Diagnosis

Ongoing bleeding and/or replacement > half total blood volume (TBV) per hour or TBV < 24 hours

Notify Blood Bank immediately, send blood sample for type and cross
Activate institutional pediatric massive transfusion protocol. Consider RBC : FFP : Platelets = 2:1:1 or 1:1:1
- Use un-crossmatched O negative PRBCs and AB+ plasma until crossmatched blood available
- Consider intraoperative blood salvage (e.g., Cell Saver)
Obtain additional vascular access if needed
Watch for HYPERKALEMIA, if needed give calcium gluconate 60 mg/kg or calcium chloride 20 mg/kg while directly visualizing IV site (if peripheral)
- 60 mg/kg IV
- 20 mg/kg IV
Warm the room
Send labs/perform point of care testing q 30 min: hgb/hct, platelets, PT/PTT/INR, fibrinogen, rapid TEG, ABG, Na, K, Ca, lactate
Blood product administration:
- Use 140 micron filter for all products
- Use a blood warmer for RBC and FFP transfusion (NOT for platelets)
- Consider use of rapid transfusion pumps
- Monitor ABG, electrolytes, and temperature
Consider TXA 10-30 mg/kg IV bolus then 5-10 mg/kg/h IV infusion
- 10-30 mg/kg IV bolus then 5-10 mg/kg/h IV infusion
When under control: call Blood Bank to terminate
Crisis Management (If Severe)
Notify surgeon, call for help and code cart
Call for Transesophageal Echocardiography
Start chest compressions
Give epinephrine 10 MICROgrams/kg IV/IO
If cardiac arrest, go to CARDIAC ARREST
Consider ECMO

Ongoing bleeding and/or replacement > half total blood volume (TBV) per hour or TBV < 24 hours

Notify Blood Bank immediately, send blood sample for type and cross
Activate institutional pediatric massive transfusion protocol. Consider RBC : FFP : Platelets = 2:1:1 or 1:1:1
- Use un-crossmatched O negative PRBCs and AB+ plasma until crossmatched blood available
- Consider intraoperative blood salvage (e.g., Cell Saver)
Obtain additional vascular access if needed
Watch for HYPERKALEMIA, if needed give calcium gluconate 60 mg/kg or calcium chloride 20 mg/kg while directly visualizing IV site (if peripheral)
Warm the room
Send labs/perform point of care testing q 30 min: hgb/hct, platelets, PT/PTT/INR, fibrinogen, rapid TEG, ABG, Na, K, Ca, lactate
Blood product administration:
- Use 140 micron filter for all products
- Use a blood warmer for RBC and FFP transfusion (NOT for platelets)
- Consider use of rapid transfusion pumps
- Monitor ABG, electrolytes, and temperature
Consider TXA 10-30 mg/kg IV bolus then 5-10 mg/kg/h IV infusion
When under control: call Blood Bank to terminate
Crisis Management (If Severe)
Notify surgeon, call for help and code cart
Call for Transesophageal Echocardiography
Start chest compressions
Give epinephrine 10 MICROgrams/kg IV/IO
If cardiac arrest, go to CARDIAC ARREST
Consider ECMO

Drugs

Calcium gluconate	60 mg/kg IV
Calcium chloride	20 mg/kg IV
TXA	10-30 mg/kg IV bolus then 5-10 mg/kg/h IV infusion