Massive transfusion is defined as replacing more than 1 blood volume in 24 hours or more than 50% of blood volume in 4 hours or more than 40 mL/kg (in children over 1 month old).
Massive transfusion protocol is typically initiated in situations where a patient has lost a significant amount of blood, such as in cases of trauma, major surgery, or obstetric emergencies.
Massive transfusion protocol involves 1:1:1:1 ratio of PRBC, FFP, Platelets, and Cryoprecipitate. Fibrinogen may be especially important in obstetric hemorrhage and can be supplemented via the administration of fibrinogen concentrates or cryoprecipitate.
The following treatments should be considered in massive transfusion protocol: Calcium chloride 1-2 g, or Calcium gluconate 3-6 g, IV. Tranexamic acid 1 g IV stat and 1 g over 8 hours, especially in obstetric or early traumatic hemorrhage. Desmopressin (DDAVP) 0.3 mcg/kg (maximum 21 mcg) IV, especially in cases of renal failure, thrombocytopenia, or antiplatelet use.
Patients receiving massive transfusion should have their vital signs, temperature, acid-base status, calcium, hemoglobin, platelet count, PT, APTT, and fibrinogen levels monitored closely.
Complications associated with massive transfusion include volume overload transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), hypothermia, dilutional coagulopathy, hyperkalemia, hypocalcemia, excessive citrate, and disease transmission.