What is the protocol for massive transfusion in adult and pediatric patients?

Massive Transfusion Protocol

Immediate Protocol Activation and Blood Product Strategy

For trauma patients with massive hemorrhage, activate your massive transfusion protocol immediately and transfuse blood products in a 1:1:1 ratio (RBC:FFP:platelets), as this balanced resuscitation approach reduces early mortality from exsanguination. 1, 2

When to Activate the Protocol

• Activate the protocol immediately when massive hemorrhage is declared based on the nature of injury, without waiting for laboratory confirmation or formal thresholds to be met 1, 2
• Traditional definition involves transfusion of ≥10 units of packed red blood cells within 24 hours, though the dynamic definition is replacement of more than 4 red cell concentrates within one hour 2, 3
• Anticipate activation when 1-1.5 blood volumes may need to be infused acutely or within a 24-hour period 2

Critical First Actions

Hemorrhage Control (Paramount Priority)

• Control obvious bleeding immediately using direct pressure, tourniquets for extremity hemorrhage, or hemostatic dressings, as this is the most important initial step 1, 2
• Pursue early surgical or obstetric intervention to arrest bleeding at the source, as damage control surgery may be necessary before complete physiologic normalization 1

Vascular Access and Oxygenation

• Secure large-bore IV access with two large-bore peripheral cannulae, considering 8-Fr central access in adults or intraosseous access if peripheral fails 1
• Administer high FiO₂ to ensure adequate oxygenation during hemorrhagic shock 1, 2

Blood Product Resuscitation Strategy

The 1:1:1 Ratio Approach (Trauma Patients)

The European Society of Intensive Care Medicine conditionally recommends using a 1:1:1 ratio of RBC:FFP:platelets for trauma patients with massive bleeding, as this approach shows reduction in early mortality from exsanguination and improved hemostasis. 4

• This recommendation is based on the PROPPR trial and other studies comparing 1:1:1 to 2:1:1 ratios 4
• The improved hemostasis is likely driven by the higher number of platelets received 4
• Begin early FFP administration at 10-15 ml/kg to prevent dilutional coagulopathy before it develops 1, 2

Important Caveat for Non-Trauma Settings

• No recommendation can be made for or against fixed high-ratio transfusion outside of trauma settings (such as surgical or obstetric hemorrhage), due to potential differences in pathophysiology and coagulopathy compared to traumatic bleeding 4
• However, many centers have developed massive transfusion protocols covering all clinical scenarios based on extrapolation from trauma literature, which may provide benefits through coordinated and efficient response to acute bleeding 4

Blood Type Selection

• Start with O-negative blood only if blood is needed immediately, limiting to 2 units maximum 1
• For male patients, O RhD positive red cells are acceptable to preserve O-negative stock 1
• Transition to group-specific blood without antibody screening as soon as possible (approximately 10 minutes), as patients have minimal circulating antibodies during acute hemorrhage 1

Coagulopathy Management Targets

Laboratory Thresholds

• Maintain fibrinogen >1 g/L, as levels below this threshold represent established hemostatic failure and predict microvascular bleeding 1, 2
• Keep PT and aPTT <1.5 times normal, as values exceeding this indicate established coagulopathy requiring aggressive correction 1
• Target platelet count ≥75 × 10⁹/L throughout resuscitation, as thrombocytopenia below 50 × 10⁹/L is strongly associated with haemostatic compromise and microvascular bleeding 1, 2

Fibrinogen Replacement

• Use fibrinogen concentrate at 30-60 mg/kg for rapid and predictable replacement, as it requires no thawing unlike cryoprecipitate 1
• Cryoprecipitate is an alternative if fibrinogen concentrate is unavailable 1, 2

Equipment and Technical Considerations

Administration Sets and Filters

• Administer all blood components using a blood component administration set incorporating a 170-200 μm filter 4
• No additional filters are needed in massive haemorrhage when using allogeneic product, as pre-storage leucodepletion has rendered this unnecessary 4
• Administer platelets via a clean 170-200 μm giving set, as one previously used for red cells may cause platelets to stick to red cells and reduce the effective transfused dose 4

Blood Warming

• Use an adequate warming device in all massively bleeding patients, with this equipment available in all emergency rooms and theatre suites to allow adequate warming at high infusion rates 4

Laboratory Monitoring

Initial and Serial Testing

• Obtain baseline samples immediately: FBC, PT, aPTT, Clauss fibrinogen, blood bank sample, biochemical profile, and blood gases 1
• Repeat coagulation studies every 4 hours or after 1/3 blood volume replacement, as coagulopathy can develop rapidly 1

Special Considerations

Anticipated Consumptive Coagulopathy

• Anticipate consumptive coagulopathy in obstetric hemorrhage, cardiopulmonary bypass, massive trauma with head injury, and sepsis 1
• Hyperfibrinolysis is particularly associated with obstetric hemorrhage, CPB, and liver surgery 1

Warfarin Reversal (If Applicable)

• Use prothrombin complex concentrate (PCC) at 25 u/kg for INR 2-3.9,35 u/kg for INR 4-5.9, or 50 u/kg for INR >6, plus intravenous vitamin K 5-10 mg 1

Pediatric Considerations

• Apply the same principles: minimize and stop blood loss, minimize donor exposure, and use paediatric components where readily available 4
• Comprehensive pediatric transfusion guidelines are available from the British Committee for Standards in Haematology 4

Post-Resuscitation Management

Physiologic Normalization

• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature 1, 2
• Admit to critical care for ongoing monitoring of coagulation, hemoglobin, blood gases, and wound drains 1, 2

Thromboprophylaxis

• Initiate standard venous thromboprophylaxis as soon as hemostasis is secured, as patients rapidly develop a prothrombotic state following massive hemorrhage 1, 2

Critical Pitfalls to Avoid

• Avoid overdependence on group O RhD negative red cells, as this may adversely impact local and national blood stock management 1
• Do not delay protocol activation waiting for laboratory confirmation—the nature of injury typically alerts to probable massive hemorrhage before formal criteria are satisfied 1, 2
• Recognize that red cell concentrates do not contain coagulation factors or platelets, requiring all blood components during massive haemorrhage 4

Institutional Requirements

• Hospitals must have an MTP in place that includes clinical, laboratory, and logistic responses 2
• The protocol requires designated team roles: team leader (usually most senior physician), communications lead, dedicated personnel, and IV access specialist 2
• The use of cell salvage is encouraged in all cases of massive haemorrhage to reduce need for donor blood 4