Therapy indications in massive transfusion
Therapeutic Indications in Massive Transfusion (1)
- 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
- 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
- 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
- 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
- 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)
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
- 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
- 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.
- National Blood Authority. Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion. [cited 2011 Jun 30]. Available from: http://www.nba.gov.au.