What is the recommended protocol for a mass transfusion in cases of significant blood loss?

Mass Transfusion Protocol

Immediately activate your institution's massive transfusion protocol when significant hemorrhage is declared, and begin resuscitation with a 1:1:1 ratio of red cells:FFP:platelets for severely traumatized patients while simultaneously controlling the bleeding source. 1, 2

Immediate Actions Upon Protocol Activation

Control the bleeding source first - this is the paramount priority before anything else. Apply direct pressure, tourniquets, or hemostatic dressings to obvious bleeding points. 1, 2, 3

Secure vascular access and oxygenation:

• Insert large-bore peripheral IV cannulae (14-gauge or larger), or 8-Fr central access in adults 1, 2
• Consider intraosseous or surgical venous access if peripheral access fails 2
• Administer high FiO2 to ensure adequate oxygenation 2, 3

Mobilize the team immediately - designate a coordinator responsible for communication and documentation, and contact the duty anesthetist, blood bank, and duty hematologist. 1

Blood Product Resuscitation Strategy

Use balanced 1:1:1 transfusion ratios (red cells:FFP:platelets) for the most severely traumatized patients, as this military-derived approach improves outcomes in massive hemorrhage. 1, 2, 4

Blood product selection and timing:

• Use O negative blood only if blood is needed immediately (within minutes) 1, 2
• Group-specific blood can be issued without antibody screening because circulating antibodies are minimal during acute hemorrhage 1, 2
• Fully cross-matched blood when time permits 1
• Warm all blood products and fluids using blood warmers, especially when flow rates exceed 50 ml/kg/hour 1, 2

Prevention and Management of Coagulopathy

Administer early FFP prophylactically at 15 ml/kg if a senior clinician anticipates massive hemorrhage, before coagulopathy develops. 1, 2

Recognize established hemostatic failure when fibrinogen falls below 1 g/L or PT/aPTT exceeds 1.5 times normal - these thresholds predict microvascular bleeding. 1, 2

Correct established coagulopathy aggressively:

• Administer more than 15 ml/kg of FFP to correct established coagulopathy 1, 2, 3
• Use fibrinogen concentrate or cryoprecipitate (if concentrate unavailable) to rapidly achieve fibrinogen levels above 1 g/L 1, 2, 3
• Maintain platelet count at minimum 75 × 10⁹/L throughout resuscitation 1, 2, 3

Laboratory Monitoring

Obtain baseline studies immediately: FBC, PT, aPTT, Clauss fibrinogen, blood bank sample, biochemical profile, and blood gases. 1, 2

Repeat coagulation studies every 4 hours or after one-third blood volume replacement, and after blood component infusion. 1

Monitor lactate and base deficit as sensitive indicators of hypoperfusion and shock severity. 2, 5

Use near-patient testing (TEG or ROTEM) if available for rapid coagulation assessment to guide component therapy. 2

Critical Pitfalls to Avoid

Do not delay protocol activation - waiting increases mortality. Activate immediately when massive hemorrhage is declared, not after laboratory confirmation. 2, 3, 5

Do not administer excessive crystalloid - this causes dilutional coagulopathy and worsens outcomes. Transition to blood products early after initial 2-liter crystalloid bolus. 2, 5

Do not use hemoglobin level as the sole transfusion trigger - this fails to account for the dynamic nature of hemorrhagic shock. 2, 5

Do not wait for laboratory results before administering blood products in obvious massive hemorrhage, as this delay increases mortality. 2, 3

Definitive Hemorrhage Control

Pursue surgical intervention early - damage control surgery may be necessary, limited to controlling bleeding before complete physiologic normalization. 2, 3

Consider interventional radiology for anatomically appropriate bleeding sources. 1

Utilize cell salvage autotransfusion when appropriate and not contraindicated by heavy wound contamination. 1, 2

Physiologic Optimization

Actively warm the patient and all transfused fluids using adequate warming devices to prevent the lethal triad of hypothermia, acidosis, and coagulopathy. 2, 6

Correct electrolyte abnormalities, particularly hypocalcemia from citrate toxicity, to prevent cardiac dysfunction. 2, 3

Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature, but avoid vasopressors during active hemorrhage. 2

Post-Resuscitation Management

Admit to critical care for ongoing monitoring of coagulation parameters, hemoglobin, blood gases, and assessment for covert bleeding. 2, 3

Commence venous thromboprophylaxis as soon as possible after hemostasis is secured, as patients rapidly develop a prothrombotic state following massive hemorrhage. 1, 2, 3

Special Considerations

The actual blood product ratios used may vary from the initial 1:1:1 protocol based on ongoing clinical and laboratory evaluation, particularly when rapid laboratory assessment is available. 7 However, the initial resuscitation should follow the balanced ratio approach until individual patient response can be assessed. 4