This document discusses blood products and massive transfusion protocols. It describes various blood components like packed red blood cells, platelets, fresh frozen plasma, and cryoprecipitate. It outlines indications for transfusing different blood products based on hemoglobin, platelet count, coagulation tests. For massive transfusion, it recommends transfusing red blood cells, plasma, and platelets in a 1:1:1 ratio to achieve therapeutic goals. It also discusses disseminated intravascular coagulation (DIC) management and complications of massive transfusion like infections, circulatory overload, and metabolic disturbances.

2. BLOOD & BLOOD PRODUCTS

3. GOALS
1. To know the variety of blood products
2. To know the right time and indications to start blood or
blood products transfusion
3. Familiar with Massive Transfusion Protocol
4. To know the complications of massive transfusion

4. Variety of blood components
Whole blood
Red blood cells
◦ Packed cells
Platelet
Fresh frozen plasma
Cryoprecipitate

5. VARIOUS BLOOD PRODUCTS
Blood products Volume
(ml/unit)
Contents Effects Compatibility
Packed red cells 280 +/- 50 RBC, WBC, plasma Increase HCT by
3%, increase HB
by 1gm/dL
ABO and RH
Platelets 50 +/- 10 PLT, RBC, WBC,
plasma
Increase PLT
between 5-10 x
103/L
ABO and RH
Fresh Frozen
plasma (FFP)
200 – 250 fibrinogen,
antithrombin III,
factor V and VIII
Increase
fibrinogen by
10mg/dL
ABO, no need RH
compatibility
Cryoprecipitate 40 +/- 10 Fibrinogen, factors
III, XIII, Von
Willerbrand factor
Increase
fibrinogen by
10mg/dL
ABO, no need RH
compatibility

6. Indication for transfusion – red
cells
Acute blood loss
◦ There is no data to suggest the use of whole blood is associated with
better outcome
◦ Indication to transfuse based on multiple factors; should be
based on clinical factors
◦ Based on haemoglobin concentration
◦ Hb > 10 g/dl – not indicated
◦ Hb < 7 g/dl – indicated
◦ Hb 7 – 10 g/dl – less clear; depends on situation and patient
◦ Based on risk of further blood loss

7. Based on estimation of blood loss
Circulating
volume lost
Signs Replacement
15%
(750 ml)
Mild increase in PR -
15 – 30%
(800 – 1500 ml)
Increase PR
Increase breathing
Use crystalloids or colloids to replace fluid loss
Replacement with crystalloids – every ml blood loss,
3ml crystalloids needed
3 to 1 ratio
Replacement with colloids – every ml blood loss, 1.5 ml
colloids needed
3 to 2 ratio
30 – 40%
(1500 – 2000ml)
Increase PR
Increase breathing
Fall in BP
Use crystalloids or colloids to replace fluid loss
Red cells transfusion likely be required
>40%
(Over 2000ml)
Immediate life
threatening
Blood transfusion is required immediately
Need rapid transfusion

8. Major problem!!!!!
Underestimation of blood lost often
happens!!
Therefore, clinical signs of shock are
important

9. Indication for transfusion of
other blood products
Platelet
◦ In DIVC or at platelet transfusion trigger of 75,000/l
Fresh frozen plasma and cryoprecipitate
◦ In DIVC (evidenced clinically or from coagulation screen) with
evidence of bleeding
◦ In massive transfusion
◦ FFP should be administered for every 4 units of red cells
transfusion; aim to maintain APTT < 1.5;12 – 15 mls/kg
◦ Cryoprecipitate should be administered early in major obstetric
haemorrhage to keep fibrinogen > 1.5 g/l; 1- 2 units/10kg

10. Therapeutic Aims of management
FACTOR AIMS
1. HB > 8 g/dL
2. Platelet > 50 x109/l
3. PT/ PTT ratio < 1.5
4. Fibrinogen level > 2.0 g/dL
Adapted from Malaysian Transfusion Practice Guidelines 2012

11. DIVC IN OBSTETRICS
Characterized by systemic activation of blood coagulation system.
Results in
◦ Depositions of fibrin, leading to microvascular thrombi in various
organs
◦ Consumption coagulopathy (depletion of platelets and coagulation
factors) that leads to further haemorrhage
Can be due to:
◦ Massive bleeding (e.g. APH, PPH, abruption)
◦ Sepsis/chorioamnionitis/septic miscarriage
◦ Amniotic fluid embolism
◦ Eclampsia
◦ IUD
◦ Molar pregnancy

12. Principles of management
◦ Identify DIC and the primary
◦ Call for help – initiate RED ALERT
◦ Treat the underlying cause (sepsis, massive blood loss, severe
vessel injury, toxins)
◦ Involves delivery or evacuation of POC
◦ Correct the coagulopathy by replacement with blood products
◦ Correct acidosis with bicarbonate and hypoxia with oxygen
◦ Management of complications

13. Adequate resuscitation from shock - most important in preventing
coagulopathy
No evidence that prophylactic regimes prevents or reduce transfusion
requirements

14. DIVC Regimes
Various regimes depends on hospital protocol
Need to contact Transfusion medicine specialist for MTP
(Massive blood transfusion protocol)
Depends on patient’s body weight and also clinical situation
NO LONGER 6U FFP, 4U Platelet, 2U cryoprecipitate

15. Various DIC regimes
Regime Components
‘Standard regime’ (60 kg
patient)
6 units (1 – 2 units/ 10 kg) cryoprecipitate
4 units (12 – 15 ml/kg) FFP
2 - 4 units of platelet
Alternative regime
(especially in massive
bleeding/refractory
DIVC)
Red cells:plasma:platelet ratio = 1:1:1; or
Red cells:plasma:platelet ratio = 2:1:1 (especially
in district hospital where there are limited blood
products

16. Recombinant factor VIIa (rFVIIa)
Used in refractory DIC (off licensed use in PPH)
Pre-requisites
◦ Hct > 24%
◦ Fibrinogen > 0.5 – 1.0 g/l
◦ Platelet > 50 x 109/L
◦ pH  7.2
Recommended dose – 90 mcg/kg, rounded to a whole vial

17. MASSIVE BLOOD LOSS
Replacement of total blood volume (5 L) within 24 hours
Loss of 50% blood volume in less than or equal to 3 hours
150ml/ min blood loss (Loss of half the blood volume in 20
minutes)
Transfusion of more than 20 units of erythrocytes

18. Massive Transfusion Protocol
A designated number to call to activate MTP
Activation of MTP should trigger a cascade of events that include:
◦ Taking blood for baseline investigations: FBC, coagulation screen including fibrinogen, GXM
◦ Emergency release of safe ‘O’ blood if crossmatched blood is not available
◦ Transfusion of Red cells:FFP:Platelet in at least 1:1:2 ratio (may consider the ratio of 1:1:1)
◦ An effective mechanism to trace lab results
Transfusion can be continued at ratio of at least 2:1:1 if bleeding continues
and lab results are not available; may consider giving cryoprecipitate
If lab results are normal but bleeding continues, repeat massive
transfusion till bleeding stop
When results are available, transfusion of blood product is tailored to
correction of the abnormalities of result
The cycle continues till bleeding stops and MTP is deactivated

19. Rapid blood transfusion in life
threatening condition
BP cuff (high-pressure infusion devices)
No blood filters
With warmers
O-ve or O +ve blood
Unmatched blood

20. COMPLICATIONS OF MASSIVE
TRANSFUSION
Adverse effects
Immune mediated Acute/delayed Haemolytic Transfusion Reaction
Transfusion Related Acute Lung Injury
Anaphylaxis/Anaphylactoid Reaction
Febrile Non Haemolytic Transfusion Reaction
Allergic Reaction
Transfusion Associated Graft Versus Host Disease (TaGVHD) – rare
Post-Transfusion Purpura - rare
Alloimminization
Non-immune mediated Bacterial contamination
Transfusion Transmitted Infection
Transfusion Associated Circulatory Overload (TACO)
Metabolic disturbances Hyperkalaemia
Hypocalcaemia
Acid base disturbance
Hypothermia