Massive Transfusion Protocol

by Chris Nickson, Last updated May 7, 2014

Reviewed and revised 10 March 2014
OVERVIEW
Massive transfusion is defined as

 replacement of >1 blood volume in 24 hours, or

 >50% of blood volume in 4 hours (adult blood volume is approximately 70
mL/kg), or
 in children: transfusion of >40 mL/kg (blood volume in children over 1 month old
is approximately 80 mL/kg)
A Massive Transfusion Protocol should be used in critically bleeding patients anticipated
to require massive transfusion

GOALS IN MANAGEMENT OF MASSIVE TRANSFUSION

 early recognition of blood loss
 maintenance of tissue perfusion and oxygenation by restoration of blood volume
and haemoglobin (Hb)
 arrest of bleeding in combination with use of early surgical or radiological
intervention, and
 judicious use of blood component therapy to correct coagulopathy
THERAPY INDICATIONS IN MASSIVE TRANSFUSION
 Check these parameters early and frequently (e.g. every 30-60 minutes while massive
transfusion is ongoing)
Parameters Values to aim for
Temperature >35 °C
Acid-base status ph >7.2, base excess <–6, lactate <4 mmol/L
Ionised calcium
>1.1 mmol/L
(Ca)
Haemoglobin This should not be used alone as transfusion trigger; and, should be interpreted in

(Hb) context with haemodynamic status, organ & tissue perfusion.

Platelet (Plt) ≥ 50 x 10^9 /L (>100 x 10^9 if head injury/ intracranial haemorrhage)
PT/APTT ≤ 1.5x of normal
Fibrinogen ≥ 1.0 g/L
MASSIVE TRANSFUSION PROTOCOL TEMPLATE
 See Massive transfusion protocol template
PROBLEMS WITH MASSIVE TRANSFUSION
Risks and complications of large volume resuscitation with blood products

 volume overload (careful monitoring of filling pressures, response to volume,

diuresis etc)
  over-transfusion (monitor Hb regularly, titrate according to needs)
 hypothermia (monitor temp, use fluid warmers and other measures to reduce
heat loss)
 dilutional coagulopathy of clotting factors and platelets (regular and early
monitoring of coagulation, involvement of haematology for replacement therapy )
 Transfusion related acute lung injury (consider use of filters, leukodepletion)
 excessive citrate causing metabolic alkalosis and hypocalcaemia (monitor pH
and ionised calcium, replace calcium as necessary)
 hyperkalaemia (use of younger blood, monitor regularly, may require specific
therapy)
 disease transmission (use of products only on a needed basis only, standard
blood banking precautions etc)
If uncross-matched / O neg blood

 Haemolytic disease of newborn if RhD mismatch

 Difficulty with cross-matching future blood product
 Difficulty with matching solid organs
Logistical issues

 distractions resulting in not controlling source of haemorrhage, and

 risks of hurried cross-checking and incompatability (allocation of sufficient
resources and personnel, standard programs in place to facilitate process and
anticipate needs)
 other problems including loss of identity, crossmatching issues, loss of baseline
haematological information etc)
Usual transfusion reactions and problems

 TRALI / TACO
 Acute / delayed haemolytic transfusion reaction
 Non-febrile haemolytic transfusion reaction
 Bacterial / viral infection
 Anaphylaxis if IgA deficient
 GVHD
 Storage lesion effects
References and Links

 National Blood Authority. Patient Blood Management Guidelines: Module 1 –

Critical Bleeding/Massive Transfusion.[cited 2011 Jun 30]. Available
from: http://www.nba.gov.au.