Massive transfusion (peds)

This page is for pediatric patients; for adult patients see massive transfusion

Overview

Blood product unit conversions

• PRBC: 1 bag = 1 unit = 350 mL
• FFP: 1 bag = 1 unit = 250 mL
• Platelets: 1 bag = 1 pack = 5 units = 250 mL
• Cryoprecipitate: 1 bag = 5 units = 200 mL

Indications

• Requiring > 40 mL/kg (40% blood volume) or 4 u for adult / patient > 30 kg over 2 hours or less
• Requiring or likely to require complete blood volume replacement or 10 u for adult in 24 hours

Age-specific blood volume

• Newborn – 1 month 90 mL/kg
• 1-12 months 85 mL/kg
• 1-14 years 80 mL/kg
• > 14 years 75 mL/kg
• Obese children 65 mL/kg

Equipment Needed

Recommended lab studies

• Initial: Type & Cross, CBC (Hgb, plt), PT/PTT, Fibrinogen, ionized Ca, K+ (basic metab panel), pH
• After first 80 mL/kg PRBC: repeat above + FDPs
• After every 40 mL/kg PRBC from then on: repeat above + FDPs, lactate

Procedure

Pediatric Massive Transfusion Protocol Amounts

MTP Pack 1	MTP Pack 2	MTP Pack 3	MTP Pack 4	MTP Pack 5
Children < 10 kg
25 mL/kg PRBC 20 mL/kg FFP call for platelets for pack 2	25 mL/kg PRBC 20 mL/kg FFP 10 mL/kg platelets	25 mL/kg PRBC 20 mL/kg FFP 10 mL/kg platelets 4 mL/kg cryoprecipitate	25 mL/kg PRBC 20 mL/kg FFP 10 mL/kg platelets 4 mL/kg cryoprecipitate	25 mL/kg PRBC 20 mL/kg FFP 10 mL/kg platelets 4 mL/kg cryoprecipitate
Children 10-20 kg
1u PRBC 1u FFP (thaw immediately after PRBC issued) call for platelets for pack 2	1u PRBC 1u FFP 1 platelet pack	1u PRBC 1u FFP 1 platelet pack 2.5u cryoprecipitate	1u PRBC 1u FFP 1 platelet pack 2.5u cryoprecipitate	1u PRBC 1u FFP 1 platelet pack 2.5u cryoprecipitate
Children 20-49 kg
2u PRBC 2u FFP call for platelets for pack 2	2u PRBC 2u FFP 1 platelet pack	2u PRBC 2u FFP 1 platelet pack 5u cryoprecipitate	2u PRBC 2u FFP 1 platelet pack 5u cryoprecipitate	2u PRBC 2u FFP 1 platelet pack 5u cryoprecipitate
Children > 50 kg
4u PRBC 4u FFP call for platelets for pack 2	4u PRBC 4u FFP 1 platelet pack	4u PRBC 4u FFP 1 platelet pack 10u cryoprecipitate	4u PRBC 4u FFP 1 platelet pack 10u cryoprecipitate	4u PRBC 4u FFP 1 platelet pack 10u cryoprecipitate

Example Instructions (Harbor-UCLA)

• Early involvement of trauma surgery attending or chief resident in decision
• Call Blood Bank and state that you are activating the MTP
• Send a type and cross BEFORE starting transfusions
• First MTP box ready within 10 min of phone call trigger: 6u PRBC, 4u thawed plasma (FFP)
• Second MTP box ready within 30 min of initial phone call trigger
• Successive boxes prepared and issued as needed q 30 minutes of prior box
• Consider platelets, cryoprecipitate (typically after 2nd box issued)
  • Cryo takes 30 min to thaw and pool – plan ahead and request
• PRBCs type specific (preferred) or O negative or O positive for men, women > 55 years
• Plasma (FFP) is Group A – incompatible with 14% of pts (B or AB), could cause some hemolysis
• Return unused boxes to Blood Bank within 20 minutes if possible (so can return to inventory)
• MTP automatically terminated 8 hours after initiation, or if you begin to order quantities less than amount in MTP box

Complications

• Coagulopathy
• Hypothermia
• Hyperkalemia
• Hypocalcemia
• Transfusion reaction
• Transfusion-related acute lung injury
• Fluid overload

References

Authors

Ross Donaldson