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