I to Level II. Provide the
following information:
a. Advise you are calling for a Level 2 Massive Transfusion Response
b. Patient Name
c. Medical Record Number, DOB, or SSN
d. Gender (if known)
e. Specific location of patient intervention
f. Verify coagulation studies have been drawn
g. Specific products ordered by physician
2. Transfusion RN is responsible for:
a. Administration of blood and blood products
b. Obtain necessary lab specimens
3. Arrange for transport for blood and blood products from the Blood Bank to the patient location and
provide the transport with necessary patient identification to release blood from Blood Bank.
4. Obtain IV access to facilitate monitoring, access for labs, and rapid transfusion of blood, blood
products and fluids
a. Large bore peripheral lines and/or
b. Central venous access and/or
c. Arterial line
5. Monitor and document the following:
a. VS at least every 1 hour, arterial or Non-invasive BP
b. Temp every 1 hour if blood infusing
* KEYPOINT: Hypothermia contributes to coagulopathy. Use warmers when administering large
volumes of blood products and fluids.
c. Lab data, coagulation studies, chemistry and blood gas profiles per physician order (See Table
2)
d. Record times and volumes of colloids, crystalloids and drugs infused
e. Record output from all tubes and ongoing estimated blood loss from all sources
6. Recommended equipment:
a. Blood warmers
b. Rapid infuser (Level 1)
c. Lab tubes
d. Blood bank armband
e. Syringes
f. Blood administration tubing
POLICY NO. 240
7. Administer blood and blood products as directed by physician order
a. Ordered blood products will be available for transfusion within the approximate time frames
depending on the ordered product:
1) O negative uncrossed matched Red Cells: 10 to 15 minutes after receiving the order.
2) Type Specific Red Cells: 30 to 45 minutes after receiving the specimen
3) Type, Screen and Cross-match: 30 to 45 minutes after receiving the specimen
4) Additional units cross-matched: 10 minutes, if Type and Screen negative.
5) Frozen Plasma: Approximately 45 minutes
6) Platelets and Cryoprecipitate: Approximately 1 to 2 hours (must come from Regional
Blood Center)
* KEYPOINT: The following circumstances may cause variance from these timeframes: Patient
identification (sample), shortage/availability of product, antibody incompatibilities, or
delay in transportation personnel.
b. All packed cells will be administered with an appropriate filter using a blood warming device.
Refer to Policy and Procedure “Transfusing Blood and Blood Components.”
c. Pumps can be used when increased flow is needed.
d. Packed cells and fresh frozen plasma not immediately transfused will be held under wet ice at
the patient’s bedside until administered.
e. Platelets, and cryo should be kept at room temperature.
8. Monitor lab data - draw blood samples for coagulation, hematology and chemistry profiles per
physician order. See Table 2
9. Blood Bank responsibilities for Level II response:
a. No automatic response. Products will be issued according to physician orders.
b. Keep ahead orders for red cells may be requested.
10. Reassess need to continue every 2-4 hours.
POLICY NO. 240
Table 2 LABORATORY MONITORING IN MASSIVE TRANSFUSION
TEST
SPECIMEN
FREQUENCY of
TURN
TEST
AROUND
TIME
(2) 4ml purple
3 days
Type
top tubes and
10-15
&
(1) 10ml red
min for
Crossmatch
top tube*
Uncrosslabeled,
matched
initialed,,
blood

dated and
30-45
timed with
minutes
blood bank
for full
armband
cross
number
match,
attached
from
time
Peds:
specimen
Purple
received
microtainer
<4mo 2 full
>4mo 3-4 full
0.5-2ml
Level I – q 15-30 min
CBC and BMP
heparinized
Level II – upon
 20
arterial or
initiation of MTP post minutes
venous sample 2 – 4 unit of packed
*
red cells and at least q
or
1 hr x 2, q 2 hr x 2,
5 ml green top then q 4 hr.
tube
PT, PTT, and INR
2.7 ml Blue
Top **,
fully filled,
Peds:
3ml blue top
Fibrinogen < 100
ACT
2.7 ml Blue
Top **,
fully filled
(run on the
same tube as
PT, PTT
Level I - q 30 min
Level II – upon
initiation of MTP at
least q 1 hr x 2, q 2hr
x 2, and, then q 4 hr.
Level 1: q 30 min as
appropriate
20
minutes
30
minutes
POLICY NO. 240
*Notify blood bank if specimen collected after emergency transfusion uncross-matched Type O negative
(positive) blood.
** Completely clear arterial line of heparinized solution prior to drawing sample
***Baseline PTT is run on every case. When fibrinogen <100 mg/dL, additional PTT’s will not be run
until Fibrinogen > 100 mg/dL.
DOCUMENTATION:
1. Temperature
2. Lab values
3. Intake (colloids, crystalloids and drugs infused)
4. Output (tubes, drains and estimated blood loss from lab draws, generalized oozing and other
sources).
Ref:
Riskin, DJ., Tsai, TC., Riskin, L., Hernandez-Boussard, T., & Purtill, M. (2009). Massive transfusion protocols: the role of
aggressive resuscitation versus product ratio in mortality reduction. Journal of the American College of Surgeons, 209, 198205.
O'Keefe, T., Refaai, M., Tchorz, K., Forestner, JE., & Sarode, R. (2008). A massive transfusion protocol to decrease blood
component use and costs. Archives of Surgery, 143(7), 686-691.
Malone, DL., Hess, JR., & Fingerhut, A. (2006). Massive transfusion practices around the globe abd a suggestion for a
common massive transfusion protocol. The Journal of Trauma Injury, Infection, and Critical Care, 60, S91-S96.
Repine, TB., Perkins, JG., Kauvar, DS., & Blackborne, L. (2006). The use of fresh whole blood in massive transfusion. The
Journal of Trauma Injury, Infection, and Critical Care, 60, S59-S69.
Standards for Blood Banks and Transfusion Services.27th ed. Bethesda, MD:AABB,2011
Technical Manual 16th ed.Bethesda,MD AABB,2008
POLICY NO. 240
Attachment # 1: Indications for Massive Transfusion
POLICY NO. 240
Attachment # 2: Massive Transfusion Protocol Flowchart
POLICY NO. 240
Attachment # 3: Massive Transfusion Component Timeline