What is the recommended protocol for massive transfusion?

Massive Transfusion Protocol

The recommended massive transfusion protocol should follow a high-ratio transfusion strategy of at least 1:1:1 or 1:1:2 (RBC:plasma:platelets) with implementation of a well-defined hospital protocol to improve communication, facilitate timely delivery of blood products, and reduce morbidity and mortality. 1, 2

Definition of Massive Transfusion

• Massive blood loss is defined as:
  • Loss of one blood volume within a 24-hour period (approximately 7% of ideal body weight in adults)
  • 50% blood volume loss within 3 hours
  • Blood loss occurring at a rate of 150 ml/min 1
• Alternative definition: Administration of 10 or more units of red blood cells in less than 24 hours 3

Key Components of Massive Transfusion Protocol

Initial Assessment and Management

1. Immediate Actions:

   • Control obvious bleeding points using direct pressure, tourniquets, and hemostatic dressings
   • Administer high concentration oxygen
   • Establish large-bore IV access (at least two sites)
   • Obtain baseline blood tests including CBC, PT, APTT, fibrinogen levels, and blood typing 1

2. Blood Product Administration:

   • Use warmed blood products (critical to prevent hypothermia-induced coagulopathy)
   • Follow blood product availability order: O-negative → type-specific → cross-matched 1

Transfusion Ratios and Strategy

• Recommended ratio: 1:1:1 or 1:1:2 (RBC:plasma:platelets) 1, 2
• This balanced approach helps prevent and treat coagulopathy rather than treating it after development 3, 2
• Target laboratory values:
  • Fibrinogen levels >1.5 g/L
  • Platelet count >75 × 10⁹/L
  • Consider platelet transfusion for significant active bleeding 1

Monitoring and Adjunctive Management

1. Laboratory Monitoring:

   • Repeat coagulation tests every 30-60 minutes during active bleeding
   • Consider viscoelastic testing (TEG/ROTEM) for more rapid assessment of coagulopathy 1, 4

2. Temperature Management:

   • Actively warm the patient
   • Warm all transfused fluids to prevent hypothermia 1

3. Electrolyte Management:

   • Monitor and correct hypocalcemia and hypomagnesemia, which frequently occur with massive transfusion 1

4. Post-Transfusion Care:

   • Admit to critical care for monitoring
   • Regularly assess coagulation parameters, hemoglobin, and blood gases
   • Monitor wound drains to identify ongoing bleeding
   • Initiate standard venous thromboprophylaxis once bleeding is controlled 1

Evidence-Based Considerations

The PROPPR trial and subsequent studies have confirmed the benefits of balanced transfusion ratios 2. While the 2018 systematic review 5 found insufficient evidence to definitively recommend 1:1:1 over 1:1:2 ratio, more recent evidence from 2020 2 and 2024 4 supports the use of balanced ratios between 1:1:1 and 1:1:2.

Implementation Considerations

• Having a formal, written massive transfusion protocol improves outcomes 1, 6
• Faster blood product delivery correlates with better patient outcomes 2
• Consider keeping emergency blood products readily available in trauma bays 2
• The protocol should be well-communicated to all staff involved in trauma care 1

Common Pitfalls to Avoid

• Delayed activation: Failure to recognize massive hemorrhage early can lead to worse outcomes
• Unbalanced transfusion: Giving only RBCs without appropriate plasma and platelets can worsen coagulopathy
• Inadequate warming: Cold blood products exacerbate coagulopathy
• Neglecting calcium: Citrate in stored blood products binds calcium, requiring supplementation
• Failing to reassess: Continuous monitoring of coagulation status is essential to guide ongoing therapy