Massive Blood Transfusion When, What to Care & Alternatives

S Bhanumurthy

Contents:
Introduction : Definition Patho-physiology When : Types of Situations Implications What to care: Management Alternatives : Autologous Blood HB solution

Introduction

Definition
Massive Blood Transfusion: Replacement equivalent to pt bl. Volume in 24 hours Or the Bl vol in 3 hours UK military: Transfusion of 4u RCC in 1hr Or 10u of RCC in 24 hours

Introduction

Patho-Physiology
Trauma & Ops.: Third Space Fluid Loss & Blood loss Leading to: Decreased perfusion Hypotension & Shock Tissue hypoxia Resulting in: Met. Abnormalities Multi- System failure

When

Situations
Expected: i) Specific : Liver Transplant Open Heart Surgery ii) Non Specific: Any major Surgery associated with massive blood loss Unexpected: i) In hospital: Post Op bleed ii) Out of hospital: Trauma, Blast injury

When

Implications
Expected
Pt. Prepared Elective & Planned Social hours & good Communication Organised Theatre available Senior Team Blood products ready Monitor & Freq Invest. Adeq. Warming devices Early slow IV warm transfusion ITU & Post Op care Ahead in the game

Unexpected
Moribund, not prepared Emerg. & Aggressive Often in out of hours so poor communication Organised theatre? Often junior doctors Bl. Products may not ready Monitor&Invest. inadequate Warming device usage? Often IV fluids late & Rapid ITU/HDU care may not Chasing the numbers

What to care for

Factors involved in Management
Stop further blood loss Manage hypovolemia Maintain Oxygenation Prevent/ treat coagulopathy Prevent/ treat hypothermia Judicious monitoring & freq. Invest. Watch and correct electrolyte Imbalance Consider alternatives

What to care for

Decreasing the Bl. Loss

Trauma: C before ABC Emergency Bandage, CAT Indirect pressure Quikclot, Hemcon Prevent Hypothermia In OT: Surgical measures Anaesthetic measures Avoid hypothermia Prevent/treat coagulopathy Drugs

What to care for

Field Bandage & Tourniquet

What to care for

HemCon Bandage Made its debut in the 2003 Iraq war

has positively charged chitosan, extracted from shrimp shells. Attracts negatively charged red blood cells and create a tight-fitting plug over the wound. "You can have a hole in your heart and 60 seconds later it's sealed," says inventor Kenton Gregory.

What to care for

QuikClot Granulated mineral, non-biological So minimal or no allergic reaction Rapid absorption of fluidconc. of clot. Factors & Haemostasis Stops moderate to severe bleeding by rapid coagulation Painless

What to care for

Drugs
Desmopressin: Mild Hemophilia, Uremia Defective platelets, Ch. Liver disease Antifibrinolytics: Aprotonin, Tranexemic acid, Aminocaprioic Acid in CPB, transplants, ortho & vascular surgeries Other specific: Protamine

What to care for

Hypovolemia
More dangerous than hypoxemia, So early treatment is essential Two Big bore IV cannulae, Rapid Infuser Consider Main.& Third space losses as

well
Crystalloids Vs Colloids, Combination is better Hypotension may be due to other causes

What to care for

Maintenance of Oxygenation
Increase FiO2 Replace the Volume RCC transfusion If Hb% <6gm : Must If Hb% >10g : No Based on time available O neg/positive Gr. Spec. Uncross/Cross Matched RCC Use Warming device

What to care for

Prevent/treat coagulopathy
Causes: Dilutional Hypothermia Pre-op patient status DIC Surgical: CPB, Transplants Transfusion Reactions

What to care for

Prevent/ treat coagulopathy

Prevent hypothermia Observe intra-Op bleed Frequent investigations Liaise with Haematologist If APTT & PT >1.5 treat with FFP/CPP Empirical Tt: RCC:FFP= 1:1

DIC? : Additional measures may be needed

What to care for

Recombinant Factor VIIa

Licensed to treat Hemophilia Other Indication: Salvageable pt. with Uncontrolled bleed despite surgical/ Non surgical methods Correct Acidosis and Hypothermia Consider after 6-8u of PRBC, if bleeding continues Dose: 100ug kg-1 if needed another in 20-30min. Contraindication: In last 6 months Thrombo-embolic events

What to care for

Thrombocytopenia
Critical level: 50x109/L Trigger level: 75x109/L In CNS & major trauma etc aim for 100X109/l Dont use the same bl. Giving set

What to care for

Monitor, Investigate, Coms/Records

Dedicated Coordinator Monitoring: Vital Signs, SpO2, Dir. Art. BP CVP, Temp., Urine Output & Fluid balance, blood loss Investigate: Frequent FBC, U&E, Ca++ Clotting Screen, Bl.gases

What to care for

Electrolyte Imbalance
Lactates, Citrates & Acidosis Hyperkalaemia Hypocalcaemia: Ca++, Albumin levels Freq investigations & Correction

Alternatives

Autologous blood
Pre-op blood donations/intra-op admin Blood Salvage: Replaces only RBC Limitations: Needs trained & Dedicated personnel Equipment & Disposables PO drained Blood: Anticoagulants++

Alternatives

Oxygen Carrying solutions

Hb. Solution: 3 types in Phase iii trials Long shelf life, No Cross match/infection Problems: With earlier versions Renal failure, Hypertension With recent versions Trans-capillary leak Increased O2 affinity

Key Learning Points

Expected and Unexpected massive transfusions are different Prompt and aggressive management is needed in unexpected group New agents: Hemcon, Quickclot Volume replacement is vital Prevent Hypothermia & Coagulopathy Needs multidisciplinary consultant input & Coordination Communication & record keeping are imp. Alternatives are not yet fully alternative

Thank You

Bad Prognostic Indicators at admission

INR>1.5 Base Deficit>6 Temp: 350C or less Sys BP<90mmHg HB<11gm/dl Abnormal Mental status Severe Injury

Complications in Summary
Haemolytic reactions: Early& Delayed Transfusion Transmitted Infections Transfusion Related Acute Lung Injury Hypothermia, Hyperkalaemia Hypocalcaemia, Hypomagnaesemia Acidosis and Coagulopathy