Massive transfusion: a review

Abstract

Patients with massive hemorrhage require a nuanced resuscitation to maintain circulation and achieve hemostasis. Massive transfusion (MT) forms the central core of this resuscitation and involves the rapid administration of large volumes of blood products including red blood cells (RBCs), plasma, platelets (PLT), cryoprecipitate (CRYO), and whole blood (WB). Referred to as hemostatic resuscitation, this transfusion strategy of providing plasma- and platelet-containing blood products in addition to RBCs has been recommended to prevent hemodilution and to restore coagulation function closer to normal, potentially providing better control of hemorrhage and improving outcomes. As a result, many institutions have implemented MT protocols (MTPs) designed to efficiently deliver pre-determined amounts of RBCs, plasma/CRYO, and PLT. A multidisciplinary team is necessary to ensure safe and efficient MT activation, allocation, documentation, and transfusion; necessary representatives include members from units such as surgery, medicine, anesthesiology, and obstetrics, the blood bank, and hospital quality committee to name but a few. This review article will discuss the history of MT, provide various definitions for massive hemorrhage and MT, explain the pathophysiology of the acutely bleeding patient, highlight balanced hemostatic resuscitation and its critical elements in various patient populations, examine various clinical tools to predict those who may require MT, elucidate blood bank and quality activities that support MT, assess different adjunctive therapies, inform about possible complications of MT, and speculate about the possible future evolutions in MT.