Bleeding After Massive Transfusion

Summary

Surgically intractable diffuse microvascular bleeding (MVB) occurs in approximately 20% of patients who have undergone massive blood transfusion. Standard transfusion regimens up to one blood volume, or approximately 10 U of red cell concentrates (RBCs), probably cannot prevent this complication. There is no evidence to support prophylactic replacement with RBCs or fresh frozen plasma (FFP) up to this degree of blood loss. This is due mainly to the complexity of the hemostatic disturbance. In cases of greater blood loss (multiple blood volumes, or approximately 20 U of RBCs), packed red cells and FFP can be transfused in a 1:1 ratio to limit the extent of the dilutional coagulopathy. Clinical examination raises initial suspicion of this complication. The most frequent cause of MVB is thrombocytopenia or platelet dysfunction. Platelet concentrates should be administered, therefore, when platelet counts fall below 50 000/µl following massive transfusion and hemorrhage. Since these patients also tend to have impaired platelet function, it is occasionally necessary to institute platelet replacement in patients who have higher platelet counts. With a concomitant disturbance of plasmatic hemostasis, the product of first choice is FFP. If the hemostatic impairment is so severe that effective replacement therapy with FFP does not appear feasible (hypervolemia), additional factor concentrates should be administered, most notably PPSB and fibrinogen concentrate (fibrinogen < 0.8 g/l). Since the antithrombin III level is generally depressed as well, and since many patients have DIC, antithrombin III concentrate should be given to correct the deficiency before PPSB is administered. It should also be determined whether low-dose heparin therapy should be provided, and if so, it should be instituted prior to replacement with PPSB or fibrinogen concentrate.