Massive Transfusion Protocol

• Activating the massive transfusion protocol involves the blood bank mobilizing large amounts of O negative blood (to avoid ABO incompabitility issues).  This is done in situations where blood products are needed STAT and there is not enough time for type and crossing.  
• At Stanford, the protocol involves 6 PRBCs, 4 FFP, and 1 unit of plts that come up in a cooler.
• Blood products can be given regularly via IVs, but sometimes will be given via a “Level One Infuser” which essentially is an apparatus used for rapid warming of IVFs and blood products using a heat exchange and circulating water bath flow, with high flow capacity, and built-in filters to remove air bubbles (which are often formed during warming of blood products).  Ideally, fluids are infused through a cordis, but can use peripheral IVs or triple lumen CVCs as well.

Complications of massive transfusions (in addition to the typical transfusion risks):

• Transfusion-associated Circulatory overload (TACO) – distinguish from TRALI
• Dilutional coagulopathy – this is the rationale for including FFP and plts in the transfusions, because otherwise massive amounts of PRBCs alone would cause coagulopathy and thrombocytopenia.  Be aware that the one necessary blood product that is not included is cryoprecipitate, which is often needed due to dilutional depletion of fibrinogen (as well as consumption in DIC, etc).  
• Hypocalcemia – can be severe, due to the presence of the anticoagulant citrate in the blood, which binds calcemia.
• Hyperkalemia – each unit of blood contains about 10 mEQ of Kcl, which can be a problem especially with concurrent renal failure
• Hypothermia – if blood products are not warmed à can lead to cardiac arrhythmias, infection susceptibility, and further coagulopathies!

So in summary, watch for fluid overload, hypothermia, and closely monitor coagulation parameters and fibrinogen, ionized calcium, and potassium.

(Chanu Rhee MD, 11/23/10)