Massive Transfusion Protocol (MTP)

1. MASSIVE
TRANSFUSI
ON
PROTOCOL
Dr. HAITHAM S
HABTAR
SBEM PGY-4

2. ● A massive transfusion is defined as the replacement of >1 blood volume in
24 h
(Different definitions exist, with a common one being >10 units in 24 hours )
● >50% of the blood volume in 4 h.
( >5 units within four hours )
● Transfusion of 3 unit of PRBC over 1 hr
DIFENITION OF MTP
DIFENITION OF ULTRA MTP
● Ultramassive transfusion” has been defined as the administration of >20 units PRBC
within a 48-hour time span

3. Initiation is based on clinician
judgment
WHEN TO INITIATE MTP ?
• The hemoglobin level takes hours to fall after bleeding. Consequently, checking the hemoglobin has little
role in determining need for MTP.
• Hypotension is usually a late manifestation of hemorrhage. Worsening hypotension and vasopressor
requirement should prompt consideration for MTP.

4. ● scoring tools such as an assessment of blood (
ABC )
WHEN TO INITIATE MTP ?
scores ≥2 were likely to require massive transfusion, with
sensitivity and specificity ranging from 75% to 90% and 67% to
88%, respectively, at multiple trauma centers.

5. Although it is possible to
perform MTP via a
peripheral IV catheter,
central access is preferable
because this is more
secure. Options include the
following:
HOW TO GIVE
?

6. ● blood products in a 1:1:1 OR 2:1:1 ratio of PRBC:FFP:Platelets
● The cornerstone of MTP is balanced transfusion with PRBCs, platelets, and fresh
frozen plasma (FFP).
● Most hospitals should have a protocol in place to deliver these products rapidly and in
the appropriate ratio.
● Current evidence generally supports a 1:1:1 ratio, which is used in most massive
transfusion protocols.
● avoid crystalloid resuscitation
● For hemorrhagic shock with ongoing bleeding, crystalloid administration may dilute
out coagulation factors and erythrocyte concentration.
● Ultimately blood products will be needed (to achieve target hemoglobin
concentrations and coagulation factor levels), so front-loading your resuscitation with
crystalloid may eventually serve to promote volume overload.
● Whenever feasible, hemorrhagic shock resuscitation should be performed with blood
products.
HOW TO GIVE
?

7. ● fibrinogen
supplementation?
WHAT TO MONITOR AND TO
GIVE ?
•Fibrinogen may become depleted in massive transfusion, due to dilution.
•There is some fibrinogen in fresh frozen plasma, but not necessarily enough
•. Fibrinogen can be supplemented via the administration of fibrinogen concentrates or cryoprecipitate
•. In the United States, cryoprecipitate is most commonly used (10 units should increase the fibrinogen by ~75
mg/dL).
•Recent guidelines for trauma-induced bleeding suggest targeting a fibrinogen level >150-200 mg/dL.

8. ● fibrinogen
supplementation?
WHAT TO MONITOR AND TO
GIVE ?
• It may be best to replase this early, rather than waiting for levels to drop.
•High-level evidence doesn't exist regarding exactly how aggressive to be with fibrinogen supplementation.
• Different hospitals may have varying protocols.
• This may also bear individualization depending on the type of hemorrhage and any available laboratory data (if the
patient's fibrinogen is known).
• Thromboelastogram may assist in guiding therapy.
Thromboelastogram is a rapid, whole blood test to determine the efficacy of a patient’s
coagulation system and can guide the transfusion of platelets, plasma, and cryoprecipitate.

9. ● Hypothermia
WHAT TO MONITOR AND TO
GIVE ?
Each unit of blood reduces the core temperature by 0.25°C.
Use a fluid warmer or convective warmer (Bair hugger) to minimize risk.

10. ● calcium
WHAT TO MONITOR AND TO
GIVE ?
Hypocalcemia may occur for several reasons:
Critically ill patients are often mildly hypocalcemic to begin
Citrate in blood products chelates calcium, leading to hypocalcemia.
When blood is given gradually, citrate is metabolized by the liver – so this isn't an issue.
However, when blood is infused rapidly, citrate may temporarily accumulate and promote
hypocalcemia.
Hypocalcemia is problematic because it causes coagulopathy.
Moderate hypercalcemia is well tolerated Therefore, the therapeutic target is a high-normal level
of calcium (in a massively hemorrhaging patient, it's probably better to err on the hypercalcemic
side).

11. ● calcium
WHAT TO MONITOR AND TO
GIVE ?
•When administering one round of MTP (containing 6 units
PRBCs), it's probably reasonable to add either 1-2 gram of IV
calcium chloride or 3-6 grams of IV calcium gluconate.
• Calcium gluconate causes less tissue damage with
extravasation, so this is preferred for peripheral
administration.
•If possible, bedside measurement of ionized calcium with a
point-of-care monitor may help guide calcium administration in
real-time.

12. ● acidosis
WHAT TO MONITOR AND TO
GIVE ?
Acidosis impairs the
interaction between
calcium and negatively
charged phospholipids,
blocking the initial steps
in the coagulation
cascade.
Even mild acidosis (e.g.,
pH 7.20) may reduce
coagulation
considerably

13. ● Potasium
WHAT TO MONITOR AND TO
GIVE ?
Hypokalemia is related to hepatic metabolism of citrate to bicarbonate, with an associated
intracellular shifting of serum potassium.
Hyperkalemia is related to accumulation during storage of blood products.

14. ● Transfusion complication
WHAT TO MONITOR AND TO
GIVE ?
Distinguishing minor reactions from life-threatening reactions is challenging in the early stages;
thus, all reactions should be considered serious until determined otherwise.
Serious Hazard of Transfusion data from the U.K. indicate that pulmonary complications,
including transfusion-associated circulatory overload, remain a leading cause of transfusion-
related death.
Importantly, transfusion delays are another leading cause of transfusion-associated mortality.
From an emergency care perspective, it is helpful to approach transfusion reactions based on
categorization of observed symptoms,

15. ● Transfusion Complication
WHAT TO MONITOR AND TO
GIVE ?
In all cases of a suspected transfusion reaction in any form, it is essential to immediately halt
the transfusion, carefully reassess the patient, and verify patient and blood product
compatibility.
Respiratory symptoms: Possible transfusion-associated circulatory overload ( TACO ) ,
transfusion-related acute lung injury ( TRALI ) , septic transfusion reaction, or anaphylaxis.
Symptoms may include dyspnea, bronchospasm, tachypnea, or hypoxia.
Transfusion-related acute lung injury pulmonary edema similar to acute respiratory distress
syndrome, typically occurring within 6 h of transfusion.
Treatment is guided by the severity of the symptoms as well as findings on chest radiography
and inferior vena cava ultrasound.

16. WHAT TO MONITOR AND TO
GIVE ?

17. WHAT TO MONITOR AND TO
GIVE ?

18. WHAT TO MONITOR AND TO
GIVE ?
TRALI
• If TRALI is suspected, the transfusion should be stopped, and the blood bank notified.
• Respiratory support should be provided, which may include noninvasive positive-pressure
ventilation (NIPPV) or intubation and mechanical ventilation.
• It is safe to continue transfusion of blood products from a different donor.
• Complete resolution is usually seen within 48 to 96 hours.
• The overall prognosis is better than would be expected with many other causes of acute
lung injury, with a reported mortality rate of 6% in one series.
• One strategy suggested for reducing TRALI has been to use only male donors for plasma
to avoid allotypic leukocyte antibodies or to screen for these antibodies and exclude
donors when the antibodies are found.

19. WHAT TO MONITOR AND TO
GIVE ?
Transfusion-associated circulatory overload (TACO)
• Reactions to blood component transfusion can range from mild to potentially fatal. Transfusion-associated
circulatory overload (TACO) is a common transfusion reaction in which pulmonary edema develops primarily
due to volume excess or circulatory overload.
• Management of TACO is similar to other causes of volume overload.
• The transfusion (if ongoing) should be stopped.
• Diuretics should be given.
• Theoretically, nitroglycerine would have similar effect in TACO as in any other volume overload
situation and can be started at 50 to 100 mcg/min IV and titrated to effect.
• NIPPV can be initiated early to improve oxygenation and the work of breathing.
• If the patient develops intractable symptoms, intubation and mechanical ventilation may be required.
• In future transfusions, the rate of transfusion may be slowed, and prophylactic diuretics can be given
to decrease the risk of another episode of TACO.

22. THANK
YOU
Dr. HAITHAM S HABTAR
SBEM PGY-4