Massive Surgical Hemorrhage
Significant intraoperative blood loss
All Pathways
AnesthesiologyEmergency
Intraoperative Massive Transfusion Protocol
Intraoperative Massive Transfusion Protocol: Massive Surgical Hemorrhage → Recognition & Communication → Activate MTP → Initial Resuscitation → Continuo...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action 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)
03Action 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
04Action 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
05Action 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
06Decision Specific Coagulopathy?
Based on labs or point-of-care testing
07Action Low Fibrinogen (<1.5 g/L)
Supplement fibrinogen
- Cryoprecipitate 10 units (2 pools)
- OR Fibrinogen concentrate 3-4g IV
- Recheck after administration
08Decision Surgical Hemostasis Achieved?
Coordinate with surgical team
09Action 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
10Outcome Hemorrhage Controlled
ICU for post-op monitoring
- Path rejoins step 05Shared downstream outcome
11Action 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
- Path rejoins step 08Shared downstream outcome
12Warning ⚠️ 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
- Path rejoins step 08Shared downstream outcome
- Path rejoins step 08Shared downstream outcome
13Action 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
- Path rejoins step 05Shared downstream outcome
14Action 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
- Path rejoins step 05Shared downstream outcome
Guideline Source
ACS TQIP Massive Transfusion in Trauma Guidelines / AABB 2023
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Blood bank logistics vary by institution
- TEG/ROTEM availability varies
- Cell saver not appropriate for all cases
- Specific product ratios may vary by protocol
Applicable Regions
USEUglobal
EU: Compatible with European guidelines
US: Based on ACS TQIP and AABB guidelines
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Intraoperative Massive Transfusion Protocol?
The Intraoperative Massive Transfusion Protocol is a emergency clinical algorithm for Anesthesiology. It provides a structured decision tree to guide clinical decision-making, based on ACS TQIP Massive Transfusion in Trauma Guidelines / AABB 2023.
What guideline is the Intraoperative Massive Transfusion Protocol based on?
This algorithm is based on ACS TQIP Massive Transfusion in Trauma Guidelines / AABB 2023 (DOI: 10.1001/jama.2023.12914).
What are the limitations of the Intraoperative Massive Transfusion Protocol?
Known limitations include: Blood bank logistics vary by institution; TEG/ROTEM availability varies; Cell saver not appropriate for all cases; Specific product ratios may vary by protocol. Individual patient factors may require deviation from these recommendations.
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