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Policies,Clinical,UW Health Clinical,General Care and Procedures,Blood Products

Massive Transfusion Protocol (Adult and Pediatric) (2.2.2)

Massive Transfusion Protocol (Adult and Pediatric) (2.2.2) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Blood Products

2.2.2


UW HEALTH CLINICAL POLICY 1
Policy Title: Massive Transfusion Procedure (Adult and Pediatric)
Policy Number: 2.2.2
Category: UW Health
Type: Inpatient
Effective Date: November 15, 2016

I. PURPOSE

The Massive Transfusion Procedure (MTP) is a pre-determined, multi-step sequence of blood product
preparation and distribution, initiated by physicians when a blood loss of more than one total blood volume is
expected in a short period of time. The purpose of this procedure is to provide a standardized and effective
approach to deliver appropriate amounts and types of products to the patient who is in need of large
amounts of all blood product types. MTP is not for ordering emergency release blood. MTP is for providing
balanced massive transfusion. For emergent transfusion needs order emergency release blood.

II. POLICY ELEMENTS

A. This policy addresses only the procedures to prepare large amounts of blood product in anticipation of
possible orders to administer such blood products. Initiating the MTP does not authorize administration of
blood products. A separate order in compliance with other policies is required to administer the blood
products to a patient.
B. The procedure is designed to facilitate early and intensive red cell, plasma, and platelets therapy
maintaining the hemostasis of whole blood as this process has been associated with better patient
outcomes. Keeping plasma coagulation factor activity at least above 40% of normal and platelet counts in
the range of 50 to 100 x 109/L will usually support adequate coagulation. For practical purposes, massive
transfusion procedures should utilize a 1:1 ratio of red cells to plasma for all patients who are
hypocoagulable with traumatic injuries. The aim of treatment is to restore blood volume rapidly and
effectively to a level and composition adequate to maintain hemostasis, oxygen-carrying capacity, oncotic
pressure, and biochemical parameters.
C. The MTP may be activated in the following cases:
i. Life-threatening trauma presenting to the Emergency Department
ii. Unexpected surgical emergencies
iii. Surgeries expected to require massive transfusion (i.e., AAA)
iv. Patient who requires transfusion of more than one total blood volume within a 24-hour period
D. Once activated a MTP remains in effect regardless of patient location and must be inactivated when no
longer needed. Without inactivation, additional blood products will continue to be set up which may reduce
product availability for other patients.
E. Initiating a MTP does not necessarily cause products to be available faster, especially when only specific
products are needed, as the Transfusion Service is dedicated in the process to preparing the MTP sets
which include all blood product types.
F. This procedure can be used with a Level 1 Trauma after the trauma pack has been used in the ED. Units
from the trauma pack should not leave the ED unless they are hanging, whereas MTP units can be sent with
the patient (from ED to OR).
G. Patients being treated with MTP require two patient identifiers (full patient name and medical record number
or date of birth). For unidentified patients, refer to the process in UW Health clinical policy #3.2.7,
Unidentified Patient.
H. Blood warmers should be used throughout this process as coagulation factors and platelet products react
more efficiently at body temperature.
I. Products must either be stored in a validated cooler (ED, PICU, or available from the Transfusion Service),
or in an OR refrigerator. Any products not stored in these locations must be returned to the Transfusion
Service or transfusion must begin within 30 minutes of product issue.

III. PROCEDURE

A. Activation
i. Activation of the MTP is done by placing one of three Health Link orders [i.e. Adult Massive
Transfusion (>40 Kg), Child Massive Transfusion (11 Kg – 40 Kg) or Infant Massive Transfusion
(≤10Kg)] or phone call to the Transfusion Service (263-8367). Upon oral authorization from an
attending physician, any member of the health care team can make the Health Link order or phone
call to activate the MTP, but must provide the name of the ordering attending physician to the
Transfusion Service. The information that the Transfusion Service needs from this phone call



UW HEALTH CLINICAL POLICY 2
Policy Title: Massive Transfusion Procedure (Adult and Pediatric)
Policy Number: 2.2.2

includes:
a. Patient’s first and last name
b. Medical record (MR) number
c. Name of requesting physician
d. Location/contact phone number
ii. If needed, the Transfusion Service will notify the Transfusion Service resident and/or attending who
may contact the location for more details.
iii. The location must draw a type and screen blood specimen as soon as possible if one has not been
drawn. This type and screen blood specimen will help expedite the process, conserve blood for
other traumas, and is necessary for the Transfusion Service to setup crossmatched blood which is
better for the patient. Lack of a type and screen blood specimen may require Transfusion Service’s
to change blood types.
B. Adult Process
The Transfusion Service will begin by setting up and issuing 5 units of red blood cells, 5 units of plasma, and
a dose of platelets. While this dose is being issued, the Transfusion Service will follow the Massive
Transfusion Selection Chart (See appendix), starting at row 2. The aim is to be issuing a line while setting up
the next one in order to stay ahead of product need.
i. The first and second line of the MTP will be issued automatically by the blood bank. After these are
issued, the blood bank will hold subsequent sets and issue when requested to do so. This is done
by sending a request slip to the Transfusion Service, or sending a runner to pick up products (either
method must have the patient’s name and MR). A reminder of this will be sent at the end of the
second set.
ii. In order for hemostasis to be maintained, if a separate order for administration has been entered in
accordance with other policies, the products should also be transfused according to the above
lines.
iii. At any point in the process, if additional products are needed of a certain type (i.e. more platelets)
these can be requested by calling the blood bank. Because of product limits, especially for
platelets, only 1 extra dose can be requested at a time. The attending should incorporate laboratory
test results as transfusion guidelines for ordering these products and continuing with the MTP.
iv. Once bleeding is controlled and the patient is hemodynamically stable, the attending should
discontinue the MTP by notifying the Transfusion Service by phone (263-8367).

Adult (>40 Kg) - Massive Transfusion Blood Product Selection Chart
Issue Packed RBC’s Plasma Platelet Dose Cryo
1st 5 5 1
2nd 5 5
3rd 5 5 1
4th 5 5 10
5th 5 5 1
6th 5 5
7th 5 5 1
8th 5 5 10

C. Pediatric Process
The logistics of the pediatric process is the same as the adult process for steps III.B.i-iv. In addition infants
less than 10 Kg will receive fresh red blood cell units (≤14 days when available) and irradiated (if time
allows) cellular blood products. The allocation of blood products for pediatric massive transfusions will be
divided into 3 categories based on following patient weight ranges: ≤10Kg, 11 Kg – 40 Kg, and >40 Kg.

Infant (≤10 Kg) - Massive Transfusion Blood Product Selection Chart
Issue Packed RBC’s Plasma Platelet Dose Cryo
1st 1 1 1
2nd 1 1
3rd 1 1
4th 1 1 1 1
5th 1 1
6th 1 1



UW HEALTH CLINICAL POLICY 3
Policy Title: Massive Transfusion Procedure (Adult and Pediatric)
Policy Number: 2.2.2

7th 1 1 1
8th 1 1 1

Child (11 Kg – 40 Kg) - Massive Transfusion Blood Product Selection Chart
Issue Packed RBC’s Plasma Platelet Dose Cryo
1st 3 3 1
2nd 3 3
3rd 3 3
4th 3 3 1 5
5th 3 3
6th 3 3
7th 3 3 1
8th 3 3 5

Child >40 Kg – Refer to Adult Massive Transfusion Blood Product Selection Chart in section III.B. above.

B. Review
i. Selected MTP cases will be reviewed by the Transfusion Service attending physicians with further
review by the Transfusion Service manager, trauma coordinators, or surgical services personnel.
ii. Selected MTP cases will be discussed at the Tissue and Blood Product Committee, which will
review these as a potential for improvement. This committee may disseminate this information to
be used in other committees (Trauma, Surgical) as information for education and process
improvement.

IV. COORDINATION

Author: Director, Lab Services
Senior Management Sponsor: VP, Professional Services
Reviewers: Director Transfusion Services; Transfusion Service Manager; Adult and Pediatric Trauma
Operations Committee
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: October 17, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

AABB Standards for Blood banks and Transfusion Services, current edition
Pham H, Shaz B. Update on massive transfusion. British journal of anaesthesia. 2013;111(suppl 1):i71-i82.

Ogura T, Nakamura Y, Nakano M, Izawa Y, Nakamura M, Fujizuka K, et al. Predicting the need for massive
transfusion in trauma patients: The Traumatic Bleeding Severity Score. Journal of Trauma and Acute Care
Surgery. 2014;76(5):1243-50.




UW HEALTH CLINICAL POLICY 4
Policy Title: Massive Transfusion Procedure (Adult and Pediatric)
Policy Number: 2.2.2

Baumann Kreuziger L, Morton C, Subramanian A, Anderson C, Dries D. Not only in trauma patients:
hospital‐wide implementation of a massive transfusion protocol. Transfusion Medicine. 2014;24(3):162-8.

UW Health clinical policy #3.2.7, Unidentified Patient

VII. REVIEW DETAILS

Version: Revision
Next Revision Due: November 2019
Formerly Known as: Hospital Administrative policy #8.94