Complications of massive transfusion

When to suspect this adverse reaction?

Complications of massive transfusion include metabolic and haemostatic abnormalities, immune haemolysis and air embolism (1) which can result in a patient presenting with cardiac arrhythmia or cardiac arrest.

Massive transfusion is an independent risk factor for developing multi-organ failure.(2)

Usual causes?

The complications associated with massive transfusion are dependent on the following factors:(2)

  • Number of units transfused
  • Rate of transfusion
  • Patient factors

Some of the complications of massive transfusion include:(1,2)

  • Hypothermia
  • Dilutional coagulopathy
  • Hypocalcaemia, hypomagnesaemia, citrate toxicity
  • Metabolic acidosis
  • Hyperkalaemia
  • Air embolism

These complications are rarely seen outside the massive transfusion setting and the incidence rate is variable depending on the clinical situation.(1)


Monitor core temperature and keep above 36°C.

Monitor electrolytes including potassium, ionized calcium and acid base status.

Watch for dilutional coagulopathy by measuring platelets, INR/APPT and fibrinogen often.

Consider thromboelastography where appropriate and cardiac monitoring.


What to do?

Massive transfusion should follow the national Patient Blood Management Guidelines: Module 1 Critical Bleeding/Massive Transfusion(3) and your institutional protocols.

Use blood warmers where appropriate for all blood components and IV fluid.

Consider calcium replacement and tranexamic acid infusions.

  1. Fung MK, Grossman BJ, Hillyer CD, Westhoff CM (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 18th edition. AABB, Bethesda, 2014.
  2. Callum JL, Pinkerton PH, Lima A, Lin Y, Karkouti K, Lieberman, L, et al. Chapter 5, Transfusion Reactions. Bloody Easy 4: Blood Transfusions, Blood Alternatives and Transfusion Reactions: A Guide to Transfusion Medicine, 4rd edition. Canada: Ontario Regional Blood Coordinating Network, 2016.
  3. National Blood Authority. Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion. [cited 2013 May 29]. Available from: