From the Guidelines
Massive transfusion protocols (MTPs) themselves do not directly cause disseminated intravascular coagulation (DIC), but they can be associated with coagulopathy that may resemble or contribute to DIC in severely injured or bleeding patients. MTPs involve rapid administration of large volumes of blood products to treat massive hemorrhage. The coagulopathy that develops during massive transfusion is multifactorial, resulting from dilution of clotting factors, consumption of platelets and clotting factors at sites of injury, hypothermia, acidosis, and hypocalcemia. According to the most recent guideline on management of major bleeding and coagulopathy following trauma, published in 2023 1, modern MTPs aim to prevent coagulopathy by providing balanced ratios of blood components.
Some key points to consider in the management of MTPs include:
- Monitoring coagulation parameters, such as platelet count, fibrinogen, PT, and APTT, as recommended in the British Journal of Anaesthesia guideline from 2000 1
- Maintaining normothermia to prevent hypothermia-induced coagulopathy
- Correcting acidosis to optimize coagulation function
- Providing calcium supplementation to minimize complications, as suggested in the guideline from 2023 1
- Using balanced ratios of blood components, such as 1:1:1 or 1:1:2 ratios of packed red blood cells, plasma, and platelets, to prevent coagulopathy
The underlying condition necessitating massive transfusion, such as severe trauma, obstetric hemorrhage, or major surgery, is more likely the primary cause of any DIC that develops. Clinicians managing patients on MTPs should be aware of the potential for coagulopathy and take steps to minimize complications and optimize outcomes, as recommended in the 2023 guideline 1.
From the Research
Massive Transfusion Protocols and DIC
- Massive transfusion protocols can contribute to the development of disseminated intravascular coagulation (DIC) due to factors such as hemodilution, hypothermia, and the use of fractionated blood products 2, 3, 4.
- The pathophysiology of coagulopathy in massively transfused patients is complex and multifactorial, involving the activation of coagulation pathways, consumption of clotting factors and platelets, and the development of microvascular bleeding 2, 3, 4.
- The use of platelets and/or fresh frozen plasma should depend on clinical judgment as well as the results of coagulation testing, and should be used mainly to treat a clinical coagulopathy 2, 3, 4.
- Treatment strategies for coagulopathy associated with massive transfusion include the maintenance of adequate tissue perfusion, the correction of hypothermia and anemia, and the use of hemostatic blood products to correct microvascular bleeding 2, 3, 4.
Diagnosis and Management of DIC
- The diagnosis of DIC should encompass both clinical and laboratory information, using scoring systems such as the International Society for Thrombosis and Haemostasis (ISTH) DIC scoring system 5.
- The cornerstone of the treatment of DIC is the treatment of the underlying condition, and transfusion of platelets or plasma should not primarily be based on laboratory results, but rather on clinical judgment and the presence of bleeding or high risk of bleeding 5.
- In patients with DIC and bleeding or at high risk of bleeding, administration of fresh frozen plasma, platelets, or other hemostatic blood products may be useful, but should be used judiciously and based on clinical judgment 5, 6.
Therapeutic Strategies for DIC
- Treatment of the underlying disease and elimination of the trigger mechanism are the cornerstone therapeutic approaches for DIC 6.
- Therapeutic strategies specific for DIC aim to control activation of blood coagulation and bleeding risk, and may include the use of anticoagulants, transfusion of platelet concentrates or clotting factor concentrates, and other supportive measures 6.
- The efficacy and safety of various therapeutic strategies for DIC have not been fully established, and further research is needed to guide the management of patients with DIC 6.