Position Statement of the Hong Kong Society of Critical Care Medicine
Massive Transfusion Protocol in Trauma
Dr Chau Chin Man, Associate Consultant, Intensive Care Unit, North District Hospital, Hong Kong
On behalf of the Hong Kong Society of Critical Care Medicine
This Position Statement was endorsed by the HKSCCM Council in the 20th Council Meeting on 22nd July 2012

Early identification of the patient at risk for massive transfusion
Formula driven transfusion practice due to evolving data from military penetrating trauma, suggests improved outcomes for patients transfused in excess of 10 U of packed red cells in retrospective cohort studies.
Plasma transfusion in patients without massive transfusion was associated with a trend toward increased mortality and was also associated with an increased rate of lung injury. Additionally, transfusion of plasma to patients who do not require it raises issues of resource utilization.1

Rapid correction of acidosis and hypothermia
Hypothermic patients were hypercoagulable with a body temperature >34.0°C. Body temperature of less than 34 °C is associated with increased bleeding, hypotension and coagulopathy in severely injured patient. The effects of hypothermia include altered platelet function, impaired coagulation factor function (a 1°C decrease in temperature is associated with a 10% decrease in function), enzyme inhibition, and fibrinolysis.
Steps to prevent hypothermia and the risk of hypothermia-induced coagulopathy include removing wet clothing, covering the patient to avoid additional heat loss, increasing the ambient temperature, forced air warming, warm fluid therapy, and (in extreme cases) extracorporeal re-warming devices. 9
A coagulation factor complex with normal activity at pH 7.4 has 50% of normal activity at pH 7.2, 30% at pH 7.0, and 20% of normal activity at pH 6.8. Furthermore, acidosis can also act synergistically with hypothermia in its detrimental effect on the coagulation cascade.

Formula driven transfusion protocol
Red blood cell transfusion
Consider transfusion if Hb is _7g/dL in resuscitated critically ill trauma patients. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb is _10 g/dL) in resuscitated critically ill trauma patients.10
Plasma transfusion
In patients undergoing massive transfusion in the setting of trauma, the transfusion of plasma at plasma : RBC ratios greater than 1:3 (in the range of 1:2.5- 1:1) at 24 hours was associated with a significant reduction in mortality and multi-organ failure. The evidence for this effect, however, was derived from observational studies subject to potentially important biases, e.g. survivor bias. 1,2 Stronger evidence from controlled trials and experimental studies has not been published to date, although current published opinion suggests that a ratio of 1:1 FFP: RBC is the most effective.

Platelet transfusion
Transfusion of platelet at 1: 1 ratio of platelet to RBC showed improved survival in only 2 retrospective studies. 3,4 The platelet count in trauma patients should be kept
above 50,000/ μl
Plasma and platelet transfusion
Use of FFP:PRBC:Platelets in a ratio of 1:1:1 is based on expert opinion and consensus rather than clinical data.5

Hypofibrinogenemia is not likely to contribute to bleeding until the level falls below 100 mg/dL; hence, cryoprecipitate is recommended for patients with documented decrease in fibrinogen below 100 mg/dL.
Massive transfusion protocol
Massive transfusion protocol consists of predetermined and standardized ration of blood component, e.g. 6 U of group O pRBCs, 4 U of thawed plasma, and 1 U of aPLT. If continued resuscitation is needed, then a ratio of 6:4:1 of pRBC/ plasma/aPLT are delivered until the protocol is discontinued. Once hemorrhage is controlled, the MTP is discontinued, and further transfusions should be guided by clinical and laboratory assessment.
MTPs shorten both the time for delivery of first shipment of products as well as delivery of subsequent shipments to the bedside. It also appears to decrease overall blood use and blood component costs. 6, 7, 8

Goal directed correction of coagulopathy
Plasma-based tests (PT and APTT) have never been validated as indicators of coagulopathy in the context of massive bleeding. Viscoelastic hemostatic assays (VHAs) provide information on the time course of clot formation in whole blood and offer advantages over the conventional tests for evaluation of coagulation.

Using laboratory tests to diagnose coagulopathy results in unacceptable delays, and point-of-care devices have yet to be validated in trauma. The classical measures of coagulation have their own shortcomings. PT and PTT will show disorders of plasma coagulation but will miss platelet dysfunction and hyperfibrinolysis.11 These tests have been noted to have poor correlation with clinical bleeding.12 Furthermore, PT will not identify coagulation deficiencies caused by hypothermia as PT is determined in the laboratory at a standard temperature of 37°C, which masks temperature effects on enzyme activities. These assays serve mainly as a measure of time to clot initiation.

Thromboelastography (TEG) is a simple test that can broadly determine coagulation abnormalities and give information about fibrinolytic activity and platelet function that is not available from routine coagulation screens. Its use during cardiopulmonary bypass surgery for the detection of coagulopathy has improved accuracy in diagnosing hemostatic abnormalities.

Algorithms directing transfusion have proven to significantly reduce blood product use in cardiopulmonary bypass.14, 15 This technology has recently been applied to the description of the coagulation profile of the trauma patient. This novel modality has yet to be fully validated in trauma hemorrhage, and some devices are user dependent, as is interpretation of the resultant thromboelastograms.

Experience in trauma patients has identified specific parameters of TEG™ and ROTEM™ that can be used as a guide to blood component treatment18, 19. However, Cochrane review found lack of evidence that transfusion guided by TEG™ or by ROTEM™ improved morbidity or mortality in patients with severe bleeding.20

Early identification of the patient at risk for massive transfusion (in excess of 10 U of packed red cells )
Rapid correction of acidosis and hypothermia
Formula driven transfusion protocol
Red blood cell transfusion ( Hb is <7g/dL)
Plasma transfusion
Plasma : RBC ratios greater than 1:3 (in the range of 1:2.5- 1:1)
Platelet transfusion
1: 1 ratio of platelet to RBC
Plasma and platelet transfusion
FFP: PRBC: Platelet in a ratio of 1:1:1
Transfuse if fibrinogen below 100 mg/dL.
Goal directed correction of coagulopathy
Further transfusions should be guided by clinical and laboratory assessment.

1. Roback JD, Caldwell S, Carson J, Davenport R, Drew MJ, Eder A, Fung M, Hamilton M, Hess JR, Luban N, Perkins JG, Sachais BS, Shander A, Silverman T, Snyder E, Tormey C, Waters J, Djulbegovic B. Evidence-based practice guidelines for plasma transfusion. Transfusion 2010;50:1227-39.
2. Murad MH, Stubbs JR, Gandhi MJ, Wang AT, Paul A, Erwin P, Montori VM, Roback JD. The effect of plasma transfusion on morbidity and mortality: a systematic review and meta-analysis. Transfusion 2010;50:1370-83.
3. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabel LA, Schreiber MA, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008;248:447-58.
4. Gunter OL, Au BK, Isbell JM, Mowery NT, Young PP, Cotton BA. Optimizing outcomes in damage control resuscitation: identifying blood product ratios associate with improved survival. J Trauma 2008;65:527-34.
5. E Kirkman, S Watts, T Hodgetts, P Mahoney, S Rawlinson, M Midwinter. A proactive approach to the coagulopathy of trauma: the rationale and guidelines for treatment. JR Army Med Corps 153(4): 302-306
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7. Cotton BA, Gunter OL, Isbell J, et al. Damage control hematology: The impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma. 2008; 64:1177–1183.
8. O’Keefe T, Refaai M, Tchorz K, et al. A massive transfusion protocol to decrease blood component use and costs. Arch Surg. 2008; 143:686–690.
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11. MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55:39–44.
12. Aucar JA, Norman P, Whitten E, et al. Intraoperative detection of traumatic coagulopathy using the activated coagulation time. Shock. 2003;19:404–407
13. Traverso CI, Caprini JA, Arcelus JI. The normal thromboelastogram and its interpretation. Semin Thromb Hemost. 1995;21(suppl 4):7–13.
14. Shore-Lesserson L, Manspeizer HE, DePerio M, et al. Thromboelastography- guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg. 1999;88:312–319
15. Spiess BD, Gillies BS, Chandler W, Verrier E. Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiothorac Vasc Anesth. 1995;9:168 –173.
16. Schreiber MA, Differding J, Thorborg P, et al. Hypercoagulability is most prevalent early after injury and in female patients. J Trauma. 2005;58:475– 480; discussion 480–481
17. Tieu BH, Holcomb JB, Schreiber MA. Coagulopathy: its pathophysiology and treatment in the injured patient. World J Surg. 2007;31: 1055–1064.
18. Schochl H, Nienaber U, Maegele M, Hochleitner G, Primavesi F, Steitz B, Arndt C, Hanke A, Voelckel W, Solomon C: Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care 2011, 15:R83.
19. Schochl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, Kozek-Langenecker S, Solomon C: Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fi brinogen concentrate and prothrombin complex concentrate. Crit Care 2010, 14:R55
20. Afshari A, Wikkelso A, Brok J, Moller AM, Wetterslev J: Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev 2011, 3:CD007871.
21. Balogh Z, McKinley BA, Cocanour CS, et al. Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Arch Surg. 2003;138:637– 642; discussion 642–643.