Massive Transfusion

Links:

ACS TQIP Massive Transfusion in Trauma Guidelines (PDF)

(Information from UMCNO Level 1 Trauma Center)
  • Most common definition of “Massive Transfusion” is transfusion of 10 RBC units in a 24 hour period
    • Not practical for immediate assessment
    • Consider initiating Massive Transfusion response if hemorrhage is >150 mL/min or if transfusion (or anticipated transfusion) of >4 RBC units in 1 hour.
    • Literature shows that only approx. 50% of Massive Transfusion responses result in a Massive Transfusion (>10 RBC units in 24 hours)
      • So, do not be afraid to call for a Massive Transfusion response if you feel it is indicated – unused blood products can be returned to Blood Bank and used for other patients if properly handled
    • At UMCNO, requires attending physician authorization. Must be “activated” by calling Blood Bank at 702-3482.  When blood products are no longer required, Blood Bank must be contacted to “deactivate”.  Any remaining blood product containers must be returned to Blood Bank ASAP.
    • Do not remove cold packs from blood product containers at any time (temperature of all blood products must be tightly controlled).
    • Every institution has their own “protocol” in regards to the blood product mix provided and the number of products provided at one time.
    • At UMCNO, the 1st container of blood products contains 6 units of RBCs, 6 units of thawed plasma, and 1 unit of platelets; the 2nd container contains 6 units of RBCs, 6 units of thawed plasma; the 3rd container contains 6 units of RBCs, 6 units of thawed plasma and 1 dose (2 pools) of cryoprecipitate.
    • Empiric Plasma:RBC ratios remain controversial, and should only be used in circumstances where laboratory value-based monitoring/transfusion is not feasible due to rate of hemorrhage.
      • PROPRR Trial (NEJM 2015) – 1:1:1 RBC:plasma:platelet ratio did not confer an overall survival benefit over a 2:1:1 ratio.
    • When in a Massive Transfusion type scenario, must also consider:
      • Source control – involve Surgical, GI and IR services as appropriate early
      • Vascular access – standard CVCs and PICC lines have slow maximal infusion rates and should be avoided; maximal infusion rates through large bore PIVs or IO lines are significantly better; optimal access is either a Cordis or MAC line.
    • Complications to look out for when performing Massive Transfusion resuscitation:
      • Dilutional coagulopathy
      • Hypothermia (1 unit of RBCs can lower core body temperature approx. 0.5°C)
      • Acidosis (due to underlying tissue dysfunction; can contribute to coagulopathy)
      • Hypocalcemia (due to citrate preservative in blood products; can contribute to coagulopathy)
      • Hypokalemia/Hyperkalemia (both complications can develop after large quantities of RBCs are transfused)
    • Labs/conditions to monitor/treat when in a Massive Transfusion resuscitation:
      • Temperature – consider external/internal warming devices; Rapid Infuser/Blood Warming devices (“Level One”) can also be considered – may need to call OR/ED/Surgical Units to locate.
      • ABG with electrolytes – monitor pH (if mechanically ventilated, might need higher minute ventilation to maintain normal pH range), ionized calcium (would replace to high-normal range).
      • CBC/PT/aPTT/fibrinogen – fibrinogen levels very important, often forgotten. Order labs as STAT.
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