What is the protocol for massive transfusion?

From the Guidelines

Massive transfusion protocol should follow a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets, as this approach has been shown to be the most reasonable in initiating empiric transfusion when massive hemorrhage is suspected 1.

Key Components of Massive Transfusion Protocol

• Initial resuscitation begins with 6 units of PRBCs, 6 units of FFP, and 1 unit of platelets (equivalent to 6 units), with subsequent rounds following the same ratio.
• Cryoprecipitate (10 units) should be administered when fibrinogen levels fall below 150-200 mg/dL.
• Calcium chloride (1g) or calcium gluconate (3g) should be given with every 4 units of blood products to prevent hypocalcemia caused by the citrate preservative.
• Tranexamic acid (TXA) should be administered within 3 hours of injury at a dose of 1g IV over 10 minutes, followed by 1g over 8 hours.

Laboratory Monitoring and Temperature Management

• Regular laboratory monitoring is essential, including complete blood count, coagulation studies, fibrinogen, and ionized calcium levels.
• Temperature management is crucial as hypothermia worsens coagulopathy, so blood warmers should be used and the patient kept warm.

Institutional Protocol

• Every institution should have a massive transfusion protocol which is regularly audited and reviewed 1.
• Group O red cells for transfusion should be readily available in the clinical area, in case haemorrhage is life-threatening.
• Group-specific red cells should be available within a very short time (15–20 min) of the laboratory receiving correctly-labelled samples and being informed of the emergency requirement for blood.

Considerations for Specific Patient Populations

• In patients with ongoing bleeding or a large deficit, red blood cells should be transfused one unit at a time, and the patient’s Hb should be checked before each unit transfused 1.
• In traumatic and obstetric major haemorrhage, consideration should be given to transfusing red cells and FFP in preference to other intravenous fluid.
• Patients who continue to actively bleed should be monitored by point-of-care and/or regular laboratory tests for coagulation, fibrinogen and platelet counts or function, and a guide for transfusion should be FFP if fibrinogen < 1.5 g.l−1, INR > 1.5, cryoprecipitate if < 1.5 g.l−1 and platelets if platelet count < 75 x 109.l−1 1.

From the Research

Massive Transfusion Protocol

The protocol for massive transfusion is a critical aspect of trauma care, aiming to replace significant blood loss with a balanced ratio of blood products.

• The definition of massive transfusion varies, but it is generally considered as the transfusion of 10 or more units of packed red blood cells (PRBCs) within a 24-hour period 2.
• The use of fresh frozen plasma (FFP) and platelets in massive transfusion has been shown to improve outcomes, with higher ratios of FFP:PRBCs and platelets:PRBCs leading to improved mortality rates 3.
• A study published in the Journal of Trauma found that early initiation of plasma therapy can reduce the incidence of coagulopathy in massively transfused individuals, and that ideal platelet concentrations in trauma patients are generally held to be greater than 50 x 10^9/L 4.
• The cell-based model of hemostasis has contributed to a change in resuscitation strategy and transfusion therapy of massive hemorrhage, with a focus on proactive resuscitation with blood products in a balanced ratio of RBC:plasma:platelets 5.
• However, the use of FFP and platelets also carries risks, including immunologic reactions, transfusion-related acute lung injury (TRALI), and hemolysis due to anti-A or anti-B if transfused across ABO groups 6.

Key Components of Massive Transfusion Protocol

• PRBCs: The primary component of massive transfusion, aiming to replace lost red blood cells.
• FFP: Used to correct coagulopathy and replace plasma coagulation factors.
• Platelets: Used to prevent or treat thrombocytopenia and coagulopathy.
• Cryoprecipitate: May be used to rapidly increase fibrinogen and von Willebrand's factor concentrations.
• The ratio of FFP:PRBCs and platelets:PRBCs is critical, with higher ratios leading to improved outcomes 3.

Implementation of Massive Transfusion Protocol

• The protocol should be activated early in the treatment of massively hemorrhaging patients.
• Blood products should be transfused in a balanced ratio, with regular monitoring of coagulation parameters and clinical status.
• The use of whole blood viscoelastic hemostatic assays can help guide transfusion therapy and monitor coagulopathy 5.
• The protocol should be regularly reviewed and updated to reflect new evidence and best practices.