Management of Massive
Defined as giving greater than one blood
volume (8-10 units of blood in an adult) in
24 hrs or less.
Practically defined as giving one blood
volume in two hrs or less.
The replacement of a patient’s
total blood volume by stored
blood in a relatively short period
Patients with massive
transfusion need close attention
to detail and careful monitoring
Occur reasonably quickly.
Usually results from dilution.
Increased consumption may also occur.
When the platelet count is less than 50x10
9/l microvascular bleeding and general
oozing from wounds or venapuncture sites
Most common complication.
Red cells stored at 4° C can cool the
Core temperatures below 35 ° C have been
associated with development of
coagulopathies and variety of metabolic
A plasma or additive solution K+ in a
unit of red cells or whole blood
increases with storage period.
Presence of acidaemia, hypothermia
and hypocalcaemia with
hyperkalaemia can lead to cardiac
This problem is best prevented by
keeping the patient warm.
Due to citrate present in anticoagulant
As normal liver can metabolize citrate, this
condition is rare.
In neonates and hypothermic patients, the
combined effects of hypocalcaemia and
hyperkalaemia can lead to cardiac arrest.
If there is clinical or ECG evidence, treat
with IV calcium gluconate (5ml of 10%
Due to dilution of plasma. (replacement with
packed cells lead to dilutional coagulopathy)
Patient may develop coagulopathy due to
underlying medical condition or trauma.
Hypothermia leads to coagulation defects.
Degree of coagulopathy cannot be predicted
according to the amount of blood replaced.
Management of massive
Replacement therapy according to the five
Use blood warmers and keeping the patient
Five basic tests
Prothrombin time (INR)
Activated partial thromboplastin time
Assess need for blood products based on five
Platelets < 50-75000/L : give platelet
concentrates (6-8 packs)
Fibrinogen<125 mg/dl, unusually prolonged
PT and APTT or evidence of DIC: Give
cryoprecipitate 6-8 units of cryoprecipitate
PCV below 30%: give red cells
INR > 2.0 and aPTT abnormal 2-4 units of
Isolated abnormalities of PT: no specific
replacement is needed.
When laboratory tests are not
FFP 10-15 ml/kg will replace both
fibrinogen and coagulation factors.
If hypofibrinogenaemia is suspected
consider giving cryoprecipitates.
Largest determinant of microvascular
bleeding in massively transfused patients.
Priority should be directed towards keeping
platelet count about 50-75000/ L.
Each platelet concentrate will increase
platelet count by 5000-7000/L.
Either 6-8 platelet concentrates or single
donor (apharesis) platelets.
If there is evidence of DIC cryoprecipitate
transfusion is indicated.
Fibrinogen levels below 125mg/dl needs
Each unit of cryoprecipitate will increase
fibrinogen level by 10 mg/dl.
When indicated transfuse at least 7-10 units
Fresh frozen plasma
Used only when there is micro-vascular
bleeding with laboratory results showing
Given 15 ml/kg dosage
treatment should be guided
by the patients clinical
response and results of
repeated laboratory tests
Indiscriminate use of blood
component therapy can be
avoided by routine tests of
haemostasis performed early
in order to define precise
Clinical manifestation of inappropriate
Clinically present as asymptomatic, severe
bleeding, thrombosis, purpura fulminans
Aetiology of DIC
Penetrating brain injury
Amniotic fluid embolism
PT, APTT, Fibrinogen assay (non specific)
Consequences of excessive
Conversion of fibrinogen to fibrin :
thrombosis and depletion of fibrinogen