A 43-year-old man with a history of alcoholism and liver cirrhosis presented with a large gastrointestinal bleed from esophageal varices. He was unresponsive with a heart rate of 164 and low blood pressure. His labs showed anemia, thrombocytopenia, and elevated lactic acid. The next best step to stabilize the patient before transferring to interventional radiology would be to transfuse 3 units of red blood cells, 3 units of platelets, and 3 units of fresh frozen plasma while also bolusing 2 liters of lactated ringers.

1. Afternoon Report
Chad Rieck, MD

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43M hx of alcoholism, liver cirrhosis, GIB due to esophageal varices s/p banding 2 years ago comes in
after episode of large volume hematemesis and BRBPR. He is currently unresponsive.
HR 164
BP 65/30
Temperature 37.4
RR 38
Labs are notable for WBC 6.5, Hgb of 4.5, platelet 120.
Na 144, K 5.2, Cl 106, HCO3 22, BUN 65, Cr 1.6
INR 1.2
Fibrinogen 253
Lactic Acid 12.6
In addition to calling a massive transfusion protocol, starting 2 large bore IVs, Which of the following is
the next best step to stabilize pt before sending to IR?
A. Transfuse 3u RBC, 2L LR
B. Transfuse 3u RBC, 3u platelets
C. Transfuse 3u RBC, 3u platelets, 3u FFP
D. Transfuse 3u RBC, 3u platelets, 3u plasma
E. Transfuse 3u RBC, 3u platelets, 3u FFP, bolus 2L LR
F. Transfuse 3u RBC, 3u platelets, 3u plasma, bolus 2L LR
2
QUESTION

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• Causes:
– Most common, polytrauma
• Major surgeries
– GI bleeds
– Obstetric hemorrhage
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Massive Blood Transfusion

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Massive Blood Transfusion
• Definition
– Replacement of one entire blood volume within 24 h
– Transfusion of >10 units of packed red blood cells
(PRBCs) in 24 h
– Transfusion of >20 units of PRBCs in 24 h
– Transfusion of >4 units of PRBCs in 1 h when on-
going need is foreseeable
– Replacement of 50% of total blood volume (TBV)
within 3 h.
Massive transfusion protocol (MTP) for hemorrhagic shock ASA committee on blood management. Available
from: https://www.asahq.org/For-Members/About-ASA/ASA-Committees/Committee-on-Blood-Management.aspx
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Classes of shock
Class of hemorrhagic shock
I II III IV
Blood loss (ml) Up to 750 750-1500 1500-2000 >2000
Blood loss (%
blood volume)
Up to 15 15-30 30-40 >40
Pulse <100 100-120 120-140 >140
Blood
Pressure
Normal Normal Decreased Decreased
Pulse pressure Normal or
increased
Decreased Decreased Decreased
Resp Rate 14-20 20-30 30-40 >35
Urine output
(cc/hr)
>30 20-30 5-15 Negligible
CNS status Slightly
anxious
Mildly anxious Anxious,
confused
Confused,
lethargic
5American College of Surgeons Committee on Trauma (2008)

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• Intravascular volume loss
– Hemorrhagic shock
– Overzealous resuscitation
• Loss of blood components
– Use
– Lose
– Dilute
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Management

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Complications from only RBC transfusion
• Coagulation proteins
– 10% decrease in concentration of clotting proteins
for each 500cc of blood loss being replaced
• Bleeding due to dilution occurs when the level of
coagulation proteins fall to 25% of normal (8-10u of
RBC)
• Platelets
– 10-12 u of RBC associated with 50% fall in the
platelet count
• 1 six pack of platelets raise level by 30,000.
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Complications from massive transfusion
• Acidosis
– Impaired assembly of coagulation factor complexes
• Increased fibrinolysis
• Delayed fibrin production
• Altered fibrin structure
• Metabolic alkalosis
– 1mmol of Citrate -> 3 mEq of bicarbonate
• Hypothermia
– Platelet function decreased
• Dilution
• Hypocalcemia
– Citrate infusions
• Hyperkalemia
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Complications from massive transfusion

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Prospective Observational Multicenter
Major Trauma Transfusion (PROMMTT)
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The bars represent cumulative ratios at the start of each time interval. Most patients received a
plasma:red blood cell (RBC) ratio of 1:2 or higher by 3 hours (A) and a platelet:RBC ratio of 1:2 or
higher by 6 hours (B). In the last time interval (24 hours), the percentage of patients receiving 0 units of
platelets or plasma increases, reflecting the dynamic cohort with newly eligible patients entering and
others exiting owing to death in the previous interval.

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Prospective Observational Multicenter
Major Trauma Transfusion (PROMMTT)
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Improved mortality with higher blood product
ratios:
First 24 hours for plasma
First 6 hours for platelets
After these times, other high competing risk
for nonhemorrhagic deaths were not
associated with morality
The Prospective Observational Multicenter
Major Trauma Transfusion (PROMMTT)
study demonstrated that clinicians generally
were transfusing patients with a blood
product ratio of 1:1:1 or 1:1:2 and that early
transfusion of plasma (within minutes of
arrival to a trauma center) was associated
with improved 6-hour survival after
admission.

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PROPPR trial
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Among the 680 patients
predicted to receive a massive
transfusion and transfused with
a 1:1:1 or 1:1:2 ratio, no
significant differences in overall
mortality at 24 hours or 30 days
were detected. However, more
patients achieved hemostasis in
the 1:1:1 group, fewer patients
died of exsanguination, and this
transfusion ratio appears to be
safe.

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PROMMTT/PROPPR
• Transfusing patients based on an empirical ratio
rather than guided solely by laboratory data (goal-
directed) is considered controversial by some
researchers
• Taken together, these data support early use of a
1:1:1 transfusion ratio in patients with rapid bleeding
• No higher rates of multiple inflammatory-mediated
complications such as acute respiratory distress
syndrome, multiple organ failure, infection, venous
thromboembolism, and sepsis
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MTP
• Two options:
– Code blue
• IV therapy/surgery 210/Anesthesia/nursing/RT
– Dial ‘‘ B-L-O-O-D ’’ (x25663)
• A Massive Transfusion Pack contains:
– 6 units red blood cells
– 4 units plasma
– 1 apheresis platelet unit
– 1 cryoprecipitate pooled unit
• RBCs and plasma will be delivered first, with a goal
delivery time of 15 minutes.
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Adjunct therapies
• DDAVP
– Von Willebrand or CKD
• Anti-fibrinolytics
– Aminocaproic acid, tranexamic acid
• Kcentra/Vitamin K
– Elevated INR (warfarin)
• Cryoprecipitate
– Uremia
• Protamine
– Elevated PTT, heparin used
• Sodium bicarbonate
– pH <7.2
• Normal saline
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Wellness
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