1. Dr. RAFIQ AHMAD Massive Transfusion 2. Definition It is most commonly defined as replacing 1 blood volume or more within 24 hours One blood volume corresponds to 70 mL/Kg of a typical adults body weight (15 units of blood for a 70 Kg patient; however many facilities estimate 10 units as 1 blood volume). Half of the patients blood volume is replaced within 3 hours. More than 4 red cell units transfused within 4 hours with continuous bleeding. 3. Other Conditions More than 10 units of red cells transfused within 24 hours, or from the time of admission in ER to ICU transfer. More than 20 units of red cells transfused during the entire course of admission Blood loss is more than 150mL/min. In children, it is defined as transfusion of >40 mL/kg (blood volume over 1 month old is approximately 80 mL/kg). 4. Morbidity/Mortality The overall mortality of patients requiring massive transfusion is 40%. In patients who develop hemostatic disorders , the mortality rate is > 75%. Other prognostic indicators include underlying conditions such as cirrhosis, cardiopulmonary or cerebrovascular disease, advanced age, and prolonged hypertension Massive transfusion can have numerous deleterious effects on the body 5. Morbidity and mortality due to massive transfusion is a direct result of concomitant metabolic disturbances. They include dilution coagulopathies, hypothermia, and tissue hypoxia causing tissue damage and acidosis. The abilities to recognize and treat these adverse conditions associated with massive transfusion can minimize morbidity. 6. Complications of Massive Transfusion Hemodilution from crystaloid fluid resuscitation Lethal Triad Hypothermia Acidosis Coagulapathy 7. Red cell storage Lesions 8. Altered Parameters in stored RBCs Characteristic Pre-storage Post-storage pH 6.8 6.4 ATP (mol/g Hb) 4.1 2.9 DPG (mol /g Hb) 9.0 0.3 Potassium (mEq/L) 2.4 63 Glucose (mg/dl) 608 402 Plasma Hb (mg/dl) 39 372 Hemolysis (%) -- 0.61 9. Pre &Post transfusion Effects 10. Additional Complications Citrate Toxicity Potassium abnormalities Air embolism 11. Management of Massive Transfusion Massive Transfusion Protocol (MTP) 2 Models >Laboratory-driven (Pull) MTP: >Formula-driven (Push) MTP: 12. Laboratory-driven (Pull) MTP: Measuring Coagulation Thromboelastography (TEG) 13. TEG interpretation 14. Rotational Thromboelastometry (ROTEM) 15. Variables measured by the TEG and ROTEM Variable TEG ROTEM Measurement period - Reaction Time [RT] Time from start to when the waveform reaches 2mm above baseline R Clotting Time [CT] The time from 2mm above baseline to 20mm above baseline K Clot Formation Time [CFT] Alpha angle [] [slope between R and K] [angle of tangent at 2mm amplitude] Maximum angle - CRF Maximum strength Maximal Amplitude [MA] Maximal Clot Firmness [MCF] Time to Maximum strength - MCF-t Amplitude at a specific time A30, A60 A5, A10... Clot elasticity G MCE Maximum lysis - CLF Clot Lysis[CL] at a specific time [minutes] CL30, CL60 LY30, LY45, LY60 Time to lysis 2mm from MA CLT [10% difference from MCF] 16. New Research Products Whole Blood Transfusion Walking blood bank program Freeze-dried plasma Developed freeze-dried plasma- HemCon Medical Technologies Stem-cell derieved red blood cells 17. The end!! Thank you