Massive transfusion protocol

University of Minnesota medical center, Fairview department of trauma services
Category:	Provision of care, treatment and services department of trauma services
Subject:	Massive transfusion protocol
Purpose:	To ensure timely and appropriate treatment of or anticipation of massive transfusion episodes. To maximize the availability of blood and blood components, and to utilize resources efficiently.
Policy:	The massive transfusion protocol (MTP) is a multidisciplinary process whereby blood and blood components are obtained rapidly for an exsanguinating patient. Initiation of the MTP is reported to the transfusion service physician (BB MD) on-call as soon as possible by the blood bank staff. The BB MD serves as a consultant in the evaluation and management of the patient's transfusion therapy during the massive transfusion episode.
Procedure:	Example reasons for initiation:
	1. Replacement of at least one blood volume (8 to 10 red blood cell units in a 70 kg adult) within 24 hours or at least one half blood volume within 2 hours.
	2. Life-threatening trauma presenting to the emergency department.
	3. Unexpected or anticipated surgical blood emergencies.
	Trauma service responsibilities:
	1. The massive transfusion protocol (MTP) is initiated by the patient's staff physician or the staff anesthesiologist by calling the blood bank (this phone call may be delegated to another individual).
	a. Clearly state to the blood bank: "Initiate the massive transfusion protocol." Indicate whether it is an adult MTP or pediatric MTP (for patient's less than 35 kg).
	b. Give the patient's name and medical record number.
	c. Provide the patient's current location and a phone number that can be used to reach the patient's care team.
	d. Determine if patient requires emergency release of two uncrossmatched and untagged O Neg red blood cells for immediate transfusion. Note: Average time for first MTP set is 15 to 20 minutes.
	2. Send a properly labeled specimen (3 mL purple tube) to the blood bank for a type and screen if not done in last three days. The specimen label must contain the patient's name, medical record number, date, and the initials of the collector written on the tube.
	3. Record initiation of protocol in patient's chart.
	Blood bank responsibilities:
	1. Release two emergency O Neg red blood cells (RBCs) if requested.
	2. Prepare 4 RBCs, 4 plasma, and 1 dose of platelets for adult MTP or 2 RBCs, 2 plasma, and ½ platelet apheresis for pediatric MTP. Note: Group "O" uncrossmatched RBCs will be issued, if necessary, until type specific and later crossmatched becomes available.
	3. Provide a cooler with ice for each set of RBC and plasma components.
	4. Notify the patient's care team when a set of components is ready for pickup.
	5. Notify BB MD on-call.
	6. Stay 1 MTP set ahead (prepare each set immediately following pickup of previous set).
	7. Continue process until notified to discontinue the protocol.
	Nursing responsibilities:
	1. Assign personnel to obtain the set of components from the blood bank.
	a. Blood bank will call when each set is ready for pickup.
	b. Send a completed release form with the personnel picking up the components.
	2. Order labs as directed by the trauma team.
	3. Communicate the lab results to the trauma team and the blood bank.
	Attending physician, surgeon, or anesthesiologist responsibilities:
	1. Obtain baseline CBC and coagulation studies.
	2. Determine if rFVIIa is required (see section below for guidelines).
	3. Monitor CBC, ABG, potassium, ionized calcium, and coag tests frequently.
	4. If a coagulopathy is suspected measure the fibrinogen test and other coagulations studies.
	5. Determine when the protocol should be discontinued.
	a. Call the blood bank (this phone call may be delegated to another individual).
	b. Document discontinuation in the patient's chart.
	Use of rFVIIa (Novaseven) in surgery and trauma:
	1. Indication of the use of rFVIIa
	a. Active bleeding following administration of 6 to 8 units of red blood cells, 6 to 8 units of plasma, and one dose of platelets.
	b. Administer 10 units of cryoprecipitate if the fibrinogen is <100 mg/dL.
	2. Contraindications for the use of rFVIIa
	a. pH <7.00
	b. Immediately following cardiac arrest
	c. Patient considered "unsalvageable" by staff surgeon
	d. Pregnancy
	e. Recent thrombotic event, MI, or stroke
	3. Dosing of rFVIIa
	a. If the patient has been on warfarin and arrives with an elevated INR and rapid bleeding, consider using one small vial of rFVII or 1.2 mg. This is usually a 15 micrograms/kg dose for adults.
	b. If the patient is not on warfarin, consider using 45 micrograms/kg as a half dose and repeat this dose in 30 to 60 minutes.
	c. Always round down to the nearest full vial for doses of rFVIIa.
	Review of massive transfusion protocol events by transfusion services:
	1. Each event is summarized by blood bank staff.
	2. Review is performed by blood bank supervisor and transfusion service physicians.
	3. The events are reported to the transfusion committee.
References:	1. Technical Manual, American Association of Blood Banks. Bethesda, MD.
References:	2. Guidelines for Massive Transfusion, American Association of Blood Banks. Bethesda, MD.
Approved by:	Dr. Matthew Byrnes Director of the Trauma Service Department of General Surgery University of Minnesota Medical Center, Fairview Dr. Donovan Hess Director of the Pediatric Trauma Service University of Minnesota Medical Center, Fairview Transfusion Committee University of Minnesota Medical Center, Fairview
Date effective:	10/01/2007
Date revised:	May 16, 2008; April 6, 2010
Date reviewed:	April 6, 2010
Original authors:	James Harmon, MD Department of General Surgery Trauma Service University of Minnesota Medical Center, Fairview Julie Welbig Blood Bank Technical Supervisor University of Minnesota Medical Center, Fairview

References:

Bracey A. Guidelines for Massive Transfusion, American Association of Blood Banks, Bethesda, MD 2005.
Technical Manual, 16th ed, American Association of Blood Banks, Bethesda, MD 2008.

Data reproduced with permission from: the American Association of Blood Banks (AABB).

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Massive transfusion protocol