• Knowledge of aseptic technique and principles of fluid resuscitation and blood transfusions is essential.

• A unit of fresh whole blood contains approximately 500 mL of warm blood with a hematocrit of 38% to 50%, a platelet count of 150,000 to 400,000, essentially full coagulation function, and 1500 mg of fibrinogen.¹ The combination of one unit of packed red blood cells (PRBCs), one unit of platelets, one unit of fresh frozen plasma (FFP), and a 10 pack of cryoprecipitate provides 660 mL of fluid with a hematocrit of 29%, a platelet count of 87,000, coagulation activity approximating 65%, and 750 mg of fibrinigen.¹

• Events from the battlefields of Afghanistan and Iraq have shown the need to rethink current practices regarding massive transfusion (MT). The Joint Theater Trauma Registry has refocused attention to rapid correction of trauma-induced coagulopathy, permissive hypotension, the early correction of hypothermia and acidosis, and the increased use of component blood transfusion therapy.^1,13 Damage control resuscitation emphasizes treatment of the lethal triad of hypothermia, acidosis, and coagulopathy with surgical techniques.^1,9 The use of MT occurs in 3% to 5% of all civilian trauma and 8% to 10% of all military trauma.^3,10,15

• Hemorrhage is a major cause of death in the first hours after trauma.^11,15

• Current strategies suggest an MT protocol with predefined blood protocols, permissive hypotension, minimizing of crystalloid products, and MT protocol of 1:1 FFP:PRBC during the first 24 hours for patients who are hypocoagulable with traumatic injuries.^4,6,9 Aggressive use of FFP and platelets drastically reduces 24-hour mortality rates and early coagulopathy in patients with trauma.⁵

• Previously, the goal of shock resuscitation has been to support blood pressure, urine output, and reverse metabolic changes associated with ischemia and blood loss. Current civilian and combat strategies seek to immediately identify coagulopathy and simultaneously treat hypothermia and acidosis (which can impair thrombin generation rates) and achieve hemostasis to then volume load with blood components in ratios of 1:1 FFP:PRBC.⁹

• Use of a rapid infusion device, such as the one described in this procedure (Fig. 115-1), can warm and infuse fluids at rates from 75 to 30,000 mL/hr (Level 1, Inc, Rockland, MA). The tubing is made of soft plastic that expands to allow rapid infusion of fluids under pressure. Some rapid infusers include automated pressure chambers to compress intravenous (IV) bags. They allow for fast and easy bag changes and can accommodate both 1-L IV bags and 500-mL blood product bags. Pressure is maintained at a constant 300 mm Hg and is turned on and off via a simple toggle switch at the top of each pressure chamber. Older infusers simply have an IV pole from which to hang fluids, and separate pressure infusor bags must be used.

• IV catheters for aggressive fluid resuscitation should have a large bore and short diameter to facilitate the rapid infusion of large volumes of IV fluids and blood products. Usually, multiple IVs are used, including peripheral and central sites. Venous access may also be obtained surgically via a venous cut-down of the basilic or saphenous veins when peripheral access cannot be obtained.¹²

• Both crystalloid and colloid IV solutions are used for resuscitating patients who are hypovolemic with hemodynamically unstable conditions. Crystalloids directly increase the intravascular volume. Colloids expand plasma volume by pulling interstitial fluid back into the vascular space via osmosis. Numerous crystalloid and colloid preparations are available in isotonic, hypotonic, and hypertonic preparations. Crystalloids most commonly used in aggressive fluid resuscitation are 0.9% normal saline (NS) and lactated Ringer’s (LR) solutions.

• The use of colloids such as albumin, dextran, and hetastarch allows the effective restoration of intravascular volume with smaller amounts of fluid; however, these colloids coat red blood cells (RBCs) and platelets, which may result in type and cross-match difficulties and clotting problems. Even slight overresuscitation with colloids increases the risk for fluid overload and pulmonary edema.^12,14

• Blood and blood products are natural colloids used to replace lost blood and restore coagulation factors. In the patient with significant ongoing hemorrhage, infusion of blood and clotting factors is critical to restoring intravascular volume. Type O-negative blood is the universal donor for all patients and can be given in extreme emergencies before the completion of typing and crossmatching. PRBCs and whole blood are used to replace oxygen-carrying components; FFP, platelets, and cryoprecipitate are used to replace essential clotting factors.²

• When large volumes of IV fluids are being infused into patients, the fluids must be warmed to prevent hypothermia. (Although institutions vary in what constitutes large volumes, a good rule of thumb is to institute fluid rewarming measures when more than 2 L of fluid are required in less than 1 hour.)

• Hypothermia is a common consequence of aggressive fluid resuscitation and has serious physiologic consequences. It is correlated with mortality when the patient’s body temperature decreases below 34°C¹⁷ and significantly prolongs coagulation times at or below 35°C.⁷ Moderate hypothermia (32° to 34°C) reduces coagulation factor activity approximately 10% for each degree Celsius decrease in temperature while markedly affecting platelet function.⁸ Measures to prevent and treat hypothermia include solar blankets, heated blankets, body bags, warmed blood products and fluids, continuous arteriovenous rewarming, and cardiopulmonary bypass, used in extreme cases of hypothermia (see Procedure 94).¹