Massive Blood Transfusion by Dr.bhanumurthy

8/6/2019 Massive Blood Transfusion by Dr.bhanumurthy

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Massive Blood TransfusionMassive Blood Transfusion

When, What to Care & AlternativesWhen, What to Care & Alternatives

S BhanumurthyS Bhanumurthy



Contents:

� Introduction : Definition

Patho-physiology

� When : Types of SituationsImplications

� What to care: Management

� Alternatives : Autologous Blood

HB solution



Definition

Massive Blood Transfusion:

Replacement equivalent to

pt bl. Volume in 24 hours

Or ½ 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. AbnormalitiesMulti- System failure

Introduction



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 Unexpected

� 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 warmtransfusion

� ITU & Post Op care

Ahead in the game

� 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

When



What to care for Factors involved in Management

Stop further blood loss

Manage hypovolemia

Maintain Oxygenation

Prevent/ treat coagulopathyPrevent/ treat hypothermia

Judicious monitoring & freq. Invest.

Watch and correct electrolyte

ImbalanceConsider alternatives



Decreasing the Bl. Loss

� Trauma: C before ABC

Emergency Bandage, CAT

Indirect pressure

Quikclot, HemconPrevent Hypothermia

� In OT: Surgical measures

Anaesthetic measures

Avoid hypothermiaPrevent/treat coagulopathy

Drugs

What to care for



Field Bandage & Tourniquet

What to care for



has positively charged chitosan, extracted f rom shrimp shells.

Attracts negatively charged red blood cells and

create a tight-f itting plug over the wound.

"You can have a hole in your heart and 60 secondslater it's sealed," says inventor Kenton Gregory.

What to care for

HemCon

Bandage

Made its

debut in the

2003 Iraq war



QuikClot

Granulated mineral, non-biological

So minimal or no allergic reaction

Rapid absorption of fluid-µµconc. 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 : MustIf 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 HypothermiaConsider 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

� Don¶t use the same bl. Giving set

What to care for



Monitor, Investigate, Coms/Records

� Dedicated Coordinator

� Monitoring: Vital Signs, SpO2, Dir. Art. BPCVP, 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

What to care for



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 versionsTrans-capillary leak

Increased O2 affinity

Alternatives



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 & Co-

ordination

� 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

Massive Blood Transfusion by Dr.bhanumurthy

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