Intraoperative Massive Transfusion Protocol

Algorithm Steps

1. ▶

   Start

   Massive Surgical Hemorrhage

   Significant intraoperative blood loss

   1. ●

      Action

      Recognition & Communication

      Coordinate with surgical team

      • Estimate blood loss (suction, sponges, drapes)
      • Communicate with surgeon about surgical hemostasis
      • Assess hemodynamic status
      • Consider: EBL >1.5-2L or ongoing rapid bleeding
      • Blood in field dark (acidotic/hypoxic)
      1. ●

         Action

         Activate MTP

         Call blood bank, mobilize resources

         • Call blood bank: 'Activate MTP for OR [room]'
         • Assign team member for blood product coordination
         • Ensure large-bore IV access (14-16G x2 or RIC)
         • Consider arterial line if not present
         • Activate rapid infuser/Level 1
         1. ●

            Action

            Initial Resuscitation

            While awaiting blood products

            • 100% FiO2
            • Warm crystalloid if needed (limit to 2L)
            • Vasopressors to maintain perfusion
            • Communicate with team continuously
            • Request emergency release blood if T&S not ready
            1. ●

               Action

               Continuous Monitoring

               Lab and clinical assessment

               • ABG every 30 min (pH, lactate, Hgb, iCa2+)
               • TEG/ROTEM if available
               • Core temperature
               • Urine output
               • Hemodynamic response to transfusion
               • TARGETS:
               • Hgb >7-8 g/dL (higher for coronary disease)
               • Platelets >50K (>100K if CNS injury)
               • Fibrinogen >1.5 g/L
               • INR <1.5
               • iCa2+ >1.1 mmol/L
               • Temp >36°C
               1. ◆

                  Decision

                  Specific Coagulopathy?

                  Based on labs or point-of-care testing

                  1. ●

                     Action

                     Low Fibrinogen (<1.5 g/L)

                     Supplement fibrinogen

                     • Cryoprecipitate 10 units (2 pools)
                     • OR Fibrinogen concentrate 3-4g IV
                     • Recheck after administration
                     1. ◆

                        Decision

                        Surgical Hemostasis Achieved?

                        Coordinate with surgical team

                        1. ●

                           Action

                           MTP Deactivation

                           When bleeding controlled

                           • Notify blood bank to deactivate MTP
                           • Return unused products promptly
                           • Final labs: CBC, coags, fibrinogen
                           • Continue monitoring for DIC, TRALI, TACO
                           • Plan for ICU admission typically
                           1. ✓

                              Outcome

                              Hemorrhage Controlled

                              ICU for post-op monitoring

                  2. ●

                     Action

                     Hypocalcemia (iCa2+ <1.1)

                     Citrate toxicity common with rapid transfusion

                     • Calcium chloride 500mg-1g IV (central preferred)
                     • OR Calcium gluconate 1-2g IV (peripheral ok)
                     • Give empirically with every 4-6 units blood
                     • Monitor iCa2+ frequently
                  3. ⚠

                     Warning

                     ⚠️ Lethal Triad Prevention

                     Hypothermia, Acidosis, Coagulopathy

                     • WARM everything:
                     • All fluids through warmer
                     • Forced air warming blanket
                     • Increase OR temperature
                     • Correct acidosis with perfusion
                     • Avoid crystalloid excess
         2. ●

            Action

            Transfuse 1:1:1 Ratio

            Balanced component therapy

            • Goal: PRBC : FFP : Platelets = 1:1:1
            • Typical MTP Pack:
            • 6 units PRBC
            • 6 units FFP (or 4-plasma)
            • 1 apheresis platelet (or 6 pooled)
            • Use blood warmer for ALL products
            • Use rapid infuser if available
            • Switch to type-specific when available
         3. ●

            Action

            Adjunct Therapies

            Additional hemostatic support

            • TRANEXAMIC ACID:
            • 1g IV over 10 min (within 3h of injury/incision)
            • Then 1g over 8 hours
            • CELL SAVER:
            • Consider if >1L expected blood loss
            • Contraindicated: infection, malignancy, obstetric amniotic
            • TOPICAL HEMOSTATICS:
            • Communicate with surgeon