Massive Blood Transfusion

Massive Blood TransfusionMassive Blood Transfusion

Definition, IndicationsDefinition, IndicationsComplicationsComplications

Dr. Maha AL-MadiDr. Maha AL-MadiUrology ResidentUrology Resident

- Massive Blood Transfusion Defined- Massive Blood Transfusion Defined- Indications of Blood TransfusionIndications of Blood Transfusion- Clinical Practice Guidelines of Blood Clinical Practice Guidelines of Blood TransfusionTransfusion- Complications of Blood TransfusionComplications of Blood Transfusion- Alternatives to Blood TransfusionAlternatives to Blood Transfusion

ObjectivesObjectives

Definition of MBT…Definition of MBT…

Massive BT is loosely defined as the transfusion of more than 10 units of PRBCs in a 24-hour period. (ARCH SURG/VOL 143 (NO. 7), JULY 2008)

Massive BT , defined as the replacement of more than 50 % of a patient's blood volume in 12 to 24 hours, (Massive blood transfusion by Steven Kleinman, MD up to date article Sept. 2009)

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Massive BT is defined as a volume equivalent or exceeding the patients own volume transfused within a 12 hour period ( Clinical Surgery ,A.Cuscheieri, 2nd ed)

Massive transfusion implies a single transfusion greater than 2500 mL or 5000 mL transfused over a period of 24 hours (Schwartz’s Principles of Surgery, 8th ed)


Massive transfusion is defined as replacement of the patient's blood volume with packed RBCs in 24 hours or transfusion of more than 10 units of blood over a period of a few hours (Sabiston Textbook of surgery, 8th ed.)

General Indications …General Indications …

• In Hemorrhagic shockHemorrhagic shock and ongoing hemorrhage and anemiaanemia (to increase oxygen carrying capacity)

• In hemorrhage, the goal of transfusion is restoration of the oxygen-carrying capacity and NOT restoration to a specific hemoglobin level.

General Indications ……General Indications ……

• Anemia in critical illness is a distinct clinical entity resulting from:1) excessive phlebotomy for labs2) active hemorrhage3) reduced erythropoiesis

Most BT in ICU patients is used for treatment of anemia.

General Indications ……General Indications ……

• 40-50% of ICU patients receive at least 1, and on average close to 5 units of RBCs

• Transfusion is not risk free and there is little evidence that routine BT is beneficial to hemodynamically stable critically ill patients*

* Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med 2009 vol.37 No.12

General Indications …General Indications …Perioperative Transfusion• Several factors are involved in the decision to

transfuse a patient before surgery• Are generally not recommended when the

hemoglobin is ≥10 g/dL should be given when less than 7 g/dL *

• No specific hematocrit is an indication for preoperative transfusion in a stable patient

* Indications for red cell transfusion in the adult, by Steven Kleinman, MDAddison K May, MD, Sept 2009 uptodate article.

Indication for MBT …Indication for MBT …

• There is no clear indication for MBTMBT in any case

• The decision to transfuse in poly trauma or other critical cases is based on - the physiological state of the patient,- evidence of amount of blood loss - potential for ongoing hemorrhage

General Indications …General Indications …

No single criterion should be used as an indication for RBC transfusion and that multiple factors related to the patient's clinical status and oxygen delivery needs should be considered*


Clinical Practice Guidelines and Clinical Practice Guidelines and RecommendationsRecommendations


Clinical practice guidelines..Clinical practice guidelines..


Clinical practice guidelines..…Clinical practice guidelines..…



Benefits of BTBenefits of BT

• Increase DO2 tissues, but no evidence of increased oxygen consumption

• Increase cell mass post acute hemorrhage or blood loss;

• Alleviate symptoms of anemia

Complications of BT…Complications of BT…• Donated blood is collected and separated

into various components. CPD-A 1 added to whole blood can be stored for up to 42 days.

• Storage changesStorage changes- Leakage of intracellular K- Reduced levels 2,3-DPG- Degeneration of functional granulocytes and platelets- Deterioration of clotting factors V and VIII- Ammonia concentration rises- Decrease in pH- Decrease in RBC deformability and viability

Complications of BT…Complications of BT…

Transfusion Rxns Infective Massive BT

Acute non-hemolytic rxns

Hemolytic rxns

TRALI

GVHD

1.Hypersensitivity rxn2.Febrile non hemolytic

1. Acute immune hemolysis2. Delayed hemolysis


Transfusion Rxns

Infective

Massive BT

VIRALCMV (1:10 to 1:30) EBV (1:200)HBV ( 1 : 50,000)HCV (1 :3000-4000)HIV ( 1: 150,000)HTLV-I/ II(1:250,000 to 1:2 mill

PARASITICMalaria, (1:4 mill)

BACTERIAL1:200,000 to 1:4.8 millYersinia Serratia , Pseudomonas Enterobacter


Transfusion Rxns Infective

Massive BT

Transfusion ReactionsTransfusion Reactions

Acute Non hemolytic reactionsAcute Non hemolytic reactionsHypersensitivity reaction

• The most common.• A reaction to plasma proteins in blood

resulting in the release of vasoactive peptides and activation of complement.

• It may be a mild and rarely sever ( anaphylaxis 1 in 20,000 units)


Acute Non hemolytic reactionsAcute Non hemolytic reactionsFebrile non-hemolytic reaction• in 3-4% of all transfusions• development of high fever during or within

24 hours of a transfusion• Theories:- alloimmunization to leukocyte or platelet

antigens- formation of cytokines during storage • Self limiting


Hemolytic reactionsHemolytic reactionsAcute immune hemolytic reaction

• The most serious transfusion reaction • Occurs in 1 in 40,000 transfused units. • Recipient’s antibodies to ABO antigens

result in a rapid intravascularintravascular hemolysis of donor RBCs mediated by activation of complement.


Hemolytic reactionsHemolytic reactionsDelayed hemolytic reaction• Results from an anamnestic Ab response to

donor Rh or non-ABO antigens causing an extravascularextravascular hemolytic reaction

• Transfused blood cells take days or weeks to hemolyze and typically there are few signs or symptoms other than falling RBC count and elevated bilirubin.

Transfusion ReactionsTransfusion ReactionsTransfusion related acute lung injury (TRALI)

• Occurs in 1 in 5000 units transfused• Its is a clinical syndrome with acute hypoxemia and

non-cardiogenic pulmonary edema.• Usually occurs within 1 to 2 hours of transfusion

(anytime up to 6 hours later). • Theories:

- Donor blood containing anti-leukocyte Ab.- Mediators of inflammation form in stored

blood


• Patient develops fever, SOB, cough and hypoxemia. CXR shows the picture of ARDS with perihilar infiltrates.

• Support can vary from supplemental oxygen to intubation and ventilation. Most cases resolve on their own but some can be fatal.


Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med 2009 vol.37 No.12


GVHDGVHD

• Rare (0.15% incidence) but usually fatal complication

• Donor T lymphocytes mount an immune response against the recipient's lymphoid tissue.

- When the recipient is immunocompromised or donor is homozygous and the recipient is heterozygous for HLA, normal defense mechanisms fail.

• Mortality rate 80%, preventable by irradiation of blood.


Role of leukoreduction

• Reduces the number of transfused WBCs. • Leukoreduction is effective in reducing the

transmission of cell-associated viruses (eg, CMV, EBV) and post operative infections.


Role of leukoreduction

• But studies showed no significant effect on mortality, febrile episodes or MOF *

• Some studies have suggested it has further reduced the already low risk of transfusion related GVHD


Complications of MBTComplications of MBTA) Alteration in coagulation systemIt can be a preexisting or Induced coagulopathy.

Effects of acidosis and hypothermia• Acidosis interferes with the assembly of

coagulation factor complexes involving calcium

• Hypothermia reduces the enzymatic activity of plasma coagulation proteins and prevents plt activation

Complications of MBTComplications of MBTCoagulation proteins

• Resuscitation results in gradual dilution of plasma clotting proteins

• Bleeding due to dilution can occur when the level of coagulation proteins falls to 25 % of normal. (8- 10 units)

Complications of MBTComplications of MBTPlatelet count

• Each 10 - 12 units can produce a 50 % fall in the platelet count; thus, significant thrombocytopenia can be seen

• Also a dilutional effect

Complications of MBTComplications of MBT

B) Complications Of Citrate TransfusionB) Complications Of Citrate TransfusionMetabolic alkalosis

• At collection pH 7.10• falls 0.1 pH unit/week due to lactic and

pyruvic acids. • Acidosis does not develop in a massively

bleeding patient even if "acidic" blood is infused.


Metabolic alkalosis

Each 1 mmol of citrate 3 mEq of bicarbonate.

As a result, metabolic alkalosis can occur

Complications of MBTComplications of MBTHypocalcemia

• Due to citrate binding of ionized calcium

• Clinically significant hypocalcemia does not usually occur unless the rate of transfusion exceeds one unit every five minutes.


Hypocalcemia

• May exhibit transient tetany and hypotension.

• Calcium should only be given if there is clinical or ECG or lab evidence of hypocalcaemia

Complications of MBTComplications of MBTHypothermia • Blood warmers should be used as the rapid

transfusion of multiple units of may reduce the core temperature and can lead to cardiac arrhythmias.

• Leads to :- reduction in citrate and lactate metabolism - increases affinity of haemoglobin for oxygen,- impairment of red cell deformability

Complications of MBTComplications of MBTHyperkalemia • Potassium levels in stored blood increase by

approximately 1 meq/L per day ( peaks at 30 meq/L)

• Not a problem unless very large amounts of blood are given quickly

• To minimize the risk:- Use of < 5 days stored blood- wash unit before transfusion

Complications of MBT…Complications of MBT…

Volume overload

• In patients with poor cardiac or renal function.

• Careful monitoring of volume status and diuretic therapy can reduce the risk of this complication.

Clinical Practice Guidelines.Clinical Practice Guidelines.


Clinical Practice Guidelines.Clinical Practice Guidelines.


Alternative to BTAlternative to BT• Hemoglobin-based oxygen carriers are being

investigated for use in critically ill and injured patients, not yet approved (level 2).

• Potential uses:-Elective surgery-Hemorrhagic shock of trauma- Vaso-occlusive crises

Alternative to BTAlternative to BTSide effects:Side effects:• Vasoactivity • Gastrointestinal side effects • Immunosuppression• Myocardial infarction and death

Further phase III trials of HBOCs will not be conducted until it can be shown that these agents are at least as effective in reducing mortality or serious morbidity as the current standards of care

…Thank You…

References.. References.. • Clinical practice guideline: RBC transfusion in adult

trauma and critical care. Crit Care Med 2009 vol.37 No.12

• ARCH SURG/VOL 143 (NO. 7), JULY 2008• Massive blood transfusion by Steven Kleinman, MD

up to date article Sept. 2009• Transfusion Reactions by Eric M Kardon,

MD ,eMedicine Dec 10, 2009• Indications for red cell transfusion in the adult by

Steven Kleinman, MD up to date September 2009 • Clinical Surgery ,A.Cuscheieri, 2nd ed• Schwartz’s Principles of Surgery, 8th ed

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