MASSIVE TRANSFUSION

OB ROUNDS, JAN 23 2008

RECOMMENDATIONS FOR MASSIVE TRANSFUSION

Assuming:

• Previously healthy 70 kg adult

• No cardiac disease

• Not anaemic

• Not anticoagulated

Basics

Multiple large IVs (?Central Line)

Urinary catheter

Keep as warm as possible

Bloodwork – CBC, U&E, Creat, PT/PTT/INR (ABG and Lactate if in shock)

Cross match 6 units

First 1 – 2 litres of blood loss:

• Crystalloids 3:1 or Colloids (Voluven, Pentaspan) 1:1

• Transfuse RBC if Hb <70 if stable, <100 if acutely bleeding, higher if CAD

• If Hb starts at 150, it will be 100 after 1,700 mls lost and 70 after 2,700 mls

• Use HemoQ for rapid bedside Hb estimation• Get ready to transfuse by 1l lost, transfuse

before 2l lost in most cases

Maximum Allowable Blood Loss

MABL before transfusion=

(Hbi - Hbt)/Hbi x 72 x Wt

Hbi= Initial Hb (e.g.110)

Hbt= Transfusion trigger Hb (e.g 70)

Wt= Weight (e.g. 55kg)

MABL=(110-70)/110 x 72 x 55 = 1,440 mls

FFP• Indications: INR >1.5, or loss of 1 –

1.5 CBV (5 – 7.5 litres)

• Controversial – In Iraq war trauma FFP started with blood, 1:1

• Need ~30% normal level of clotting factors.

• Give 10 – 15 ml/kg, roughly 3 – 4 units

Platelets

• Indications: Pl < 50 (or <75 and bleeding, or <100 and head trauma)

• Expect to need platelets after 2 x CBV or 10 litres

• Order early as take time (~ 2hr) to arrive

• Give 5 units (one pool) or one apherisis unit

Other treatments

?Consult haematology, ICU

• Cryoprecipitate:

If Fibrinogen < 1g/l, give 1 unit per 10 kg or 8-10 units – (large donor pool)

• rVIIa: Consider if has had over 8 units and still bleeding

Metabolic Issues

• CaCl2 (better than gluconate, which needs metabolizing) 10 ml 10 %

• Check for – Acidosis (base deficit), – Hyperkalaemia– Lactate

Endpoints (Sunnybrook):

• HR<120,

• BP>90

• UO >15ml/hr

Risks of Transfusion #1

ALLERGY– Rash, urticaria 1:50 – 1:100– Febrile reaction, minor allergy 1:100 – 1:500– Anaphylaxis 1:25,000

FLUID OVERLOAD 1:700TRALI 1:1,500 -1:5,000 HAEMOLYSIS

– Delayed reaction 1:7,000– Acute (incompatible blood) 1:40,000

(1:700,000 die)

Risks of Transfusion #2 - INFECTIONS

Bacterial Platelets 1:2,500 per pool (1:40,000 die)

Blood 1:100,000 per unit (1:1m die)

ViralHep B 1:30,000 – 1:80,000

Hep A 1:2mHTLV 1:2-3mHep C 1:3mHIV/AIDS 1:5mWest Nile ?

OtherPrions ???

Parasites 1:4m

• COMMENTS ?

• QUESTIONS ?