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 ( 2.0 = 4 FP Platelets 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 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. 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

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Attachment # 3: Massive Transfusion Component Timeline