This document provides guidelines on managing massive blood transfusion. It defines major hemorrhage as loss of more than one blood volume within 24 hours or 50% of total blood volume lost within 3 hours. It recommends initiating a massive transfusion protocol for hemorrhagic shock classes 3 and 4, which follows a 1:1:1 ratio of packed red blood cells to fresh frozen plasma to platelets. It provides transfusion triggers based on lab values and outlines treatment with tranexamic acid and cautions on fluid resuscitation and electrolyte abnormalities during massive transfusion.

1. Guidelines on Massive
blood transfusion
Lecture-6
By Dr-C

2. Major hemorrhage
 It is defined in many ways. Here we have taken the definition by
www.transfusionguidelines.org/
 Loss of more than one blood volume within 24 hours (around 70 mL/kg, >5
liters in a 70 kg adult)
 50% of total blood volume lost in less than 3 hours
 Bleeding in excess of 150 mL/minute.
 clinically a major hemorrhage is-bleeding that cause the systolic blood
pressure to be lowered below 90mmHg causing the pulse rate more than
110bpm.

3. definitions
 Some of literature says a major hemorrhage is-
 1)>40% or equal blood loss
 2)4 liters in 24 hours
 3)2 liters in 3 hours
 4)>150ml/min
(NHS UK)

4.  30-40% blood loss needs blood transfusion
 Take blood for grouping and cross matching.
 If the patient needs immediate transfusion issue group O blood.
 Females less than 50 years of age should receive group O Rh negative blood.
 When the grouping and cross matching done relevant type of blood can be
given
 Most of the hospitals have a protocol dedicated to massive blood loss and
blood transfusion. Most of the time called as MASSIVE TRANSFUSION
PROTOCOL.

5. Classification of hemorrhagic shock

6.  In above mentioned classification class 3 and 4 need blood transfusion
 Massive transfusions follow the rule of packed RBC:FFP:Platelts=1:1:1
 Before transfusions always take blood for base line investigations. Grouping
and cross match, Hb, coagulation profile.
 take a FBC and a coagulation profile every 5 units of blood.
 Transfusion ratio 1:1:1 { 4 units of RBC’s, 4 units (2 bags or 600mls) of FFP & 4
units (1 pooled/ apheresed bag) of platelets}
 If patient comes with in first hour of the trauma always consider to give
tranexamic acid IV

7. IV tranexamic acid
 Maximum benefit from Tranexamic Acid if given within first hour after injury.
Do not give more than 3 hours after injury
 1g Tranexamic Acid iv over 10minutes followed by 1g Tranexamic acid iv
over 8 hours

8. Transfusion Triggers (in presence of
bleeding)
 Platelets < 75 x 109/L = 1 bag of platelets
 Platelets < 50 x 109/L = 2 bags of platelets
 INR > 1.5 = 2 bags FFP
 INR > 2.0 = 4 bags FFP
 Fibrinogen < 1.5g/L = 6 bags of cryo
 Fibrinogen < 1.0g/L = 12 bags of cryo
 Fibrinogen < 0.5g/L = 18 bags of cryo
 RBC’s as guided by blood loss and laboratory values

9.  Resuscitation with cristaloids is recomeneded buy don’t give more than the
needs. Aggressive fluid resuscitation isn’t recommended in major trauma now.
 As cross matching takes time till the negative O blood can be transfused.
 Hypocalcaemia and hyperkalaemia can occur especially with hypothermia and
acidosis. Treat them
 Always call on call surgical unit and arrange measures to control bleeding
surgically.

10. Further reading
 The royal Melbourne hospital- massive transfusion guidelines
 Norflock and Norwich hospital guidelines on massive transfusion NHS UK
 https://www.blood.gov.au/pubs/pbm/module1/transfusion.html