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Therapy indications in massive transfusion

Therapeutic Indications in Massive Transfusion (1)
Therapy Indications in massive transfusion
Fluid resuscitation
  • Historically, aggressive fluid resuscitation with crystalloid/colloid is recommended to maintain normal blood pressure but they are complicated by pulmonary oedema, exacerbation of thrombocytopenia & coagulopathy due to haemodilution.
  • On the other hand, permissive hypotension, where systolic blood pressure of 80–100 mmHg is tolerated & have shown survival benefit in some studies. 
  • It is contraindicated in patients with traumatic head injuries
Red cells
  • Pretranfusion compatibility should be done early
  • Depending on the clinical situation, uncrossmatched Group O, Rh(D)-negative red cells (esp for females of childbearing age) may be appropriate
  • ABO group specific when blood group is known & fully compatible blood if time permitting (further serological cross-match not required after replacement of 1 blood volume)
  • Should be given through a blood warmer
Fresh frozen plasma (FFP)
  • There is insufficient evidence to recommend a specific RC:FFP:Plt ratio but should be based on clinical criteria & frequent monitoring of laboratory values. The institution should develop own MTP (Massive Transfusion Protocol) that includes ratio of blood component therapy which may reduce mortality & ARDS.
  • Give FFP to maintain PT & APTT ≤ 1.5x mean control
  • Usual dose is 15 ml/kg
  • If the patient's blood group is unknown, give group AB FFP
  • Allow 1/2 hour thawing time
Cryoprecipitate
  • FFP may supply enough fibrinogen to correct any deficiency but if fibrinogen <1 g/L, cryoprecipitate may be indicated
  • In obstetrics haemorrhage, early DIC is often present so consider cryoprecipitate early in this situation.
  • Usual dose is 3–4 g of fibrinogen. Your local transfusion lab can advise on the no of units to provide this dose.
  • Allow 1/2 hour thawing time
Platelets
  • Thrombocytopenia <50 x 10^9 /L can be anticipated after two blood volume replacement resulting from dilution and increase consumption
  • Aim to keep the platelet count >50 x 10^9 /L (except in the presence of multiple trauma, head/spinal injury or microvascular bleeding where the aim is a platelet count >100 x 10^9 /L)
  • Normal dose is 1 adult dose (1 bag)
Recombinant factor VIIa

  • Routine use is not recommended due to lack of effect on mortality. You need to discuss its use with a haematologist or transfusion specialist.

  • Must have adequate blood component replacement, pH >7.2 and temperature >34 °C
Tranexamic acid
  • This should be considered in trauma patients with risk of significant bleeding
  • Suggested loading dose is 1 g over 10 minutes followed by infusion of 1 g over 8 hours
Patients on Warfarin
  • Add Vit K, IV 5–10 mg and
  • Fresh Frozen Plasma 150–300 mg (1 bag) and
  • Prothrombinex 25–50 u/kg

Note that the use of blood components in patients with critical bleeding may be lifesaving, but increase volumes may be independently associated with mortality and ARDS.

References

  1. National Blood Authority. Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion. [cited 2011 Jun 30]. Available from: http://www.nba.gov.au.
Updated on 30 June 2011