massive transfusion ob rounds, jan 23 2008. recommendations for massive transfusion assuming:...
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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 ?
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