What is the protocol for massive transfusion?

Massive Transfusion Protocol

The optimal massive transfusion protocol should follow a high-ratio transfusion strategy with a 1:1:1 ratio (RBC:plasma:platelets) to improve survival in patients with massive bleeding. 1

Protocol Activation Criteria

Massive transfusion protocol should be activated 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 1

Initial Assessment

• Assess vital signs, signs of internal blood loss, and obvious external bleeding
• For hemodynamically unstable patients, perform FAST scan to detect free fluid
• Patients with significant free fluid and hemodynamic instability require urgent surgical intervention 1

Transfusion Strategy

Blood Product Ratio

• Implement 1:1:1 ratio of RBC:plasma:platelets
• Initial FFP dose of 10-15 ml/kg, with further doses based on coagulation monitoring 1

Target Parameters

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

Blood Product Administration Order

1. O-negative blood (emergency)
2. Group-specific blood
3. Cross-matched blood 1

Laboratory Monitoring

• Initial coagulation screening panel should include:

  • Prothrombin time (PT)
  • Activated partial thromboplastin time (APTT)
  • Fibrinogen levels
  • Platelet count
  • Complete blood count
  • Blood typing and cross-matching
  • Serum lactate and base deficit 1

• Repeat coagulation tests every 30-60 minutes during active bleeding

• Use thromboelastography/thromboelastometry if available to guide specific component therapy 1

Adjunctive Therapies

Tranexamic Acid

• Administer early in trauma patients requiring massive transfusion
• Loading dose: 1g over 10 minutes
• Maintenance: 1g over 8 hours 1

Prevention of Complications

• Monitor and correct hypocalcemia associated with citrate toxicity
• Prevent hypothermia using blood warmers and warming blankets
• Correct hypocalcemia and hypomagnesemia 1

Ongoing Care

• Continue clinical assessment of vital signs, tissue perfusion, urine output

• Monitor response to transfusion and ongoing blood loss

• Watch for potential complications:

  • Transfusion-Related Acute Lung Injury (TRALI)
  • Transfusion-Associated Circulatory Overload (TACO)
  • Metabolic derangements
  • Hypothermia
  • Citrate toxicity 1

• Admit to critical care for close observation

• Initiate standard venous thromboprophylaxis once bleeding is controlled 1

Common Pitfalls and Caveats

1. Delayed Protocol Activation: Early activation is critical for survival. Don't wait for laboratory confirmation of severe bleeding 2

2. Inadequate Plasma and Platelet Transfusion: Historical approaches focused primarily on RBC replacement, but evidence now strongly supports balanced resuscitation with 1:1:1 ratio 3

3. Failure to Prevent Hypothermia: Hypothermia worsens coagulopathy and impairs citrate metabolism. Always use blood warmers 1

4. Overlooking Metabolic Complications: Monitor and correct hypocalcemia, especially with large volumes of FFP and platelets 1

5. Reactive Instead of Proactive Approach: Prevention of coagulopathy is superior to its treatment. Early implementation of protocol is essential 4

6. 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, 5

7. Monitoring for Rebleeding: Rebleeding carries high mortality and requires vigilant monitoring 1