APPENDIX A: EXAMPLE OF A MASSIVE TRANSFUSION PROCEDURE AT USCENTCOM LEVEL III FACILITY

CONSIDERATIONS FOR USE WITH MASSIVE TRANSFUSION (MT)

- A flexible procedure for use in the Emergency Department (ED), Operating Room (OR) and Intensive Care Unit (ICU) which can be initiated or ceased by the site-specific provider as dictated by the patient’s needs when in that specific venue. It consists of batches as defined below, which vary in composition, but are directed toward approximating a 1:1:1:1 ratio of FFP, platelets, RBC, and cryoprecipitate (CRYO). Note: one unit of apheresis platelets is approximately the equivalent of 6 units random donor platelets, therefore 1u apheresis platelets should be given for every 6 units of RBC to approximate 1:1:1 resuscitation. Crystalloid infusion should be minimized and limited to use as carrier fluid. Hextend® should not be used.
- Note that the MT protocol described below is designed for use with blood components and is designed to provide the functionality of WB. If using WB for MT, the considerations that can be applied from the protocol below include early use of TXA and calcium. Also, if using primarily CWB that has been stored for more than 2 weeks, consider supplementing with additional platelets, either from FWB (consider a ratio of 3:1 of CWB: FWB as available) or from apheresis platelets (consider adding 1 unit of platelets after every 6-10 CWB units if clinically indicated).

Initiate MT procedure if patient has received 4u RBC/4u FFP emergency release blood products.

- Pack One: 6u RBC, 6u FFP, 1u apheresis platelets, 1-2 5-unit bags of cryo. Give TXA empirically if within 3 hours of injury: Infuse 2 grams of TXA in 100 ml of 0.9% NS over 10 minutes intravenously in a separate IV line from any containing blood and blood products. (A more concentrated or rapid injection can be considered but rapid TXA infusion has been infrequently reported to cause transient hypotension.) Give one gram calcium during or immediately after first blood product administered and another gram after every four units of blood
- Pack Two: 6u RBC, 6u FFP, 1u apheresis platelets, 1-2 5-unit bags of cryo. Continue to monitor ionized calcium or give 1gm calcium after every 4 blood
- Pack Three and beyond: identical to Pack Two

Definitions

Emergency Release: Uncrossmatched 4u RBC (generally O+ but may be O- for females under the age of 50 if available) and 4u AB or A plasma (NOTE: A plasma is not “universal” but risk of hemolysis in B or AB patients is very low and its use in massive transfusion patients when supplies of AB FFP are limited or absent may improve survival and help preserve resources. A plasma is commonly used as emergency release plasma throughout the United States.)