What is not typically part of a massive transfusion protocol for a patient with profound blood loss: Red Blood Cells (RBCs), Albumin, Platelets, or Fresh Frozen Plasma (FFP)?

Albumin is NOT Typically Part of Massive Transfusion Protocol

Albumin is not typically included as a component in massive transfusion protocols for patients with profound blood loss. 1 Massive transfusion protocols (MTPs) focus on replacing blood components that directly address coagulopathy and restore oxygen-carrying capacity rather than providing colloid volume expansion.

Standard Components of Massive Transfusion Protocol

The core components of a massive transfusion protocol include:

1. Red Blood Cells (RBCs): Restore oxygen-carrying capacity. In emergency situations, O-negative (for premenopausal females) or O-positive (for males and postmenopausal females) uncrossmatched blood may be used until type-specific or fully crossmatched blood is available. 1

2. Fresh Frozen Plasma (FFP): Provides coagulation factors to correct coagulopathy. Current guidelines recommend high-ratio transfusion strategies with at least one unit of plasma for every two units of RBCs. 1

3. Platelets: Maintain adequate platelet counts to support clot formation. Expert consensus recommends maintaining platelet counts above 50 × 10⁹/L in acutely bleeding patients, with higher targets (100 × 10⁹/L) for patients with multiple trauma or central nervous system injury. 1

4. Cryoprecipitate: Used when fibrinogen levels fall below critical thresholds (< 1.0 g/L). In some cases, cryoprecipitate is preferred over FFP in the setting of massive transfusion to minimize the risk of volume overload. 1

Why Albumin is Not Typically Included

Albumin is a colloid solution used primarily for volume expansion but lacks the essential components needed to address the specific deficiencies that occur during massive hemorrhage:

• It does not contain coagulation factors
• It does not provide oxygen-carrying capacity
• It does not contribute to platelet function
• It is relatively expensive compared to crystalloids for volume expansion

Transfusion Ratios in Massive Bleeding

Current evidence supports a balanced approach to blood product administration:

• High-ratio transfusion strategies (at least 1:2 plasma:RBC ratio) are recommended for trauma patients with massive bleeding 1
• Some protocols use a 1:1:1 or 1:1:2 ratio of plasma:platelets:RBCs 2
• These balanced ratios have been associated with reduced mortality from exsanguination 1

Laboratory Monitoring During Massive Transfusion

Regular laboratory monitoring is essential during massive transfusion:

• Hemoglobin/hematocrit
• Platelet count (target > 50 × 10⁹/L)
• Prothrombin time (PT) and activated partial thromboplastin time (APTT)
• Fibrinogen levels (target > 1.0 g/L)
• Monitoring should occur at least every 4 hours or after each third of blood volume replacement 1, 3

Common Pitfalls in Massive Transfusion

1. Underestimation of blood loss: Blood loss is frequently underestimated, and hemoglobin/hematocrit values don't fall for several hours after acute hemorrhage. 1

2. Hypothermia: Can worsen coagulopathy and increase mortality. Use blood warmers and patient warming devices. 1

3. Acidosis: Monitor and correct metabolic acidosis which can worsen coagulopathy.

4. Hypocalcemia: Massive transfusion of citrated blood products can lead to hypocalcemia, which should be monitored and corrected. 3

5. Delayed activation of MTP: Early activation of massive transfusion protocols improves outcomes. 2

In summary, massive transfusion protocols typically include RBCs, FFP, platelets, and sometimes cryoprecipitate, administered in balanced ratios to address both oxygen-carrying capacity and coagulopathy. Albumin, being primarily a volume expander without these specific properties, is not typically included in these protocols.