From the Guidelines
The most effective protocol for massive transfusion is to use either fibrinogen concentrate or cryoprecipitate and packed red blood cells (pRBCs), or fresh frozen plasma (FFP) or pathogen-inactivated FFP in a FFP/pRBC ratio of at least 1:2 as needed, along with a high platelet/pRBC ratio. This approach is based on the most recent and highest quality evidence from the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. The guideline recommends two strategies for initial management of patients with expected massive hemorrhage:
- Fibrinogen concentrate or cryoprecipitate and pRBCs (Grade 1C)
- FFP or pathogen-inactivated FFP in a FFP/pRBC ratio of at least 1:2 as needed (Grade 1C) In addition, a high platelet/pRBC ratio is suggested (Grade 2B).
The use of a high-ratio transfusion strategy has been shown to reduce mortality and improve hemostasis in critically ill adults with bleeding 1. However, the European Society of Intensive Care Medicine guideline notes that the evidence is limited and the recommendation for fixed, high-ratio transfusion is conditional, particularly outside of the trauma setting.
Key components of a massive transfusion protocol include:
- Initial activation with 4-6 units each of pRBCs, FFP, and platelets
- Administration of 1 gram of tranexamic acid (TXA) intravenously within 3 hours of bleeding onset, followed by 1 gram over 8 hours
- Monitoring of coagulation parameters (PT, PTT, fibrinogen, platelets) every 30-60 minutes during active resuscitation
- Maintenance of body temperature above 36°C using warming devices and warmed fluids
- Calcium supplementation with 1 gram of calcium chloride for ionized calcium below 1.0 mmol/L.
Overall, the goal of a massive transfusion protocol is to rapidly deliver large volumes of blood products to patients experiencing severe hemorrhage, while minimizing the risk of coagulopathy and improving outcomes.