Massive Transfusion Protocol / Disseminated Intravascular Coagulation

 MASSIVE TRANSFUSION

 Transfusion Medicine Resident p21829 (x63623) and run down pick-up slip 

• Activate when anticipate transfusing 50% TBV (~5U pRBC) in 2h OR 100% TBV (~10U pRBC or 5L plasma) in 24h 

• Complications: dilutional coagulopathy, hypothermia, hypocalcemia (citrate), metabolic alkalosis (citrate metabolized to bicarb) 

• Emergency release un-crossmatched pRBCs (O- for pre-menopausal females, O+ ok for males and older females)  

• Transfuse 1U FFP for every 3-4 pRBCs (if >6 U pRBCs anticipated), 6-pk PLT (PLT<100,000 anticipated), 10U cryo (fibrinogen <100) 

o No evidence for 1:1:1 transfusion protocol, combat trauma studies confounded by survival bias (JAMA 2015;313:471) 

o Excessive FFP a/w higher ARDS in pts not requiring massive transfusion 

o Goals: Hb >7-10, PLT >50,000, INR <2, fibrinogen >100 

• Correct coagulopathy (A/C, liver dz) → IV vit K, FFP 15cc/kg; platelet dysfunction (ASA, plavix, uremia) → PLTs, DDAVP 0.3 mcg/kg 

• Consider IV aminocaproic acid @ 5g bolus over 1h, then 1g/hr gtt x 8h or IV TXA @ 1g bolus over 10min, then 1g over 8h 

INR - Vitamin K 10 intravenously over 30-60 minutes - PCC Kaycentra

PT / PTT

FFP

Platelet < 10,000 transfusion, procedure 50,000

Fibrinogen may increase risk of bleeding maintain > 50 - 80, > 150mg before procedure - cryoprecipitate or fibrinogen concentrates

Thromboelastography: true balance INR only clotting factors ignoring protein C and S. TEG - good for opearting room, not possible to treat INR / FTT R-time, FFP and PCC (kaycentra)

pltlts < 50k hold ac

fibrinogen < 80 hold anticoagulation