Massive Transfusion Guidelines
Purpose: This document provides guidelines only for efficient and effective transfusion
support for patients who have massive blood loss. As always, individual circumstances
need to be considered for each patient. This document will be reviewed and updated
periodically.
Definition: Replacement of at least 1 blood volume (80cc/kg) in the first 24 hours of
resuscitation.
Triggers for massive transfusion:
1) Replacement of  20 ml/kg of RBCs within the first hour of resuscitation
2) Anticipated continued blood loss that would amount to 1 blood volume in 24
hours.
Either the clinical team or the Blood Bank can activate the Blood Bank Massive
Transfusion Protocol (see appendix K of the Patient Care Policy Blood and Blood
Components” . At the Blood Bank, the following will be available once massive
transfusion is called by the physician or triggered by the Blood Bank:
Age (y)
0-3
4-7
8-12
>12
# units pRBC used
in 24 h
4
6
8
10
# units FFP thawed
and available
1
2
4
4
# units SDP platelet
available
1
1
1
1
Overall management:
1. Restore circulating volume
2. Timely sample for blood type and crossmatch is required
3. Keep patient normothermic (core body temperature  36C; refer to Guidelines
for Prevention and Management of Hypothermia in Trauma).
4. Anticipate and treat electrolyte imbalance (hypocalcemia, hyperkalemia)
5. Above parameters should be monitored at least every 6 hours post-stabilization
and at 24 hours post stabilization.
6. Correct underlying cause of DIC if possible.
Laboratory monitoring:
1) Initial: CBC, type and crossmatch, PT, PTT, fibrinogen, chemistry, glucose,
blood gas
2) Ongoing: hemoglobin, platelet count, ICa, K, glucose, ABG (known as a
surgical panel in the OR), PT, PTT, fibrinogen: Note
Obtained by defined order set for intraoperative lab monitoring q1h
In the PICU, obtained at least q 2-3h until stabilization.
End points of resuscitation:
In general, the goals of therapy are maintenance or restoration of tissue perfusion and
oxygenation by restoring blood volume and hemoglobin and arrest of bleeding by
surgical treatment of the source and correction of coagulopathy.
Blood component therapy
Blood product
Packed red
blood cells
Frozen plasma
Triggers
- Hb < 8 gm/dl
- If a third 20 ml/kg fluid
bolus is required to
maintain blood pressure
Dose
15 ml/kg
Comments
- O neg RBCs are provided
until sample is received for
crossmatch, then group
compatible uncrossmatched
blood given
- Blood bank may switch to
Rh pos for males
- FFP takes 20 min to thaw
- If PT >15 sec (INR
20 ml/kg
>1.5), PTT >40 sec
- Once 40 ml/kg pRBC
given, if still bleeding
- Diffuse microvascular
bleeding
Platelets
- If Weight
- Platelet count
≥30 kg, 1
<75,000/ul if ongoing
single donor
bleeding
pheresed
- Once 40-80 ml/kg
(SDP) unit;
RBCs have been
replaced, platelet count is if Weight
<30 kg, ½
likely <50,000/ul (may
SDP unit
occur sooner)
Cryoprecipitate - Fibrinogen <100 mg/dl 1 unit/10kg - Cryoprecipitate takes 20
- “Clinical” DIC: oozing,
minutes to thaw
major head injury,
uncontrolled hemorrhage
NOTE: It is Blood Bank policy to irradiate all blood products for children  12 months of
age. Irradiation takes about 7 additional minutes per unit of blood product. The clinical
team could instruct the Blood Bank to forego irradiation in urgent cases.
Recombinant
factor VIIa
- May be considered if
ongoing bleeding despite
conventional therapy and
surgical management
40-90
mcg/kg
- Optimal dose is not known
(there are studies showing
beneficial effect with doses
as low as 20 mcg/kg). There
are no controlled studies
that address benefit and
safety in trauma. DIC is a
relative contraindication.
Stopping massive transfusion support
When the patient is stabilized, the clinical team should inform the Blood Bank of the
decreased need for support, so as not to waste resources.
Developed by the Trauma Program at Children’s Hospital of Wisconsin
Revisions 4/2008
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