Blood Product Administration

Transfusion Strategies

The American Society of Anesthesiologists recommends using Group O RhD positive blood for male patients, and switching to group-specific blood as soon as grouping is available, which takes approximately 10 minutes 1
Maintaining platelets at a minimum of 75 × 10⁹/L is recommended during active hemorrhage, according to the Anaesthesia guidelines 1
A high-ratio transfusion strategy with at least 1 unit plasma per 2 units RBCs, approaching a 1:1:1 ratio (RBC:plasma:platelets) is recommended to improve survival in patients with massive bleeding, as supported by the Critical Care journal and recommended by various guidelines 1, 2

Fibrinogen concentrate may be used at a dose of 30-60 mg/kg, with a maximum infusion rate of 20 mL per minute for acquired fibrinogen deficiency, and is associated with faster administration and more predictable dosing 1
Cryoprecipitate may be used when fibrinogen levels are low, but may be associated with delays due to thawing and transportation, as noted by the Anaesthesia guidelines 1
Target parameters include maintaining fibrinogen levels >1.5 g/L using cryoprecipitate or fibrinogen concentrate 1, 3, 2
Cryoprecipitate is indicated when fibrinogen levels are <1.5 g/L 1

Tranexamic acid is most effective when given with adequate fibrinogen levels, and should be used according to local protocols agreed in advance, as recommended by the Anaesthesia guidelines 1
Monitoring and correcting hypocalcemia and hypomagnesemia is crucial in massively transfused patients, according to the Anaesthesia guidelines 1
Initial coagulation screening panel should include prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen levels, and platelet count, with coagulation tests repeated every 30-60 minutes during active bleeding, as recommended by the American Society of Anesthesiologists and the Society of Critical Care Medicine 1, 4, 5, 6, 2
Monitoring both platelet count and clinical bleeding is essential, with serious hemorrhage sometimes occurring even at relatively high platelet counts, and baseline blood tests should include FBC, PT, aPTT, Clauss fibrinogen, and cross-match 1, 7

Establishing a formal massive transfusion protocol is essential to ensure a rapid and coordinated response, and all persons involved in blood administration must be trained and certified according to national standards, as recommended by the Anaesthesia guidelines 1
Mechanical methods, such as intermittent pneumatic compression devices, should be used initially to avoid increasing bleeding risk, as recommended by the American College of Chest Physicians 8
Pharmacological prophylaxis can be initiated when bleeding risk has decreased, according to the Anaesthesia society guidelines 9
A minimum target platelet count of 75 × 10⁹/L is recommended for management in patients with significant hemorrhage, with a basic threshold of 50 × 10⁹/L for patients with significant bleeding, and 100 × 10⁹/L for patients with multiple trauma or traumatic brain injury, as recommended by the American Gastroenterological Association and other societies 1, 3, 10

Massive blood loss is defined as loss of one blood volume within a 24-hour period, and heavy bleeding is defined as overt bleeding that requires medical intervention, causes significant hemoglobin drop, occurs in critical sites, or requires transfusion of blood products, as defined by various guidelines 11, 12, 13
Patients should be monitored for rebleeding, which carries high mortality, and for potential complications, including Transfusion-Related Acute Lung Injury (TRALI), Transfusion-Associated Circulatory Overload (TACO), metabolic derangements, hypothermia, and citrate toxicity, as recommended by the European Society of Anaesthesiology 1, 2
Administering tranexamic acid is recommended if there is evidence of hyperfibrinolysis, with a loading dose of 1g over 10 minutes, followed by 1g over 8 hours, as recommended by the European Society of Anaesthesiology with a strength of evidence level of 1A 1, 2
Platelet transfusion is recommended for severe thrombocytopenia (platelet count <35 × 10⁹/L) in the setting of active upper gastrointestinal bleeding, according to the American Gastroenterological Association and other guidelines 1, 10
Target parameters include keeping platelet count >75 × 10⁹/L, and monitoring PT/APTT (goal <1.5 times normal), as recommended by the American Society of Anesthesiologists and the Society of Critical Care Medicine 1, 3, 2