Massive transfusion protocol (MTP) template
The information below, developed by consensus, broadly covers areas that should be included in a local MTP. This
template can be used to develop an MTP to meet the needs of the local institution's patient population and resources
Senior clinician determines that patient meets criteria for MTP activation
OPTIMISE:
• oxygenation
• cardiac output
Baseline:
Full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistry, • tissue perfusion
arterial blood gases • metabolic state
MONITOR
(every 30–60 mins):
• full blood count
Notify transfusion laboratory (insert contact no.) to:
• coagulation screen
‘Activate MTP’ • ionised calcium
• arterial blood gases
AIM FOR:
Senior clinician
Laboratory staff • Request:a • temperature > 350C
• Notify haematologist/transfusion specialist o 4 units RBC • pH > 7.2
• Prepare and issue blood components o 2 units FFP • base excess < –6*
as requested • Consider:a
• Anticipate repeat testing and • lactate < 4 mmol/L
o 1 adult therapeutic dose platelets
blood component requirements • Ca2+ > 1.1 mmol/L
o tranexamic acid in trauma patients
• Minimise test turnaround times • platelets > 50 × 109/L
• Consider staff resources • Include:a
o cryoprecipitate if fibrinogen < 1 g/L • PT/APTT < 1.5 × normal
• INR ≤ 1.5
Haematologist/transfusion a Or locally agreed configuration
• fibrinogen > 1.0 g/L
specialist
• Liaise regularly with laboratory
and clinical team Bleeding controlled? *The numerical representation of base excess can be shown
• Assist in interpretation of results, and
advise on blood component support
YES NO differently in varying texts. Please be aware that for the
purposes of this template, a base excess of <-6 refers to a
Notify transfusion laboratory to: base excess of -5, -4, -3 and so forth. A base excess of -7, -
‘Cease MTP’ 8, -9 and so on is associated with a worsening prognosis. The
normal range for base excess is -2 - +2.
Suggested criteria for activation of MTP
• Actual or anticipated 4 units RBC in < 4 hrs, + haemodynamically unstable, +/– anticipated ongoing bleeding
• Severe thoracic, abdominal, pelvic or multiple long bone trauma
• Major obstetric, gastrointestinal or surgical bleeding
Initial management of bleeding Resuscitation
• Avoid hypothermia, institute active warming
• Identify cause • Avoid excessive crystalloid
• Initial measures: • Tolerate permissive hypotension (BP 80–100 mmHg systolic)
- compression until active bleeding controlled
- tourniquet • Do not use haemoglobin alone as a transfusion trigger
- packing
• Surgical assessment:
- early surgery or angiography to stop bleeding
Special clinical situations
•Warfarin:
Specific surgical considerations
• add vitamin K, prothrombinex/FFP
• If significant physiological derangement, consider • Obstetric haemorrhage:
damage control surgery or angiography • early DIC often present; consider cryoprecipitate
• Head injury:
Cell salvage • aim for platelet count > 100 × 109/L
• permissive hypotension contraindicated
•Consider use of cell salvage where appropriate
Dosage Considerations for use of rFVIIab
The routine use of rFVIIa in trauma patients is not recommended due to
its lack of effect on mortality (Grade B) and variable effect on morbidity
Platelet count < 50 x 109/L 1 adult therapeutic dose (Grade C). Institutions may choose to develop a process for the use of
INR > 1.5 FFP 15 mL/kga rFVIIa where there is:
• uncontrolled haemorrhage in salvageable patient, and
Fibrinogen < 1.0 g/L cryoprecipitate 3–4 ga
• failed surgical or radiological measures to control bleeding, and
Tranexamic acid loading dose 1 g over 10
min, then infusion of 1 g • adequate blood component replacement, and
over 8 hrs • pH > 7.2, temperature > 340C.
a Local transfusion laboratory to advise on number of units Discuss dose with haematologist/transfusion specialist
needed to provide this dose
b
rFVIIa is not licensed for use in this situation; all use must be part of practice review.
ABG arterial blood gas FFP fresh frozen plasma APTT activated partial thromboplastin time
INR international normalised ratio BP blood pressure MTP massive transfusion protocol
DIC disseminated intravascular coagulation PT prothrombin time FBC full blood count
RBC red blood cell rFVlla activated recombinant factor VII
