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Massive Blood Transfusion
Aka: Massive Blood Transfusion, Massive Transfusion, Dilutional Coagulopathy
- See Also
- Hemorrhage Management
- Indications
- ABC Hemorrhage Score of 2 or more OR
- Trauma with Hemorrhage requiring Transfusion of Packed Red Blood Cells that replace >50% of Blood Volume
- More than 50% of Blood Volume in 4 hours (4-6 units replaced in an average adult)
- More than 100% of Blood Volume in 24 hours (8-12 units replaced in an average adult)
- Calculating total Blood Volume in units
- Blood Volume is 70 ml/kg in adults, 80 ml/kg in children, 100 ml/kg in infants
- One unit or pint of blood is 450 ml
- Blood Volume in Units = wtKg/6.4 in adults, wtKg/5,6 in children, wtKg/4.5 in neonates
- Critical Administration Threshold (CAT)
- Three or more units pRBC transfused within 60 minutes
- CAT+1: 3 units in 1 hour
- CAT+2: A second set of 3 units pRBC transfused in 1 hour
- CAT+3: A third set of 3 units pRBC transfused in 1 hour
- CAT+4: A fourth set of 3 units pRBC transfused in 1 hour
- Savage (2015) J Trauma Acute Care Surg 78(2):224-9 +PMID: 25757105 [PubMed]
- Mechanism
- Dilutional Coagulopathy
- Coagulopathy develops with Massive Blood Transfusion (dilution of Coagulation Factors)
- FFP helps treat the Coagulopathy by replacing Fibrinogen, C1 esterase, antiplasmins and other factors
- Thromboelastography (TEG)
- Measures overall coagulation efficiency and can identify the severity of coagulation defects
- Typically limited to large Trauma Centers
- Protocol: Primary 1:1:1 replacement
- Notify the blood bank early regarding need for Massive Transfusion protocol
- Red Blood Cell replacement remain the first priority
- Continue Blood Transfusion until bleeding is controlled or patient becomes hemodynamically stable
- Ratio of 1:1:1 of platelets : plasma : Red Blood Cells is preferred (decreased mortality compared with 1:1:2)
- Replace 1 unit of Fresh Frozen Plasma for every 1 unit of Packed Red Blood Cells (pRBC)
- Typically the limiting factor (insufficient supply)
- Ideal universal donor is AB Plasma, which is in short supply
- Replace 1 unit of apheresis platelets for every 6-8 units of Packed Red Blood Cells
- Each unit of apheresis platelets is equivalent to prior platelet 6-pack
- Protocol: Other Measures
- Consider Cryoprecipitate
- Cryoprecipitate primarily replaces Fibrinogen (but also Von Willebrand Factor, Factor VIII)
- If bleeding continues despite 1:1:1 replacement, obtain a Fibrinogen level
- Transfuse Cryoprecipitate if Fibrinogen level <150 mg/dl
- One unit Cryoprecipitate per 5 kg wtKg raises Fibrinogen 100 mg/dl
- Consider Prothrombin Complex Concentrate (PCC) 1-2 doses
- Do not use beyond 6-7 hours from bleeding onset (due to increased bleeding risk)
- Consider if bleeding is refractory to multiple units with 1:1:1 replacement
- Consider Tranexamic Acid
- Give within first 3 hours of injury
- Avoid if more than 3 hours after injury (no benefit, and possible harm)
- Precautions
- Avoid Hypothermia (worsens Coagulopathy when <35 C, and especially when <32 C)
- Keep Body Temperature >35 C
- Warm blood (each unit may lower Body Temperature 0.25 C)
- Consider Bair Hugger
- Complications
- Dilutional Coagulopathy
- Hypothermia
- Hyperkalemia
- Hypocalcemia
- Metabolic Acidosis
- References
- Orman and DeLoughery in Herbert (2017) EM:Rap 17(4): 5-6
- Holcomb (2012) Arch Surg 15:1-10 [PubMed]
- Holcomb (2015) JAMA 313(5): 471-82 +PMID:25647203 [PubMed]