MASSIVE TRANSFUSION PROTOCOL WORKSHEET FOR LABORATORY USE 1. A verbal order to initiate the Massive Transfusion Protocol (MTP) has been received for the following patient Patient Name ____________________________ 2. (page 1 of 2) Account # ________________ Medical Record # _______________ The verbal order to initiate the MTP was received from ________________________ on ___________________ (date/time) and was received by ________________________ on ___________________ (date/time) 3. I acknowledge initiating the Massive Transfusion Protocol and the corresponding lab test and blood product orders for this patient as indicated below ________________________ (prescriber/title) on ___________________ (date/time) Initial Massive Transfusion Order 1. Issue initial package (within 35 min of initial order to initiate MTP)  6 units of RBC’s  4 units FFP Initial package picked up by ________________________ on ___________________ (date/time) 2. Continue with  OR Massive Transfusion Protocol (if patient is going to OR)  ICU Massive Transfusion Protocol (if patient is remaining on a nursing floor) OR Massive Transfusion Protocol (all packages will be delivered within 35 min of the last delivered package) 1. Have second package ready within 35 min of issue of first package. Picked up by __________________on ____________ (date/time)  Six units RBC’s  Four units FFP  One Single Donor Platelet or one “six pack” random platelets 2. Have third package ready within 35 min of issue of second package. Picked up by __________________on ____________ (date/time)  Six units RBC’s  Four units FFP  One “ten-pack” pooled Cryoprecipitate 3. Continue making packages q 35 min until the MTE has been discontinued. All even numbered packages will contain 6 units RBC’s, 4 units FFP and 1 Single Donor Platelet or one “six pack” random platelets. All odd number packages (starting with #3) will contain 6 units RBC’s, 4 units FFP and “ten-pack” pooled cryoprecipitate. Continue with packages until patient moves to ICU, expires or surgeons discontinue the MTE. If patient moves to ICU, continue with ICU Massive Transfusion Protocol. Fourth package picked up by ________________________ on ___________________ (date/time) Fifth package picked up by ________________________ on ___________________ (date/time) 4. OR Massive Transfusion Protocol stopped or changed to ICU Massive Transfusion Protocol on ___________________ (date/time) Authorization is hereby given to dispense the Generic, Chemical, or Therapeutic equivalent as per Medical Staff approved Therapeutic Interchange Policy unless otherwise indicated by the words: “No drug product selection (NDPS)”. For Patient Label Use Only 9900.168 01/12 BC 1302 CHART COPY – White with pink color bar PHARMACY COPY – White MASSIVE TRANSFUSION PROTOCOL WORKSHEET FOR LABORATORY USE (page 2 of 2) ICU Massive Transfusion Protocol st nd rd 1. Order the following lab tests x 3 (order 1 set STAT, 2 set timed for 2 hrs, and 3 set pending). Additional orders may be requested by the Blood Bank depending upon the duration and circumstances of the MTE  PT  PTT  Hemogram  Fibrinogen st 1 labs drawn ____________________________ (date/time) 2 nd labs drawn ____________________________ (date/time) rd 3 labs drawn ____________________________ (date/time) th 4 labs drawn ____________________________ (date/time) 2. Blood products to be ordered immediately (Depending on the duration and circumstances of the MTE, additional orders may be requested by the Blood Bank/Pathologist)  Six units RBC’s (XM6)  Two units FFP (FFP2) 3. Additional Blood products may be ordered by the Blood Bank, Pathologist, or via Physician verbal order 4.  Single Donor Platelet or “six pack” random platelets – Ordered on _______________ (date/time) by ________________________  “Ten-pack” pooled Cryoprecipitate– Ordered on _______________ (date/time) by ________________________ ICU Massive Transfusion Protocol stopped on ___________________ (date/time) Authorization is hereby given to dispense the Generic, Chemical, or Therapeutic equivalent as per Medical Staff approved Therapeutic Interchange Policy unless otherwise indicated by the words: “No drug product selection (NDPS)”. For Patient Label Use Only 9900.168 01/12 BC 1302 CHART COPY – White with pink color bar PHARMACY COPY – White