Massive intraoperative blood loss requires expectant measures, efficient coordination among providers, and timely feedback to optimize outcomes. In the Philippines, case reports on massive blood loss and transfusion are lacking. This report describes a 67-year-old female who underwent elective adrenalectomy, nephrectomy, and hepatic resection, with a total intraoperative blood loss of 20 L in a 13-h surgery. Efficient conduct of the institution’s massive transfusion protocol, multiple pressor support, electrolyte and glucose correction, and anticipatory management of associated complications of hypovolemia and transfusion were important elements of successful management. The patient tolerated the surgery and was discharged well after 12 days. In the absence of more sophisticated monitoring and management options in a low-resource setting, maximizing available means and anticipatory interventions is key.