MASSIVE OR LARGE

VOLUME BLOOD

TRANSFUSION

DR. AASHISH SHAH

NEPAL MEDICAL COLLEGE

Massive transfusion or large volumetransfusion is defined as the replacement ofblood loss equivalent to or greater than thepatient’s total blood volume in less than 24hours:

70 mL/kg in adults

80-90 mL/kg in children or infants.

Morbidity and mortality tend to be high amongsuch patients,not because of the large volumesinfused,but because of the initial trauma andthe tissue and organ damage secondary tohaemorrhage and hypovolaemia.

It is often the underlying cause and

consequenses of major haemorrhage,that

result in complications,rather than the

transfusion itself.

However administering large volumes of

blood and intravenous fluids may itself give rise

to the following complications:

Acidosis

Hyperkalaemia

Citrate toxicity and hypocalcaemia

Depletion of fibrinogen and coagulation factors

Depletion of platelets

Disseminated intravascular coagulation(DIC)

Hypothermia

Microaggregates

Acidosis

Acidosis in a patient receiving a large volumetransfusion is more likely to be the result ofinadequate treatment of hypovolaemia than dueto the effects of transfusion.

Under normal circumstances, the body caneasily neutralise this acid load from transfusion.

The routine use of Bicarbonate or otheralkalizing agents, based on the number of unitstransfused,is unnecessary.

Hyperkalaemia

The storage of blood will result in a small

increase in extracellular potassium

concentration,which will increase the longer it is

stored.

This rise is rarely of clinical significance other

than in neonatal exchange transfusions.

The freshest blood available in the blood bank

and which is less than 7 days old should be used.

Citrate toxicity and hypocalcaemia

Citrate toxicity is rare but is most likely to occur during the course of a large volume transfusion of whole blood.

Hypocalcaemia, particularly in combination with hypothermia and acidosis can cause a reduction in cardiac output,bradycardia and other disrhythmias.

Citrate is usually rapidly metabolised to bicarbonate.

It is therefore unnecessary to attempt to neutralise the acid load of transfusion.

There is very little citrate in Red Cell concentrates and Red Cell suspension.

DEPLETION OF FIBRINOGEN AND COAGULATION

FACTORS

Plasma undergoes progressive loss of coagulation factors during storage,particularly factors V and VIII,unless stored at -25 degree celsius or colder.

Red cell concentrates and plasma reduced units lack coagulation factors which are found in the plasma component.

Dilution of coagulation factors and platelets will occur following administration of large volumes of replacement fluids.

Massive or large volume transfusions can result in disorders of coagulation.

MANAGEMENT

If there is prolongation of the prothrombintime(PT), give ABO-compatible Fresh Frozen Plasma in a dose of 15mL/kg.

If the Activated Partial ThromboplastinTime(APTT) is also prolonged, factor VIII/fibrinogen concentrates is recommended in addition to the FFP.If none is available,give 10-15 units of ABO compatible cryoprecipitates, which contains factorVIII and fibrinogen.

DEPLETION OF PLATELETS

Platelet function is rapidly lost during the

storage of whole blood and there is virtually no

platelet function after 24 hrs

MANAGEMENT

Give platelet concentrates only when :

1)the patient shows the clinical signs of microvascular bleeding: i.e. bleeding and oozing from mucus membranes,wounds,raw surfaces and catheter sites.

2)the patient’s platelet counts falls below 50 x 10 9/L

Give sufficient platelet concentrates to stop the microvascularbleeding and to maintain an adequate platelet count.

Consider platelet transfusion in cases where the platelet count falls below 20 x10 9 /L,even if there is no clinical evidence of bleeding because there is a danger of hidden bleeding such as into the brain tissue.

The prophylactic use of platelet concentrates in patients receiving large volume blood transfusions is not recommended.

DISSEMINATED INTRAVASCULAR

COAGULATION(DIC)

DIC is the abnormal activation of the coagulation and fibrinolytic systems,resulting in the consumption of coagulation factors and platelets.

DIC may develop during the course of massive blood transfusion,although its cause is less likely to be due to the transfusion itself than related to the underlying reasons for transfusion,such as:

Hypovolaemic shock

Trauma

Obstetric complications

MANAGEMENT

Treatment of DIC should be directed at

correcting the underlying cause and at

correction of the coagulation problems as they

arise.

HYPOTHERMIA

The rapid administration of large volumes of blood or replacement fluids directly from the refrigerator can result in a significant reduction in body temperature.

Management

If there is evidence of hypothermia,careshould be taken during large volume infusions of blood or intravenous fluids.

MICROAGGREGATES

White cells and platelets can aggregate together in stored whole blood,forming microaggregates.

During transfusion, particularly a massive transfusion,these microaggregates embolize to the lung and their presence there has been implicated in the development of Adult Respiratory Distress Syndrome(ARDS).

However, ARDS following transfusion is most likely to be primarily caused by tissue damage from hypovolaemic shock.

MANAGEMENT

1. Filters are available to remove microaggregates,

but there is little evidence that their use prevents

this syndrome.

2. The use of buffy coat-depleted packed red cells

will decrease the likelihood of ARDS.

ADVERSE EFFECTS OF BLOOD TRANSFUSION

Acute transfusion reactions occur during

or shortly after(within 24 hrs) the transfusion.

INITIAL MANAGEMENT AND INVESTIGATIONS

When an acute reaction first occurs,it may be

difficult to decide on its type and severity as the

signs and symptoms may not initially be

specific or diagnostic.However,with the

exception of allergic urticarial and febrile non-

haemolytic reactions, all are potentially fatal

and require urgent treatment.

If an acute transfusion reaction occurs,first check the blood pack labels and the patient’s identity.Ifthere is any discrepancy, stop the transfusion immediately and consult the blood bank.

In order to rule out any possible identification errors in the clinical area or blood bank,stop all transfusions in the same ward or operating room until they have been carefully checked.In addition, request the blood bank to stop issuing any blood for transfusion until the cause of the reaction has been fully investigated and to check whether any other patient is receiving transfusion, especially in the same ward or operating room, or at the same time.

GUIDELINES FOR THE RECOGNITION AND

MANAGEMENT OF ACUTE TRANSFUSION

REACTIONS

CATEGORY

1:MILD

REACTIONS

SIGNS

Localized

cutaneous

reactions:-

urticaria,rash

SYMPTOMS

Pruritis(itching)

POSSIBLE CAUSE

Hypersensitivity

(mild)

CATEGORY 2:MODERATELY SEVERE

REACTIONS

SIGNS:

Flushing

Urticaria

Rigors

Fever

Restlessness

Tachycardia

SYMPTOMS:

Anxiety

Pruritis

Palpitations

Mild dyspnoea

Headache

POSSIBLE CAUSE:

Hypersensitivity(moderat

e-severe)

Febrile non-haemolytic

transfusion reactions:

-Antibodies to

WBCs,platelets

-Antibodies to

proteins,including IgA

Possible contamination

with pyrogens and/or

bacteria

MANAGEMENT

Management of CATEGORY 1:

1)Slow the transfusion

2)Administer antihistamine IM(e.g.chlorpheniramine 0.1mg/kg or equivalent)

3)If no clinical improvement within 30 minutes, or if sign and symptons worsen,treat as category 2.

Management of CATEGORY 2

1. Stop the transfusion.Replace the the infusion set and keep IV line open with Normal saline.

2. Doctors should be notified who are responsible for the patient and blood bank immediately.

3. Send blood unit with Infusion set,freshly collected urine and new blood samples(1 clotted and 1 anticoagulated) from vein opposite to infusion site with appropriate request form to blood bank for laboratory information.

4. Administer antihistamine IM and oral or rectal antipyretic(e.g., Paracetamol 10mg/kg:500mg-1gm in adults).Avoid Aspirin in thrombocytic patients.

5. Give IV corticosteroids and bronchodilators if there areanaphylactoid features(e.g.,bronchospasm,stridor)

6. Collect urine for next 24hrs for evidence of

haemolysis and send to laboratory.

7. If there is clinical improvement,restart transfusion

slowly with new blood unit and observe carefully.

8. If there is no clinical improvement within

15minutes or if sign and symptoms worsen,treat

as category 3.

CATEGORY 3:LIFE-THREATENING REACTIONS

SIGNS

Rigors

Fever

Restlessness

Hypotention(fall of 20%

in systolic BP)

Tachycardia(rise of 20%

inheart rate)

Hemoglobinuria(red

urine)

Unexplained

bleeding(DIC)

SYMPTOMS

Anxiety

Chest pain

Pain near infusion site

Respiratory

distress/shortness of

breath

Loin/back pain

Headache

Dyspnoea

POSSIBLE CAUSES

Acute intravascular

hemolysis

Bacterial contamination

and septic shock

Fluid overload

Anaphylaxis

Transfusion- associated

acute lung injury(TRALI)

MANAGEMENT OF CATEGORY 3:LIFE

THREATENING REACTIONS

1. Stop the transfusion. Replace the infusion set and keep IV line open with

normal saline.

2. Infuse normal saline(initially 20-30 mL/kg) to maintain systolic BP.If

hypotensive,give over 5 minutes and elevate patients leg.

3. Maintain airway and give high flow oxygen by mask.

4. Give adrenaline(as 1:1000 solution)0.01mg/kg body weight by slow

intramuscular injection).

5. Give IV corticosteroids and bronchodilators if there are

anaphylactoidfeatures like bronchospasm and stridor.

6. Notify the doctor responsible for patientnand blood bank immediately.

7. give diuretic e.g.,frusemide 1mg/kg IV or equivalent

8. Send blood unit wth infusion set,fresh urine sample and new blood

samples(1 clotted and 1 anticoagulated)from vein opposite infusion site

with appropriate request form to blood bank for investigations.

9.Check fresh urine specimen visually for signs of haemoglobinuria.

10.Start a 24 hr urine collection and fluid balance chart and record all intake and

output.Maintain fluid balance

11.Assess for bleeding from puncture sites or wounds.If there is clinical or

laboratory evidence of DIC,give platelets(adults=5-6 units) and either

cryoprecipitates(adult-12units) or fresh frozen plasma(adults-3 units).

12.Reassess-if hypotensive

-give further saline 20-30mL/kg over 5 mins.

-give ionotrope if avalaible

13.If urine output falling or lab.evidence of acute renal failure(rising

K+,urea,creatinine):

-maintain fluid balance accurately

-give frusemide further

-consider dopamin infusion,if available

-seek expert help:the patient may need renal dialysis

14.If bacteremia is suspected(rigors,fever,collapse,no evidence of a haemolytic

reaction,start broad spectrum antibiotics.

REFERENCES

• WHO Handbook on ‘THE CLINICAL USE OF BLOOD’ – 2007

•DAVIDSON’S PRINCIPLE & PRACTICE OF MEDICINE – 21ST

EDITION

•BAILEY & LOVE’S – SHORT PRACTICE OF SURGERY - 2010