Massive Transfusion Guidelines (Adult)

Definition
Initiate Massive Transfusion protocol 
Platelet Transfusion
Cryoprecipitate
Crystalloids
Fresh frozen plasma

Massive transfusion is defined as:

• More than 10 units in 24 hours
• Replacement of entire blood volume in 24 hours
• Replacement of more than 50% of total blood volume within 3 hours
• Rate of loss >150ml/min.

The dilutional coagulopathy resulting from rapid red cell replacement, with concomitant crystalloid and colloid administration, may be corrected with supplemental fresh frozen plasma and cryoprecipitate when more than 50% of blood volume has been replaced.

Platelet concentrates should be used together with RBC and FFP in a ratio of 1:1:1.² This regime is recommended by the” Clinical Guidelines for the use of Blood Products in South Africa – SA Blood Transfusion Service”.

Early and aggressive use of whole blood or blood component therapy has been called “haemostatic resuscitation”. Haemostatic resuscitation typically involves delivering RBCs and blood components in a fixed ratio, as opposed to relying on laboratory assays (which are typically delayed and do not accurately reflect true coagulation status).

Time to initiation of transfusion is critically important, and must be expedited as urgently as possible. For delays in collection of cross-match specimens and/or delivery of blood products see below.

The lethal triad of exsanguinating haemorrhage:

• Acidosis
• Hypothermia
• Coagulopathy

Independent variables predicting Massive Transfusion:

• Penetrating injury ²
• INR > 1.5 ²
• Haemoglobin < 11g/dL²or haematocrit < 32 ³
• pH < 7.25 ³
• Positive FAST ⁴ (free fluid in abdomen on ultrasound scan)
• Systolic BP < 90 ⁴
• Heart rate > 120 ⁴

Initiate Massive Transfusion protocol if:

• More than 4 units packed red cells in 1 hour.
• Expected transfusion requirement of more than 10 units in 12 hours.
• Consideration of above independent predictors.

Consider limiting crystalloid volume replacement (Ringer’s lactate, Plasmalyte L, Normal Saline) to 2 to 3 litres; thereafter administer colloid (Voluven).   Excessive crystalloid administration is harmful.

Initiation of MT protocol:

1. Recognise the need for massive transfusion.
2. Declare the situation to the entire team.
3. Notify Anaesthesia and Surgery consultant-on-call.
4. Draw baseline blood specimens:  FBC, CEUG, INR, cross-match tube (if not sent already).
5. Keep the patient warm.
6. Consider Tranexamic Acid (Cyclokapron) 1g IV over 10 minutes.
7. Check with the blood bank your unit uses that they have an adequate cross-match specimen.
8. Request Massive Transfusion Pack:

• 6 units packed red blood cells.
• 6 units FFP (fresh frozen plasma).
• 1 unit of random donor pooled platelets.

1. Put request through as STAT and not ASAP.
2. Ensure adequate large-bore high-capacity venous access.
3. Ensure active warming of patient and IV fluids.
4. Commence transfusion on arrival of products.
5. Repeat “Massive Transfusion Pack” as necessary.
6. Consider the addition of 10 units (1000iu) cryoprecipitate when ordering second and subsequent Massive Transfusion Packs.
7. Before transferring to ICU, contact laboratory and send STAT blood for:
   1. FBC (Hb & platelet count)
   2. INR & PTT
   3. Fibrinogen levels
8. Repeat Tranexamic Acid 1g in 200ml or 1000ml saline over 8 hrs in ICU.

The British Committee for Standards in Haematology recommendations include the following:

• Maintain Hb >8g/dl
• Keep Platelets >75 x10⁹/l
• Maintain fibrinogen >1.0g/l
• Maintain INR & APTT <1.5 x mean

Platelet transfusion:

• Platelet transfusion – use the dedicated platelet filter provided.   Standard blood filters will trap platelets, reducing the amount of platelets actually administered.
• For Massive Transfusion maintain platelet count above 50 x 10⁹/L.
• Random donor pooled platelets – platelets from 5 individual donations pooled together to produce one unit of platelet concentrate – indicated in acute thrombocytopenia in patients unlikely to require long term platelet transfusion.
• Platelet count should increase by 20 – 40 x 10⁹/L per standard adult dose, but will be lower in splenomegaly, DIC and septicaemia.
• Single donor apheresis platelet concentrates should NOT be ordered – these platelets are indicated for patients on long-term platelet replacement therapy.

Cryoprecipitate:

• Indicated in the treatment of acquired or congenital hypofibrinogenaemia.
• Contains Factor VIII, von Willebrand Factor, fibrinogen, fibronectin and factor XIII.
• Contains approximately 100 IU Factor VIII and vWF, and 150 – 250mg fibrinogen, per unit.
• Administered in pools of 10 units (1000iu Factor VIII and vWF), given through a standard blood-giving IV admin set).

Crystalloids:

• Crystalloids are pro-inflammatory and are acidotic – giving rise to hyperchloraemic acidosis.   
• Limit to 2 to 3 litres in the average adult patient.   
• Crystalloids have also been implicated in ARDS and abdominal compartment syndromes, increased ventilator days and longer ICU stays⁵.

Fresh frozen plasma:

• Administration of FFP replaces coagulation proteins (400mg fibrinogen with each unit), acts as a buffer (improving acid-base status in already-acidotic patients), is an excellent volume-expander and maintains oncotic pressure⁵.
• Concern over the increased incidence of Transfusion-related acute lung injury (TRALI) and multi-organ failure (MOF) with increased transfusion of FFP and platelets are unfounded.   
• Massive transfusion patients comprise 3% of patients, and have a mortality between 30 and 60%.   
• TRALI has an incidence of 1 in 5000 to 10 000 transfusions, is managed with ventilator support, usually resolves within 24 hrs, and carries a mortality of 6 to 9%⁵.

References:

1. Riskin, Tsai et al. Massive transfusion protocols: The role of aggressive resuscitation versus product ratio in mortality reduction.   J Am Coll Surg 2009.04.016. [Used a 1:1.5 FFP to PRBC ratio.   Showed that by halving time to initiation of transfusion products, survival more than doubled.]
2. Scheiber, Perkins et al. Early predictors of massive transfusion in combat casualties.   J Am Coll Surg 2007.05.007.
3. McClaughlin et al. Predictive model for massive transfusion in combat casualties. J Trauma 2008: 64: 557-63. [HR > 105; SBP < 110; pH < 7.25; HCT < 32]
4. Nunez et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption).  J Trauma 2009; Feb 66 (2): 346-52. [ABC score of 2 or more for the following: Penetrating trauma, positive FAST, SBP < 90, HR > 120.  75% sensitive and 86% specific for predicting MT.]
5. Holcomb et al.  Increased plasma and platelet to red blood cell ratio improves outcome in 466 massively transfused civilian trauma patients. Annals of surgery 2008.
6. Clinical guidelines for the use of blood products in South Africa, 4^th edition, Western Province Blood Transfusion Service.