Massive Transfusion Protocol

A massive transfusion protocol is a pre-agreed hospital process that releases blood components in prepared packs and mobilises the team with one call. It exists because ad hoc ordering in life-threatening haemorrhage is too slow, and delay in plasma, platelets and fibrinogen worsens coagulopathy. Massive transfusion is usually defined as loss of one blood volume in 24 hours, loss of half a blood volume in 3 hours, ongoing loss over 150 mL/minute, or replacement of 10 or more units of red cells in 24 hours.

Balanced resuscitation. Red cells, plasma and platelets are given early in near physiological proportions, with tranexamic acid, calcium and warming, while the source of bleeding is controlled. Low titre group O whole blood is an alternative that supplies all three in one unit.

Risk context. The ratio is not the whole answer. Over-reliance on a fixed ratio leads to over-transfusion once bleeding is controlled, overload, lung injury and wasted stock. Under-activation and late activation cause preventable death.

Special groups. Pregnancy (rapid loss and early fibrinogen depletion), children (weight based packs), older adults and patients on anticoagulants, and trauma with brain injury. In East Africa, plasma and platelets may be scarce or slow, so a locally adapted plan built around red cells or whole blood, early tranexamic acid, calcium, early fibrinogen replacement and early surgical control is needed.

Activation criteria. Any one of the following in a bleeding patient justifies activation, and activation can be cancelled later:

• Systolic blood pressure under 90 mmHg or heart rate over 120 beats a minute not responding to a small crystalloid bolus.

• Shock index (heart rate divided by systolic pressure) of about 0.9 to 1 or more.

• Trauma scoring predicting massive transfusion (penetrating mechanism, positive focused ultrasound, systolic pressure of 90 mmHg or less, heart rate of 120 or more, two or more positive).

• Estimated blood loss of over 1000 mL in obstetric haemorrhage with ongoing bleeding or shock.

• Clinician judgement of ongoing life-threatening bleeding.

Roles. Team leader, airway and breathing, circulation and access, blood bank liaison or runner, scribe and timekeeper, and a surgeon or obstetrician for source control. Use closed loop communication and record times.

Activation call. One telephone call to the blood bank stating the activation, the patient's identity (or emergency identity), location and age or weight, and sex, with a sample sent urgently.

Red flags. Failure to respond to the first pack, rising lactate, worsening acidosis, hypothermia and clinical oozing.

Typical pack structure (adult).

• Pack 1: 4 to 6 units of red cells (group O uncrossmatched until group is known) with 4 to 6 units of plasma, issued within about 10 to 15 minutes.

• Pack 2: a further 4 to 6 units of red cells and plasma, with one adult platelet dose and two pools of cryoprecipitate (or 3 to 4 g of fibrinogen concentrate).

• Later packs: alternate the same pattern, directed by laboratory or viscoelastic results from about the second pack onwards.

• Approximate overall proportion: red cells, plasma and platelets as 1 : 1 : 1, taking one adult platelet dose to correspond to 6 units of red cells and 6 units of plasma. Plasma to red cells of 1 : 2 up to 1 : 1 is a usual range.

• Low titre group O whole blood: one unit replaces about one unit each of red cells and plasma with some platelet function, followed by components as results direct.

Adjuncts.

• Tranexamic acid 1 g intravenously over 10 minutes within 3 hours of injury or birth, then 1 g over 8 hours in trauma, and a second 1 g in postpartum haemorrhage after 30 minutes if bleeding continues.

• Calcium chloride 1 g (10 mL of 10%) intravenously early and after about every 4 units, keeping ionised calcium at or over about 1.1 mmol/L.

• Warming of the patient and of all fluids and products.

• Fibrinogen when it falls under 1.5 g/L (under 2 g/L in postpartum haemorrhage).

Targets once results arrive. Haemoglobin about 7 to 9 g/dL, platelets over 50 x 10⁹/L (over 100 x 10⁹/L in brain injury), prothrombin time and activated partial thromboplastin time under 1.5 times normal, fibrinogen over 1.5 g/L (over 2 g/L postpartum), ionised calcium at or over 1.1 mmol/L, pH over 7.2 and temperature of 36 degrees Celsius or more.

Children. Weight based dosing: red cells 10 to 20 mL/kg (or whole blood 20 mL/kg), plasma 10 to 20 mL/kg, platelets 10 to 20 mL/kg and cryoprecipitate 5 to 10 mL/kg, in about the same proportions.

Stopping the protocol. Deactivate when bleeding is controlled, haemodynamics are stable, lactate is falling and haemoglobin, platelets and fibrinogen are at target. Inform the blood bank, return unused products within the validated time and temperature limits, and reconcile units given.

Special groups.

• Pregnancy: early fibrinogen and obstetric source control.

• Anticoagulated patients: prothrombin complex concentrate with vitamin K, or specific reversal agents.

• Patients refusing blood: all non-blood measures, with early senior input.

Monitoring. Continuous vital signs and urine output. Blood gas with lactate, ionised calcium, potassium and haemoglobin every 30 to 60 minutes, and coagulation, platelets and fibrinogen (or viscoelastic tests) after each pack.

Complications. Hypocalcaemia, hyperkalaemia, hypothermia, acidosis, dilutional and consumptive coagulopathy, transfusion associated circulatory overload, transfusion related acute lung injury and multi organ failure.

Referral and escalation. Surgeon, anaesthetist, intensivist, obstetrician and haematologist early, with the blood bank medical lead to manage stock.

Disposition. Transfer to intensive or high dependency care after control. Document all products and times, and review the activation after the event.