Massive Transfusion

Definition
>= 10 RBC units within 24 h

> 4 RBC units in 1 hr with anticipation
of continued need for transfusion

Replacement of > 50% of TBV within 3
hr

Epidemiology of MT
Variety of clinical settings
Trauma, obstetric, major surgery

Uncontrolled bleeding
40% trauma related mortality
#1 cause of maternal mortality worldwide
Pathophysiology changes
3 components
ETIC (early trauma-induced coagulopathy)
Tissue injury tissue factor coagulation DIC

Hyperfibrinolysis
Hypoperfusion thrombomodulin expression EC
enhance plasmin formation fibrinolysis
Prominent in obstetric haemorrhage

Infusion of crystalloid, bloods -> dilutional
coagulopathy, acidosis, hypocalcemia &
hypothermia
Clinical Mx of MT

Massive transfusion protocol

Early recognition of pt requiring MT, facilitate
communications between different services
and avoid delay in clinical care

Demonstrated to improve patients survival,
reduced rates of organ failure.




Blood products
Optimal transfusion ratio

Blood: plasma :platelets = 1: 1: 1 (645ml)
Resembles whole blood
Haematocrit 26%, coag activity 50% & plt
count of 90 000microL
Evidence supported by US military & then
civilian studies
Pragmatic Randomized Optimal Platelet&
Plasma Ratios (PROPPR)
Trigger level for blood
components transfusion
Insufficient data to identify an INR,
fibrinogen level or platelet count to
trigger a blood component transfusion

NBA guidelines
Suggested doses
FFP 15ml/kg
Platelets: 1 adult therapeutic dose
Cryoprecipitate 3-4 g
Values indicative of critical
physiologic derangement

Temperature < 35
pH < 7.2, BE >-6, lactate >4
Ionised calcium < 1.1mmol/L
Plt count < 50x10
9
/L
PT > 1.5 x normal
INR > 1.5
APTT > 1.5xnormal
Fibrinogen level < 1.0



Pharmacological therapy
rFVIIa
No effect on 48hr or 30 day mortality
Blunt trauma reduced RBC transfusion req
& ARDS
Penetrating trauma no effect on morbidity
90mcg/kg

Prothombinex
Indicated for warfarin reversal
Insufficient evidence to support the general
use in MT

Pharmacological therapy
TXA
CRASH 2 trial international multicentre RCT
Improved survival in trauma patients

Obstetric setting
Suggested reduces blood loss @ CS & the risk of progression
to severe PPH
RCT is currently investigating the effect of TXA in treating
PPH




Laboratory monitoring
Assessment of status
O2 carrying capacity, haemostasis, metabolic


Conventional testing has limited utility
Coagulation panel
Not available in real time fashion
Do not detect all haemostatic abnormalities such as
hyperfibrinolysis

Use of Point-of-care testing is increasing



Laboratory monitoring
Thromboelastograph (TEG)

Point- of- care Haemostasis assay
Shorter turn-around time (15 mins)
Detect hyperfibrinolysis
Detect coagulopathy due to hypothermia
Shown to reduce transfusion requirement /MT
in major surgery
R = reaction time (s); time of latency from start of test to initial fibrin formation
K = kinetics (s); time taken to achieve a certain level of clot strength (amplitude of
20mm)
alpha = angle (slope between R and K); measures the speed at which fibrin build
up and cross linking takes place, hence assesses the rate of clot formation
TMA = time to maximum amplitude(s)
MA = maximum amplitude (mm); represents the ultimate strength of the fibrin clot
A30 or LY30 = amplitude at 30 minutes; percentage decrease in amplitude at 30
minutes post-MA and gives measure of degree of fibrinolysis
CLT = clot lysis time (s)
TEG AS A GUIDE TO TREATMENT


Increased R time => FFP

Decreased angle => cryopreciptate

Decreased MA => platelets (consider
DDAVP)

Fibrinolysis => transexamic acid (or
aprotinin)
Conclusions
MT protocol is important

Early transfusion of blood products in ratio of 1:1:1
may reduce mortality & improve patient outcome but
further RCT needed to determine optimal ratio

TXA improved survival in several RCT and should be
used in MT

New laboratory monitoring, such as TEG might
improve patient outcome when used in combination
with MTP
Reference
Update on Massive Transfusion. H.P Pham, B.H Shaz. Br. J. Anaesth. (2013)
111 (suppl 1): i71-i82.

Patient Blood Management Guidelines: Module 1. Critical Bleeding Massive
Transfusion. National Blood Authority, 2011.

Life in the
Fastlanehttp://lifeinthefastlane.com/education/ccc/thromboelastogram-teg/.