What is the protocol for managing massive bleeding requiring transfusion?

Massive Blood Transfusion Protocol

The optimal massive transfusion protocol should implement a high-ratio transfusion strategy with at least 1 unit plasma per 2 units RBCs, approaching a 1:1:1 ratio (RBC:plasma:platelets), as this has been shown to improve survival in patients with massive bleeding. 1

Definition of Massive Transfusion

Massive transfusion is typically defined as:

• Transfusion of more than 10 units of packed red blood cells (RBCs) within 24 hours
• Loss of one blood volume within a 24-hour period (approximately 7% of ideal body weight in adults)
• Alternative definitions include 50% blood volume loss within 3 hours or bleeding at a rate of 150 ml/min 1, 2

Initial Assessment and Activation

1. Rapid hemodynamic evaluation:

   • Assess vital signs: heart rate, blood pressure, capillary refill, skin color, consciousness level
   • Look for signs of internal blood loss and obvious external bleeding
   • For unstable patients, perform FAST scan to detect free fluid 1

2. Laboratory investigations:

   • Complete blood count
   • Coagulation profile (PT, APTT)
   • Fibrinogen levels (Clauss method)
   • Blood typing and cross-matching
   • Serum lactate and base deficit (better indicators of shock than single hematocrit) 1

3. Activate massive transfusion protocol when:

   • Anticipated need for >10 units of RBCs in 24 hours
   • Severe ongoing hemorrhage with hemodynamic instability
   • Severe trauma with signs of shock and ongoing bleeding

Transfusion Strategy

Phase 1: Initial Resuscitation (Crisis Phase)

1. Fixed-ratio transfusion:

   • Implement 1:1:1 ratio (RBC:plasma:platelets) or at minimum 1:2 (plasma:RBC) ratio 1
   • Deliver blood products in "transfusion packages" containing:
     • 5 units RBCs
     • 5 units FFP
     • 2 units platelet concentrates 3

2. Early FFP administration:

   • Initial recommended dose: 10-15 ml/kg 4
   • Further doses based on coagulation monitoring and other blood products given

3. Target parameters:

   • Maintain fibrinogen levels >1.5 g/L using cryoprecipitate or fibrinogen concentrate
   • Keep platelet count >75 × 10⁹/L
   • Monitor PT/APTT (goal <1.5 times normal) 1

Phase 2: Transition to Goal-Directed Therapy

Once the crisis phase is averted, transition from fixed-ratio transfusion to goal-directed therapy based on laboratory values:

1. Laboratory monitoring:

   • Repeat coagulation tests every 30-60 minutes during active bleeding 1
   • Use thromboelastography/thromboelastometry if available to guide specific component therapy 3

2. Targeted blood component therapy:

   • RBCs: Maintain hemoglobin >7-9 g/dL depending on patient status
   • Plasma: Administer for PT/APTT >1.5 times normal
   • Platelets: Transfuse when count <75 × 10⁹/L
   • Cryoprecipitate/Fibrinogen concentrate: Give when fibrinogen <1.5 g/L 1

Adjunctive Therapies

1. Tranexamic acid:

   • Administer early in trauma patients requiring massive transfusion
   • Loading dose of 1g over 10 minutes, followed by 1g over 8 hours 5

2. Calcium replacement:

   • Monitor and correct hypocalcemia associated with citrate toxicity
   • Particularly important with FFP and platelet transfusion which contain high citrate concentrations 4

3. Temperature management:

   • Prevent hypothermia using blood warmers and warming blankets
   • Hypothermia worsens coagulopathy and impairs citrate metabolism 4

Monitoring and Complications

1. Ongoing clinical assessment:

   • Vital signs, tissue perfusion, urine output
   • Response to transfusion
   • Ongoing blood loss

2. Potential complications:

   • Transfusion-Related Acute Lung Injury (TRALI): Most commonly associated with FFP and platelet concentrates 1
   • Transfusion-Associated Circulatory Overload (TACO)
   • Metabolic derangements: hypocalcemia, hyperkalemia, acid-base disturbances
   • Hypothermia
   • Citrate toxicity 4

Post-Resuscitation Care

1. Admit to critical care for close observation
2. Regular assessment of coagulation parameters, hemoglobin, and blood gases
3. Monitor for signs of rebleeding, which carries high mortality
4. Initiate standard venous thromboprophylaxis once bleeding is controlled 1

Implementation Considerations

Having a well-defined hospital protocol for managing massive hemorrhage improves communication among staff and facilitates timely delivery of blood products. The protocol should clearly delineate how blood products are ordered, prepared, and delivered; determine laboratory algorithms to use as transfusion guidelines; and outline duties and facilitate communication between involved personnel 1.

Military and civilian studies have shown improved survival with higher plasma:RBC ratios approaching 1:1, highlighting the importance of aggressive early coagulation factor replacement rather than just volume replacement 1, 3.

A key pitfall to avoid is delayed recognition and treatment of coagulopathy. Prevention of coagulopathy is superior to its treatment, which underscores the importance of early administration of blood components in appropriate ratios 6.