CONTINUING PROFESSIONAL DEVELOPMENT
Massive hemorrhage and transfusion in the operating room
Brian Muirhead, MD
Andrew D. H. Weiss, MD
Received: 30 January 2017 / Revised: 11 May 2017 / Accepted: 20 June 2017 / Published online: 17 July 2017
Ó Canadian Anesthesiologists’ Society 2017
Purpose In this Continuing Professional Development
module, we review the pathophysiology and clinical
manifestations associated with massive hemorrhage as
well as laboratory investigations and appropriate
therapeutic measures. In addition to reviewing the
available blood/plasma products and adjunct therapy, we
also explore the role of the anesthesiologist in a massive
transfusion protocol scenario.
Principal ﬁndings Massive hemorrhage can be either
anticipated or unexpected. The coinciding presence of
acidosis, hypothermia, and hypotension contribute greatly
to a poor outcome. Red blood cells not only increase
oxygen carrying capacity, but they also play a role in
providing hemostasis. While timely laboratory results,
including point-of-care testing, are important, transfusion
remains a clinical decision. Adjunct therapies other than
blood components have contributed to improved outcomes.
The pathophysiology of massive obstetric hemorrhage is
unique when compared with the non-obstetric population.
The approach to massive hemorrhage and its treatment
vary considerably from institution to institution.
Conclusions Massive hemorrhage is a multidisciplinary
challenge that requires immediate response and
communication between clinicians, nurses, other
healthcare providers, laboratory testing, and blood
banks. Basic knowledge and utilization of available
products and therapies are inconsistent. A massive
transfusion protocol can be used effectively to reduce
chaos and ensure that correct treatments and proper
dosing occur in a timely manner.
Objectives of this Continuing Professional Development
After reading this module, the reader should be able to:
1. Describe both the clinical and pathophysiological
manifestations of massive hemorrhage.
2. Correctly order the appropriate blood products with the
appropriate dosing and delivery.
3. List other available treatment modalities, besides
4. Organize a real-time massive transfusion checklist.
Deﬁnition and overview
The deﬁnition of massive hemorrhage or massive
transfusion varies from institution to institution. The
conventional deﬁnition of ten units of red blood cells
(RBCs) transfused or blood loss of more than one
circulating volume in a 24-hr period has been amended
to include ongoing blood loss - e.g., four units of RBCs
with continued bleeding (some specify a minimum rate per
hour). Regardless, evidence of a massive hemorrhage may
be apparent clinically well before transfusion has begun.
Massive transfusion remains one of the greatest
challenges for the anesthesiologist. It is most commonly
seen in acute trauma, complex cardiac surgery, obstetric
hemorrhage, and coagulopathic patients, but it may also
occur with any intraoperative event. In some cases it can be
anticipated, resulting in proper preparation and an
B. Muirhead, MD (&) Á A. D. H. Weiss, MD
Department of Anesthesia, University of Manitoba, 2nd Floor
Harry Medovy House, 671 William Ave, Winnipeg,
MB R3E 0Z2, Canada
Can J Anesth/J Can Anesth (2017) 64:962–978