If a large amount of packed red cells is infused rapidly, then a dilutional coagulopathy may occur. This may involve thrombocytopenia and/or a decrease in coagulation factors, depending on the rate of blood loss and whether platelet concentrates or fresh frozen plasma were given concurrently with the red blood cells.


Criteria for massive blood loss:

(1) transfusion of more than 10 units of packed red blood cells in the 70 kg adult

(2) replacement of 1 blood volume within 24 hours

(3) replacement of more than 50% of the circulating blood volume in 3 hours or less.


Patients at increased risk for development of dilutional coagulopathy:

(1) those with significant comorbidities

(2) those with pre-existing coagulation disorders


Testing to be performed once a massive transfusion program has been initiated:

(1) platelet count

(2) PT and PTT, with fibrinogen

(3) fibrin split products or other screen for DIC


Clinical features may include:

(1) oozing from surgical wounds

(2) bruising

(3) spontaneous bleeding



(1) If thrombocytopenia is present, then 6-8 platelet concentrates are usually sufficient to raise the platelet count to hemostatic levels.

(2) If the fibrinogen is very greatly decreased, then cryoprecipitate may be indicated.

(3) 1-2 units of fresh frozen plasma (FFP) are usually sufficient to replace the other depleted coagulation factors.

(4) Prevention of hypotension and hypoxemia by adequate fluid and blood replacement and by control of bleeding.


Implementation Notes:

• Blood volume estimate in implementation based on "blood vol children and adults" from Chapter 2.

• Blood volume replacement may need to be more specific to distinguish red cell volume replaced vs colloidal solution volume vs crystalloid replacement.


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