What is the protocol for managing massive hemorrhage requiring transfusion?

From the Guidelines

The protocol for managing massive hemorrhage requiring transfusion involves rapid activation of a massive transfusion protocol (MTP), immediate blood product administration in a 1:1:1 ratio of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets, and early use of tranexamic acid (TXA) as recommended by the European Society of Intensive Care Medicine 1.

Upon recognizing massive hemorrhage, promptly activate the MTP and establish large-bore IV access. Administer TXA as soon as possible at a dose of 1g IV over 10 minutes, followed by 1g over 8 hours. Maintain the 1:1:1 ratio of blood products to prevent dilutional coagulopathy. Monitor calcium levels and replace as needed with calcium chloride 1g IV or calcium gluconate 3g IV. Target hemoglobin >7-9 g/dL, platelets >50,000/μL (>100,000/μL for CNS injuries), fibrinogen >150-200 mg/dL, and INR <1.5. Use point-of-care testing like thromboelastography (TEG) or rotational thromboelastometry (ROTEM) if available to guide specific component therapy. Maintain normothermia using warming devices and warmed fluids, as hypothermia worsens coagulopathy. Correct acidosis by ensuring adequate tissue perfusion and judicious use of buffer solutions if pH <7.2. This approach addresses the lethal triad of hypothermia, acidosis, and coagulopathy that often complicates massive hemorrhage and improves survival outcomes.

Some key considerations in managing massive hemorrhage include:

• Rapid activation of the MTP and establishment of large-bore IV access
• Early administration of TXA and maintenance of the 1:1:1 ratio of blood products
• Monitoring of calcium levels and replacement as needed
• Targeting specific hemoglobin, platelet, fibrinogen, and INR levels
• Use of point-of-care testing to guide specific component therapy
• Maintenance of normothermia and correction of acidosis

It is also important to note that the use of cryoprecipitate may be preferred over FFP in certain situations, such as amniotic fluid embolism, to minimize the risk of volume overload 1. Additionally, the use of a massive transfusion protocol has been shown to improve outcomes in patients with severe traumatic brain injury 1.

Overall, the key to managing massive hemorrhage is to rapidly activate the MTP, administer blood products in a 1:1:1 ratio, and use TXA and other interventions as needed to prevent dilutional coagulopathy and address the lethal triad of hypothermia, acidosis, and coagulopathy.

From the Research

Massive Transfusion Protocol

The protocol for managing massive hemorrhage requiring transfusion involves the administration of blood products in a specific ratio to restore circulating volume and prevent coagulopathy.

• The optimal ratio of plasma, platelets, and red blood cells (RBCs) is still a topic of debate, but recent studies suggest that a 1:1:1 ratio may be beneficial in improving survival outcomes 2, 3.
• The use of a massive transfusion protocol (MTP) has been shown to decrease mortality in trauma patients 3.
• The timing of blood product delivery is also crucial, with shorter times to delivery associated with better outcomes 3.

Blood Product Ratios

• A study published in 2010 found that high fresh-frozen plasma (FFP)- and platelet-to-RBC ratios seem to improve survival in patients with massive bleeding 4.
• Another study published in 2015 found that resuscitation with a 1:1:1 ratio of units of plasma and platelets to RBCs was well tolerated and reduced hemorrhagic mortality during resuscitation 2.
• A literature review published in 2020 recommended that current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and RBCs 3.

Adjuncts and Monitoring

• The use of adjuncts such as tranexamic acid has been shown to improve outcomes in bleeding trauma patients 5.
• The role of laboratory monitoring, such as thromboelastography, in guiding transfusion therapy is still unclear and requires further study 5.
• A study published in 2013 found that transfusion to hematocrits between 29.1 and 39 per cent conveyed a survival benefit, whereas resuscitation to supraphysiologic hematocrits 39 per cent or greater conveyed no additional survival benefit 6.

Implementation and Outcomes

• The implementation of a massive transfusion protocol has been shown to be effective in decreasing mortality in trauma patients 3.
• A study published in 2012 emphasized the need for a massive transfusion protocol in all hospitals that manage bleeding patients, to ensure a prompt and coordinated response to hemorrhage 5.
• The outcomes of patients resuscitated according to common massive transfusion protocols have been shown to be improved with the use of a balanced, blood-product-based resuscitation approach 2.