Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 145 Small font size Default font size Increase font size Print this article Email this article Bookmark this page


    Advanced search

    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

   Case Report

 Article Access Statistics
    PDF Downloaded28    
    Comments [Add]    

Recommend this journal


Table of Contents
Year : 2018  |  Volume : 21  |  Issue : 4  |  Page : 433-436
The value of institutional protocols and focused cardiac ultrasound during a case of ultramassive transfusion

Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA

Click here for correspondence address and email

Date of Web Publication17-Oct-2018


A 53-year-old female was admitted to the emergency department with an exsanguinating bleed from the rectum which was of unclear origin. In what could be considered an ultramassive transfusion, 60 units packed red blood cells, 23 units fresh frozen plasma, 20 units platelets, 6 units cryoprecipitate, 30 L of crystalloids, 2 L of colloids, and 4 g of tranexamic acid were transfused over the course of 7 h. An arterio-enteric fistula was diagnosed and treated by an interventional radiologist. The patient recovered rapidly thereafter without any major neurologic, pulmonary, cardiac, or hematologic complications.

Keywords: Blood components, focused cardiac ultrasound, massive transfusion

How to cite this article:
Tahir Janjua MS, Agarwal S, Castresana MR. The value of institutional protocols and focused cardiac ultrasound during a case of ultramassive transfusion. Ann Card Anaesth 2018;21:433-6

How to cite this URL:
Tahir Janjua MS, Agarwal S, Castresana MR. The value of institutional protocols and focused cardiac ultrasound during a case of ultramassive transfusion. Ann Card Anaesth [serial online] 2018 [cited 2019 Jun 24];21:433-6. Available from:

   Introduction Top

Massive transfusion (MT) is most commonly defined as a transfusion of 10 or more units of packed red blood cells (PRBCs) in <24 h.[1],[2] Several protocols based on varying institutional practices are available. The use of MT protocols (MTPs) is becoming common;[3] however, transfusion of more than 30 units in 24 h, which could be referred to as ultra-MT, is rare.[4],[5] MT is often complicated with hypothermia, coagulopathy, sepsis, immunosuppression, as well as respiratory, cardiovascular, neurologic, and thrombotic complications.[1] The 30-day mortality associated with transfusion of PRBC increases from 8.9% with 1–4 units to 21.5% when more than 5 units were given and as high as 57% when the number of units transfused exceeded 50 in 24 h.[6]

Blood component based transfusion therapy was introduced in the 1970s to decrease the risk of transmitting infections through whole blood transfusions as well as to maximize the utility of each donated unit of blood. In elective cases, wherein massive blood loss may be expected, coagulation tests are typically used to guide blood component transfusions. However, this strategy may not be practical when managing massive blood loss.[7] We present a case in which a massive administration of blood components and fluids to treat a rapidly exsanguinating patient over a very short-time period resulted in excellent clinical recovery.

   Case Report Top

A 53-year-old African American female with a body mass index of 27.2 kg/m2 and a history of coronary artery disease, end-stage renal disease, cervical carcinoma and a right atrial thrombus, presented to our emergency department from an outside hospital bleeding profusely from her rectum. At an outside facility, two self-expanding nasal tampons (Rhino Rockets, Shippert Medical Technologies, Centennial, Colorado, USA) were placed in the rectum to control bleeding and two units of PRBCs were transfused. While still in the emergency department, MTP was started, and 2 g of intravenous tranexamic acid (TXA) were administered.

The patient was emergently taken to the operating room, but surgical efforts failed to control the bleeding as the pelvic radiation therapy she had previously received to treat a cervical carcinoma had distorted her anatomy such that her internal iliac artery could not be visualized. Proctoscopy performed after total colectomy revealed a still massive amount of blood coming from the lower rectum or anal canal. A balloon was fashioned with a Penrose drain and Foley catheter to create a tamponade effect in the rectum; however, this was effective for only a short while. Thromboelastography (TEG) results – a normal reaction time (R) time of 7 min, a decreased alpha angle of 40° and decreased maximum amplitude of 36.7 mm – pointed toward a coagulopathy secondary to fibrinogen and platelet deficiency. The patient continued to receive fresh frozen plasma (FFP), cryoprecipitate and platelets. While there was a concern of a coagulopathy related to the apixaban, the patient was prescribed for atrial thrombus, the etiology of bleeding, in this case, was surgical. During the consultation with the interventional radiology service for angioembolization, she was brought to the Surgical Intensive Care Unit (SICU) for interval management with the rectal balloon in place.

In the SICU, two rapid transfuser devices (Level 1, H-1200 Fast Flow Fluid warmer, Dublin, OH, USA) were assembled, and a wide-bore central venous catheter was inserted. MT was continued with a goal mean arterial pressure (MAP) of 50–60 mmHg through the administration of blood products, norepinephrine, and vasopressin infusion and intermittent boluses of epinephrine. Resuscitation was guided by vital signs, bedside echocardiography, serial TEG and perfusion biomarkers such as serum lactate and base deficit. A >14 L blood loss was recorded in the SICU in 90 min.

In the interventional radiology suite, a fistula between the right common iliac and the rectum was identified as the source of bleeding. A 10 mm × 40 mm covered self-expanding intravascular stent (Fluency, Bard Peripheral Vascular, Tempe, AZ, USA) successfully stopped the bleeding. In total, the patient received 60 units PRBC, 23 units FFP, 20 packs of platelets, 6 units cryoprecipitate, 2 g TXA, 30 L of crystalloid, and 2 L of albumin in <7 h.

Serial focused cardiac ultrasound (FoCUS) guided the resuscitation. Hypothermia, serum lactate, and base deficit improved from 35.4, 7 and − 10–36.8, 1.9 and − 4 respectively, in the next 4 h. By that point, the patient was able to follow commands and required minimal ventilatory support. In the ensuing days, there were no signs of lung injury, volume overload, coagulopathy, or cardiomyopathy. Her abdomen was closed 2 days later, successfully extubated shortly thereafter, and transferred to the floor.

   Discussion Top

MT is a life-saving intervention with many risks. According to the American College of Surgeons National Surgical Quality Improvement Program, the incidence of MT (>5 units) among all surgical patients was 0.6%–0.7% over a 3-year period. The 30-day mortality for patients receiving MT was 21.5%. Of the 54% of patients, who had major complications, 38% were respiratory and 23% related to infection, sepsis, or septic shock. Other major complications were related to acidosis, coagulopathy, hypothermia, and cardiac dysfunction.[1],[6],[8]

The establishment of an MTP is not a requirement for certification as a trauma center in the US. One study reported that, out of 59 centers, only 85% used MTP-based volume replacement and only 62% included FFP in their first batch.[9] This has resulted in widely variable transfusion practices. In general, three components are considered necessary for any MTP: early start while gaining control of the bleeding, anticipation of further transfusion, and the use of laboratory results for goal-directed management.[3] The goals are usually set for a hemoglobin level above 8–10 g/dL, platelet count >50 × 109/L, prothrombin time <1.5 times normal, partial thromboplastin time <40, and fibrinogen levels >100 mg/dL depending on the individual institution.

At our institution, MTP is activated by the surgeon, emergency room physician, or physician anesthesiologist. Initially, 4 units of type O PRBCs and 1 unit of type A plasma are delivered by a dedicated transport individual along with a 1 g bolus of intravenous TXA. Transfusion therapy continues while the patient's blood sample is being delivered by the dedicated transport individual to the blood bank for cross-matching. Complete blood count, coagulation studies, fibrinogen, TEG, and chemistries are sent at regular intervals. The second phase of transfusion includes PRBCs, FFP, and platelets in a 2:1:1 ratio and the sequence is repeated until hemostasis is achieved.

Transfusion pathways providing PRBC, FFP, and platelets in a ratio of 1:1:1 were adopted in the military setting,[10] but in the civilian setting, the optimum ratio is unknown. Several studies suggest that the optimal ratio is somewhere between 1.5 and 2.5 units of RBC to 1 unit of FFP.[11] The 2:1 ratio of RBC to FFP at our institution minimizes patient exposure to the deleterious effects of excessive plasma.[12] Clinically significant thrombocytopenia is unlikely to develop until one complete blood volume has been replaced. In our case, dilutional thrombocytopenia was suspected, and platelets were transfused empirically at first, then later, based on platelet count and TEG results. Evidence of the usefulness of preemptive platelet transfusion is lacking. Fibrinogen levels may decrease significantly in consumption coagulopathy, disseminated intravascular coagulation, and hyperfibrinolysis – all of which may be present in the massively bleeding patient. While FFP contains lower levels of fibrinogen as compared to cryoprecipitates, there is no evidence to support the use of one over the other.

Although it is controversial to restrict the crystalloids in cases of trauma to avoid coagulopathy,[2] we used crystalloids for hemodynamic support when the rapid transfusion system tubing had to be replaced, after every 7–10 units of PRBCs. Permissive hypotension during massive volume resuscitation in trauma cases is another factor that has shown survival benefit especially in the immediate postoperative period. Setting MAP goals to 50 mmHg rather than the conventional goal of 65 mmHg, until surgical hemostasis is achieved, has shown to reduce the incidence and severity of postoperative coagulopathy. In our case, we kept the MAP around 55–60 mmHg.[13]

Monitoring of the blood coagulation factors is yet another important component of the MTP. Conventional methods to monitor coagulation status were designed to manage anticoagulant therapy and their use in the setting of blood loss is controversial.[14] In fact, their value in predicting bleeding tendency in patients receiving MT is poor.[15] Furthermore, the long turnaround time is undesirable.[16] TEG is a relatively rapid viscoelastic whole blood coagulation test that allows tailoring of fibrinogen, cryoprecipitate, plasma, and to the specific clinical needs of the patients. Furthermore, the use of TEG allows early recognition of hyperfibrinolysis.[17] TXA was used in our case to prevent excessive fibrinolysis. Although the effect of TXA in reducing all-cause mortality in profusely bleeding trauma patients is minor, the low cost and favorable side effect profile of TXA make it a valuable adjunct to MTP, especially when the etiology of bleeding is unclear.[18] The time to administration of the first unit of blood may be another important prognostic factor. A recent systematic review examining the utility of MT policies suggested that shorter times to initiating transfusion result in improved survival.[19]

Adequacy of volume resuscitation is difficult to assess in these situations. Monitoring of cardiac filling pressure is fraught with fallacies due its dependence on several factors including changes in venous capacitance, ventricular function as well as effect of mechanical ventilation and abdominal pressure.[20],[21] Moreover, unless there is a dedicated central line to measure central venous pressure (CVP), the ongoing large volume resuscitation through the existing central line prevents the ability to transduce the line to obtain any meaningful CVPs, as in our patient. Pulse pressure variability is another modality often used to guide fluid resuscitation; however, it is dependent on several factors including controlled mechanical ventilation, respiratory system compliance of ≥30 mL cm H2O and tricuspid annular peak velocity of ≥0.15 m/s.[22] FoCUS has, therefore, become a rapidly available first line tool in these emergent situations, where it can substitute comprehensive echocardiography in the assessment of volume status, pericardial effusion, cardiac global and regional systolic function, right and left ventricular enlargement as well as to guide pericardiocentesis and transvenous pacing wire placement.[23] It involves five views, namely the parasternal short axis, parasternal long axis, apical four chamber, subcostal inferior vena cava (IVC) and subcostal four chamber. Furthermore, in a mechanically ventilated patient, transthoracic echocardiographic assessment of IVC distensibility during inspiration has been utilized to assess fluid responsiveness. A lack of any variation points toward a fluid nonresponder, although just like CVP, it has its own limitations.[24] In our case, in addition to quick assessment of volume resuscitation, it allowed us to not interrupt administration of volume and/or vasoactive medications during CVP measurements. At the conclusion of the transfusion, the patient had no respiratory variations in the IVC diameter and adequate left ventricular end-diastolic volume.

   Conclusion Top

This case emphasizes the role of a strict disciplinary approach that should include an aggressive and timely resuscitation with blood products, close coordination with the blood bank, prompt management of physiological derangements and guidance by both FoCUS as well as clinical and biochemical parameters. Although reports of ultra-MT in the medical literature are not unusual, we believe that the patient's size and comorbidities, the difficulty in detecting the source of bleeding, and the rapid recovery devoid of transfusion-related complications make for a particularly valuable educational case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Turan A, Yang D, Bonilla A, Shiba A, Sessler DI, Saager L, et al. Morbidity and mortality after massive transfusion in patients undergoing non-cardiac surgery. Can J Anaesth 2013;60:761-70.  Back to cited text no. 1
Hardy JF, de Moerloose P, Samama CM; Members of the Groupe d'Intérêt en Hémostase Périopératoire. Massive transfusion and coagulopathy: Pathophysiology and implications for clinical management. Can J Anaesth 2006;53:S40-58.  Back to cited text no. 2
Malone DL, Hess JR, Fingerhut A. Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. J Trauma 2006;60:S91-6.  Back to cited text no. 3
Dzik WS, Ziman A, Cohn C, Pai M, Lozano M, Kaufman RM, et al. Survival after ultramassive transfusion: A review of 1360 cases. Transfusion 2016;56:558-63.  Back to cited text no. 4
Allen CJ, Shariatmadar S, Meizoso JP, Hanna MM, Mora JL, Ray JJ, et al. Liquid plasma use during “super” massive transfusion protocol. J Surg Res 2015;199:622-8.  Back to cited text no. 5
Vaslef SN, Knudsen NW, Neligan PJ, Sebastian MW. Massive transfusion exceeding 50 units of blood products in trauma patients. J Trauma Acute Care Surg 2002;53:291-5.  Back to cited text no. 6
Geeraedts LM Jr., Demiral H, Schaap NP, Kamphuisen PW, Pompe JC, Frölke JP, et al. 'Blind' transfusion of blood products in exsanguinating trauma patients. Resuscitation 2007;73:382-8.  Back to cited text no. 7
Sihler KC, Napolitano LM. Complications of massive transfusion. Chest 2010;137:209-20.  Back to cited text no. 8
Schuster KM, Davis KA, Lui FY, Maerz LL, Kaplan LJ. The status of massive transfusion protocols in United States trauma centers: Massive transfusion or massive confusion? Transfusion 2010;50:1545-51.  Back to cited text no. 9
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma Acute Care Surg 2007;63:805-13.  Back to cited text no. 10
Bhangu A, Nepogodiev D, Doughty H, Bowley DM. Meta-analysis of plasma to red blood cell ratios and mortality in massive blood transfusions for trauma. Injury 2013;44:1693-9.  Back to cited text no. 11
Callum JL, Rizoli S. Plasma transfusion for patients with severe hemorrhage: What is the evidence? Transfusion 2012;52 Suppl 1:30S-7S.  Back to cited text no. 12
Morrison CA, Carrick MM, Norman MA, Scott BG, Welsh FJ, Tsai P, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: Preliminary results of a randomized controlled trial. J Trauma Acute Care Surg 2011;70:652-63.  Back to cited text no. 13
Gonzalez E, Pieracci FM, Moore EE, Kashuk JL. Coagulation abnormalities in the trauma patient: The role of point-of-care thromboelastography. Semin Thromb Hemost 2010;36:723-37.  Back to cited text no. 14
Counts RB, Haisch C, Simon TL, Maxwell NG, Heimbach DM, Carrico CJ, et al. Hemostasis in massively transfused trauma patients. Ann Surg 1979;190:91-9.  Back to cited text no. 15
Haas T, Fries D, Tanaka KA, Asmis L, Curry NS, Schöchl H, et al. Usefulness of standard plasma coagulation tests in the management of perioperative coagulopathic bleeding: Is there any evidence? Br J Anaesth 2015;114:217-24.  Back to cited text no. 16
Afshari A, Wikkelso A, Brok J, Moller AM, Wetterslev JT. Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev 2011;3.3.  Back to cited text no. 17
Williams-Johnson JA, McDonald AH, Strachan GG, Williams EW. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) A randomised, placebo-controlled trial. West Indian Med J 2010;59:612-24.  Back to cited text no. 18
Enticott JC, Jeffcott S, Ibrahim JE, Wood EM, Cole-Sinclair M, Fitzgerald M, et al. A review on decision support for massive transfusion: Understanding human factors to support the implementation of complex interventions in trauma. Transfusion 2012;52:2692-705.  Back to cited text no. 19
Gelman S. Venous function and central venous pressure: A physiologic story. Anesthesiology 2008;108:735-48.  Back to cited text no. 20
Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008;134:172-8.  Back to cited text no. 21
Mahjoub Y, Lejeune V, Muller L, Perbet S, Zieleskiewicz L, Bart F, et al. Evaluation of pulse pressure variation validity criteria in critically ill patients: A prospective observational multicentre point-prevalence study. Br J Anaesth 2014;112:681-5.  Back to cited text no. 22
Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al. Focused cardiac ultrasound in the emergent setting: A consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010;23:1225-30.  Back to cited text no. 23
Miller A, Mandeville J. Predicting and measuring fluid responsiveness with echocardiography. Echo Res Pract 2016;3:G1-12.  Back to cited text no. 24

Correspondence Address:
Muhammad Salman Tahir Janjua
Department of Anesthesiology and Perioperative Medicine, 1120 15th Street BIW 2144, Augusta, GA
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_49_18

Rights and Permissions