Massive Transfusion Protocol

Definition of Transfusion

Replacement of the entire blood volume of the patient by more than 10 Units of whole blood within 24 hours or more than 2.5 L (5 units) of whole blood given within 4 hours period

6 units of Packed RBC, 6 units of FFP, 6 units of PRP can be given to the patient.

• 6 units of platelet-rich plasma are condensed into a single bag and are available as SDP (Single donor Platelet), which is prepared by the process of  Apheresis.
• Efficacy of SDP: 6 Units of Platelet Rich Plasma (PRP)
• The ratio of administration: PRBC: FFP: PRP is 1:1:1
• In a bleeding patient, there would be hypoxia and acidosis due to blood loss.
• In these patients, the first thing to be administered is Packed RBC (followed by FFP and PRP), which carries oxygen and neutralizes the acidosis component.
• Acidosis impairs blood clotting, which may worsen the patient's coagulopathy. Hence, platelets should not be given first.

• RED COOLER BAG: Have 6 units of packed RBC
• Plasma is stored at -30^o C.
• Plasma, when required for transfusion, is thawed and kept at room temperature.
• Platelets are not kept in cooler bags, and these are stored at room temp (20-24^o C)

Trauma Induced Coagulopathy

• Trauma in a patient causes blood loss, which can lead to loss of clotting factors and hypothermia (due to loss of heat), leading to trauma-induced coagulopathy.
• The human coagulation system is slow and weak.

Clotting takes time (2-10 minutes in the best circumstances)

• Clotting takes time (2-10 minutes in the best circumstances)
• Clots are physically weak.
• There is limited clotting material to work with (even in the whole body):
• 10 g of fibrinogen total
• 15 ml of platelets total in normal individuals.
• If we give packed RBCs which are stored at 4^o C to these patients it worsens hypothermia which further results in coagulopathy.

Bloody Vicious Cycle

• Poor circulation results in metabolic acidosis (because cells are in anaerobic respiration)
• Giving cold blood components triggers Hypothermia and interferes with the clotting process leading to coagulopathy.
• Triad of acidosis with hypothermia and coagulation is difficult to manage.
• To minimize hypothermia, it ensures in-line warmers in the rapid infusion pump.
• In obstetric hemorrhage, resuscitation of a patient with massive transfusion protocol:
  • When so much crystalloid fluids followed by blood transfusion is given, hemodilution occurs, causing hypothermia, which Interferes with the coagulation process and worsens coagulopathy.
• Ensure in-line warmers in the rapid infusion pump: components are warmed to a sufficient temperature to minimize the hypothermia component. If a patient loses 150 ml of blood per minute within 20 minutes, the circulating volume is depleted, causing decompensated shock (↓↓ BP), which leads to Death.
• So, in a bleeding patient, infused blood should be equal to output, that is, blood loss, so as to prevent the patient from going into decompensated shock.

In order to start the transfusion, we have to assess the bleeding in a patient. The ASSESSMENT OF BLOOD COMPONENT SCORE (ABC SCORE) is used to decide if the massive transfusion protocol should be started. Following are the components of this score: 

• If ABC score ≥ 2, then there is 75% accuracy in the prediction of Massive Transfusion Protocol [MTP]

Setup Required For Initiating MTP in A Patient

• Pressurized Rapid Transfusion (PRT)
  • Ensures that the blood components reach the body of the patient on time
  • Ensures that infusion matches output & chances of survival increases
  • The in-line Warmer reduces the chances of Hypothermia. Hence, coagulation problems are solved, and hemostasis is achieved.
• Tranexamic Acid
  • Antifibrinolytic agent
  • Stabilize the clot: Provide the hemodynamic stability

Adult Massive Transfusion Protocol

Triggers

• ABC Score (ABC > 2)
• Surgery (trauma to the major blood vessel)
• Hematemesis due to Peptic Ulcer Disease (PUD)
• PPH (Postpartum Hemorrhage)
• Penetrating traumatic Injury
• Presence of Low BP

Round 1

• Call Blood Bank and inform MTP protocol to be initiated
• Assign Team Members to do specific tasks and Divide Teams into A, B, and C.
• Team A: Administer blood Components to patients (not be responsible for drawing, labeling blood samples, or writing notes in a file about units of blood sample given)
  • Give 1g of Tranexamic acid to patient I.V Stat, then give 8 hourly
  • Connect the pressurized rapid transfuser to the patient
  • Give 4 Units of PRBC (O-VE) & 2 units of FFP (AB +)
  • After Round 1, Reassess the patient. If there is NO Improvement, then move on to ROUND 2
• Team B: Record Keeping, Sampling, labeling of samples, an entry in the file of units of blood, etc, so that proper documentation is maintained.
  • Blood Sample: CBC or CMP (complete metabolic profile)
  • PT or aPTT
  • ABG (from a radial artery)
  • Team C: The runner goes to the blood bank and gets a cooler bag or blood units to the hospital

Round 2

• Infuse
  • 4 Units PRBC 
  • 4 Units FFP
  • 1 Unit SDP (Single Donor Platelet)
• Team B: Resend blood to the Lab so that we can evaluate coagulopathy and metabolic acidosis components.
• Calcium gluconate is given to prevent tetany (caused by citrate in PRBC).
• Cryoprecipitate is given: If the fibrinogen < 100 mg/L
• If No Improvement:  ROUND 3

Round 3

• Repeat Round 2   + Factor VII a
• Indications to administer Factor VIIa:
  • Surgical hemostasis
  • temperature-37 degrees Celsius (stabilized)
  • pH-7.35 (stabilized) has been achieved, but the patient is still bleeding

Challenges During Massive Transfusion Protocol

Hypovolemia

• All efforts should be made to stop the bleeding rather than replace blood loss.
• The loss of 150 ml of blood per minute results in a loss of half the blood volume in 20 Minutes

Hypothermia

• Because Erythrocytes are stored at 1°C-6°C, rapid blood product administration can lead to hypothermia, which leads to coagulopathy.
• 6 Units of RBC will decrease body temperature by 1°C.

Hypo-Coagulopathy

• There is a dilution effect from an infusion of crystalloid volume expanders.
• Hypothermia reduces the activity of coagulation proteins and prevents the activation of the platelet.

Complications Of Massive Transfusion Protocol

• Coagulopathy: Minimized by Pressurized Rapid Transfusion within line warmer
• TRALI (Transfusion Related Acute lung injury): Respiratory Distress [non-cardiogenic pulmonary edema] + BP normal + BNP normal
• TACO (Transfusion Associated Circulatory Overload): Respiratory Distress (cardiogenic pulmonary edema) + BP ↑ + BNP ↑
• Hyperkalemia: packed R.B.C are stored at a lower temperature, near expiry date, causing the Na+/ k+ pump is shut down, which leads to hyperkalemia, which causes Diastolic arrest (Bradycardia)
• Hypocalcemia: Laryngospasm (Difficulty in breathing, stridor in clear chest).

Respiratory Distress Can Be Due To

• TRALI (Transfusion Related Acute lung injury): Pulmonary edema [non-cardiogenic pulmonary edema]
• TACO (Transfusion Associated Circulatory Overload): Pulmonary edema (cardiogenic pulmonary edema)
• Laryngospasm: chest is B/L clear, but adventitious sounds are heard - (adventitious sounds are the sounds from the upper airway)

This topic is important not only for all exams like NEET-PG/ FMGE and INICET but also for doctors’ daily clinical practice. To know more about this topic, watch the video by signing up for the PrepLadder application. 

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