Part III Intercollegiate exam / Massive transfusion

When would you consider a patient to have had massive transfusion?

It’s defined as the entire blood replaced with in 24 hrs (7% of body volume) or 50% with in 3 hours(1)

What are problems related to massive transfusion?

Dilutional coagulopathy
↓ platelet counts
Hypothermia
Hypocalcaemia due to citrate toxicity
Hyperkalaemia
TRALI: transfusion related acute lung injury- 5to 6 times more often following FFP and platelet transfusion in comparison to transfusion of Red cells
Metabolic acidosis

Other complications of transfusion:

Intra-vascular haemolysis – seen in ABO incompatibility – very rare
Extra-vascular haemolysis – seen in Rh incompatibility or rare groups like C or D
Febrile reactions: usually due to leucocyte or antigens from platelets

If low grade fever - slow the rate. If high grade discontinue and check for haemolysis

Transmission of infection:

Ø Hep C

Ø HIV

Ø CJD

How would you replace blood products in a patient with massive blood loss?

1) Red Cells: are required to improve O2 delivery not for volume expansion. Their transfusion is indicated when blood loss is > 30% of blood volume. Hb should be regular checked and transfusion is rarely indicated if Hb >10 and always indicated if Hb < 6.

Regarding Hb between 6 and 10 depends on patient’s age, co-morbidities, cardio-respiratory reserve and presence of active bleeding. (1)

2) FFP: the need for FFP transfusion should be anticipated after 1 -1.5 times whole blood volume replacement. Start transfusion when INR >1.5. Dose: 15mls/kg; around 4 in an adult. (Please note that the dose of FFP doesn’t depend on value of INR). Also check for S Fibrinogen levels and if less than <1.0 g/l, consider transfusion of Cryoprecipitate.

3) Platelet transfusion: usually required after two blood volumes have been replaced or platelet count <50 ×109. Try to maintain counts of > 75×109

Are there any agents that can reduce blood loss?

1) Anti-fibrinolytic agents: Tranexamic acid and aprotinin have been used but no sufficient evidence to support their use.

2) Re-combinant factor VIIa (Nova 7): it has been used in control of bleeding with some success. It’s use should be considered only in situations where surgical control is not possible, FFP, cryo and platelets have been adequately replaced , there is no heparin or warfarin effect and the blood loss is > 300mls/hr.(1)

Further reading: Guidelines on management of blood loss by British Committee for Standards in Haematology (2006); http://www.bcshguidelines.com/pdf/bloodloss_2006.pdf (Free Download)

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