Massive Transfusion Protocol

Definition

 

> 10 units of packed red blood cells per 24 hours

 

Goal of massive transfusion protocol

 

Limit critical hypoperfusion while surgical hemostasis obtained

Limit complications

 

Issues

 

1.  Volume status and oxygenation

 

Volume via crystalloids required to maintain tissue perfusion

At some stage blood is also required for oxygenation

 

2.  Acidosis

 

Hypoperfusion results in acidosis

Acidosis interferes with coagulation

- delayed and thin fibrin clot

- more susceptible to fibrinolysis

 

3. Hypothermia

 

Caused by trauma circumstance and lower blood volume

Affects coagulation cascade and platelet plug formation

 

4.  Coagulopathy

 

Caused by

- use of coagulation factors due to bleeding

- dilution by volume expansion

- worsened by hypothermia / acidosis

 

Target parameters

 

Mean arterial BP -  60 to 65 mm Hg

Hemoglobin - 7 to 9 g/dL
INR < 1.5
Fibrinogen > 1.5 to 2 g/L
Platelets > 50 times 10/L
pH 7.35 to 7.45
Core temperature > 35 C

 

Components of Massive Transfusion protocol

 

Packed Red Blood Cells

Fresh frozen plasma (FFP)

Platelets

 

Ratios

 

1:1:1 Plasma / Platelets / RBC

 

Results

 

Meneses Am J Emerg Med 2020

- systematic review of 11 studies looking at transfusion ratios

- protocols effective at reducing mortality

- shorter time to blood products improved outcome

https://pubmed.ncbi.nlm.nih.gov/33071074/

 

Holcomb et al JAMA 2015

- PROPR RCT of 680 patients massive transfusion protocol

- compared 1:1:1 to ratio of 1:1:2

- reduced mortality at 24 hours in 1:1:1 (13% v 17%), although not significant

- reduced mortality at 30 days in 1:1:1 (22.4% v 26%), although not significant

- reduced exsanguination in 1:1:1 group

- no difference in ARDS, MOF, DVT, transfusion complications, sepsis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374744/

 

TEXA (tranexamic acid)

 

Shown to reduce the risk of death in bleeding trauma patients

 

Loading dose 1g over 10 min then infusion of 1g over 8 h

 

CRASH-2 trial collaborations Lancet 2010

- RCT of 20,000 patients

- loading dose + infusion TEXA v placebo

- significant reduction in all cause mortality + mortality secondary to bleeding

https://pubmed.ncbi.nlm.nih.gov/20554319/