Therapeutic Indications in Massive Transfusion (1)
- Aggressive fluid resuscitation with crystalloid solution has previously been recommended to achieve and maintain normal blood pressure - however this can be complicated by: pulmonary oedema and acute lung injury; exacerbation of anaemia, thrombocytopenia & coagulopathy due to haemodilution; and exacerbation of bleeding due to possible clot disruption.
- Permissive hypotension and minimal volume resuscitation, where systolic blood pressure of 80–100 mmHg is tolerated while bleeding is controlled have shown survival benefit in several studies. It is widely practiced for ruptured abdominal aortic aneurysm; but contraindicated in patients with traumatic brain and spinal injuries.
- The decision to administer red cell transfusion during resuscitation should include assessment of the patient's intravascular volume status, cardiopulmonary parameters, and the extent of, or potential for, ongoing haemorrhage
- Red cell transfusion is likely to be required when 30–40% blood volume is lost (approximately 2000 mL in an adult); >40% blood volume loss is immediately life-threatening (2)
- Pretranfusion compatibility testing should be done early
- It is best practice to transfuse red cells of the same ABO and RhD group as the patient; however if there are insufficient supplies of the patient's ABO group available locally, red cells of another ABO compatible group may be released by the transfusion provider
- In an emergency situation uncrossmatched Group O, RhD negative red cells (especially for females of childbearing age) may be appropriate
- Should be given through a blood warmer
- There is insufficient evidence to support or refute a specific RBC:FFP:PLT ratio – transfusion should be based on clinical criteria & frequent monitoring of laboratory values.
- Institutions should develop their own MTP (Massive Transfusion Protocol) with locally agreed ratios of blood component therapy.
- 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 provider can advise on the number of units to provide this dose.
- Allow 1/2 hour thawing time
- Thrombocytopenia <50 x 109 /L can be anticipated after two blood volume replacement due to dilution and increased consumption
- Aim to keep the platelet count >50 x 109 /L (or >100 x 109/L in situations such as CNS injury or diffuse microvascular bleeding)
- The usual dose in an adult is 1 unit
- Routine use is not recommended due to lack of effect on mortality.
- It is not licensed for the prevention or management of haemorrhage in critically bleeding patients.
- The MTP should include considerations for rFVIIa use
- Consider in trauma patients with or at risk of significant bleeding
- Suggested loading dose is 1 g over 10 minutes followed by infusion of 1 g over 8 hours
For life-threatening (critical organ) and clinically significant bleeds, the consensus is to use the maximum dose of Prothrombinex-VF (with vitamin K1 and FFP) and the maximum amount of FFP when Prothrombinex-VF is unavailable (3):
- Vitamin K1: 5–10 mg IV
- Prothrombinex (PTX-VF): 50 IU/kg
- Fresh Frozen Plasma: 150–300 mL or 15 mL/kg if PTX-VF not available
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.
- American College of Surgeons (ACS) Committee on Trauma. Advanced trauma life support for doctors: ATLS student course manual ACS, Chicago 2008.
- Tran HA, Chunilal SD, Harper PL, Tran H, Wood EM, Gallus AS. An update of consensus guidelines for warfarin reversal. MJA 2013;198(4);198–199