What is the management for a massive blood transfusion reaction?

Management of Massive Blood Transfusion Reaction

Immediately stop the transfusion, maintain IV access, control bleeding with direct pressure/tourniquets, and activate the massive hemorrhage protocol while simultaneously administering warmed blood products in a 1:1:1 ratio (RBC:FFP:platelets) for severely injured patients. 1, 2

Immediate Actions When Reaction Suspected

Stop the transfusion immediately - this is the single most critical step that can affect patient outcome 3

• Control obvious bleeding points using direct pressure, tourniquets, or hemostatic dressings as the paramount priority 1
• Maintain IV access and secure large-bore access (8-Fr central access is ideal in adults; consider intra-osseous or surgical venous access if peripheral fails) 1
• Administer high FiO2 to ensure adequate oxygenation 1, 2
• Report the reaction to the blood bank immediately as this affects patient outcome and is required for hemovigilance 4, 3

Laboratory Assessment

• Obtain baseline bloods: FBC, PT, aPTT, Clauss fibrinogen (not derived fibrinogen, which is misleading), and cross-match 1, 2
• Use near-patient testing (TEG or ROTEM) if available for rapid coagulation assessment 1
• Monitor blood lactate and base deficit as sensitive indicators of hypoperfusion and shock severity 5

Blood Product Resuscitation Strategy

For severely traumatized patients with massive hemorrhage, use 1:1:1 red cell:FFP:platelet regimens as used by the military 1, 2

• Begin early FFP administration at 10-15 ml/kg to prevent dilutional coagulopathy before it develops if a senior clinician anticipates massive hemorrhage 1, 2, 5
• Use warmed blood and blood components for fluid resuscitation - blood group O is quickest, followed by group-specific, then cross-matched blood 1, 2
• In massive bleeding, group-specific blood can be issued without performing an antibody screen because patients will have minimal circulating antibodies 1
• O negative blood should only be used if blood is needed immediately 1

Management of Coagulopathy

A fibrinogen <1 g/L or PT/aPTT >1.5 times normal represents established hemostatic failure and predicts microvascular bleeding 1

• Established coagulopathy requires more than 15 ml/kg of FFP to correct 1, 2
• The most effective way to achieve rapid fibrinogen replacement is by giving fibrinogen concentrate or cryoprecipitate if fibrinogen is unavailable 1, 2
• Maintain a minimum target platelet count of 75 × 10⁹/L in this clinical situation 1, 2

Active Warming and Physiologic Optimization

• Actively warm the patient and all transfused fluids using adequate warming devices available in all emergency rooms and theatre suites 1
• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature, but avoid vasopressors 1, 2
• Monitor and correct electrolyte abnormalities, particularly hypocalcemia from citrate toxicity, to prevent cardiac dysfunction 2, 6

Definitive Hemorrhage Control

• Consider surgery early - damage control surgery may be necessary, limited to controlling bleeding before complete physiologic normalization 1, 2
• Rapid access to imaging (ultrasound, radiography, CT) or focused assessment with sonography for trauma scanning if patient sufficiently stable 1
• Alert theatre team about the need for cell salvage autotransfusion 1, 2

Post-Resuscitation Management

• Admit to critical care area for monitoring of coagulation, hemoglobin, blood gases, and wound drain assessment to identify overt or covert bleeding 1
• Commence standard venous thromboprophylaxis as soon as possible after hemostasis is secured as patients rapidly develop a prothrombotic state following massive hemorrhage 1, 2
• Temporary inferior vena cava filtration may be necessary 1

Critical Pitfalls to Avoid

• Do not delay activation of the massive transfusion protocol - activate immediately when massive hemorrhage is declared, as delay increases mortality 1, 2
• Do not wait for laboratory results before administering blood products in obvious massive hemorrhage, as this increases mortality 2
• Do not administer excessive crystalloid as this causes dilutional coagulopathy and worsens outcomes; transition to blood products early 5
• Do not use hemoglobin level as the sole trigger for transfusion, as this fails to account for the dynamic nature of hemorrhagic shock 5
• Do not attempt to achieve normal blood pressure initially - restore organ perfusion but avoid aggressive normalization until bleeding is controlled 1

Traceability Requirements

• It is a statutory requirement that the fate of all blood components must be accounted for and records held for 30 years 1
• Staff must be familiar with local protocols for recording blood use in clinical notes and informing the hospital transfusion laboratory 1