This document defines massive transfusion as replacing one blood volume or more within 24 hours, which corresponds to approximately 10 units of blood for a 70 kg adult. Massive transfusion can cause numerous complications including dilution coagulopathies, hypothermia, acidosis, and tissue hypoxia. The overall mortality for patients requiring massive transfusion is around 40% but increases to over 75% for those who develop hemostatic disorders. Proper use of massive transfusion protocols which rapidly provide blood products can help minimize complications and reduce mortality rates.

1. Dr. RAFIQ AHMAD
Massive Transfusion

2. Definition
 It is most commonly defined as replacing 1 blood
volume or more within 24 hours
 One blood volume corresponds to 70 mL/Kg of a
typical adults body weight (15 units of blood for a
70 Kg patient; however many facilities estimate
10 units as 1 blood volume).
 Half of the patient’s blood volume is replaced
within 3 hours.
 More than 4 red cell units transfused within 4
hours with continuous bleeding.

3. Other Conditions
 More than 10 units of red cells transfused within
24 hours, or from the time of admission in ER to
ICU transfer.
 More than 20 units of red cells transfused during
the entire course of admission
 Blood loss is more than 150mL/min.
 In children, it is defined as transfusion of >40
mL/kg
(blood volume over 1 month old is approximately
80 mL/kg).

4. Morbidity/Mortality
 The overall mortality of patients requiring massive
transfusion is 40%.
 In patients who develop hemostatic disorders ,
the mortality rate is > 75%. Other prognostic
indicators include underlying conditions such as
cirrhosis, cardiopulmonary or cerebrovascular
disease, advanced age, and prolonged
hypertension
 Massive transfusion can have numerous
deleterious effects on the body

5.  Morbidity and mortality due to massive
transfusion is a direct result of concomitant
metabolic disturbances.
 They include dilution coagulopathies,
hypothermia, and tissue hypoxia causing tissue
damage and acidosis.
 The abilities to recognize and treat these adverse
conditions associated with massive transfusion
can minimize morbidity.

6. Complications of Massive Transfusion
Hemodilution from crystaloid fluid resuscitation
“Lethal Triad”
 Hypothermia
 Acidosis
 Coagulapathy

7. Red cell storage Lesions

8. Altered Parameters in stored RBCs
Characteristic Pre-storage Post-storage
pH 6.8 6.4
ATP (μmol/g Hb) 4.1 2.9
DPG (μmol /g Hb) 9.0 0.3
Potassium (mEq/L) 2.4 63
Glucose (mg/dl) 608 402
Plasma Hb (mg/dl) 39 372
Hemolysis (%) -- 0.61

9. Pre &Post transfusion Effects

10. Additional Complications
 Citrate Toxicity
 Potassium abnormalities
 Air embolism

11. Management of Massive Transfusion
Massive Transfusion Protocol (MTP)
2 Models
>Laboratory-driven (Pull) MTP:
>Formula-driven (Push) MTP:

13. Laboratory-driven (Pull) MTP:
Measuring Coagulation
 Thromboelastography (TEG)

14. TEG interpretation

15.  Rotational Thromboelastometry (ROTEM)

16. Variables measured by the TEG® and ROTEM®
Variable TEG® ROTEM®
Measurement period - Reaction Time [RT]
Time from start to when the
waveform reaches 2mm above
baseline
R Clotting Time [CT]
The time from 2mm above
baseline to 20mm above baseline
K Clot Formation Time [CFT]
Alpha angle [°] α [slope between R and K] α [angle of tangent at 2mm
amplitude]
Maximum angle - CRF
Maximum strength Maximal Amplitude [MA] Maximal Clot Firmness [MCF]
Time to Maximum strength - MCF-t
Amplitude at a specific time A30, A60 A5, A10...
Clot elasticity G MCE
Maximum lysis - CLF
Clot Lysis[CL] at a specific time
[minutes]
CL30, CL60 LY30, LY45, LY60
Time to lysis 2mm from MA CLT [10% difference from MCF]

17. New Research Products
 Whole Blood Transfusion
“ Walking blood bank program”
 Freeze-dried plasma
Developed freeze-dried plasma- “HemCon
Medical
Technologies”
 Stem-cell derieved red blood cells

18. The end!!
Thank you