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Massive Blood Loss and Transfusion

  • Definition: replacement by transfusion of more than 50% of a patient’s blood volume in 12–24 hours
  • Contact blood bank and activate rapid transfusion protocol if available: the blood bank will then always keep a certain number of blood products on hold for this patient


Avoid acidosis:

  • Acidosis affects coagulation factor involving calcium and phospholipids

Avoid hypothermia:

  • Hypothermia slows any enzymatic activity including coagulation factors and activation of platelets by von Willebrand factor (vWF)
  • Not detected by laboratory tests: samples are warmed to 37°C
  • Not correctable with plasma and factor concentrates

Check coagulation profiles (including fibrinogen levels) frequently.

Avoid citrate toxicity:

  • Metabolic alkalosis:
    • pH of PRBC at 37°C = 7.10 due to citric acid and production of lactate by red cells during storage; however, metabolism of 1 mmol of citrate generates 3 mEq of bicarbonate (23 mEq of bicarbonate/1 U PRBC)
  • Hypocalcemia:
    • Citrate binds ionized calcium: measure calcium frequently and replace generously

Avoid hyperkalemia:

  • Potassium levels in stored PRBC increase by 1 mEq/L
  • Peak K concentration: 90 mEq/L in PRBC
  • Measure K concentration frequently
  • Treat hyperkalemia aggressively: insulin/glucose, calcium, furosemide, dialysis (continuous venovenous hemodialysis [CVVHD])
  • Consider washing PRBC in Cell Saver if plasma K >5 mmol/mL or rapidly rising
  • Consider storing 2–3 U washed PRBC prior to surgery in case of massive bleeding and worsening hyperkalemia
  • Replace calcium generously


Consider 1:1:1 resuscitation: 1 U PRBC combined with 1 U plasma and 1 U platelets.

Recent studies have shown a survival benefit of 1:1:1 transfusion in combat and civilian trauma.


Dilutional coagulopathy: 500 mL blood loss causes a 10% decrease in clotting factors.

Coagulopathy can occur with a 25% decrease of clotting factors (usually 8–10 U packed red blood cells).

Dose for reversal of anticoagulants:

  • Determine current and target INR
  • Convert INR to approximate percentage of prothrombin complex:
    • INR 1 = 100 (%)
    • INR 1.4–1.6 = 40
    • INR 1.7–1.8 = 30
    • INR 1.9–2.1 = 25
    • INR 2.2–2.5 = 20
    • INR 2.6–3.2 = 15
    • INR 4.0–4.9 = 10
    • INR > 5 = 5 (%)
  • Amount of FFP (mL) = (target level [%] − current level [%]) × weight (kg)


Fifty percent decrease in platelets with 10–12 U of packed red blood cells.

Transfuse if platelets <50,000 and bleeding or <20,000 without bleeding.

Six units of platelets (=1 “large” unit) increases platelet count by 5–10,000.

Avoid and Treat Disseminated Intravascular Coagulation (DIC)

  • Depletion of coagulation factors and release of tissue factor from ...

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