A comprehensive review of massive transfusion and major hemorrhage protocols: origins, core principles and practical implementation

Abstract

Until the beginning of the century, bleeding management was similar in elective surgeries or exsanguination scenarios: clotting tests were used to guide blood product orders and, while awaiting these results, an aggressive resuscitation with crystalloids was recommended. The high mortality rate in severe hemorrhages managed with this strategy endorsed the need for a special resuscitation plan. As a result, modifications were recommended to develop a new clinical approach to these patients, called "Damage Control Resuscitation". This strategy includes four principles: damage control surgery, minimization of crystalloids, permissive hypotension and hemostatic resuscitation. The latter involves the use of antifibrinolytics, correction of preconditions of hemostasis (calcium, pH and temperature) and the early and rapid restoration of intravascular volume with blood products. To enable timely availability and transfusion of blood products, specific actions in different hospital areas need to be synchronized, which are usually organized through Massive Transfusion Protocols or, as they have recently been rebranded, Major Hemorrhage Protocols (MHPs). Although these bundles of actions represent a paradigm change, essential aspects such as their historical evolution, theoretical foundations, terminology and operational elements have yet to be well explored. Considering the wide application range of these tools (emergency departments, interventional radiology, operating rooms and military fields), it is essential to integrate all professionals involved with severe hemorrhage scenarios in the implementation of the aforementioned protocols, from conception to execution and management. This review paper addresses MHP aspects relevant to anesthesiologists, transfusion services and other areas involved with the care of patients with severe bleeding.

Keywords: Blood coagulation disorders; Blood component transfusion; Exsanguination; Hemorrhage; Hemostasis; Shock, hemorrhagic.

Figure 1

Damage Control Resuscitation, its pillars and proposed actions. MAP, Mean Arterial Pressure; SAP, Systolic Arterial Pressure; TBI, Traumatic Brain Injury.

Figure 2

General organization of actions during Damage Control Resuscitation. Among trauma-related hemorrhages, only a few are severe enough to activate the commonly used triggers for DCR. Most bleedings should be managed using traditional lab-guided strategy. Severe hemorrhages activate a series of actions involving first movements followed by a cycle of non-hemostatic interventions in parallel to hemostatic resuscitation, which are maintained until any of the interruption criteria arrives. DCS, Damage Control Surgery; Ca²⁺, Ionised Calcium.

Figure 3

Example of MTP in a Level-1 Trauma Center (Instituto Dr. José Frota, Fortaleza-CE, Brazil). HR, Heart Rate; SAP, Systolic Arterial Pressure; bpm, beats per minute; FAST, Focused Assessment with Sonography for Trauma; RBC, Red Blood Cell Concentrates; FFP, Fresh Frozen Plasma; PC, Platelet Concentrate; MTP, Massive Transfusion Protocol; Cryo, Cryoprecipitate; CBC, Complete Blood Count; PT, Prothrombin Time; aPTT, Activated Partial Thromboplastin Time; TBI, Traumatic Brain Injury; Ca²⁺, Ionized Calcium.

Figure 4

Transfusion packs in a MTP in a Level-1 Trauma Center (Instituto Dr. José Frota, Fortaleza-CE, Brazil). (A and B) Release of blood components may be expedited by the conservation of group-O RBC previously retyped with a negative direct antiglobulin test and marked with a transfusion emergency label partially filled in; (C) Example of a first package of MTP containing RBC and FFP units in a cooler box, according to local protocol (thawed plasma is available 24h a day).