Massive Transfusion Protocol UMMC This document was printed: Mon Aug

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1 Page 1 of 5 Hospital University of Minnesota Medical Center, Fairview University of Minnesota Amplatz Childrens Hospital Policy Massive Transfusion Protocol UMMC This document was printed: Mon Aug This printed document is valid for 30 days and will expire on: Wed Sep Purpose: To ensure timely and appropriate treatment of or anticipation of massive transfusion episodes. To maximize the availability of blood and blood components, and to utilize resources efficiently. Policy: 1. The massive transfusion protocol (MTP) is a multidisciplinary process whereby blood and blood components are obtained rapidly for an exsanguinating patient. 2. Initiation of the MTP is reported to the Transfusion Service Physician (Blood Bank MD) on-call as soon as possible by the Blood Bank staff. 3. The Blood Bank MD serves as a consultant in the evaluation and management of the patient s transfusion therapy during the massive transfusion episode. 4. This procedure covers the implementation of a massive transfusion protocol in non-operating room departments. The NICU team will continue to run MTPs per their unit routine. General Considerations: 1. Example reasons for initiating an MTP a. Massive bleed due to trauma b. Uncontrolled bleeding c. Transfusion of >4 RBC units in one hour 2. MTPs will be initiated by the patient care unit (PCU). If this occurs on a non-intensive care unit (ICU) or nonemergency department (ED), an Adult or Pediatric Code Blue will be initiated and the code team will coordinate the MTP and stay with patient, as needed, until the patient is moved to the OR or ICU. 3. MTPs will be coordinated by defined roles. a. RN Coordinator (See MTP Nurse Coordinator Role below): Coordinates communication between PCU and Blood Bank; coordinates blood product administration and related lab draws in collaboration with MD Coordinator b. MD Coordinator (See MTP MD Coordinator Rode below): Makes decisions regarding order of blood product administration, lab draws, and related medications based on individual clinical situation, in collaboration with RN Coordinator

2 Page 2 of 5 Procedure: Initiating an MTP: may be done by resident MD or fellow, who then informs attending MD as soon as possible. Activating an MTP: 1. A Massive Transfusion Protocol (MTP) is activated by a phone call to Blood Bank. The initial call should be made by the patient s physician or nurse. a. For MTP on a non-icu/ed area, PCU will: Call Blood Bank to initiate MTP Initiate Adult or Pediatric Code Blue 2. Clearly state to Blood Bank that a Massive Transfusion Protocol is being initiated. Indicate if it is an adult MTP ( 35kg) or pediatric MTP (<35kg). 3. Supply Blood Bank with the following information: a. Patient name and medical record number b. Patient location and phone number that can be used for initial communication c. Name of provider initiating MTP 4. If red blood cell units (RBCs) are required within 10 minutes, request emergency release of 2 uncrossmatched and untagged O negative RBCs for immediate transfusion. Note: Average time for first MTP cooler is minutes. 5. Blood Bank will notify MTP Activator if there are potential delays in sending compatible RBC units due to: a. No type and screen on record b. History of positive antibody screen c. Irradiation required d. Other requirements that will delay blood availability 6. If a type and screen has not been done within 3 days, send a properly labeled specimen (3 ml purple tube) to the Blood Bank stat. The specimen label must contain the patient s name, medical record number, date, time, and 2 sets of initials (person who collected the specimen and someone who verified the patient s identification). 7. Identify the nurse who will act as the MTP Nurse Coordinator (ICU/ED RN) and relay all Blood Bank information to them. Communication: 1. The first cooler with blood components will contain a red ASCOM phone that has the Blood Bank phone number pre-programmed. Only this phone should be used by the MTP RN or MD Coordinator to communicate with the Blood Bank. 2. The Blood Bank MD will call the red ASCOM phone to follow the status of the MTP. Orders and Lab Tests:

3 Page 3 of 5 1. No blood component order set is used in Epic. 2. MTP coolers will contain packets of tubes for the recommended blood tests (see MTP Guide ). Role Responsibilities: MTP Nurse Coordinator Responsibilities 1. MTP Initiation a. Print patient labels if necessary. b. Designate a runner. Give runner a patient label. Send runner to Blood Bank to retrieve first cooler. c. Relay Blood Bank information from MTP Activator to MTP MD Coordinator. d. Non-ICU/ED areas: send runner for rapid infuser East Bank: On arrival for MTP, ICU RN will call the ICU to have the Rapid Infuser delivered to the code. West Bank: Code Team RN will call the ED to have the Rapid Infuser delivered to the code. 2. Arrival of First MTP Cooler a. Take charge of red ASCOM phone provided. b. Obtain initial set of recommended labs. Specimen tubes will come with first cooler. c. ICU and ED RNs will determine who will be the MTP Nurse Coordinator and who will run the Rapid Infuser; will require assistance of at least one RN from the PCU to assist with infusing blood products. 3. Running the MTP a. Use MTP Guide (included in first cooler) as general recommendations for transfusions and lab draws throughout the MTP, in collaboration with the MTP MD. b. Component handling 1. Perform mandatory safety checks on each component. Designate a nurse to help if necessary. 2. When approximately half of units in cooler have been transfused, check with MTP MD Coordinator to evaluate if next cooler is required. Use red ASCOM phone to alert Blood Bank. Send designated runner with patient label. c. Use the red ASCOM phone to communicate with Blood Bank and Blood Bank MD. 1. Act as the only person to call Blood Bank to relay requests, ask questions, etc. 2. Receive phone calls on red ASCOM phone from Blood Bank and Blood Bank MD. Answer questions. Relay information to MTP MD Coordinator. d. If Blood Bank MD needs to speak to an attending MD/MTP MD Coordinator, locate him/her and use red ASCOM phone. 4. Discontinuation of MTP a. Notify Blood Bank when MTP is discontinued. b. If emergency units were issued and transfused, ensure the Emergency Order for Uncrossmatched

4 Page 4 of 5 Blood form is signed by the physician and returned to the Blood Bank. c. Oversee return of red ASCOM phone and unused components to Blood Bank. MTP MD Coordinator Responsibilities 1. A resident or fellow may be the MTP MD coordinator. In a non-icu/ed area, this will be the Code Team MD s/he will utilize the covering physician team s expertise and knowledge of patient. 2. Gives verbal permission to: a. Give emergency RBCs if necessary (non-crossmatched RBCs). MD must sign for these components at end of MTP. 3. Waive requirement for Irradiation to avoid delay. MD must sign for these components at end of MTP. Receives lab results to guide care, per general recommendations on MTP guide. 4. Makes global decisions regarding: a. Transfusion needs b. Moving patient to OR or ICU c. If positive type and screen present, discuss implications with Blood Bank MD 5. Receives phone call from Blood Bank MD if complications arise 6. Makes decisions regarding use of Tranexamic acid and/or other coagulation factors 7. Directs order in which components are transfused. If busy, this responsibility may fall to MTP Nurse Coordinator in consultation with the Blood Bank MD 8. Determines when MTP should be discontinued. Notifies MTP Nurse Coordinator Blood Bank Responsibilities 1. Releases 2 emergency O negative RBCs if requested 2. Obtains patient information regarding type and screen, special unit or irradiation requirements 3. Reminds MTP activator to call an Adult or Pediatric Code Blue if the patient is located on a non ICU/ED area 4. Notifies the Blood Bank MD regarding MTP activation, and provides ongoing information as requested 5. Provides coolers with ice with the appropriate components. a. Adult ( 35kg): 4 RBCs, 4 plasma, 1 dose platelets; 2 cryoprecipitate pools every 3rd cooler b. Pediatric (<35kg): 2 RBCs, 2 plasma, ½ dose platelets; 1 cryoprecipitate pool every 3rd cooler c. Note: Group O uncrossmatched RBCs will be issued, if necessary, until type-specific and later crossmatched becomes available. 6. Calls red ASCOM phone to notify PCU when set of components is ready for pickup 7. Performs first safety check within Blood Bank and checks information on patient label before releasing cooler 8. Stays 1 MTP set ahead (prepares each set immediately following pickup of previous set) 9. Continues process until notified to discontinue the protocol. Blood Bank MD Responsibilities 1. Coordinates patient care with Blood Bank and MTP Nurse Coordinator 2. Brings complicated patient issues to the attention of the attending provider. 3. Checks for history of severe transfusion reactions.

5 Page 5 of 5 Review of MTP events 1. Each event is summarized by Blood Bank staff for review by Blood Bank supervisor and Transfusion Service physicians, then reported to the Transfusion Committee. 2. Each event in a non-icu/ed area is reviewed by the Emergency Medical Response Committee (adults) or Pediatric Resuscitation Committee (pediatrics). Policy Owner: Bec Dangerfield Approved By: Claudia Cohn, MD Date(s): Date Effective: 1/08 Date Review/Revised: 11/13 Related Information Additional Approvers: UMMC/UMCAH Transfusion Committee