What is the protocol for managing massive hemorrhage requiring transfusion?

Massive Transfusion Protocol for Managing Hemorrhagic Shock

The optimal massive transfusion protocol for hemorrhagic shock should follow a 1:1:1 ratio of RBC:plasma:platelets while maintaining fibrinogen levels >1.5 g/L and platelet counts >75 × 10⁹/L to reduce mortality in patients with massive bleeding. 1

Definition and Initial Assessment

• Massive blood loss: Loss of one blood volume within a 24-hour period
• Initial coagulation screening should include:
  • Prothrombin time (PT)
  • Activated partial thromboplastin time (APTT)
  • Fibrinogen levels
  • Platelet count
  • Cross-match
• Repeat coagulation tests every 30-60 minutes during active bleeding 1

Immediate Resuscitation Steps

1. Blood Product Administration:

   • Use a high-ratio transfusion strategy with RBC:plasma:platelets in a 1:1:1 ratio 1
   • Group O RhD negative blood is preferred for immediate transfusion in emergencies
   • Group O RhD positive blood may be acceptable for male patients 2
   • Switch to group-specific blood as soon as grouping is available (takes approximately 10 minutes) 2

2. Target Parameters:

   • Maintain fibrinogen levels >1.5 g/L using cryoprecipitate or fibrinogen concentrate
   • Keep platelet count >75 × 10⁹/L (increase to 100 × 10⁹/L for patients with traumatic brain injury)
   • Monitor PT/APTT (goal <1.5 times normal) 1

Specific Blood Component Management

Platelets

• Maintain platelets at minimum 75 × 10⁹/L during active hemorrhage 2, 1
• Consider higher threshold (100 × 10⁹/L) for patients with multiple trauma or traumatic brain injury 1

Fibrinogen Replacement

• Options for fibrinogen replacement:
  1. Fibrinogen concentrate: 30-60 mg/kg (faster administration, more predictable dosing) 2
     • Maximum infusion rate of 20 mL per minute for acquired fibrinogen deficiency 3
  2. Cryoprecipitate: When fibrinogen levels are <1.5 g/L 1
     • Note: May be associated with delays due to thawing and transportation 2

Plasma

• Fresh Frozen Plasma (FFP) should be administered in a 1:1 or 1:2 ratio with RBCs 1

Pharmacological Management

Tranexamic Acid

• Administer in situations where increased fibrinolysis is anticipated
• Dosing: 1g loading dose over 10 minutes, followed by 1g over 8 hours 1
• Particularly beneficial in traumatic hemorrhage 2

Prothrombin Complex Concentrate (PCC)

• Primarily indicated for urgent reversal of vitamin K antagonists
• May be used in certain clinical situations such as liver disease 2, 1

Recombinant Factor VIIa (rFVIIa)

• Consider only when hemorrhage is unresponsive to conventional therapy
• Note: Associated with risk of arterial thrombotic complications
• Should be used according to local protocols agreed in advance
• Most effective when given with tranexamic acid and adequate fibrinogen levels 2

Monitoring and Complications Management

Electrolyte Monitoring

• Monitor and correct hypocalcemia and hypomagnesemia, which are common in massively transfused patients 2

Temperature Management

• Actively prevent and treat hypothermia, which worsens coagulopathy 1

Acidosis Correction

• Monitor and correct acidosis, which impairs coagulation 1

Implementation Considerations

• Establish a formal massive transfusion protocol to ensure rapid and coordinated response
• Ensure proper patient identification with two identification bands in situ
• All persons involved in blood administration must be trained and certified according to national standards 2

Potential Complications to Monitor

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

The evidence strongly supports that implementing a standardized massive transfusion protocol with balanced blood component ratios significantly improves survival in patients with hemorrhagic shock compared to traditional approaches that delay plasma and platelet administration.