Blood Product Utilization Among Trauma and

Nontrauma Massive Transfusion Protocols at an Urban

Academic Medical Center
Eshan U. Patel, MPH,* Paul M. Ness, MD,* Christi E. Marshall, MT(ASCP),*
Thomas Gniadek, MD,* David T. Efron, MD, Peter M. Miller, MD,* Joseph A. Zeitouni, MD,
Karen E. King, MD,* Evan M. Bloch, MD,* and Aaron A. R. Tobian, MD, PhD*

BACKGROUND: Hospital-wide massive transfusion protocols (MTPs) primarily designed for

trauma patients may lead to excess blood products being prepared for nontrauma patients.
This study characterized blood product utilization among distinct trauma and nontrauma MTPs
at a large, urban academic medical center.
METHODS: A retrospective study of blood product utilization was conducted in patients who
required an MTP activation between January 2011 and December 2015 at an urban academic
medical center. Trauma MTP containers included 6 red blood cell (RBC) units, 5 plasma units, and
1 unit of apheresis platelets. Nontrauma MTP containers included 6 RBC and 3 plasma units.
RESULTS: There were 334 trauma MTP activations, 233 nontrauma MTP activations, and 77
nontrauma MTP activations that subsequently switched to a trauma MTP (switched activa-
tions). All nontrauma MTP activations were among bleeding patients who did not have a
traumatic injury (100% [233/233]). Few patients with a nontrauma activation required ad hoc
transfusion of RBC units (1.3% [95% confidence interval (CI), 0.3%3.7%]) or plasma (3.4%
[95% CI, 1.5%6.7%]), and only 45.5% (95% CI, 39.0%52.1%) required ad hoc transfusion
of apheresis platelets. Compared to trauma and switched activations, nontrauma activations
transfused a lower median number of RBC, plasma, and apheresis platelet units (P < .001 for
all comparisons). There was also a lower median number of prepared but unused plasma units
for nontrauma activations (3; [interquartile range (IQR), 35]) compared to trauma (7; [IQR,
510]; P < .001) and switched activations (8; [IQR, 511]; P < .001). The median number of
unused apheresis platelet units was 1 (IQR, 12) for trauma activations and 0 (IQR, 01) for
switched activations. There was a high proportion of trauma and switched activations in which
all of the prepared apheresis platelet units were unused (28.1% [95% CI, 23.4%33.3%] and
9.1% [95% CI, 3.7%17.8%], respectively).
CONCLUSIONS: The majority of initial nontrauma MTP activations did not require a switch to
a trauma MTP. Patients remaining under a nontrauma MTP activation were associated with a
lower number of transfused and unused plasma and apheresis platelet units. Future studies
evaluating the use of hospital-wide nontrauma MTPs are warranted since an MTP designed for
nontrauma patient populations may yield a key strategy to optimize blood product utilization
in comparison to a universal MTP for both trauma and nontrauma patients. (Anesth Analg
2017;XXX:0000)

M
assive transfusion is a key intervention for
patients with uncontrolled hemorrhage.1,2 There
are several definitions of adult massive transfu-
sion, such as the administration of 10 red blood cell (RBC)
units within 24 hours or the acute administration of >4 RBC
units within 1 hour.2 There is also evidence supporting the
early administration of plasma and platelets during mas-
sive transfusiona strategy that seeks to restore clotting
function in the setting of active blood loss.3 Therefore, many
From the *Department of Pathology and Department of Surgery, Johns
Hopkins University, Baltimore, Maryland; and Department of Pathology,
University of Miami, Miller School of Medicine, Miami, Florida.
Accepted for publication April 20, 2017.
Funding: None.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Aaron A. R. Tobian, MD, PhD, Division of Trans-
fusion Medicine, Department of Pathology, Johns Hopkins University, 600 N.
Wolfe St, Carnegie 437, Baltimore, MD 21287. Address e-mail to atobian1@
jhmi.edu.
Copyright 2017 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000002253
institutions have implemented massive transfusion proto-
cols (MTPs) designed to systematically deliver preassigned
ratios of RBC, plasma, and platelet units in a quicker and
less variable manner than ad hoc transfusions.4 However,
the optimal ratio of blood components to guide an MTP is
debatable, varies by institution, and is likely differential by
patient group.46
MTPs have typically been designed to meet the clinical
needs of trauma patients. However, studies have shown
that implementation of an MTP can improve patient out-
comes in both trauma and nontrauma patients.4,711 While
some institutions have observed no significant change in
blood product utilization after extending eligibility of uni-
versal (trauma-based) MTPs to nontrauma patients,12,13
other studies suggest this type of practice may direct
resources toward a population that may not necessar-
ily need them.9,14 As an alternative strategy, some institu-
tions have reported the use and benefits of implementing
specialized MTPs in select nontrauma patient subgroups,
specifically in the setting of gastrointestinal, cardiac, and
obstetrical hemorrhage.1518 In fact, a recent survey of US

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 Blood Product Utilization Among Trauma and Nontrauma MTPs
academic medical centers found that 41% of responding
institutions implemented specialized MTPs for different
clinical services; however, none reported use of a general
nontrauma MTP to encompass all nontrauma patients.19 In
order to enhance logistical feasibility for the blood bank, a
general nontrauma MTP protocol for multiple services may
be better than having different nontrauma MTPs for each
clinical service.
In our initial experience at a large, urban academic medi-
cal center, implementation of a single hospital-wide MTP
that included apheresis platelets for all patients suggested
platelets were commonly being wasted among nontrauma
patients (unpublished data). Therefore, in 2011, we imple-
mented distinct hospital-wide trauma and nontrauma
MTPs. Compared to the trauma MTP, the nontrauma MTP
did not release any apheresis platelets. Little is known about
the implementation and uptake of a hospital-wide non-
trauma MTP and if its availability reduces blood component
utilization. In this retrospective study, we characterized
blood product utilization among trauma and nontrauma
MTP activations.
METHODS
Ethics Approval
This study was approved by the Institutional Review Board
of the Johns Hopkins Medical Institutions. Requirement for
written informed consent was waived. This article adheres
to the applicable Equator guidelines.
Study Subjects
A retrospective study was conducted among patients who
had an MTP activation at the Johns Hopkins Hospital
between January 2011 and December 2015. Clinical nar-
ratives and other relevant data were extracted from the
electronic medical record. Data on transfusion of blood com-
ponents were determined from blood bank records. Since
the primary purpose of this study was to characterize blood
product utilization among patients undergoing an MTP,
activations were excluded if the blood bank was immedi-
ately notified that the clinical team no longer needed blood
and the container had not been prepared (ie, there was no
blood product utilization or waste). In addition, if a second
MTP activation occurred for the same patient, this second-
ary activation was excluded to minimize selection bias.
The classification of patients as trauma versus nontrauma
was determined by the clinical narrative provided by the
ordering physician at the time of the MTP activation. To be
considered a trauma patient, the clinical narrative had to
include a description of physical injuries of sudden onset
and severity that required immediate medical attention
and/or resuscitation (eg, gunshot wounds).
MTP Protocol Designs
A phone call to the blood bank was required to formally
activate an MTP (either trauma or nontrauma), and the
blood bank immediately prepared and issued the first con-
tainer without further consultation (Figure 1). All adult
emergency trauma patients received a trauma MTP activa-
tion by the trauma service (Acute Care Surgery [Trauma
and Emergency General Surgery]) if one was required.
2
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For other services, there were no specific criteria for the
clinical teams decision to activate a trauma versus non-
trauma MTP; the transfusion medicine resident helped
to coordinate the decision of a trauma versus nontrauma
MTP activation (eg, reviewed protocol differences and
clinical indication) for the continuation of the MTP. For
some patients, it was clear that the initially activated non-
trauma MTP needed to be switched to a trauma MTP to
meet patient needs, often because the patient was bleeding
more profusely than initially anticipated. According to our
policy, the clinical team could immediately place the order
with the blood bank themselves and/or reconsult with
the transfusion medicine resident to make this change.
Regardless, the transfusion medicine service always fol-
lowed up to help coordinate the MTP.
The trauma MTP containers initially included 6 units of
RBCs, 6 units of plasma, and 1 unit of apheresis platelets.
However, after March 14, 2014, the trauma MTP contain-
ers were modified to include 5 units of plasma (3 group AB
and 2 group A) instead of the original 6 units of plasma for
patients who did not have a type and screen sample avail-
able. Every third trauma MTP container that was released
from the blood bank also contained 10 units of cryopre-
cipitate, which were set out to thaw ahead of preparing the
third container. The nontrauma MTP containers included 6
units of RBCs and 3 units of plasma; apheresis platelets and
cryoprecipitate were not included in nontrauma MTP con-
tainers. Containers were packed and validated for 24 hours.
Plasma was kept thawed at all times in preparation for an
MTP activation.
MTP containers were returned to the blood bank (includ-
ing unused units), but this was not necessary in order to
retrieve the next container. Requests for RBCs, plasma, or
apheresis platelets in addition to the contents of MTP con-
tainers could be directly ordered. Factor concentrates (eg,
recombinant FVIIa or prothrombin complex concentrates)
could be requested in consultation with a transfusion medi-
cine resident. MTPs were terminated by the ordering phy-
sician or transfusion medicine resident when the massive
transfusion requirement abated. In general, transfusions
at our institution are goal-directed. However, for MTPs,
especially trauma MTPs, transfusions become empiric with
a focus on maintaining the proper ratio of blood products
transfused.
It should be noted that at our institution, limited RBC units
are also directly available at primary locations of highest
use either through a Hemosafe (Haemonetics Corporation,
Braintree, MA) (operating rooms) or refrigerators containing
emergency release units (intensive care units and emergency
rooms). In addition, thawed plasma is available for immedi-
ate issue from the blood bank at all times.
Statistical Analysis
MTP activations were analyzed by the protocol the patient
experienced: (1) trauma MTP; (2) nontrauma MTP; or (3)
switched MTPan initial nontrauma MTP switched
midcourse to a trauma MTP. Switched MTP activations
were analyzed separately since patients in this group were
transfused with blood components from both nontrauma
and trauma containers.
ANESTHESIA & ANALGESIA


Figure 1. Procedural diagram of the trauma and nontrauma massive transfusion protocols. *1 apheresis platelet unit is equivalent to 6
individual units of platelets. ABG indicates arterial blood gas; aPTT, activated partial thromboplastin time; CBC, complete blood count; CMP,
complete metabolic panel; MTP, massive transfusion protocol; PT; prothrombin time; RBC, red blood cell.

Descriptive statistics were used to explore patient char-
acteristics and blood product utilization (RBCs, plasma,
and apheresis platelets) for patients in each MTP activation
group. For each type of blood product, primary outcomes
of interest included the total number of transfused units,
the proportion of patients requiring ad hoc transfusion in
addition to the MTP, the total number of unused MTP units
(ie, potential waste), and the proportion of patients who had
MTP units prepared but were never transfused. Categorical
variables were summarized by percentages and 95% confi-
dence intervals (CIs), which were calculated from a bino-
mial distribution. Continuous variables were summarized
by median values and the interquartile range (IQR: 25th
75th percentiles). Differences in categorical and continu-
ous variables by MTP activation group were determined
by Pearson 2 tests and Wilcoxon-Mann-Whitney rank sum
tests, respectively. The threshold for statistical significance
was set at a P value <.05 (2-tailed).
Due to the retrospective design of this study, a priori
power analyses were not conducted. However, with a
total N for each of the 3 activation groups of 334 (trauma
MTP), 233 (nontrauma MTP), and 77 (switched MTP), we
had 90% power at the .05 significance level to detect differ-
ences of 0.25 standard deviations between trauma MTP and
nontrauma MTP activations and 0.34 standard deviations
between the switched MTP and nontrauma MTP activa-
tion groups. Since nonparametric analyses were conducted
instead of t tests, actual power was somewhat lower but still
sufficient to detect moderate to large effect sizes in blood
product usage, for example. Power was considerably lower
to detect differences on binary outcome variables.
We conducted a sensitivity analysis limited to non-
trauma patients (ie, patients without a traumatic injury)
the intended population of the nontrauma MTP. For this
analysis, we compared the number of unused plasma and
apheresis platelet units between each MTP activation group.
To ensure findings were not confounded by time since the
implementation of the nontrauma MTP, we repeated the
sensitivity analysis limited to data collected in 2015. All
statistical analyses were conducted in Stata SE, version 14.2
(StataCorp, College Station, Texas).
RESULTS
Characteristics of the MTP Activations
Over the 5-year study period, there were 644 patients with
an MTP activation. There were 334 patients who had a
trauma MTP activation and 310 patients who started with
a nontrauma MTP activation; however, 24.8% (77/310) of
the initial nontrauma MTP activations required a switch to
a trauma MTP activation midcourse (switched MTP acti-
vations). Patient characteristics including blood product
use prior to MTP activation differed between the 3 MTP
activation groups (Table 1). The trauma service, which is
involved in both trauma and nontrauma surgeries, was the

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 Blood Product Utilization Among Trauma and Nontrauma MTPs

Table 1.Characteristics of the Massive Transfusion Protocol Activations

MTP Type
Trauma, Nontrauma, Nontrauma Switch,
Total, N (%) N (%) N (%) N (%) P Valuea
Total MTP activations N = 644 N = 334 N = 233 N = 77
Requesting clinical serviceb <.001
Trauma 184 (28.6) 184 (55.1) 0 (0.0) 0 (0.0)
Cardiology 168 (26.1) 67 (20.1) 75 (32.2) 26 (33.8)
Gastroenterology 76 (11.8) 14 (4.2) 50 (21.5) 12 (15.6)
Obstetrics/gynecology 34 (5.3) 12 (3.6) 12 (5.2) 10 (13.0)
Other 182 (28.3) 57 (17.1) 96 (41.2) 29 (37.7)
Clinical indicationc <.001
Trauma patient 161 (25.0) 160 (47.9) 0 (0.0) 1 (1.3)
Nontrauma patient 483 (75.0) 174 (52.1) 233 (100.0) 76 (98.7)
Pre-MTP red blood cell use
No 93 (14.4) 62 (18.6) 29 (12.5) 2 (2.6) .001
Yes 551 (85.6) 272 (81.4) 203 (87.6) 75 (97.4)
Pre-MTP plasma use <.001
No 306 (47.5) 200 (59.9) 87 (37.3) 19 (24.7)
Yes 338 (52.5) 134 (40.1) 146 (62.6) 58 (75.3)
Pre-MTP platelet use <.001
No 393 (61.0) 232 (69.5) 125 (53.6) 36 (46.8)
Yes 251 (39.0) 102 (30.5) 108 (46.4) 41 (53.3)
Abbreviation: MTP, massive transfusion protocol.
a
P values were calculated by Pearson 2 test and compare all 3 MTP groups.
b
Includes medical and surgical subspecialties. The trauma service refers to the Acute Care Surgery division, which includes trauma and emergency general
surgery.
c
Based on descriptive narrative as provided by ordering physician at the time of massive transfusion protocol activation. True traumas were defined as those that
involved physical injuries of sudden onset and severity that required immediate medical attention/resuscitation (eg, gunshot wounds).

Figure 2. Temporal trends in massive transfusion protocol activations (20112015). MTP indicates massive transfusion protocol.

most common service to activate the trauma MTP (55.1%
[184/334]; Table 1). The nontrauma MTP (32.2% [75/233])
and switched MTP (33.8% [26/77]) were most commonly
activated by cardiac services (Table1). In general, clinical ser-
vices other than the trauma team were more likely to initially
activate the nontrauma MTP than the trauma MTP (Table1).
However, despite the availability of a nontrauma MTP, 36.0%
(174/483) of patients with a nontrauma clinical indication (ie,
without a traumatic injury) had a trauma MTP activation.
Overall, MTP activations have increased annually (Figure2).
Blood Product Utilization During MTP Activations
Compared to patients who had a nontrauma MTP activation
(n = 59; 25.3% [95% CI, 19.9%31.4%]), patients who had
a trauma MTP activation (n = 125; 37.4% [95% CI, 32.2%
42.9%]; P < .001) or switched MTP activation (n = 48; 62.3%
[95% CI, 50.6%73.1%]; P < .001) were significantly more
likely to be transfused with 10 RBC units during the MTP
activation period.
The median number of total transfused RBC units was sig-
nificantly lower among nontrauma MTP activations (median,
4 [IQR, 110]) than trauma MTP activations (median, 6 [IQR,
216]; P < .001) or switched MTP activations (median, 15
[IQR, 730]; P < .001; Table 2). Nontrauma MTP activations
(median, 3 [IQR, 16]) also had a significantly lower median
number of total transfused plasma units in comparison to
trauma MTP activations (median, 5 [IQR, 212]; P < .001) or
switched MTP activations (median, 12 [IQR, 623]; P < .001).

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Table 2.Blood Product Usage During Massive Transfusion Protocol Activation

Total (n = 644) Trauma MTP (n = 334) Nontrauma MTP (n = 233) Switched MTP (n = 77)
Median (Interquartile Range)
Containers prepared via MTP 2 (24) 2 (24) 2 (13) 4 (37)
Red blood cells
Units prepared via MTP 12 (1224) 12 (1224) 12 (618) 24 (1842)
Units transfused via MTP 6 (215) 6 (216) 4 (110) 15 (730)
Total units transfuseda 6 (215) 6 (216) 4 (110) 15 (730)
Unused MTP units 8 (612) 8 (511) 8 (612) 12 (817)
Plasma
Units prepared via MTP 10 (618) 12 (1024) 6 (39) 18 (1533)
Units transfused via MTP 5 (210) 5 (212) 3 (16) 12 (623)
Total units transfuseda 5 (211) 5 (212) 3 (16) 12 (623)
Unused MTP units 5 (39) 7 (510) 3 (35) 8 (511)
Apheresis platelets
Units prepared via MTP 2 (03)b 2 (24) 2 (24)b
Units transfused via MTP 0 (02)b 1 (02) 2 (13)b
Total units transfuseda 1 (02) 1 (03) 0 (01) 3 (15)
Unused MTP units 0 (01)b 1 (12) 0 (01)b
Abbreviation: MTP, massive transfusion protocol.
a
Includes units transfused outside MTP.
b
Includes the zero platelets for the nontrauma MTP containers.

Few patients who had a nontrauma MTP activation
required ad hoc transfusion of RBCs (n = 3; 1.3% [95% CI,
0.3%3.7%]) or plasma (n = 8; 3.4% [95% CI, 1.5%6.7%])
outside the protocol (Figure3). Similarly, <10% of patients
who had a trauma or switched MTP activation required
ad hoc transfusion of RBCs or plasma outside the proto-
col (Figure3). However, the proportion of patients requir-
ing ad hoc transfusion of apheresis platelets outside
the protocol was expectedly higher among nontrauma
MTP activations (n = 106; 45.5% [95% CI, 39.0%52.1%];
P < .001) and switched MTP activations (n = 26; 33.8%
[95% CI, 23.4%45.4%]; P < .001) than trauma MTP activa-
tions (n = 13; 3.9% [95% CI, 2.1%6.6%]; Figure3). Among
the nontrauma MTP activations (n = 106) and switched
MTP activations (n = 26) that required ad hoc transfusion
of apheresis platelets, the median number of transfused
apheresis platelet units outside the protocol was 2 (IQR,
13) for both subgroups.
activation group had any unused apheresis platelet units
(0% [95% CI, 0%1.6%]).
There was no significant difference in the median
number of unused RBC units between the trauma MTP
(median, 8 [IQR, 511]) and the nontrauma MTP (median,
8 [IQR, 612]) activations (P = .686; Table 2). The highest
median number of unused RBC units was observed among
switched MTP activations (median, 12 [IQR, 817]; P < .001
for both comparisons; Table2). The highest median number
of unused plasma units was also observed among switched
MTP activations (median, 8 [IQR, 511]; P < .001 for both
comparisons; Table 2). However, nontrauma MTP activa-
tions (median, 3 [IQR, 35]) had a lower median number of
unused plasma units than trauma MTP activations (median,
7 [IQR, 510]; P < .001; Table 2). There was a median of 1
(IQR, 12) and 0 (IQR, 01) unused apheresis platelet units
among patients who had trauma and switched MTP activa-
tions, respectively (Table2).

Unused MTP Blood Products MTP Activations Without Any Transfusions

There was a high proportion of trauma MTP activations
among which all dispensed RBC units (n = 50; 15.0% [95%
CI, 11.3%19.3%]) and plasma units (n = 48; 14.4% [95% CI,
10.8%18.6%]) were unused (Table3). In addition, there was
a high proportion of nontrauma MTP activations among
which all of the dispensed RBC units and plasma units
were unused (n = 53; 22.7% [95% CI, 17.5%28.7%] for both
components; Table3). Only a few patients in the switched
MTP activation group had RBC and plasma units prepared
but never transfused (Table3). Similar to RBCs and plasma,
there was a high proportion of patients who had trauma or
switched MTP activations among whom all apheresis plate-
let units from MTP containers were unused (28.1% [95%
CI, 23.4%33.3%] and 9.1% [95% CI, 3.7%17.8%], respec-
tively; Table3). Additionally, 83.8% (95% CI, 79.4%87.6%)
of the patients who had a trauma MTP activation and 41.6%
(95% CI, 30.4%53.4%) of the patients who had a switched
MTP activation had at least 1 unused apheresis platelet
unit. By design, none of the patients in the nontrauma MTP
Our analytic sample population excluded 19 MTP activa-
tions that never had blood products prepared by the blood
bank, which primarily reflected activations that were imme-
diately terminated. However, in our sample, there were
an additional 32 patients who had a trauma MTP activa-
tion (9.6% [95% CI, 6.6%13.5%]), 39 patients who had a
nontrauma activation (16.7% [95% CI, 12.2%22.2%]), and
1 patient who had a switched MTP activation (1.3% [95%
CI, 0.0%7.0%]) who never received a single transfusion of
any blood product during the MTP activation period. This
finding was not associated with study year or the patients
trauma status (data not shown).
Sensitivity Analyses
We performed a sensitivity analysis limited to MTP acti-
vations among nontrauma patients (N = 483). There was a
lower median number of unused plasma units among non-
trauma patients with a nontrauma MTP activation (median,
3 [IQR, 35]) compared to nontrauma patients with a

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 Blood Product Utilization Among Trauma and Nontrauma MTPs
Figure 3. Proportion of patients requiring any blood product transfusion outside the massive transfusion protocol (20112015). MTP indi-
cates massive transfusion protocol; RBC, red blood cell.
Table 3.Individuals With Blood Products Prepared via Massive Transfusion Protocol but Never Transfused a
Particular Product
Blood Product Not Transfused Total, N (%) Trauma MTP, N (%)
Total patients N = 644 N = 334
Red blood cells 105 (16.3) 50 (15.0)
Plasma 103 (16.0) 48 (14.4)
Apheresis platelets 101 (15.7) 94 (28.1)
Abbreviation: MTP, massive transfusion protocol.
trauma MTP activation (median, 7 [IQR, 59]; P < .001)
or switched MTP activation (median, 7.5 [IQR, 4.511]);
P < .001). Nontrauma patients with a trauma MTP activation
and switched MTP activation had a median of 1 (IQR, 12)
and 0 (IQR, 01) unused apheresis platelet units, respec-
tively. These findings were replicated in a separate analysis
limited to recent data collected in 2015 (data not shown).
DISCUSSION
This study characterized the implementation and utility
of 2 distinct MTPs for trauma and nontrauma patients at
a large, urban academic medical center. As expected, non-
trauma MTP activations were associated with a lower quan-
tity of total transfused units of RBCs, plasma, and platelets
in comparison to trauma MTP activations. However, there
was also a lower number of unused blood products among
nontrauma MTP activations than trauma MTP activations.
Although we were unable to quantify if the blood products
returned to the blood bank were reentered into inventory or
alternatively wasted, the availability of a nontrauma MTP
that issues fewer units of plasma and platelets may be a use-
ful strategy to conserve resources. Based on the data pre-
sented in this study, carefully planned prospective studies
to evaluate the efficiency and appropriateness of nontrauma
MTPs for nontrauma patients are warranted.
There is significant heterogeneity in the utilization and
composition of MTPs between institutions.6 In a recent sur-
vey of US trauma centers, 82% of respondents reported they
activate a trauma-based MTP for nontrauma patients at a
similar rate as they do for trauma patients.6 This highly prev-
alent practice has been criticized as inefficient and wasteful
6
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Nontrauma MTP, N (%) Switched MTP, N (%)
N = 233 N = 77
53 (22.7) 2 (2.6)
53 (22.7) 2 (2.6)
... 7 (9.1)
in terms of the blood product supply, and our study supports
these concerns. In particular, several studies have previously
reported a trauma MTP overactivation rate of 19% to 29%
among trauma patients and 51% to 54% among nontrauma
patients.9,10,14 We observed a high number of patients who
had an MTP activation but were never transfused; however,
these activations without transfusions occurred at a similar
rate between trauma and nontrauma patients and did not
change by study year. As others have suggested, there is a
need for a validated algorithm to predict the necessity for
MTP activation to additionally help prevent wastage of
blood components.1,9,10,14,20 We recommend this may need to
be done for nontrauma and trauma patients separately.
This study was not designed to determine the clini-
cal appropriateness of each MTP; however, it is promising
that only a small proportion of patients required RBCs and
plasma outside of the trauma, nontrauma, and switched
MTP activations. This finding suggests that the 2 distinct
protocols are meeting the clinical needs of the patients. The
data in this study support not routinely including plate-
lets for nontrauma MTPs since only half of the patients
with the nontrauma MTP activation required any platelet
transfusions. Due to our large transfusion service (>20,000
apheresis platelets transfused annually), there was likely
no substantial delay in providing platelets outside of the
trauma or nontrauma MTP. However, this may be an opera-
tional issue for smaller clinical services. Future investiga-
tions of nontrauma MTPs should quantify the delay in time
for ad hoc platelet transfusion and the impact of any kind of
delay on patient outcomes.
This study has limitations. Because of the single-center
study design, our findings may not be generalizable to other
ANESTHESIA & ANALGESIA

institutions. The studys retrospective design did not allow
us to explore associations that may further characterize
blood product utilization and patient characteristics under
each MTP. For example, we did not know the duration of
the MTP activation in hours and thus were unable to quan-
tify the number of true massive transfusions. In addition,
we were unable to compare product use and wastage before
and after the implementation of the nontrauma MTP. We
were also unable to quantify if the blood products returned
to the blood bank were reentered into inventory or alter-
natively wasted, as this information was not systematically
documented. Anecdotally, however, we noted there was at
least a high wastage rate of cryoprecipitate among trauma
MTP activations. Although cryoprecipitate is only included
in every third trauma MTP container, the blood bank sets
it out to thaw ahead of preparing the third container for
release. In many cases, the trauma MTP was deactivated
before the third container was needed, and since cryopre-
cipitate outdates in 4 hours, the cryoprecipitate units set out
to thaw were ultimately wasted. Since cryoprecipitate was
not included in the nontrauma MTP, we did not have issues
with this potentially wasted product.
It is important to reiterate that this descriptive analysis was
designed to provide the blood banks perspective and not eval-
uate best clinical practice. Thus, the evaluation of optimal blood
product ratio and patient outcomes was beyond the scope of
this study. We do not have data on the role of antithrombotic
agents versus anatomic defects, which could play a large role
in individuals who used large numbers of RBC units. These
new agents could also reduce plasma use. Moreover, we did
not have data on whether the nontrauma patients could ben-
efit from RBCs alone and not need plasma. However, our insti-
tution has embraced platelet and RBC transfusion guidelines
from the AABB (formerly the American Association of Blood
Banks),21,22 and we have an active patient blood management
program to limit unnecessary transfusion, which includes
reducing plasma usage.23 Future studies are needed to address
the impact of antithrombotic agents or more focused goal-
directed therapy for massively bleeding patients. Although
data on when and why a nontrauma MTP was switched to a
trauma MTP was unfortunately not available, we believe the
majority of individuals who switched from a nontrauma to
trauma protocol were surgical patients, especially cardiac sur-
gery. This group of patients requires further characterization.
Overall, this study shows that implementation of a
distinct nontrauma MTP with a lower quantity of issued
plasma and platelet units was associated with a lower num-
ber of transfused and unused units compared to a trauma-
based MTP. Less than half of the patients remaining under
a nontrauma MTP activation required any platelet transfu-
sion, which gives credence to the notion that MTPs based
on predicted clinical need may optimize utilization of an
institutions supply of blood products. Future studies are
needed to prospectively and concurrently examine pre-
dicted need for MTP activation, blood product utilization,
and patient outcomes for nontrauma MTPs. E
DISCLOSURES
Name: Eshan U. Patel, MPH.
Contribution: This author helped analyze the data and write the
report.
XXX 2017 Volume XXX Number XXX www.anesthesia-analgesia.org
7
Copyright 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Name: Paul M. Ness, MD.
Contribution: This author helped design the study and write the
report.
Name: Christi E. Marshall, MT(ASCP).
Contribution: This author helped collect and analyze the data and
write the report.
Name: Thomas Gniadek, MD.
Contribution: This author helped collect the data and write the
report.
Name: David T. Efron, MD.
Contribution: This author helped design the study and write the
report.
Name: Peter M. Miller, MD.
Contribution: This author helped collect and analyze the data and
write the report.
Name: Joseph A. Zeitouni, MD.
Contribution: This author helped analyze the data and write the
report.
Name: Karen E. King, MD.
Contribution: This author helped design the study and write the
report.
Name: Evan M. Bloch, MD.
Contribution: This author helped design the study and write the
report.
Name: Aaron A. R. Tobian, MD, PhD.
Contribution: This author helped design the study, analyze the
data, and write the report.
This manuscript was handled by: Marisa B. Marques, MD.
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ANESTHESIA & ANALGESIA