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
Components of Massive Transfusion protocol
Packed Red Blood Cells
Fresh frozen plasma (FFP)
Platelets
Ratios
1:1:1 Plasma / Platelets / RBC
Results
Meneses et al 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
- 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
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