What is the management of massive transfusion?

Management of Massive Transfusion

Massive transfusion requires immediate activation of a structured protocol with concurrent hemorrhage control, balanced blood product resuscitation using a 1:1:1 ratio of red cells:plasma:platelets, aggressive prevention of hypothermia and coagulopathy, and early surgical or interventional radiology intervention to stop bleeding.

Immediate Actions and Team Activation

A senior clinician must immediately declare a massive hemorrhage situation and assume the role of team leader to coordinate all aspects of care. 1 This person directs the multidisciplinary response and assigns specific roles including a communications lead for laboratory liaison, a dedicated runner for blood product transport, and a team member focused solely on securing vascular access. 1

Initial Resuscitation Steps

• Control obvious bleeding points immediately using direct pressure, tourniquets, or hemostatic dressings. 1
• Administer high-flow oxygen to all patients. 1, 2
• Establish large-bore IV access (ideally 8-Fr central venous catheter in adults; if unsuccessful, use intraosseous or surgical venous access). 1, 2
• Obtain baseline blood samples immediately: full blood count, PT, aPTT, Clauss fibrinogen (not derived fibrinogen), and cross-match. 1, 2
• Utilize near-patient viscoelastic testing (TEG or ROTEM) if available for rapid coagulation assessment. 1, 2

Blood Product Resuscitation Strategy

Resuscitate with warmed blood products, not crystalloids, in massive hemorrhage. 1, 2 The hierarchy of blood availability is: Group O (fastest) → group-specific → cross-matched. 1, 2 In extreme emergency, no more than 2 units of un-crossmatched O negative blood should be used (O positive is acceptable for males or postmenopausal females). 1

Transfusion Ratios and Targets

Administer blood products in a 1:1:1 ratio of red cells:plasma:platelets to approximate whole blood and prevent dilutional coagulopathy. 3, 4, 5 This approach has demonstrated improved survival compared to historical practices. 5

• Fresh frozen plasma: 12-15 ml/kg body weight (approximately 4 units or 1 liter for an adult), targeting PT and aPTT <1.5 times control mean. 1
• Platelets: Anticipate platelet count <50×10⁹/L after 2 blood volume replacement; maintain >50×10⁹/L (>100×10⁹/L if traumatic brain injury present). 1, 2
• Cryoprecipitate: Administer when fibrinogen <1.0 g/L, as fibrinogen <0.5 g/L is strongly associated with microvascular bleeding. 1

Coagulopathy Prevention and Management

Target fibrinogen level >1.5 g/L in massive hemorrhage using fibrinogen concentrate 3-4g or cryoprecipitate (15-20 single donor units). 2, 6 Fibrinogen deficiency develops early when plasma-poor red blood cells are used for replacement. 1

• Administer tranexamic acid 1g IV over 10 minutes as soon as possible if the patient is bleeding or at risk of significant bleeding, followed by 1g infusion over 8 hours. 2, 6
• Tranexamic acid must be given within 3 hours of bleeding onset for maximum benefit. 2, 6
• Repeat coagulation studies every 4 hours or after 1/3 blood volume replacement, and after blood component infusion. 1

Critical Pitfall: Hypothermia and Acidosis

Hypothermia carries high mortality due to organ failure and disseminated intravascular coagulation. 1 Actively warm the patient using warm air blankets and temperature-controlled blood warmers for all transfused fluids. 1, 2 Blood warmers are indicated when flow rate exceeds 50 ml/kg/h in adults. 1

Hemodynamic Management

Restore organ perfusion but do not aggressively normalize blood pressure until bleeding is controlled. 1, 2, 6 If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate. 1

Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature, but avoid vasopressors during active bleeding. 1, 2, 6

Definitive Hemorrhage Control

Early surgical or interventional radiology intervention is essential. 1 Surgery may need to be limited to "damage control" procedures, with definitive repair delayed until abnormal physiology is corrected. 1

• Consider intraoperative blood salvage if available and appropriate (contraindicated if wound heavily contaminated). 1
• Interventional radiology for embolization should be considered when surgical control is difficult. 1

Laboratory Monitoring

Blood loss is usually underestimated, and hemoglobin/hematocrit values do not fall for several hours after acute hemorrhage. 1 Clinical assessment of injury patterns, visible blood loss, and physiological parameters (skin color, heart rate, capillary refill, conscious level) provides critical real-time information. 1

Post-Resuscitation Care

Admit to critical care unit for continued monitoring after bleeding control. 1, 2, 6 Monitor coagulation parameters, hemoglobin, blood gases, and assess wound drains for rebleeding. 1, 2, 6

Initiate venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state. 1, 2, 6 Temporary inferior vena cava filtration may be necessary in select cases. 1

Common Pitfalls to Avoid

• Do not wait for laboratory results to initiate transfusion in massive hemorrhage; components may need to be given before results are available. 1
• Avoid prophylactic calcium chloride, as citrate toxicity and hypocalcemia are usually self-limiting and prophylactic calcium is dangerous and unnecessary. 7
• Do not underestimate blood loss; clinical signs and measured losses are more reliable than initial hemoglobin values. 1
• Suspect DIC early when shock, hypothermia, and acidosis are present, as mortality from DIC is high. 1