Massive Transfusion is defined as:
- Rate of blood loss is >150ml/min
- Loss of >50% blood volume within 3 hours
- Ongoing blood loss more than 10% of TBV/min
Identification of massive bleeding and the requirement of massive transfusion is the responsibility of the attending Clinician.
Initial Steps:
- Send Request Form and Specimen to Blood Bank (7-8 ml in plain bottle)
- Give 2 units of blood
- In an emergency:
- Group O Rh D negative red blood cells (RBCs) when the blood group is not known.
- O Rh D negative blood for females of child-bearing potential (depending on the availability) (other categories of patients could receive O Positive blood).
- Switch to ABO group specific crossmatched RBC as soon as the blood group is known.
- This request can be made over the phone .
Clinician informs the Blood Bank to activate the Massive Transfusion Protocol & to the relevant Consultant Transfusion Physician.
The blood bank is responsible for preparing the following boxes in an orderly and timely manner:
- BOX ONE: 2 Units RBC and 2 Units Fresh Frozen Plasma (FFP)
- BOX TWO: 4 Units RBC, 4 Units FFP and 1 Adult dose of Platelets
- BOX THREE: 4 Units RBC, 4 Units FFP and 10 Units of Cryoprecipitate
- BOX 2 and 3 alternatively as required
Concurrent Actions: - Give Tranexamic acid as soon as possible to a limb other than the transfusion site. (1g diluted in 100ml N saline given over 10 minutes followed by 1g diluted in 500ml N Saline given over 8 hours).
- Monitor Coagulation regularly (ROTEM, PT, APTT, Fibrinogen, FBC, Ca++, Arterial blood gases).
- Consider early cryoprecipitate (10 – 20 units) transfusion in case of Obstetric hemorrhage.
- Consider factor VIIa if indicated.
Further Actions:
- Clinician decides to terminate the MTP and informs the Blood Bank (Usually when the bleeding is stopped).
- Further transfusions depend on the clinical and laboratory parameters.
The routine use of rFVIIa in trauma patients is not recommended due to its lack of effect on mortality (Grade B) and variable effect on morbidity (Grade C). Indications may be to develop a process for the use of rFVIIa where there is:
- uncontrolled haemorrhage in salvageable patient, and
- failed surgical or radiological measures to control bleeding, and
- adequate blood component replacement, and pH > 7.2, temperature > 37°C. Discuss dose with Haematologist/Transfusion physician
Therapeutic Goals
| Indicator | Goal |
|---|---|
| Hemoglobin | Normal adult- 7-9 g/dl <br> With Cardiorespiratory morbidity – 8-9g/dl <br> Critically ill, Stable angina – >7g/dl |
| Hematocrit | 25-30% |
| Clotting factors | Aim to keep the PT and / or APTT < 1.5 times normal values |
| Fibrinogen | Aim to keep the fibrinogen levels <br> > 1.5g/L in normal adults <br> > 2g/L in obstetric patients |
| Platelets | Aim to keep platelet count > 50 x10^9/L |
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In an emergency, ABO group of Red Cell Concentrate (RCC), Plasma and Platelets can be switched as follows, according to the plasma and red cell compatibility.
However please take advice from the Transfusion medicine team with regards to transfusing group switched blood and components as unsolicited transfusions can lead to hemolysis and transfusion reactions.