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Massive transfusion in The Netherlands
  1. Tim W H Rijnhout1,2,
  2. Femke Noorman3,
  3. Annemarije Bek3,
  4. Margreet Zoodsma3,
  5. Rigo Hoencamp1,2,4,5
  1. 1 Department of Surgery, Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands
  2. 2 Trauma Research Unit Department of Surgery, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
  3. 3 Military Blood Bank, Dutch Ministry of Defence, Utrecht, The Netherlands
  4. 4 Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
  5. 5 Defence Healthcare Organization, Ministry of Defence, Utrecht, The Netherlands
  1. Correspondence to Tim W H Rijnhout, Trauma Surgery, Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands; twhrijnhout{at}


Objectives Massive transfusion protocols (MTPs) may improve survival in patients with uncontrolled haemorrhage. An MTP was introduced into the Dutch transfusion guidelines in 2011, the ninth edition of the advanced trauma life support course in 2012 and the third version of the European guideline in 2013. This is the first survey of MTPs in Dutch trauma centres.

Methods The aim of the study was to compare MTP strategies in level 1 trauma centres in The Netherlands, and with (inter)national guidelines. A contact in each government assigned level 1 trauma centre in The Netherlands and the Dutch Ministry of Defence was approached to share their MTPs and elucidate their protocol in a survey and oral follow-up interview.

Results All 11 level 1 trauma centres responded. The content of the packages and transfusion ratios (red blood cells/plasma/platelets) were 3:3:1, 5:5:1, 5:3:1, 2:3:1, 4:4:1, 5:2:1, 2:2:1 and 4:3:1. Tranexamic acid was used in all centres and an additional dose was administered in eight centres. Fibrinogen was given directly (n=4), with persistent bleeding (n=3), based on Clauss fibrinogen (n=3) or rotational thromboelastometry (n=1). All centres used additional medication in patients in the form of anticoagulants, but their use was ambiguous.

Conclusion MTPs differed between institutes and guidelines. The discrepancies in transfusion ratios can be explained by (inter)national differences in preparation and volume of blood components and/or interpretation of the '1:1:1' guideline. We recommend updating MTPs every year using the latest guidelines and evaluating the level of evidence for treatment during massive transfusion.

  • transfusion
  • trauma
  • massive
  • protocol
  • tranexamic acid
  • emergency
  • surgery
  • military
  • blood
  • platelets

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  • Contributors TWHR and FN conducted the research and wrote the manuscript. All authors read and approved the final manuscript.

  • Funding This study and the future clinical trial (the MAssive transfusion of Frozen bloOD (MAFOD)) is fully funded by the Dutch Ministry of Defence and the Dutch Army Health Insurance Foundation (SZVK).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.