I was recently assessed by the AABB and was cited for not having a policy for massive transfusion. We had previously decided our hospital does not require one, because we perform an IS x-match and also transfuse blood components as needed, not based on a formula.

As the standard now requires that you have a policy for massive transfusion, (i.e. compatibility testing when, within 24 hours, a patient has received an amont of blood approximating the total blood volume), can some indiviuals share with me there massive transfusion protocol, or can share with me their statement that their massive transfusion ppolicy is not to have one at all?

We do not have one at our facility but I saw a discussion about this topic on the California Blood Bank Society website (www.cbbsweb.org). Several people had shared their facilities policies for massive transfusion.

We do not have one at our facility but I saw a discussion about this topic on the California Blood Bank Society website (www.cbbsweb.org). Several people had shared their facilities policies for massive transfusion.

Jane,

I went on this site. Lots of different opinions, and different policies. Some of them are confusing an emergency release protocol with a massive transfusion protocol. It gets more confusing when I read so I will have to try to distill all the information down to a workable policy. It looks like a minimum of 10 units is the standard to initiate a massive transfusion protocol.

Are you going to develop a massive transfusion protocol to meet AABB standards?

Still looking for additional policies, protocols and opinions.

We have a very old policy, but it is only related to patients with clinically significant antibodies.

The policy states to notify the medical director who may decide to give antigen negative units at immediate spin.

Something we elected to do after our last aaBB assessment was to perform a gap analysis. It was rather enlightening and time consuming. We have a large staff and they all helped. We reviewed each standard and documented where it was met in our procedures, or where we weren't meeting it. It took many months to complete. The benefit is now we really know where we stand and what we need to accomplish.

We have a simple procedure that states to notify pathologist when in a massive situation->10 units RBC/24 hrs. Then we define that when patient is no longer in massive i.e. <10 units/24hrs to draw a new specimen and repeat testing. We also give antigen negative units with IS testing on patients with antibodies.

Our policy is simple. If the patient has no history of antibodies and has received 10 or more units of RBC in less then 24 hours then we can issue uncrossmatched blood to the patient. If those units are brought back (like from OR) we will keep them around and if we still have them after about 8 hours we will crossmatch them.

We currently have a policy that defines a massive transfusion as >10 units of PRBC in a 24 hour period. Since we can perform IS crossmatches, we have elected to continue to perform these procedures unless emergency blood is necessary. Taking the negative screen into account, we would release uncrossmatched type specific units during those emergencies. With good communication it is not difficult to keep ahead of these cases. There are many opinions about this, but I think its important to have a documented policy, regarding of which way you go.