Overview
Definition:
A massive transfusion protocol (MTP) is a standardized, algorithm-driven approach to manage severe hemorrhage in critically ill patients, characterized by the rapid administration of large volumes of blood products
In pediatrics, it is defined as the replacement of one or more estimated blood volumes within a 24-hour period, or transfusion of >40 mL/kg of red blood cells in 3 hours.
Epidemiology:
Pediatric massive hemorrhage is less common than in adults, but occurs in specific scenarios like severe trauma, surgical complications (e.g., neurosurgery, cardiac surgery), and neonatal emergencies (e.g., prematurity-related bleeding, ruptured omphalomesenteric cysts)
Incidence varies based on the underlying etiology and patient population.
Clinical Significance:
Effective and timely management of pediatric massive hemorrhage is critical to prevent hypovolemic shock, organ dysfunction, coagulopathy, and death
A well-defined MTP improves patient outcomes by ensuring rapid availability of blood products and guiding resuscitation strategies, thereby reducing mortality and morbidity.
Clinical Presentation
Symptoms:
Tachycardia or bradycardia
Hypotension or narrow pulse pressure
Pale or mottled skin
Decreased capillary refill time (>2-3 seconds)
Altered mental status (irritability, lethargy, coma)
Oliguria or anuria
Cold extremities.
Signs:
Signs of ongoing bleeding (external or internal)
Signs of hypovolemic shock
Distended abdomen (in abdominal hemorrhage)
Chest trauma with paradoxical breathing
Pale mucous membranes
Cool, clammy skin.
Diagnostic Criteria:
No single universal diagnostic criteria for initiating MTP in pediatrics
It is primarily a clinical decision based on the severity of hemorrhage, patient's hemodynamic status, and expected need for massive blood product transfusion
Key indicators include rapid blood loss, hemodynamic instability unresponsive to initial fluid resuscitation, and laboratory findings suggestive of coagulopathy and anemia.
Diagnostic Approach
History Taking:
Detailed history of the event leading to hemorrhage (trauma mechanism, surgical procedure, obstetric history)
Pre-existing medical conditions (bleeding disorders, liver disease, renal disease)
Medications (anticoagulants, antiplatelets)
Allergies
Previous transfusions.
Physical Examination:
Assess airway, breathing, and circulation (ABC)
Thorough search for external bleeding
Palpate for abdominal distension or tenderness
Assess for signs of internal bleeding (e.g., hemothorax, hemoperitoneum)
Assess skin perfusion, capillary refill, and temperature
Monitor vital signs closely (heart rate, blood pressure, respiratory rate, oxygen saturation).
Investigations:
Complete blood count (CBC) with differential and platelet count
Coagulation profile (PT, aPTT, INR, fibrinogen)
Blood type and crossmatch (immediate O-negative blood may be used initially)
Arterial blood gases (ABGs) to assess for acidosis and hypoxemia
Lactate levels to assess tissue perfusion
Serum electrolytes, BUN, creatinine
Chest X-ray, FAST scan, or CT scan to identify internal bleeding sources.
Differential Diagnosis:
Other causes of shock in children (septic shock, anaphylactic shock, cardiogenic shock, neurogenic shock)
Anemia from other causes
Hemorrhage from non-traumatic/non-surgical causes (e.g., gastrointestinal bleeding in conditions like Meckel's diverticulum, intussusception, or inflammatory bowel disease)
Disseminated intravascular coagulation (DIC) without massive external hemorrhage.
Management
Initial Management:
Immediate resuscitation with isotonic crystalloids (e.g., Normal Saline or Lactated Ringer's) in a 1:1 to 3:1 ratio of fluid to estimated blood loss, while preparing for blood transfusion
Hemorrhage control (direct pressure, tourniquet if applicable, surgical intervention)
Oxygen therapy to maintain adequate oxygenation.
Medical Management:
Initiate MTP according to institutional protocol
Typically involves a balanced ratio of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets
A common starting ratio is 1:1:1 (PRBCs:FFP:Platelets)
Monitor hemodynamic parameters and laboratory values closely
Administer tranexamic acid (TXA) early in trauma patients (e.g., 15 mg/kg IV bolus followed by 2 mg/kg/hr infusion) to reduce bleeding
Consider cryoprecipitate if fibrinogen is low (<100 mg/dL)
Administer calcium (e.g., 10% calcium gluconate 0.1-0.2 mL/kg) with massive PRBC transfusions to counteract citrate toxicity.
Surgical Management:
Urgent surgical consultation for definitive hemorrhage control
This may involve exploration, ligation of bleeding vessels, packing, and repair of injuries
Reversible Intestinal Obstruction (RIO) and damage control surgery principles are often applied
Application of pelvic binders or external fixation in pelvic fractures to reduce bleeding.
Supportive Care:
Continuous hemodynamic monitoring (arterial line, central venous pressure monitoring if available)
Strict core body temperature monitoring and active warming to prevent hypothermia (temperature <35°C)
Monitoring urine output
Mechanical ventilation if indicated
Adequate analgesia and sedation
Early nutritional support once hemodynamically stable.
Complications
Early Complications:
Transfusion reactions (febrile, allergic, hemolytic)
Hypocalcemia due to citrate toxicity
Hyperkalemia from stored blood
Hypothermia
Dilutional coagulopathy and thrombocytopenia
Volume overload or pulmonary edema
Acute respiratory distress syndrome (ARDS)
Multi-organ dysfunction syndrome (MODS)
Airway compromise.
Late Complications:
Post-transfusion purpura
Graft-versus-host disease (rare)
Iron overload (with multiple transfusions)
Post-traumatic stress disorder (PTSD)
Hospital-acquired infections.
Prevention Strategies:
Use of warmed blood products
Careful monitoring of ionized calcium levels and administration of calcium
Transfusion of leukocyte-reduced blood products
Strict adherence to MTP protocols
Early institution of warming measures
Prompt surgical control of bleeding
Judicious use of blood products to avoid unnecessary transfusions.
Prognosis
Factors Affecting Prognosis:
Severity and cause of hemorrhage
Speed of resuscitation and blood product administration
Effectiveness of hemorrhage control
Age and comorbidities of the patient
Development of complications such as MODS or ARDS.
Outcomes:
Outcomes vary widely
With prompt and appropriate management using a well-defined MTP, survival rates can be significantly improved in patients experiencing massive hemorrhage
However, high mortality remains a concern in severe cases, particularly with delay in definitive care or presence of multiple organ failure.
Follow Up:
Close monitoring of vital signs, laboratory parameters (CBC, coagulation profile, electrolytes, renal function), and organ system function post-resuscitation
Rehabilitation and psychological support may be required for survivors
Long-term follow-up depends on the underlying cause of hemorrhage and any residual organ dysfunction.
Key Points
Exam Focus:
Remember the definition of massive transfusion in pediatrics (e.g., >40 mL/kg in 3 hours)
Understand the balanced resuscitation ratio (e.g., 1:1:1 PRBC:FFP:Platelets)
Recall the importance of early TXA administration in trauma
Know the physiological derangements addressed by MTP (coagulopathy, acidosis, hypothermia)
Recognize the role of calcium supplementation.
Clinical Pearls:
Don't delay initiation of blood products if massive hemorrhage is suspected, even before crossmatch is complete (use O-negative)
Prioritize bleeding control
Continuously reassess the patient and adjust resuscitation strategy based on response
Hypothermia and acidosis are potent drivers of coagulopathy and mortality.
Common Mistakes:
Delaying the initiation of MTP
Relying solely on crystalloid resuscitation in massive hemorrhage
Using unbalanced blood product ratios
Forgetting to administer calcium or monitor it
Failing to control the source of bleeding definitively
Inadequate warming measures.