Download MBBS Transfusion Medicine and Blood Bank Presentations 6 Massive Transfusion Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Transfusion Medicine and Blood Bank 6 Massive Transfusion PPT-Powerpoint Presentations and lecture notes


Massive blood

Transfusion

Massive transfusion protocol (MTPs)

? Established to provide rapid blood replacement in a

setting of severe hemorrhage

? Early optimal blood transfusion is essential to sustain

organ perfusion and oxygenation
What is Massive transfusion?

10 units of red cel s in 24 hours

Total blood volume is replaced within 24 hours

Three units over one hour

50% of total blood volume is replaced within 3

hours

Massive Transfusion-Clinical Settings

? Trauma
? Surgery (e.g. Liver, Cardiovascular)
? Less frequent

? abdominal aortic aneurysm

? liver transplant

? obstetric catastrophes

? GI bleeding
? Cardiac surgery -- Most common cause of massive transfusion
? Obstetric hemorrhage -- Gravid and parturient women are

hypercoagulable with compensatory hyperfibrinolysis.

? Liver disease --

? leads to the reduced production of normal coagulation factors

? production of abnormal factors

Types of Shock

? Cardiogenic ? MI, cardiomyopathy
? Obstructive ? Tamponade, PE
? Distributive ? Sepsis, Anaphylaxis

? Hypovolemic ? Hemorrhage
Chal enges

? Types of components to be administered
? Selection of the appropriate amounts

? TIME

Blood Products

? RBC
? Plasma
? Platelets
? Cryoprecipitate


Emergency blood issue

Immediate

Minutes

Within an hour

Group O Rh neg

ABO & Rh D type

ABO & Rh D type

Packed RBCs

Group specific blood

Complete crossmatch

Immediate spin

(5-10 min)

crossmatch

( 15-20) min)

If units are issued without X match ? written consent of physician to be taken,

-complete X match protocols followed after issue

Emergency Release Blood - Universal Donor

? O, RhD neg/pos RBCs ? 5 min
? AB or A Plasma/Platelets


Recommendations

? "Damage control" approach
? Improved survival when the ratio of transfused Fresh Frozen Plasma

(FFP, in units) to platelets (in units) to red blood cells (RBCs, in units)

approaches 1:1:1



Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing

the early coagulopathy of trauma. J Trauma 2007; 62:307.

Important

At the onset - aggressive fluid replacement and bleeding control can

reduce the tissue injury, inflammation, and hypoperfusion

Untimely or incomplete control of massive bleeding- systemic

consumptive coagulopathy with hemodilution and endothelial damage

If uncorrected, concurrent hypothermia and acidosis can further

exacerbate coagulopathy and lead to irreversible multiorgan failure

(MOF).


Patients who have sustained severe traumatic

injuries and/or who are likely to require

massive transfusion should receive a

1:1:1 ratio of FFP to platelets to RBCs at

the outset of their resuscitation and

transfusion therapy

?

Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma

2007; 63:805.

?

Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg

2008; 248:447.

?

Cotton BA, Au BK, Nunez TC, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009; 66:41.

?

Shaz BH, Dente CJ, Nicholas J, et al. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients.

Transfusion 2010; 50:493.

?

Inaba K, Lustenberger T, Rhee P, et al. The impact of platelet transfusion in massively transfused trauma patients. J Am Coll Surg 2010; 211:573.

?

de Biasi AR, Stansbury LG, Dutton RP, et al. Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma (CME). Transfusion

2011; 51:1925.

Important!

Uncrossmatched group O Rh D negative

RBCs /Whole blood

Residual plasma with both antibodies

(Anti A & B) can accumulate when large

quantities are transfused

Repeat the blood group and do antibody

titres before resuming transfusion of

RBCs of the patient's own blood group.


Fibrinogen concentrate


? European guidelines recommend fibrinogen concentrate when the

level falls below 1.5g

? Cost of fibrinogen concentrate is much more than cryoprecipitate

? Availability

Cryoprecipitate

? Most common blood product used to replace fibrinogen

? Contains approximately 200?250 mg of fibrinogen per unit

? Standard dose of two 5-unit pools should be administered early

in major obstetric haemorrhage.

? Subsequent cryoprecipitate transfusion should be guided by

fibrinogen results, aiming to keep levels above 1.5 g/l.
Platelet Transfusion

? It becomes necessary after two volumes of blood loss.
? 10 to 12 units of transfused RBCs- 50 percent fall in the

platelet count

? Platelet concentrates should be transfused as 1

pack/10 kg body weight.

Massive Transfusion Protocol

Regional West Medical Center

? Six units RBC's

Immediately prepare ? Four units FFP

first transfusion

? Deliver first "package" within 35 minutes of the initial

"package" :

order.

Have second "package" ? Six units RBC's

ready within 35

? Four units FFP

minutes of issue of first ? One Single Donor Platelet or one "six-pack" random

"package".

platelets

Have third "package" ? Six units RBC's

ready within 35

? Four units FFP

minutes of issue of

? One "ten-pack" pooled Cryoprecipitate

second "package."


Complications of Massive Transfusion

? Hypothermia

? Acid/base derangements

? Coagulopathy

? Citrate toxicity

? Electrolyte abnormalities

? hypocalcemia

? hypomagnesemia

? hypokalemia

? hyperkalemia

? Transfusion-associated acute lung injury


Acidosis and hypothermia

Acidosis

Interferes with formation of coagulation factor complexes

Hypothermia

Reduces enzymatic activity of coagulation factors
Prevents activation of platelets
Hypothermia

10 units of cold blood

products and an hour of

surgery can lead to a 3?C

drop in core temperature

and hypothermic

RBCs that are stored at 4C are transfused rapidly

coagulopathy

Lowers the recipient's core temperature and further

impairs haemostasis.

Reduces the metabolism of citrate and lactate
Increases the likelihood of hypocalcaemia, metabolic

acidosis and cardiac arrhythmias.

Shifts the oxyhaemoglobin dissociation curve to the left,

reducing tissue oxygen delivery

Prevention of hypothermia

? A high capacity commercial blood warmer should be used to warm

blood components


Coagulopathy

? Dilutional coagulopathy
? Disseminated intravascular coagulation.
? Consumption of platelets and coagulation factors

ALTERATIONS IN HEMOSTASIS

? Acute DIC

? microvascular oozing

? prolongation of the PT and aPTT in excess of that expected by dilution

? significant thrombocytopenia

? low fibrinogen levels

? increased levels of D-dimer


Hypocalcaemia

? Citrate binds calcium

? Results in hypotension, small pulse pressure, flat ST-segments and

prolonged QT intervals on the ECG.

? Slow i.v. injection of calcium gluconate 10%

Hyperkalaemia

? The potassium concentration of blood increases during storage, by as

much as 5?10 mmol u1 .

? Hyperkalaemia rarely occurs during massive transfusions unless the

patient is also hypothermic and acidotic
Monitoring recommendations

? PT, aPTT
? Platelet count
? Fibrinogen
? Electrolytes
? Viscoelastic test

? after the administration of every five to seven units of red cells.

Goals

Investigation

Target value

Haemoglobin

10 gm/dl

Hematocrit

32%

Platelet count

> 50 x 10 9 /l

PT

< 1.5 x control

PTT

< 1.5 x control

Fibrinogen

> 0.8 g/l


Viscoelastic whole-blood assays

? TEG? and ROTEM?
? provide information on the coagulation process through the graphic

display of clot initiation, propagation and lysis.

? used to guide transfusion of blood components


? Costeffective -since it reduces inappropriate transfusions, thus

improving transfusion management and patients' clinical outcome

Depletion of fibrinogen and coagulation

factors

? PT prolonged ? FFP in a dose of 15 ml/kg

? aPTT prolonged ? factor VI I/fibrinogen concentrate
Summary and recommendations

? Need to define protocol triggers , an algorithm for preparation and

delivery of blood products, including continued support

? The protocol should be updated annually and practised in `skills drills'

to inform and train relevant personnel.

This post was last modified on 08 April 2022