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Massive

transfusion
Speaker : R2 Chang, H.C.
Supervisor : VS Jeng, C.S.

Transfusion Therapy <Miller's Anesthesia, 6th


ed>
Massive blood transfusion in the elective
surgical setting
 Massive transfusion
 Blood component therapy
 Complication
Massive transfusion
 Transfusion > 3000 ml
 More than 10 units of PRBCs over 24 h
 Replacement of 50% of blood volume in 3 h
 Blood loss of 150 ml/min
 Loss of 1.5 ml blood per kg body weight per
minute over 20 min
 When blood loss is so rapid and severe that
blood product support with red cells and volume
replacement with fluids exceeds the
compensatory mechanisms of the body
 Anticipated & Unexpected

 Early recognition of massive blood loss


 Resuscitation to prevent shock and tissue
hypoxia
 Blood transfusion
General principles
 Communication and collaboration
 Replace the deficit of cells ( RBCs
and platelets) and plasma proteins
 No simple formula

 
Blood Component
 Whole blood
 Packed red blood cells
 Platelet concentrates
 Fresh frozen plasma
 Cryoprecipitate
 Others
Table 47-1 -- American College of Surgeons' classes of acute hemorrhage
Class I Class II Class III Class IV
Factors
Blood loss (mL) 750 750–1500 1500–2000 2000 or more
Blood loss (% blood volume) 15 15–30 30–40 40 or more
Pulse (beats/min) 100 100 120 140 or higher
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Hg) Normal or Decreased Decreased Decreased
increased

Capillary refill test Normal Positive Positive Positive


Respirations per minute 14–20 20–30 30–40 35
Urine output (mL/hr) 30 20–30 5–10 Negligible
Central nervous system: mental Slightly anxious Mildly Anxious, Confused,
status anxious confused lethargic

Fluid replacement (3-1 rule) Crystalloid Crystalloid Crystalloid + Crystalloid +


blood blood
Whole Blood
 Active bleeding with sustained a loss
of greater than 25% of total blood
volume
Value Whole Blood PRBC
Volume (mL) 517 300
Erythrocyte mass 200 200
(mL)
Hematocrit (%) 40 70
Albumin (g) 12.5 4
Globulin (g) 6.25 2
Total protein (g) 48.8 36
Plasma sodium 45 15
(mEq)
Plasma potassium 15 4
(mEq)
Plasma acid (citric- 80 25
lactic) (mEq)
Donor-to-recipient 1 unit per patient 1 unit per 4–6
ratio patients
Packed Red Blood Cells
 Less severe degrees of hemorrhage
 Reconstituted with crystalloid
 Tonicity
 Osmolarity
 Serum albumin deficiencies
Compatibility of blood with intravenous
solutions
Hemolysis at 30 Minutes
Blood to Intravenous Room 37°C
Solution (1:1 Ratio) Temperature

5% Dextrose in water 1+ 4+
Plasmanate 1+ 3+
5% Dextrose in 0.2% 0 3+
saline
5% Dextrose in 0.4% 0 0
saline
5% Dextrose in 0.9% 0 0
saline
0.9% Saline 0 0
Normosol-R, pH 7.4 0 0
Lactated Ringer's 0 (clotted) 0 (clotted)
Platelet Concentrates
 Effectiveness
 19 gauge needle or larger
 Storage at room temperate ( 20 - 24 ℃ )
 7000 to 10000 platelets/mm3 after transfusion of
one platelet concentrate to the 70-kg adult
 Decreased recovery
 Splenomegaly
 Previous sensitization
 Fever
 Sepsis
 Active bleeding

 Bacterial contamination
Platelet Concentrates
 Should not be given
 Prophylactically with massive blood transfusion
 Prophylactically after cardiopulmonary bypass
 Immune thrombocytopenia purpura
(unless there is life-threatening bleeding)
Platelet Concentrates
 ASA Task Force 2 recommendation
 1. Prophylactic platelet transfusion is rarely indicated when
thrombocytopenia is due to increased platelet destruction (e.g.,
ITP).
 2. In surgical patients with thrombocytopenia due to decreased
platelet production or with microvascular bleeding
 Platelet count is below 50 × 109/L : indicated
 Platelet counts is 50 to 100 × 109/L : Based on the patient's risk of
bleeding.
 Platelet count is greater than 100 × 109/L: Rarely indicated

 3.  Vaginal deliveries or operative procedures associated with


insignificant blood loss
 Platelet counts less than 50 × 109/L.

 4.  Despite an apparently adequate platelet count


 Known platelet dysfunction and microvascular bleeding
Fresh Frozen Plasma
( FFP )
 All plasma protein
 Factors V
 Factors VIII
 Fibrinogen ( 2-5 mg/ml )

 Major risk
 Transmission of infectious diseases

 Sensitization to foreign proteins


FFP
 ASA Task Force 2 recommendation
 Reversal of warfarin effect
 Antithrombin III deficiency
 Treatment of immunodeficiencies
 Treatment of thrombotic thrombocytopenia purpura
 Prothrombin and partial thromboplastin times at least
1.5 times longer than normal.
 Massive blood transfusion (rarely and only when factors V
and VIII are less than 25% of normal)
 Replacement of isolated factor deficiencies
FFP
 Policy at the University of California, San Francisco
 Patients with clinical bleeding or oozing or those
with an invasive procedure
 Prothrombin time of 17 seconds
 Platelet count is more than 50,000 cells/mm3

 Blood fibrinogen concentration is more than 100 mg/dL

 Dilutional coagulopathy
 Prothrombin time more than 17 seconds
 Administration of more crystalloids is anticipated
FFP
 FFP is contraindicated for augmentation
of plasma volume or albumin
concentration
 The practice of administering PRBCs
and FFP to the same patient should be
discouraged
Cryoprecipitate
 Factor VIII
 Fibrinogen (150 – 300 mg/unit)
 Von Willebrand factor ,Fibronectin

 Rate of administration : at least 200 ml/hour


 Within 6 hours of thawing

 Dose: 2 ml/kg Body weight


 One unit should increase the fibrinogen level by
0.1 g/l.

 Indication
 Factor VIII deficiency
 Hemophilia A
 Fibrinogen deficiencies
Others
 Prothrombin complex
 Single-Donor plasma
Laboratory tests
 PT , APTT
 Platelet count
 Fibrinogen
 Thrombin time
 D-dimer
 TEG
Complication
 Changes in oxygen transport
 Coagulopathy
 Hemolytic transfusion reaction
 Transfusion-related acute lung injury
 Citrate intoxication
 Hyperkalemia
 Hypothermia
 Acid-Base abnormalities
 Infectivity of blood
 Microaggregates
 Others
Changes in Oxygen Transport
 Leftward shift of the oxygen
dissociation curve in vitro
 P50 and 2,3-DPG levels decrease

 Older blood is not as beneficial as fresher


blood in critically ill patients
Coagulopathy
 Only after a large amount of blood transfusion
 Volume of blood given
 Duration of hypotension or hypoperfusion
 Clinical manifestations
 Oozing into the surgical field
 Hematuria
 Gingival bleeding
 Petechial bleeding from venipuncture sites
 Ecchymoses
 Differential diagnosis
 Low levels of factor V and VIII

 DIC-like syndrome

 Dilutional thrombocytopenia

 Hemolytic transfusion reaction


 Low levels of factor V and VIII
 Factors V and VIII rarely decrease below those
levels required for hemostasis.
 An unlikely primary cause of bleeding during
massive blood transfusion, such deficiencies may
intensify bleeding from other causes

 FFP therapy
 Generalized bleeding that cannot be controlled with
surgical sutures or cautery
 Partial thromboplastin time at least 1.5 times normal
 Platelet count greater than 70,000/mm3
 DIC-like syndrome
 Accompanying microvascular thrombosis is uncommon.
 Rarely causes significant organ damage and infarction.
 Accompanying large-vessel thrombosis is relatively
common but is probably not primarily caused by DIC
 Although bleeding is common, severe bleeding usually
originates from sites of local disorder (e.g., lacerated liver).
 High mortality rates primarily because of the severity of
patients' underlying disorders.

 Survival rates of patients who have DIC associated with


hypovolemia or septic shock are not increased by the
administration of heparin.
Dilutional
thrombocytopenia
 After multiple units of whole blood or PRBCs
 Rarely decreases to a low a level as wound be
predicted from dilution alone

 Platelet therapy
 Clinical coagulopathy is also present.
 Platelet counts is less than 50000 to 75000/mm3
Transfusion reaction
 Acute hymolytic reaction
 Errors involving ABO incompatibility
 Intravascular v.s. Extravascular hemolysis
 Under anesthesia
 Bleeding diathesis
 Hypotension
 Hemoglobinuria
 Acute renal failure
 Stop the transfusion
 Maintain the urine output at a minimum of 75 to 100mL/hour
 Generously administer IV fluids ( Lactated Ringer's solution )

and possibly mannitol (12.5 to 50 g, given over 5 to 15 minutes).   


 Furosemide (20 to 40 mg) intravenously.3.

 Alkalinize the urine


 40 to 70 mEq of sodium bicarbonate per 70 kg of body weight to raise
the urine pH to 8
 Assay urine and plasma hemoglobin concentrations.
 Determine platelet count, aPTT, and serum fibrinogen level.
 Return unused blood to blood bank for repeat crossmatch.
 Send patient's blood and urine sample for examination
 Prevent hypotension to ensure adequate renal blood flow.
 Delayed hemolytic transfusion reaction
 After a variable delay ( 2 to 21 days)
 Not be preventable
 High risk
 Previous blood transfusions
 Pregnancy
 females who have a known disposition of alloimmunization

 Decrease in hematocrit value


 Jaundice
 hemoglobinuria
 Impairment in renal function
 Nonhemolytic transfusion reaxtions
 Febrile
 No clear consensus on whether the transfusion should be

terminated when a febrile reaction occurs

 Allergic
 Urticaria associated with itching., facial swelling
 Not necessary to discontinue the transfusion
 Antihistamines

 Anaphylactic reaction
 Dyspnea, hypotension, laryngeal edema, chest pain, and
shock
Transfusion-Related Acute
Lung Injury
 Under-diagnosed and under-reported
 Noncardiogenic pulmonary edema
 Caustic factors : All blood components, especially FFP
 Symptoms and signs
 1 to 2 hours after transfusion and in force within 6 hours
 Fever, dyspnea, fluid in the ETT, severe hypoxia
 During anesthesia
 A persistent decrease in blood oxygen saturation

 Stopping the transfusion


 Supportive measures
 Recover in 96 hours
Citrate intoxication
 Signs of hypocalcemia
 Hypotension, Narrow pulse pressure
 Elevated intraventricular end-diastolic pressure and CVP

 At a rate more rapid than 150 mL/70 kg/min or about 1


unit of blood per 5 minutes
 Low flow states
 Ionized calcium levels returned toward normal when hemodynamic
status was improved
 Isoproterenol infusion
 Blood transfusion
 Calcium chloride therapy
 Not readily corrected by IV administration of calcium salts
 At rates as rapid as 1.5 mg/kg/min
 Not be given without close monitoring of serum ionized calcium levels
 Increase the possibility
 Hypothermia
 Liver disease
 Liver transplantation
 Hyperventilation

 If a hemorrhagic diathesis starts after


administration of blood, low calcium levels
are not part of the differential diagnosis.
Hyperkalemia
 At a rate of 120 mL/min or more
 Rare
 Rules against the routine
administration of calcium
Hypothermia
 A decrease in body temperature as small as
0.5°C to 1.0°C may induce shivering
postoperatively
 Increase oxygen consumption by as much as
400%
 Vasoconstriction, cardiac arrhythmias,
and coagulopathy.

 Blood warmer
 Dilution
Acid-Base Abnormalities
 Metabolic acidosis
 Storage media
 plastic container of blood
 Metabolic alkalosis
 Citrate

 Bicarbonate administration should be reserved


for patients in whom severe metabolic acidosis
(base excess > 7 mEq/L) has been diagnosed
Infectivity of Blood
 Hepatitis
 AIDS
 HTLV-1
 West Nile virus
 Cytomegalovirus
 Others
Microaggregates
 Accumulation of this particulate material in
the lungs
 Respiratory insufficiency in patients with
severe trauma and hemorrhage (so-called
shock lung)
 Acute respiratory distress syndrome

 Need for micropore filter ?


Others
 Graft-versus-host disease
 Irritation of blood

 Adverse ocular reaction


 Bilateral conjunctival erythema
 Toxic reaction to a chemical or material

 Transfusion-related
immunomodulation
Thanks for your
attention!!

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