Major Transfusion Protocol CUH (Adult)

Definition (massive transfusion)

Blood volume is defined as the total quantity of blood in the body. A patient may be defined as suffering a massive haemorrhage if any of the following occur:

  • Transfusion of more than 10 units of red cells in a 24 hr period or
  • Transfusion of >4 units in <1 hour with ongoing haemorrhage or
  • Predicted need for > 8 units in 2 hours or
  • An ongoing transfusion requirement in an adult of more than 150ml/min or
  • Replacement of one blood volume within a 24hr period or
  • Replacement of more than 50% of blood volume in 3 hrs or less (70mls/kg for adult, 90mls/kg for a child older than a neonate)


  • An emergency supply of Fibrinogen is available in the drug fridge in anaesthetic Room 3 in CUMH for massive obstetric haemorrhage
  • Please note: Plasma will take 20 mins to thaw and platelets need to ordered from the IBTS so all products will be available for collection as they become available, rather than in a single delivery


Alert key personnel to the possibility of a massive haemorrhage:

  • EM consultant
  • Blood Transfusion Laboratory CUH Ext 22537, (OOH bleep 199)
  • Consultant haematologist


An experienced clinician (registrar or above) should assume overall responsibility for immediate management of the patient.

The senior clinician nominates a named individual (liaison person), who is familiar with the clinical details, to take responsibility for:

  • Communication with the blood transfusion lab. and
  • Documentation of all aspects of the massive haemorrhage management from time of initiation to stand down, including the status of blood product support
  • He/she should have appropriate documented training in haemovigilance

The named liaison person:

  • Notifies the blood transfusion laboratory that a 'massive haemorrhage' has been diagnosed by the named senior clinician
  • Provides identification details of the patient affected
  • Provides their own name and contact details to enable effective communication between the lab. and the clinical area
  • Checks that a transfusion sample is available in the laboratory or
  • Arranges for a transfusion sample to be sent urgently to the lab
  • Arranges for urgent FBC, coag. screen, fibrinogen to go to the haem. lab
  • Informs the lab. if the emergency O Rh (D) negative blood has been used and is required to be replaced
  • Advises the laboratory whether emergency uncrossmatched, group specific or fully crossmatched blood is required

General Mx

  • Identify and control (± surgery) cause of bleeding
  • Send baseline FBC, PT, APPT, Fibrinogen, Biochem
  • Consider TXA if trauma
  • Hourly VBG (lactate)
  • IV crystalloid (not colloid) as required
  • Beware hypothermia
  • Beware DIC (at risk):
    • Prolonged hypovolaemia or tissue hypoxia
    • Extensive tissue damage
    • Hypothermia
    • Penetrating head injury
    • Obstetric complications e.g. placental abruption, uterine rupture, amniotic fluid embolism, pre-eclampsia, sepsis
Indication by blood loss Degree of Urgency Transfuse within
≥2.5L, no response to resuscitation Emergency 15 mins
Use Emergency O Neg
1-1.5L + active bleeding
Very Urgent 30mins
6 units type specific and/or uncrossmatched
1-1.5L + loss controlled Urgent 1 Hour
Urgent Crossmatch
0.5-1L Normal Standard

Red cells

  • Start blood component therapy
  • Use a blood warmer and/or rapid infusion device
  • The choice of red cells depends on the degree of urgency
  • The presence of antibodies will delay the provision of compatible blood
  • Note: For males and females beyond child-bearing age it may be necessary to give Rh positive cells


  • Anticipate platelet count <50 x 109/L after 1.5–2 x blood vol. replacement
  • Request via Blood Transfusion Laboratory CUH Ext 22537, (out of hours bleep 199) and send Blood Product Requisition Form to Blood Transfusion Laboratory CUH
  • One unit is the standard adult dose. 10ml /kg for a small child or neonate
  • More on paediatric MTP
  • Further doses should be guided by platelet count and/or clinical condition
  • Allow time for platelet collection and delivery
  • Allow margin of safety to ensure platelet count >50 x 109/L
  • Keep platelet count >100 x 109/L if platelet function abnormal e.g. if patient taking aspirin or other antiplatelet agents
  • Head injury – aim for platelets > 100 x 109/L


  • Anticipate need for SD plasma after 1-1.5 x blood volume replacement
  • Give SD plasma (solvent detergent treated pooled plasma –‘Octaplas’) 15-20 ml/kg (Usual dose is 4-6 units)
  • Base further dosing on coagulation results- aim for PT and APTT <1.5 mean control
  • Order from Blood Transfusion Laboratory CUH using Blood Product Requisition Form (allow 20 min thawing time)
  • PT/APTT >1.5 x mean normal value correlates with increased micro-vascular bleeding


  • Anticipate need for fibrinogen after 1-1.5 blood volume replacement and give Fibrinogen 1-2g IV
  • Base further dosing on coagulation results- aim for fibrinogen >1.5 g/L (for obstetric patients maintain at >2.0 g/L in the event of ongoing haemorrhage)
  • Order from Blood Transfusion Laboratory CUH using Blood Product Requisition Form. Reconstitute at bedside
  • Fibrinogen < 0.6 – 0.8 g/L strongly associated with micro-vascular bleeding

Further Management

  • Initial doses of platelets, SD Plasma and fibrinogen can be administered before platelet or coagulation results are available
  • Repeat Hb, platelet count, PT, APTT and fibrinogen every 2-4 hrs or after administration of initial blood component/product support are necessary to assess the response to blood component therapy and facilitate ongoing management of the patient
  • As soon as the second set of results (Hb, platelet count and coagulation screen) are available, the haematology registrar/consultant covering the blood transfusion laboratory should be asked for advice on further blood product support
  • Continue to repeat Hb, platelet count, PT, APTT and fibrinogen every 4 hours or after second order of blood components/products have been transfused to assess the response to blood component therapy and guide further therapy

Factor VIIa

Circumstances where patients with massive haemorrhage may benefit from Factor VIIa include:

  • Ongoing clinically significant haemorrhage, despite appropriate attempts to achieve surgical control of bleeding and full correction of other clotting factor/platelet deficiencies
  • Severe obstetric haemorrhage requiring consideration of internal iliac artery ligation, uterine artery embolisation or hysterectomy in the setting of optimal blood product support
  • Severe haemorrhage, refractory to local control, in patient who refuses/would refuse blood products, but would accept recombinant blood factors. Administration in these patients may need to be earlier in the course of events, because transfusion is prohibited

All use of VIIa requires authorisation by consultant haematologist.

Special Circumstances

Warfarin – add Vitamin K, Prothrombin complex concentrate.

Obstetric haemorrhage – early DIC often present, consider increased use of fibrinogen.

Head injury – aim for platelets > 100 x 109/ L

Stand down

The transfusion laboratory should be notified when the massive haemorrhage is controlled and the patient is haemodynamically stable or if the patient has been transferred to another hospital/site within the network.

Content by Dr Íomhar O' Sullivan . Last review Dr ÍOS 18/07/22.