Massive Transfusion Protocol

(formerly (Massive Hemorrhage

Response)
Standard

Principle
Patients with significant blood loss may develop coagulopathy, anemia, and
thrombocytopenia that is precipitated and promoted by ongoing shock. The mainstay
of management for these patients is adequate and complete resuscitation through
the use of blood product replacement and prevention of hypothermia. The Massive
Transfusion Protocol is designed to obtain and supply adequate blood components
required for treating patients where massive transfusion is essential.
Scope
This policy pertains to patients requiring unexpected high volume rapid transfusion
deemed appropriate for resuscitation protocol by their attending physician. The
protocol should be activated for cases in which a patient is undergoing actual or
impending massive hemorrhage.

Procedure

Implementation/Activation
I. Notification of blood bank and laboratories
Once a patient is deemed appropriate for Massive Transfusion Protocol:
1. Attending physician or a designee notifies the Blood Bank (5-6260) to activate
the Massive Transfusion Protocol. The following needs to be provided to the Blood
Bank:
a. Patient information:
i. Patient’s name (or hospital assigned trauma or disaster name
for unidentified patients)
ii. Gender
iii. MR number
iv. Weight (exact or estimated)
v. Location
vi. Attending physician’s contact number
b. A blood sample should be sent to the blood bank ASAP (3 cc pink top
tube) – for type, screen, and crossmatch
c. If uncrossmatched RBC units are needed, an Emergency Release Form
must be signed by the ordering physician

© Boston Children’s Hospital, 2024 All rights reserved  Publication Date 05/22/08
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2. Attending physician or designee will notify the clinical lab (5-6351 or 5-7838) to
alert the lab to anticipate frequent blood samples and ensure expedited turn- around
time (to optimize lab turnaround times)
3. The Blood Bank will contact the Blood Bank Physician who can also be paged
directly 24/7 at pager 6260. The Blood Bank Physician can consult/advise on
transfusion therapy by monitoring patient’s labs and communicating with the patient
care team and the Blood Bank. Preparation of Blood Products
II. Upon activation of the Massive Transfusion Protocol, the Blood Bank will
follow these steps (weight dependent – see table below for weight based
recommendations)
a. Issue and place appropriate number of RBC units in a cooler. If
crossmatched blood is not available, Blood Bank will issue emergency
release units, while crossmatching process is taking place for
remaining units. An assistant from the patient’s unit will transport
blood products from the Blood Bank.
b. Prepare appropriate number of FFP units and/or other plasma product
(type specific or AB plasma, if ABO type unknown). (see Table 2
below)
c. Prepare appropriate number of platelet units. (see Table 2 below)

Table 2. Products to be issued by Blood Bank, weight based

Patient Weight Blood Products

RBCs (units) FFP (units) Platelet (units)
< 5 kg: 1 1 1
5 to 24.9 kg: 2 2 2
25-49.9 kg: 4 4 4
> 50 kg: 6 6 6

2. Cooler preparation and product release:

a. Blood products will be prepared and issued in appropriate coolers.
b. Blood bank will “keep ahead” with products in volumes, appropriate
for patient’s weight – i.e., continue thawing/preparing products to stay
ahead (once coolers with products are picked up by ordering
physician’s designee). Unless otherwise specified by the ordering
physician, “keeping ahead” means continuous preparation of products
in 1:1:1 ratio (as per Table 2), until deactivation of the Massive
Transfusion Protocol.
c. Each cooler (after first cooler) will contain PRBC and FFP as
available. Platelets will be issued separately and can be sent via
pneumatic tube if requested.
d. Coolers will continue to be prepared until a call is received for
deactivation of protocol

III. Laboratory testing

© Boston Children’s Hospital, 2024 All rights reserved  Publication Date 05/22/08
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 1. Stat tests to be obtained hourly:
i. Blood gas syringe with arterial or venous blood for whole
blood electrolytes (full panel including iCa)
ii. Blue top tube for PT, PTT, fibrinogen
iii. Purple top tube for CBC
2. Chem 7 should be obtained initially and repeated as indicated
If the Blood Bank Physician is involved, they will contact clinical area and
check labs results, recommend transfusion care, and instruct the Blood Bank
as to which blood components are to be prepared

IV. Other Products:

1. Cryoprecipitate
a. Indications:
i. Fibrinogen <100 mg/dL OR
ii. Rapidly falling fibrinogen
b. Dose: 1 U/ 5 kg
c. In contrast to RBC, FFP, and platelets, Cryoprecipitate will not
be prepared by the Blood Bank automatically, without a specific
order for cryoprecipitate. The attending physician or designee
will contact the Blood Bank or blood bank physician to order
cryoprecipitate.
2. Calcium Replacement
a. Indications for Calcium replacement: ionized Ca < 1.14 mmol/L
b. 10% Calcium Gluconate (100 mg/ml) dose should be ordered
based on patient’s weight. Dose should be 1ml/kg=100 mg/kg
c. Maximum dose:
i. Patients < 30 kg: 100 mg/kg
ii. Patients > 30 kg: 3000 mg
iii. Dose can be repeated if ionized Ca < 1.14 mmol/L after prior
dose.

Deactivation
The attending responsible for patient care or a designee will authorize deactivation of
the Massive Transfusion Protocol once the patient is stabilized and will notify the
Blood Bank (6-6260) to discontinue blood component preparation. Once Protocol is
deactivated, remaining blood products and coolers that are not needed should be
returned to the Blood Bank. Blood Bank technical staff will notify the Blood Bank
Physician.

Related Content

 None Identified

© Boston Children’s Hospital, 2012 All rights reserved  Publication Date

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References

 Technical Manual, 18th ed. Bethesda, MD: American Association of Blood

Banks, 2014
 Holcomb JB et.al. “Transfusion of plasma, platelets, and red blood cells in a
1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the
PROPPR randomized clinical trial.” JAMA 2015; 313(5)471-82

Document Attributes

Title Massive Transfusion Protocol Massive Transfusion Protocol

(formerly (Massive Hemorrhage Response)
Author Galina Lipton, MD, Division of Date of Origin 09/01/12
Emergency Medicine
Maria F. McMahon MS, RN, cPNP-AC,
Trauma Program
Anne Stack, MD, Division of
Emergency Medicine
Reviewed/ ***Herminia Shermont, MS, RN, CNA, BC, Dates
Revised by Director of Surgical Programs Reviewed/
Transfusion Committee Revised
Copyright ©Children's Hospital Boston, 2024 Last Modified
Approved Signature on File
David P. Mooney, MD, MPH
Director, Trauma Program
Signature on File
Steven Sloan, MD,
Medical Director, Blood Bank

© Boston Children’s Hospital, 2024 All rights reserved  Publication Date 05/22/08
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