What is the coagulopathy risk associated with massive transfusion and how is it mitigated?

• A. Dilutional coagulopathy; treat with balanced transfusion (PRBCs, plasma, platelets) and calcium
• B. Hypercoagulable state; treat with anticoagulants
• C. Consumptive coagulopathy; treat with vitamin K
• D. Vitamin K deficiency; give vitamin K

Answer: (A)

Massive transfusion carries a dilutional coagulopathy risk because rapidly replacing blood with packed red blood cells without enough plasma and platelets lowers the concentration of clotting factors and platelets in circulation. The coagulation system also can be hindered by citrate in stored blood, which binds calcium and can cause hypocalcemia, further impairing clot formation. The way to mitigate this is a balanced transfusion approach that replaces red cells, plasma, and platelets to restore all components needed for hemostasis, typically around a 1:1:1 ratio, plus calcium to counteract citrate and maintain adequate ionized calcium. If fibrinogen falls, adding cryoprecipitate or fibrinogen concentrate may be used. Choices proposing a hypercoagulable state, vitamin K–targeted therapies, or vitamin K deficiency do not address the dilutional coagulopathy seen with massive transfusion.