? Established to provide rapid blood replacement in a
setting of severe hemorrhage
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? Early optimal blood transfusion is essential to sustain
organ perfusion and oxygenation
What is Massive transfusion?
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10 units of red cel s in 24 hours
Total blood volume is replaced within 24 hours
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Three units over one hour50% of total blood volume is replaced within 3
hours
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Massive Transfusion-Clinical Settings
? Trauma
? Surgery (e.g. Liver, Cardiovascular)
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? Less frequent? abdominal aortic aneurysm
? liver transplant
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? obstetric catastrophes
? GI bleeding
? Cardiac surgery -- Most common cause of massive transfusion
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? Obstetric hemorrhage -- Gravid and parturient women arehypercoagulable with compensatory hyperfibrinolysis.
? Liver disease --
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? leads to the reduced production of normal coagulation factors
? production of abnormal factors
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Types of Shock? Cardiogenic ? MI, cardiomyopathy
? Obstructive ? Tamponade, PE
? Distributive ? Sepsis, Anaphylaxis
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? Hypovolemic ? Hemorrhage
Chal enges
? Types of components to be administered
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? Selection of the appropriate amounts? TIME
Blood Products
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? RBC
? Plasma
? Platelets
? Cryoprecipitate
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Emergency blood issue
Immediate
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Minutes
Within an hour
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Group O Rh negABO & Rh D type
ABO & Rh D type
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Packed RBCs
Group specific blood
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Complete crossmatchImmediate spin
(5-10 min)
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crossmatch
( 15-20) min)
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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
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? O, RhD neg/pos RBCs ? 5 min
? AB or A Plasma/Platelets
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Recommendations? "Damage control" approach
? Improved survival when the ratio of transfused Fresh Frozen Plasma
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(FFP, in units) to platelets (in units) to red blood cells (RBCs, in units)approaches 1:1:1
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Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing
the early coagulopathy of trauma. J Trauma 2007; 62:307.
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ImportantAt the onset - aggressive fluid replacement and bleeding control can
reduce the tissue injury, inflammation, and hypoperfusion
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Untimely or incomplete control of massive bleeding- systemic
consumptive coagulopathy with hemodilution and endothelial damage
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If uncorrected, concurrent hypothermia and acidosis can furtherexacerbate coagulopathy and lead to irreversible multiorgan failure
(MOF).
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Patients who have sustained severe traumatic
injuries and/or who are likely to require
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massive transfusion should receive a
1:1:1 ratio of FFP to platelets to RBCs at
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the outset of their resuscitation andtransfusion therapy
?
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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.
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?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.
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?
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.
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?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.
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?
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.
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?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.
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Important!
Uncrossmatched group O Rh D negative
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RBCs /Whole bloodResidual plasma with both antibodies
(Anti A & B) can accumulate when large
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quantities are transfused
Repeat the blood group and do antibody
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titres before resuming transfusion ofRBCs of the patient's own blood group.
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Fibrinogen concentrate? European guidelines recommend fibrinogen concentrate when the
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level falls below 1.5g? Cost of fibrinogen concentrate is much more than cryoprecipitate
? Availability
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Cryoprecipitate
? Most common blood product used to replace fibrinogen
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? Contains approximately 200?250 mg of fibrinogen per unit? Standard dose of two 5-unit pools should be administered early
in major obstetric haemorrhage.
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? Subsequent cryoprecipitate transfusion should be guided by
fibrinogen results, aiming to keep levels above 1.5 g/l.
Platelet Transfusion
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? It becomes necessary after two volumes of blood loss.
? 10 to 12 units of transfused RBCs- 50 percent fall in the
platelet count
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? Platelet concentrates should be transfused as 1
pack/10 kg body weight.
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Massive Transfusion ProtocolRegional West Medical Center
? Six units RBC's
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Immediately prepare ? Four units FFP
first transfusion
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? Deliver first "package" within 35 minutes of the initial"package" :
order.
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Have second "package" ? Six units RBC's
ready within 35
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? Four units FFPminutes of issue of first ? One Single Donor Platelet or one "six-pack" random
"package".
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platelets
Have third "package" ? Six units RBC's
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ready within 35? Four units FFP
minutes of issue of
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? One "ten-pack" pooled Cryoprecipitate
second "package."
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Complications of Massive Transfusion
? Hypothermia
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? Acid/base derangements? Coagulopathy
? Citrate toxicity
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? Electrolyte abnormalities
? hypocalcemia
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? hypomagnesemia? hypokalemia
? hyperkalemia
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? Transfusion-associated acute lung injury
Acidosis and hypothermia
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Acidosis
Interferes with formation of coagulation factor complexes
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HypothermiaReduces enzymatic activity of coagulation factors
Prevents activation of platelets
Hypothermia
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10 units of cold blood
products and an hour of
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surgery can lead to a 3?Cdrop in core temperature
and hypothermic
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RBCs that are stored at 4C are transfused rapidly
coagulopathy
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Lowers the recipient's core temperature and furtherimpairs haemostasis.
Reduces the metabolism of citrate and lactate
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Increases the likelihood of hypocalcaemia, metabolicacidosis and cardiac arrhythmias.
Shifts the oxyhaemoglobin dissociation curve to the left,
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reducing tissue oxygen delivery
Prevention of hypothermia
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? A high capacity commercial blood warmer should be used to warmblood components
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Coagulopathy? Dilutional coagulopathy
? Disseminated intravascular coagulation.
? Consumption of platelets and coagulation factors
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ALTERATIONS IN HEMOSTASIS
? Acute DIC
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? microvascular oozing? prolongation of the PT and aPTT in excess of that expected by dilution
? significant thrombocytopenia
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? low fibrinogen levels
? increased levels of D-dimer
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Hypocalcaemia
? Citrate binds calcium
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? Results in hypotension, small pulse pressure, flat ST-segments andprolonged QT intervals on the ECG.
? Slow i.v. injection of calcium gluconate 10%
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Hyperkalaemia
? The potassium concentration of blood increases during storage, by as
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much as 5?10 mmol u1 .? Hyperkalaemia rarely occurs during massive transfusions unless the
patient is also hypothermic and acidotic
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Monitoring recommendations? PT, aPTT
? Platelet count
? Fibrinogen
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? Electrolytes? Viscoelastic test
? after the administration of every five to seven units of red cells.
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GoalsInvestigation
Target value
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Haemoglobin
10 gm/dl
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Hematocrit32%
Platelet count
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> 50 x 10 9 /l
PT
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< 1.5 x controlPTT
< 1.5 x control
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Fibrinogen
> 0.8 g/l
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Viscoelastic whole-blood assays
? TEG? and ROTEM?
? provide information on the coagulation process through the graphic
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display of clot initiation, propagation and lysis.
? used to guide transfusion of blood components
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? Costeffective -since it reduces inappropriate transfusions, thus
improving transfusion management and patients' clinical outcome
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Depletion of fibrinogen and coagulationfactors
? PT prolonged ? FFP in a dose of 15 ml/kg
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? aPTT prolonged ? factor VI I/fibrinogen concentrate
Summary and recommendations
? Need to define protocol triggers , an algorithm for preparation and
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delivery of blood products, including continued support
? The protocol should be updated annually and practised in `skills drills'
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to inform and train relevant personnel.