Blood Transfusion in Burned Patients Haddadi MD Anesthesiology Department in GUMS 2014.

In the name of GOD Blood Transfusion in Burned Patients

Haddadi MD Anesthesiology Department in GUMS

2014

Need to transfusion is not a major concern during immediate resuscitation phase

During the acute resuscitation phase a fall in Hb (hemodilution, escharotomies , other invasive procedures )

In OR patients have major blood loss (excision , graft)

resuscitation phase

Surgical procedure Predicted blood loss

<24 h since burn injury 0.45ml/cm2 burn area

1-3 days since burn injury

0.65ml/cm2 burn area

2-16 days since burn injury

0.75ml/cm2 burn area

>16 days since burn injuryInfected wound

0.5-0.75ml/cm2 burn area1-1.25ml/cm2 burn area

Hct to drop to 15-20% prior to transfusion in other healthy patients with minor excision

Hct <25% in pre-existing Cardiovascular Disease

Hct near 25% in patients with more extensive burn

Hct near 30% in patients with pre-existing Cardiovascular Disease

Hb 6-6.5 gr/dl the lowest adverse metabolic or hemodynamic reactions

Evaluating the patient’s clinical status Assessment of ongoing blood loss , pre-

operative Hb level , vital sign Evidence of inadequate o2 delivery such as

hypotension, tachycardia ,acidosis Pulmonary ,cardiovascular D. ASA , Hb>10 - Hb<6 +

Need to blood transfusion

Factors Class I Class II Class III Class IVBlood loss (mL) 750 750-1500 1500-2000 2000 or more

Blood loss (% blood volume) 15 15-30 30-40 40 or more

Pulse (beats/min) 100 100 120 140 or higher

Blood pressure Normal Normal Decreased Decreased

Pulse pressure (mm Hg)

Normal or increased Decreased Decreased Decreased

Respirations per minute 14-20 20-30 30-40 35

Urine output (mL/hr) 30 20-30 5-10 Negligible

Central nervous system: mental status

Slightly anxious Mildly anxious Anxious, confused

Confused, lethargic

Fluid replacement (3-1 rule)

Crystalloid Crystalloid Crystalloid + blood

Crystalloid + blood

During excision of major burn wounds ,blood loss may reach to patient’s blood volume

Massive Hemorrhage Loss of 1 blood volume in 24 h 50% blood volume in 3 h Ongoing blood loss of 150 ml/min

Coagulation factors are lost Dilution as volume replacement Resulting coagulopathy Use of FFP in massive hemorrhage Recent clinical studies: early use of

FFP+PRBCs in replacement of massive hemorrhage

High blood loss:

Intravascular volume, with colloid( Alb,Hetastarch)

O2 carrying capacity with PRBCs until 50% of est Blood Volume

From this point ,FFP with PRBCs RBCs enhance homeostasis through effects

on platelet biochemistry and function

Exp. During burn surgery

Hypothermia Hypothermia can contribute to coagulopathy Blood warmers when flow rate of blood >100

ml/min Hypocalcemia (rapid flow rate,FFP, citrate) Hypocalcemia impairs coagulation interferes

with vascular ,myocardial contractility then, hypotension ( cacl2)

Ca Gluconate requires to hepatic metabolism

Massive Blood Transfusion

Use of tourniquets on limbs(limitations) Compression dressings at sites of excision Pharmacologic : epinephrine soaked dressings topical epinephrine sprayTachycardia, hypertension Systemic Terlipressin (vasopressin analog )

Reducing surgical blood loss

Whole blood Packed RBCs FFP Platelets Cryoprecipitate

Blood components

Contains all parts of blood After 24 h ,has not functional WBC ,Plt For burns, liver transplant, trauma,

hypovolemic shock

Whole blood

The most common means of replacing blood loss

50 ml residual plasma

Packed RBCs

1 7 14 21

PH 7.1 7 7 6.9

PCO2 48 80 110 140

K ( meq/l) 3.9 12 17 21

2,3 DPG 4.8 1.2 1 1

Viable PLT% 10 0 0 0

Factors 5,7 %

70 50 40 20

Days Of Storage At 4”c

Changes during storage in whole blood(CPD)

value Whole Blood Packed RBC

Volume(ml) 517 300

Erythrocyte mass(ml) 200 200

Hct % 40 70

Alb (gr) 12.5 4

Plasma K(meq) 15 4

Plasma acid 80 25

Plasma Na (meq) 45 15

Comparison of Whole Blood ,PRBCs

In burn injuries to replace clotting factors during massive transfusion

Clotting factors, Protein S,C In massive transfusion, if active bleeding

exists, coagulation factor deficiency approved

Fresh Frozen Plasma

Indications for FFP according to National Health Guidelines

Replacement of isolated factor deficiencies(lab evidence)

Reverse of warfarin effect

Antithrombine III deficiency

Treatment of immunodeficiencies

Treatment of TTP

Massive blood transfusion( V,VIII=25% of normal)

PT,PTT 1.5 times normal

Stored at room temperature to max viability Increasing bacterial contamination after 4

days Refrigerated PLT remain viable only 24-48h 5000-10,000PLT

Platelets

Thawing FFP at 4 c ,collecting cryoprecipitate

Rich in factors XIII, VIII, fibrinogen , Von Willebrand factor

Massive blood transfusion to treat hypo-fibrinogenemia

Plasma fibrinogen<100 mg/dl 1 unit cryoprecipitate will increase Plasma

fibrinogen by 5-7 mg/dl

Cryoprecipitate

Hemolytic Transfusion Reaction Delayed Hemolytic Transfusion Reaction

(Immune Extravascular Reaction) Nonhemolytic Transfusion Reactions

Transfusion-Related Fatalities in the United States, 2004-2006

Transfusion Reactions

Cause of Fatality 2004-06 Average per Year

TRALI 86 29Other reactions (non-ABO hemolytic therapy; anaphylaxis)

67 22

Bacterial contamination 20  7

ABO hemolytic transfusion therapy 15  5

Transfusion not ruled out 31 10

Hemolytic Transfusion Reaction

Sign or Symptom No. of Patients

Fever 19

Fever and chills 16

Chest pain  6

Hypotension  6

Nausea  2

Flushing  2

Dyspnea  2

Hemoglobinuria  1

-- Steps in the Treatment of a Hemolytic Transfusion Reaction  

   1.  STOP TRANSFUSION.    2.    Maintain the urine output at a 75 to 100 mL/hr    a.    Generously administer fluids intravenously and possibly mannitol (12.5 to 50 g, given over 5 to 15 minutes).    b.    If intravenously administered fluids and mannitol are ineffective, administer furosemide (20 to 40 mg) intravenously.    3.    Alkalinize the urine; because bicarbonate is preferentially excreted in the urine, only 40 to 70 mEq of sodium bicarbonate per 70 kg of body weight is usually required to raise the urine pH to 8, whereupon repeat urine pH determinations indicate the need for additional bicarbonate.    4.    Assay urine and plasma hemoglobin concentrations.    5.    Determine platelet count, partial thromboplastin time, and serum fibrinogen level.    6.    Return unused blood to blood bank for repeat crossmatch.    7.    Send patient's blood and urine sample to blood bank for examination.    8.    Prevent hypotension to ensure adequate renal blood flow.

the transfused donor cells may survive well initially

after a variable delay (2 to 21 days) they are hemolyzed

This type of reaction occurs mainly in recipients sensitized to RBC antigens by previous blood transfusions or pregnancy

RBC destruction occurs only when the level of antibody is increased after a secondary stimulus (i.e., anamnestic response)

a decrease in the post-transfusion hematocrit value

Delayed Hemolytic Transfusion Reaction (Immune Extravascular Reaction)

Nonhemolytic reactions to blood transfusions usually are not serious and are febrile or allergic in nature.

The most common adverse reactions to blood transfusions consist of chills, fever, headache, myalgia, nausea, and nonproductive cough occurring shortly after blood transfusion caused by pyrogenic cytokines and intracellular contents released by donor leukocytes.

Allergic reactions can be minor, anaphylactoid, or anaphylactic

The most common symptom is urticaria associated with itching. Occasionally, the patient has facial swelling.

Nonhemolytic Transfusion Reactions

 Percentage Risk of Transfusion-Transmitted Infection with a Unit of Screened Blood in the United States

Infection Risk Window Period (days)

Infectivity of Blood

Infection RiskWindow Period (days)

Human immunodeficiency virus-1

1/2,135,000 11

Human T-lymphotropic virus (HTLV-II)

1/2,993,000 51

Cytomegalovirus (CMV)

Infrequent with leukocyte-reduced components  

Hepatitis C virus (HCV) 1/1,935,000 40

Hepatitis B virus (HBV) 1/205,000  

West Nile virus (WNV) 1/1,100,000 ?