DIRECTOR : DR. S .C. GANESHPRABU M.D;D.A,CHIEF :DR. SHANMUGAM M.D;DCH

ASSISTANT: DR.GANGANAGALAKHMI M.D;DR. P.SALAMON RAJA PG

MASSIVE BLOOD TRANSFUSION AND

HAZARDS OF TRANSFUSION

Replacement of one entire blood volume within 24 hTransfusion of >10 units of packed red blood cells

(PRBCs) in 24 hTransfusion of >4 units of PRBCs in 1 h when on-

going need is foreseeableReplacement of 50% of total blood volume (TBV)

within 3 h. Definitions of MBT suggested for use in children

are transfusion of >50% TBV in 3 h, transfusion >100% TBV in 24 h or transfusion support to replace on-going blood loss of >10% TBV/min

INTRODUCTION & DEFINITION

Physiologically, haemodynamic compensatory mechanisms maintain vital organ perfusion till about 30% TBV loss, beyond which there is risk of critical hypoperfusion. Inadequate resuscitation at this stage leads to shock.

It is important to remember that overzealous resuscitation leading to high arterial and venous pressures may be deleterious as it may dislodge haemostatic clots and cause more bleeding.

Management of intravascular volume loss

Blood component loss during massive blood loss is best managed by following the massive transfusion protocol (MTP).

Mild to moderate blood loss can be managed with crystalloid or colloid infusions alone. However, with increasing loss, dilutional anaemia and later dilutional coagulopathy sets in.

Also, plasma substitutes may have direct effects on the coagulation system particularly if used in volumes >1.5 L.

A protocol based empirical replacement of coagulation factors is, therefore, recommended in massive blood losses.

Management of loss of blood components

it is a team workIt consists of Consultant in Charge, blood

bank, laboratory.

MTP pack

Massive transfusion protocol(MTP)

• 4 units PRBC, 4 units FFP, 1 pooled bag of platelets OR • 4 units PRBC, 4 units FFP, 6 units Cryoprecipitate.

• Consider in life-threatening bleeding but note that this is ‘off label’ use. There has been no randomised trial demonstrating a survival advantage of rFVIIa use in life-threatening bleeding.

• rFVIIa is most efficacious when every effort has been made to correct surgical bleeding, hypothermia and acidosis. In particular, patient pH should be > 7.2 for procoagulant effect

• Authorisation required by consultant haematologist on call

• Dose: 90 microg/kg, rounded to the nearest whole vial to minimize wastage, given as an intravenous bolus. A second dose may be required 2 hours after the first.

Recombinant activated factor (rFVIIa)

Hypothermia Dilutional coagulopathy Hypocalcaemia hypomagnesaemia citrate toxicity Lactic acidosis Hyperkalaemia Air embolism

COMPLICATIONS OF MASSIVE TRANSFUSION

HypothermiaCausescomplicationsManagement

Dilutional coagulopathyCausesManagement.

Complications of MBT

HyperkalemiaCause red blood cell membrane ATPase pump

inactivation.Predisposing factors

HypokalemiaCause

HypocalcemiaCause Citrate toxicityManagement

solution Elemental calcium

Unit volume

Total elemental calcium

osmolarity

10% calcium chloride

27mg(1.36meq)/ml

10ml ampule

270mg/10ml

2000 mosm/l

10% calcium gluconate

9mg(.46meq)/ml

10ml ampule

90mg /10ml 680mosm/l

10% calcium chloride in continuous infusion

2.45 mg/ml 5 amps/500ml NS

1350 mg/550 ml

200 mosm/l

10% calcium gluconate continuous infusion

0.82mg/ml 5 amps/500ml NS

450 mg/550 ml

200 mosm/l

Transfusion reactions (immune-related reactions)

Nonimmune reactions Infections

Hazards of blood transfusion

Non hemolytic fever reactions .

Hemolytic transfusion reactions Immediate( acute) or delayed

IMMUNE RELATED REACTIONS

TACOTRALIALLERGIC REACTIONSHYPOTENSIVE REACTIONSTADPOST TRANSFUSION PURPURATA-GVHDHEMOSIDEROSISTTI

NON IMMUNE REACTIONS

BACTERIAL CONTAMINATION

VIRAL CONTAMINATION

VARIANT CREUTZFELD JACOB DISEASE

INFECTIONS

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