Massive transfusion complications

When to suspect this adverse reaction

Massive transfusion may result in metabolic and haemostatic abnormalities. Metabolic abnormalities can cause cardiac arrhythmia or cardiac arrest. Massive transfusion is an independent risk factor for developing multi-organ failure.

Some of the complications of massive transfusion include:

  • hypothermia
  • dilutional coagulopathy
  • hypocalcaemia, hypomagnesaemia, citrate toxicity
  • metabolic acidosis
  • hyperkalaemia and hypokalaemia
  • immune haemolysis, and
  • air embolism. 

These complications are rarely seen outside the massive transfusion setting and the incidence varies depending on the clinical situation.

Usual causes

Complications of massive transfusion are dependent on the number of units transfused, rate of transfusion and various patient factors.


Monitor the patient’s core temperature and keep it 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 and your institutional protocols.

Use blood warmers where appropriate for all blood components and IV fluid. 
Consider calcium replacement and tranexamic acid infusions.