## Massive Transfusion Protocol and Coagulopathy **Key Point:** Massive transfusion (>10 units PRBC in <24 hours) causes dilutional coagulopathy due to loss of clotting factors, particularly factors II, V, VII, and X, which are present in FFP but not in PRBC. ### Pathophysiology of Dilutional Coagulopathy 1. PRBC contains no clotting factors or platelets 2. Rapid volume replacement dilutes circulating coagulation factors 3. Fibrinogen depletion occurs earlier than other factors 4. Platelet dysfunction and thrombocytopenia develop in parallel ### Component Therapy in Massive Transfusion | Component | Indication | Dosing | |-----------|-----------|--------| | FFP | Dilutional coagulopathy, INR >1.5 | 10–15 mL/kg (typically 4–6 units) | | Cryoprecipitate | Fibrinogen <100 mg/dL | 1 unit per 5–10 kg body weight | | Platelet concentrate | Platelet count <50,000/μL (intraop) | 1 unit per 5–10 kg | | PRBC | Ongoing hemorrhage, Hb <7 g/dL | Titrate to clinical response | **High-Yield:** Modern massive transfusion protocols recommend a **1:1:1 ratio** (PRBC:FFP:Platelets) to prevent dilutional coagulopathy, rather than waiting for lab confirmation of coagulopathy. **Clinical Pearl:** FFP is the primary source of vitamin K-dependent factors (II, VII, IX, X) and factor V, making it essential in acute dilutional coagulopathy when fresh frozen plasma is unavailable or time-critical. ### Why FFP Over Other Components - **PRBC** alone worsens coagulopathy by further diluting factors - **Cryoprecipitate** contains only fibrinogen, factor VIII, vWF, and fibronectin—insufficient for global coagulation factor replacement - **Platelets** address thrombocytopenia but not factor deficiency [cite:Harrison 21e Ch 108]
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