PatientsVisitorsLocations & ServicesAbout the RegionJoin Our TeamPhysicians
Find:  Locations | Services
Pathology and Laboratory Medicine HomeTest and Services CatalogueTransfusion Medicine Product CataloguePolicy and ProcedureJob AidsSpecimen Collection and TransportRequisitionsAntibiogramsGenetic Testing and Molecular GeneticsMicrobiology EssentialsTransfusion EssentialsReference RangesLaboratory SuppliesAcute Care SCM GuidelinesContact InformationPhysician Access to Patient ResultsOpening A New Clinic
Pathology and Laboratory Medicine
Transfusion Essentials

​Massive Transfusion Protocol (Adults)

Purpose

This document provides information regarding the protocol involved to ensure the safe and expeditious provision of blood products during an identified situation of massive bleeding.123

Policy

  • Massive transfusion protocol activation is appropriate only within the context of a massively bleeding patient within a SHR Saskatoon urban hospital site
    • Massive bleeding is defined as >4.5 L of blood loss in 30 minutes or >150 mL per minute of ongoing blood loss with blood loss greater than half the blood volume and ongoing uncontrolled bleeding
    • The MRP (lead physician) shall clinically assess the patient to determine when massive bleeding criteria are met and decide when to activate the MTP
    • The MRP activating the MTP shall designate a ‘Team Contact’ to notify TML of MTP activation
    • If uncrossmatched red blood cells are being requested, the requesting physician MRP shall document in the patient’s chart that the clinical situation justifies the transfusion and obtain informed consent from the recipient when possible
  • To activate the MTP, one individual should be designated as the ‘Team Contact’ and shall notify the TML of MTP activation. The following details shall be provided by the team contact to TML:
    • Team Contact name
    • Patient identification (name, HSN, sex)
    • Approximate patient age (or date of birth, if known)
    • Care team location
    • Contact phone number
    • Name of the MRP
  • Team Contact shall complete MTP Clinical ’Team Contact’ Checklist
    • Any change in patient location or team contact name should be provided to TML by phone at the time the change occurs in order to facilitate proper component delivery
    • Upon MTP discontinuation, the completed Checklist shall be sent to TML by fax
  • TML shall notify the following individuals upon MTP activation:
    • Transfusion Medicine Physician
    • Hematology/Coagulation
    • Clinical Perfusion (RUH site only)
  • MTP activation occurring outside of regularly scheduled TML staffed hours shall automatically trigger a call back of a TM technologist
  • A lavender EDTA tube shall be sent to TML for testing as soon as possible to enable issue of group specific blood components
  • Group O RBC and Group AB plasma will be issued until the patient’s blood group is known. Group specific blood components shall only be issued if a blood group has been determined during the current admission.
  • The MTP boxes will include the following components, unless customized upon request:
    • MTP Box 1 = 4 units RBC, 4 units plasma, 1 adult dose platelets (1:1:1 ratio)
      • ONE adult platelet dose is a pool of FOUR whole blood donor platelets
      • If thawed plasma is unavailable, RBC units and platelets should be issued in Box 1 in advance of plasma thaw completion. The TML technologist will notify the clinical team as soon as thawed plasma is available.
    • MTP Box 2 = 4 units RBC, 4 units plasma
    • MTP box contents may be customized upon request, based on results of patient bloodwork
  • Blood component and plasma protein product considerations within the context of a MTP:
    ​MTP Red Cell and Plasma Requirements
    Note: The Transfusion Medicine Physician may recommend alternative blood components depending on inventory limitations and degree of blood component utilization.
    ​Patient's Testing Status

    Red Cell Requirements
    ​ ​ ​
    ​Plasma
    Requirements
    Crossmatched ​Group
    Specific Uncrossmatched
    ​Group
    O Rh Pos Uncrossmatched
    ​Group
    O Rh Neg Uncrossmatched
    Group Specific
    or Group Compatible

    Group AB
    Unknown patient identification – no blood group this admission
    Male < 18 years, Female ≤ 50
    ​Yes*​Yes
    ​Unknown patient identification – no blood group this admission
    Male ≥18 years, Female > 50
    ​Yes​Yes
    ​Identified patient – no blood group this admission
    Male < 18 years, Female ≤ 50
    ​Yes*​Yes
    ​Identified patient – no blood group this admission
    Male ≥ 18 years, Female >50
    ​Yes​Yes
    ​Identified patient, blood Group done on this admission, but Screen outdated or not tested​Yes*​Yes
    ​Identified patient,
    in-date Group and Screen completed
    ​Yes*​Yes
    *If inventory allows, all female patients of childbearing potential (≤50 years of age) should receive Kell negative RBC

  • Group incompatible platelets may be issued throughout the duration of the MTP depending on inventory availability
  • Cryoprecipitate may be issued upon request
    • Cryoprecipitate does not need to be blood group matched during an MTP
  • Special instructions in the LIS will be reviewed by the Transfusion Medicine Physician for appropriateness in the context of an MTP. Special instructions for blood components may include any of the following:
    • Irradiated, CMV negative, IgA deficient, washed, HPA or HLA matched, phenotype matched
  • Requests for plasma protein products shall be reviewed with the Transfusion Medicine Physician
  • Prior to blood component issue, a requisition containing patient identifiers (name, identification number), name of the requesting physician, time of request and blood destination shall be received by TML
    • If patient identification is unknown at the time of MTP activation, the TML must be provided with patient identifiers (name, hospital number) assigned by patient registration, as per the requisition. Confirmed patient identification shall be merged with the assigned identification as soon as possible.
  • Once the blood group and/or IAT crossmatch results are available:
    • An attempt will be made by TML to retrieve all issued uncrossmatched RBC and replace with group specific uncrossmatched RBC
    • An attempt will be made to retrieve RBC units issued which have been determined to be IAT crossmatch incompatible and replace with compatible units
  • All products issued under the MTP will be provided in unsealed coolers that are not validated for product storage and therefore must either be:
    • Transfused within 4 hours of issue OR
    • Returned to Transfusion Medicine within 60 minutes of issue for return to available inventory OR
    • Discarded by TML staff if returned unused greater than 60 minutes after issue
  • The MRP shall determine when the MTP may be discontinued
    • Notification of MTP discontinuation shall be provided to the TML within 30 minutes of the decision to discontinue the MTP
  • Discussion of any problems arising from the MTP should be initiated within one week of the event if possible. A summary of any MTP activation event will be reported to the Saskatoon Health Region MTP Committee. A blood product wastage report will be provided to the MTP committee.

Definitions

For the purposes of this document, the following definitions apply:

Term, abbreviation, acronym, etc. Definition
ASAPAs soon as possible
​HSN​Health Services Number - A unique personal health number assigned to an individual. This is usually the Saskatchewan or out-of-province health number, or may be Canadian Forces (CFB), Federal Penitentiary (FPS) number, etc. The HSN is entered into the ‘PHN field’ of the LIS. See Appendix B for HSN formats.
Massive blood loss The loss of more than one blood volume in a 24 hour period. For the purposes of this protocol, massive bleeding is defined as >4.5 L of blood loss in 30 minutes or >150 mL per minute of ongoing blood loss with blood loss greater than half the blood volume and ongoing uncontrolled bleeding.
MRPMost Responsible Physician or lead physician
MTPMassive Transfusion Protocol
RBCRed blood cells
​shall​Indicates the action is mandatory
shouldIndicated the action is recommended
SHRSaskatoon Health Region
TMLTransfusion Medicine Laboratory


Procedure

Step Action
1Identify the presence of ‘massive bleeding’.
2

‘Team Contact’ to call to TML of MTP activation:

  • RUH: #2179
  • SCH: #8204
  • SPH: #5168
3

Using the MTP Clinical ‘Team Contact’ Checklist, the ‘Team Contact’ must provide TML with the following information:

  • Team Contact name
  • Patient identification (name, HSN, sex)
  • Approximate patient age
  • Care team location
  • Contact phone number
  • Lead Physician

The ‘Team Contact’ should record this information on the checklist used during the MTP. At any time during the MTP TML must be updated on patient location or team contact name to ensure accurate delivery of blood components.

Note: Copies of the checklist can be found in the Laboratory Services Manual, Transfusion Essentials.

4Confirm with the TML technologist that a blood group and screen is available. If it has not yet been collected, the ‘Team Contact’ is responsible for ensuring the sample is drawn and received by TML.
5If uncrossmatched red blood cells are being requested, MRP must document in the patient’s chart the situation which justifies the transfusion. Obtain informed consent from the recipient when possible.
  • Complete a Blood Product Request Form and send immediately to TML
    • If patient identification is unknown at the time of the MTP, the patient will remain an unidentified patient (assigned name and identification number by registration) throughout the MTP event. Confirmed patient identification will be merged once the MTP is discontinued.
6Early consideration should be given to the use of tranexamic acid for patients that are less than 3 hours from trauma.
  • Dose: Tranexamic acid 1 gram IV over 10 minutes in all patients within 3 hours of injury, followed by 1 gram IV infusion over 8 hours in trauma patients
7TML will notify the following individuals upon MTP activation:
  • Transfusion Medicine Physician
  • Hematology/Coagulation
  • Clinical Perfusion (RUH site only)
8

TML will ensure that RBC’s will be switched from Group O to group specific as soon as grouping is confirmed, and may be switched to Rh-positive according to the policy.

9TML will prepare MTP BOX 1 with 4 RBC, 4 plasma and 1 adult platelet dose. TML will notify the ward when the box is ready. The ward is responsible for picking up the box.
  • Plasma takes about 25 minutes to thaw; the RBC and platelets may be issued in advance of the plasma.
  • Platelets are stocked at RUH and SPH. Additional units will be shipped to the MTP site as required, therefore may be issued after the red cells and plasma.
10TML will begin to prepare MTP BOX 2 with 4 RBC, and 4 plasma. This box will be ready for issue within 30 minutes of MTP BOX 1. TML will notify the ward when the box is ready. The ward is responsible for picking up the box.
11

MTP BOX 1 and 2 will alternate until the clinical situation is resolved.

12The following laboratory tests (which should be ordered collectively as an “MTP Panel”) should be ordered every 30 minutes:
  • CBC, aPTT, INR, fibrinogen
  • Venous blood gas, ionized Ca
  • Point of care testing (TEG) should be considered, if possible
13Administer fluid through warming devices continuing to monitor patient temperature. If temperature <35°C actively warm patient.
  • Red blood cells or plasma may be infused through a blood warmer or rapid infuser (NOT platelets)
​14​Assess bleeding rate between doses of blood components. If possible, wait for results of laboratory tests before transfusing additional blood components.
15The contents of MTP boxes may be customized upon request on the basis of the last available laboratory tests:
ProductTreatment Considerations
​RBC’s​Maintain hemoglobin at 70-100 g/L
​Plasma​INR >1.5 or aPTT >40 and hemoglobin stabilizes, prioritize plasma transfusion over red cells
​Platelets​Platelets <75x109/L consider an additional dose of platelets
​Cryoprecipitate​Fibrinogen <1.5 g/L consider cryoprecipitate 10 units or fibrinogen concentrate

16

Consider giving 2 g Ca Gluconate IV if ionized calcium < 1 mmol/L.

17

Consider contacting the Transfusion Medicine Physician at any time to discuss the possibility of adjunctive blood component or plasma protein product therapy.

​18​Inform TML when control of bleeding has been obtained, or when resuscitation efforts have been withdrawn so that MTP can be discontinued. Return any unused blood products to TML as soon as possible.

Note: Products that are returned after more than 60 minutes may be held in the laboratory for a short period of time before being discarded taking into consideration all products must be infused within 4 hours of original release from the laboratory.
​19​Fax the completed MTP Clinical ‘Team Contact’ Checklist to TML (#2222).


Appendices

Appendix A – SHR Adult Massive Transfusion Protocol (MTP) RUH Site

Appendix B – SHR Adult Massive Transfusion Protocol (MTP) SCH Site

Appendix C – SHR Adult Massive Transfusion Protocol (MTP) SPH Site


References

1 Calgary Laboratory Services. FMC Massive Transfusion Protocol (MTP) – Adult. https://www.calgarylabservices.com. Accessed September 6, 2016.
2 Hunt BJ, Allard S, Keeling D, et al. A Practical Guideline for the Haematological Management of Major Haemorrhage. In: British Journal of Haematology. 2015. 170, 788-803.
3 Dzik WH, Blajchman MA, Fergusson D, et al. Clinical review: Canadian National Advisory Committee on Blood and Blood Products – Massive Transfusion Consensus Conference 2011: report of the panel. Critical Care 2011, 15:242.


​If you choose to print this information, it is valid only on date of print.

Laboratory Controlled Document TML-97 v4

Last Modified: Thursday, July 11, 2019 |
Questions or feedback about this page?