guideline/protocol number: t3 guidelines and protocols

of 14

Guidelines and Protocols

Lyndon B. Johnson General Hospital Trauma Services

Department

Guideline/Protocol Number: T3

TITLE: MASSIVE TRANSFUSION PROTOCOL

PURPOSE:

To establish a transfusion protocol for Harris Health System patients whose blood

loss necessitates emergent release of large volumes of Blood Products.

PROCESS:

The Massive Transfusion Protocol (MTP) is to be activated by on-site faculty

members from the Emergency Department, Trauma Team, ICU, OB, and/or the

Anesthesia/OR/ Teams. The initiating team must notify the Blood Bank immediately

(713-566-5293; x65293) of the need for MTP.

Initiation of the MTP consists of a two-step process which includes:

1. Communication, either in EPIC (using the MTP order-set), or an Emergency

Blood Request Form. The order-set instructs the provider to call Blood Bank

and the order will print out in Blood Bank.

The documentation must include the following information:

a. Valid patient information (Name and medical record number, or a

uniquely assigned number i.e. temporary unknown name/number)

b. Name and ID number of requesting physician

c. The statement “Massive Transfusion (or “MTP”) is requested.”

2. Verbal initiation by a member of the initiating team to a member of the Blood

Bank staff by telephone (x65293) or in-person is acceptable as long as the

necessary written documentation is provided and the clinical situation allows.

of 14



Department


Red blood cells (RBC’s) will be issued as follows, unless requested differently by the

initiating team:

1. O-negative/O-positive, uncross matched RBC’s (available immediately

in EC or Blood Bank)

2. O-negative, uncross matched RBC’s should be used in pregnant women

(available immediately in L&D)

3. Type-specific, uncross matched RBC’s (available within 5-10 minutes of

receipt of a properly labeled patient sample)

4. Type-specific, crossmatch-compatible units (available within 45-60

minutes of receipt of a properly labeled patient sample)

Please note that full, pre-transfusion testing will begin upon receipt of a properly

labeled patient sample and will be used to guide subsequent product release as results

become available.

Please note that additional processing (irradiation, antigen-negative units, volume

reduction, etc.) will not be performed while MTP is in progress.

The initiating team will be notified when full cross match is complete. Type-specific,

cross match-compatible units will be traded out for any remaining uncross-matched

blood.

Additional staff will be utilized from other areas of the Laboratory to maintain

continual Blood Bank support. If the patient is unable to be supported adequately

with the MTP protocol, or the hospital blood supply is compromised, a decision must

be made by the initiating team as to alternate patient options.

of 14



Department


I. PROCEDURE

a. A blood sample may be submitted with a printed EPIC label (per system

labeling policy) the EPIC system captures date/time/collection info

If there is not an EPIC label available, the sample should be submitted

with name/medical record number/time/collector’s ID written on chart and

downtime label

b. A completed form (or verbal initiation as described above) must be

provided with the patient’s name and number, the signature of the

requesting physician/designee, and taken by a designated transporter to

the Blood Bank. Units will not be issued without a medical record

number.

c. Within 5-10 minutes of receipt of a “Massive Transfusion Protocol”

directive, the Blood Bank will have a prepared cooler containing 4 units

of RBCs, 4 units of type-compatible fresh frozen plasma (FFP), and 1

apheresis unit of platelets (4:4:1). For OB patients a unit of

cryoprecipitate will be included in the initial prepared cooler.

i. If 4 type-compatible FFP units are not immediately available

(based upon the blood type of the patient and Blood Bank

inventory), the Blood Bank will issue any available units and notify

the initiating team when the remaining units are available.

ii. Initiate process to order additional blood products from blood

supplier as needed.

d. The Blood Bank will inform the lab staff of MTP initiation, lab staff will

start TEG controls. The Blood Bank staff will notify the Pathologist that

the MTP has been initiated. The Pathologist will initiate contact with

the responsible service for consult as needed.

e. With each instance of component issue, a Blood Issue Slip must be

utilized to confirm patient identity.

of 14



Department


f. After the initial 4 RBCs, 4 FFP, and 1 unit of platelets have been issued,

the Blood Bank will prepare an additional 4 RBCs, an additional

apheresis unit of platelets, and initiate the thawing of 4 additional type-

compatible FFP units.

g. This process will be automatically repeated until the Blood Bank is

informed by a member of the current clinical team that the MTP is no

longer needed.

h. The initiating team will order the following laboratory tests as clinically

indicated:

i. Fibrinogen to determine if cryoprecipitate is needed (see Empiric

Guidelines below)

ii. TEG to assess for coagulopathy, platelet dysfunction, and

fibrinolysis

i. Blood Products (with the exception of platelets and cryoprecipitate) may

be maintained in an assigned Blood Bank cooler for a maximum of 4

hours. After 4 hours have elapsed, the cooler must be returned to the

Blood Bank for a current temperature check, and installation of new ice

blocks.

j. Continual contact will be maintained between the Blood Bank and the

blood supplier to ensure uninterrupted component supply.

k. Upon hemorrhage control and hemodynamic stability, the clinical team

will notify Blood Bank to discontinue MTP.

of 14



Department


II. EMPIRIC GUIDELINES FOR MASSIVE TRANSFUSION

FFP

For every 4 RBCs, give 4 FFP (1:1 ratio)

Platelets

For every 4 RBCs, give 1 apheresis unit of platelets.

Cryoprecipitate

After first 12 to 16 RBCs, check fibrinogen level.

If <100 mg/dL, give 10 units cryoprecipitate. Repeat as needed, depending on fibrinogen level, and request appropriate amount of cryo.

NOTE: FFP also contains fibrinogen.

For OB-GYN Patients: Administration of cryoprecipitate with first series of

RBC’s and FFP is recommended.

of 14



Department


APPENDIX A: MTP ALGORITHM

of 14



Department


Stage 1: Blood loss >1000 mL after delivery with normal vital signs and lab

values. Vaginal delivery 500-999mL should be treated as in Stage 1.

APPENDIX B: OB HEMORRHAGE CHECKLIST

Obstetric Hemorrhage Checklist

Complete all steps in prior stages plus current stage regardless of stage in which the patient

presents

Recognize, call for assistance: □ Obstetric Hemorrhage Team

Designate: □ Team lead □ Checklist reader/recorder □ 2nd RN

Announce: □ Cumulative blood loss □ Vital signs □ Determine Stage

Initial Steps:

Ensure 16G or 18G IV Access

Insert indwelling urinary catheter

Fundal massage

Vital Signs Q 5 minutes

Medications:

Increase oxytocin rate

Administer appropriate medications, consider patient

history

Blood Bank:

Type and Crossmatch 2 units RBCs

Action:

PPH Kit

QBL assessed, announced and recorded q 15 minutes

Determine etiology and treat

Prepare OR, if clinically indicated

(Optimize visualization/examination)

Medications:

Oxytocin (Pitocin):

30 units per 500 mL solution

Methylergonovine (Methergine):

0.2 milligrams IM q 2 – 4 hours;

Avoid with hypertension

15-methyl PGF₂α (Hemabate, Carboprost):

250 micrograms IM (may repeat in q15 minutes,

maximum 8 doses); Avoid with asthma

Misoprostol (Cytotec):

800 micrograms PR (max dose)

600 micrograms buccal (max dose)

Tranexamic Acid (TXA): I gram IVPB over 10

minutes; may be repeated once after 30 min

Tone (i.e. atony)

Trauma (i.e. laceration)

Tissue (i.e. retained products)

Thrombin (i.e. coagulation dysfunction)

of 14



Department


Stage 2: Continued Bleeding (Blood loss up to 1500mL OR > 2

uterotonics) with normal vital signs and lab values

Huddle and move to Stage 3 if continued blood loss and/or abnormal VS

Initial Steps:

Activate OB Emergency

Place 2nd IV (16-18G)

Draw Labs (CBC, PT/PTT, INR, Fibrinogen, TEG)

Prepare OR

Medications:

Continue Stage 1 medications

Blood Bank:

Obtain 2 units RBCs (DO NOT wait for lab results. Transfuse per clinical signs/symptoms)

Action:

Consider moving patient to OR

Consider possible interventions

Initial Steps:

Mobilize additional help: Notify Trauma when at LBJ

Move to OR

Announce clinical status:

(vital signs, cumulative blood loss, etiology)

Draw Labs:

(CBC, Pt/PTT, INR, Fibrinogen, TEG)

Outline and communicate plan

Blood Bank:

Consider Initiating Massive Transfusion Protocol: State “Obstetric Patient”

Consult Trauma when at LBJ

Medications:

Continue Stage 1 Medications

Administer Transexemic Acid (TXA) 1 gram IVPB; if bleeding persists, administer

second dose of 1 gram TXA IVPB

Re-Dose Antibiotics

Possible Interventions:

Bakri Balloon

Compression suture/B-Lynch suture

Uterine artery ligation

Hysterectomy

Stage 3: Continued Bleeding (EBL >1500mL and >2RBCs given OR at risk

for occult bleeding/coagulopathy OR any patient with abnormal vital

signs/labs/oliguria)

Possible Interventions:

Bakri Balloon

Compression suture/B-Lynch suture

Uterine artery ligation

Hysterectomy

of 14



Department


Action:

Draw Labs (CBC, PT/PTT, INR, Fibrinogen; Blood Gas; TEG)

Consider etiology for appropriate interventions

Escalate Interventions

If continued bleeding is >2000mL; Massive Transfusion Protocol MUST be initiated

Initial Steps:

Mobilize additional resources

Medications:

ACLS

Blood Bank:

Continue Massive Transfusion Protocol

Action:

Immediate surgical intervention to ensure

Stage 4: Cardiovascular Collapse (massive hemorrhage, profound hypovolemic

shock, or amniotic fluid embolism)

of 14



Department


Appendix C: Massive Transfusion EPIC Order Set QRG

of 14



Department


of 14



Department


REFERENCE / BIBLIOGRAPHY:

OFFICE OF PRIMARY RESPONSIBILITY:

LYNDON B. JOHNSON HOSPITAL TRAUMA SERVICES

REVIEW / REVISION HISTORY

Effective Date Version #

(If Applicable)

Review/ Revision Date (Indicate Reviewed or Revised) Approved by:

10/20/20 10 10/20/2020 Trauma Committee








09/15/08 2 09/15/08 Trauma Services

guideline/protocol number: t3 guidelines and protocols

Documents