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Massive transfusion
From WikEM
This page is for adult patients; for pediatric patients see Massive transfusion (peds)
Contents
Background
- Although massive transfusion (MTP) does not have a universal definition, it is generally described as transfusion of >10 units of blood products (specifically Packed red blood cells within a 24-hour period)
- In addition to controlling hemorrhage the greatest concern during MTP is the lethal triad:[1]
- During MTP, focus is on "balanced resuscitation" with clotting factors (FFP) and platelets”[2]
- The PROPPR trial[3] examined a 1:1:1 (FFP:Plt:pRBC) vs 1:1:2 protocol. There was no difference in mortality at 1 or 30 days; however, the 1:1:1 group experienced less death due to exsanguination in the first day.
- The goal of MTP is to resuscitate and temporize management until definitive operative repair can be accomplished.
- MTP should follow should follow local institutional protocols[4]
Indications
- Hemorrhagic shock is the only indication for a massive transfusion
- The ABC score and the TASH score predict the need for MTP
Adjunctive Agents
- Tranexamic acid (TXA) lowers risk of death if administed in less then 3 hours after injury in trauma patients with significant hemorrhage[5]
- Thromboelastography (TEG) has been extensively studied in cardiac surgery and quantifies the coagulation cascade
- Factor VII, studied in the CONTROL trial, [6] showed no mortality benefit and was terminated early
- Other studies of Factor VII have raised concerns for MI and adverse thrombotic events
Example Protocol
MTP pack contains 6 units RBCs and 4 units FFP (O neg uncrossmatched rbc's and AB FFP until completed screen)
- Attending physician activates protocol
- Charge nurse contacts blood bank and sends runner to pick up MTP pack
- TEG is drawn
- First MTP pack is delivered within 30min of ordering
- Transfusion continues until patient expires or is hemodynamicallys stable with cessation of bleeding
- If second pack is ordered it contains an additional single donor platelet pack (six-pack)
- The third pack substitutes cryoprecipitate for platelets
- PT, aPTT, and Fibrinogen is ordered q2 hours for the duration of the massive transfusion event
Complications[7]
- Hypothermia
- Dilutional coagulopathy
- Hypocalcemia and hypomagnesemia from high citrate concentration
- Lactic acidosis from inability to breakdown citrate secondary to to hepatic dysfunction
- Hyperkalemia
- Air embolism
- Metabolic alkalosis from breakdown of citrate
External Links
See Also
- Massive transfusion (peds)
- TXA
- Packed red blood cells
- The PROPPR trial
- Coagulopathy (Main)
- Hemorrhagic shock
References
- ↑ Kashuk JL, et al. Major abdominal vascular trauma — A unified approach. J Trauma. 1982;22(8):672–679.
- ↑ Spinella PC. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. Blood Rev. 2009 Nov;23(6):231-40.
- ↑ Holcomb J. et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma The PROPPR Randomized Clinical Trial JAMA. 2015
- ↑ ACS TQIP Massive Transfusion in Trauma Guidelines fulltext
- ↑ Shakur H, et al. "Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage". The Lancet. 2010. 376(9734):23-32.
- ↑ Hauser CJ. et al. Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma. 2010 Sep;69(3):489-500. d
- ↑ Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.
