massive transfusion

+

Case Presentation

Cristina Marides Quijano, MD

+Jump Off Case

+Patient Profile

N.N 45 yrs old Female Filipino Roman Catholic CC: body malaise and abdominal pain

+Past Medical History

× Hypertensive

× Diabetic

× Asthmatic

No known food or drug allergies

+OB- Gynecologic History

Menarche 13 yrs old Menstrual Cycles : regular lasting 3 -4 days, without

associated dysmenorrhea Coitarche 18 yrs old x 1 sexual partner LMP: 01/12/16 G5 P5 (5005)

G1 – G4 delivered full term, NSD without complications G5 delivered via Low Segment Transverse Cesarean Section

sec to Non- reassuring Fetal Heart Rate Pattern + Postpartum Bilateral Tubal Ligation

+Social History

× Cigarette smoker

× Alcoholic Beverage Drinker

× Illicit Drug Use

+History of Present Illness

5 months PTA Onset of intermittent lower back pain (PS 3/10) Condition tolerated

4 months PTA Persistence of back pain now of increased severity (PS 5/10)

with radiation to hypogastric area, associated with abdominal bloatedness and increased abdominal girth

Condition tolerated

+

3 months PTA Low back pain persisted now associated with urinary

frequwncy, constipation and early satiety Consult done

TVS : Anteverted uterus 3 x 6.5 x 5cm with secretory phase endometrium; Unilocular cystic mass 14 x 12 x 10 cm within the abdominopelvic cavity, inferior pole is composed of a solid component which on color flow revealed hypervascularity, suggestive of an ovarian new growth with malignant sonographic features

Advised surgery Enrolled under Charity service

+

Morning PTA, Noted vague abdominal pain (PS 8/10) associated with

body malaise TVS : Complex, solid cystic mass 15 x 12 x 13 cm at right of

uterus which exhibits moderate color flow on color flow mapping; irregular solid component is 9.6 cm in widest diameter suggestive of Right Ovarian New Growth with Non-benign features.

CA 125 : 798 Advised Admission and scheduled for surgery

+Physical Examination

Awake , conscious, coherent, not in respiratory distress but with occasional grimacing

Vital Signs: BP 100/80 mmHg HR 100 bpm RR 20 cpm T 36.0 oC O2 sat 99% at room air

Skin: pale, cool to touch, good turgor

+

HEENT: normocephalic; anicteric sclerae, pale palpebral conjunctivae; (-) alar flaring; pale, but moist lips, tongue and mucous membranes

Neck: supple, trachea at midline, thyroid gland not enlarged

C/L : Equal Chest expansion, clear breath sounds, (-) rales, (-) wheeze

CVS: Adynamic precordium, distinct S1 and S2, tachycardic, regular rhythm, (-) murmurs appreciated

+

Abdomen: globular, distended (AG 85 cm), (+) pelvoabdominal mass approx 20 cm, firm slightly mobile and tender on palpation

Speculum Exam: closed cervix, no lesions, minimal mucoid discharge

Bimanual Pelvic Exam: Introitus: parous Cervix: closed, posterior, smooth, non-tender Uterus: (+) pelvoabdominal mass, 20 cm in size, firm, slightly

movable Adnexae: as above Discharges: minimal, mucoid

+

Extremitites: symmetrical, non-edematous, strong and palpable pulses, CRT <2 sec

CNS: Within normal limits

+Admitting Impression

Gravida 5 Para 5 (5005) Right Ovarian New Growth T/C Malignancy S/P Primary Cesearean section + Bilateral Tubal

Ligation (2000)

+On Admission (ER)

Pt conscious, oriented but with occasional facial grimacing, reported pain score 8/10 on arrival

Vital sigs within normal range Laboratories taken as outpatient were reviewed and

consistent with Anemia. IVF started PNSS 1L at 120 ml/hr To transfuse 2 units of PRBC properly screened and

crossmatched to run in 4 hours with 2 hrs interval

+

Scheduled for Exploratory Laparotomy, Peritoneal Fluid Cytology, Right Salpingo-oophorectomy with Frozen Section, Total Abdominal Hysterectomy Left Salpingo-oophorectomy possible Bilateral Lymph Node Dissection, Omentectomy

Diet: Clear liquids; NPO postmidnight Medications:

Cefoxitin (B-braun) 2 grams IVTT ANST prior to induction of anesthesia

Lansoprazole (Prevacid) 30 mg IVTT at 7AM Metoclopramide (Vitamet) 10 mg IVTT at 7AM

Referred to Dept of Internal Medicine for comanagement and CP Clearance

+Outpatient Labs Patient’s Results

Normal Value

CBC Hemoglobin 6.8 12.0 – 16.0 Hematocrit 22.8 37.0 – 47.0 WBC 17.67 4.8 – 10.8 Platelet 199 130 - 400Bleeding Time 16’30” 2.3 – 9.5 minsClotting Time 6’15” Up to 15 minsProthrombin Time Activity 77 % >70% INR 1.19 <= 1.21aPTT 31.3 26.4 – 36.7 secCreatinine 1.2 0.6 – 1.5 mg/dlElectrolytes Sodium 135 134 – 148 mmol/L Potassium 3.6 3.3 – 5.3 mmol/L

+Outpatient Labs

Patient’s Results

Normal Value

SGPT 13 5.0 - 50.0 U/LCA 125 798.6 0-35 U/mlHbsAg NRBlood Type A+

+Outpatient Labs

Minimal subsegmental atelectasis in the peripheral aspect of the left lung base; otherwise clear lung fields

Focal eventration of the right hemidiaphragm

+

IM Orders: O2 inhalation via nasal cannula at 2LPM Repeat CBC after 2nd unit of PRBC, Serum K HGT now 115 mg/dl For 2D Echo with Doppler Suggest 2 more units PRBC for OR use Medications:

KCl (K lyte ) 600 mg/tab, 3 tablets orally now then another 3 tablets orally at bedtime

+

Laboratories (On Day of Admission)

Patient’s Results

Previous Results(Outpatient)

CBC Hemoglobin 7.3 6.8 Hematocrit 23.7 22.8 WBC 14.26 17.67 Platelet 160 199

+1st Hospital Day Pt alert, still with complaints of abdominal pain (PS

6/10), had 1 febrile episode (T 38.8oC) Laboratories: (S/P 2 units PRBC)

Transfuse 1 more unit PRBC

Patient’s Results

Previous Results

CBC Hemoglobin 8.5 7.3 Hematocrit 26.6 23.7 WBC 13.14 14.2 Platelet 162 160Potassium 3.9 3.4

+

2DED Result: EF 74% Normal LV geometry with adequate wall motion and

contractility Normal right atrium, main pulmonary artery and aortic root

dimensions

Medications: Paracetamol (Aeknil) 300 mg IV now

Defer OR until medically cleared Diet: Soft

+2nd Hospital Day

Patient with same complaints, no recurrence of febrile episodes however tachypneic even on 02 supplementation.

PE: pale palpebral conjunctivae; Clear breath sounds, (-) rales (-) wheeze

Laboratories: (S/P 3 units PRBC) Patient’s Results

Previous Results


+

Transfuse another 2 units of PRBC of patient’s blood type properly screened and crossmatched

Secure another 2 units PRBC of patient’s blood type properly screened and crossmatched

Labs: Repeat CBC postBT, include Crea, SGPT, ProTime Medications:

Cefoxitin (B-braun) 2 grams IVTT ANST now then 1 gram IVTT every 8 hours thereafter

Ranitidine 50 mg IVTT every 8 hrs Ketorolac 30 mg IVTT every 6 hrs

Referred to Dept of Anesthesia for Pain Relief

+ Laboratories: (S/P 5 units PRBC)

Secure 2 units FFP of patient’s blood type; transfuse 1 unit of FFP to run for 30 minutes

Medications: Vitamin K 1 ampule IVTT every 6 hrs x 4 doses

Patient’s Results

Previous Results

CBC Hemoglobin 10.0 8.7 Hematocrit 32.1 27.6 WBC 9.48 11.33 Platelet 138 143Prothrombin Time Activity 71 77 INR 1.26 1.19Creatinine 1.1 1.2SGPT 12 13

+3rd Hospital Day

Patient comfortable, with persistence of abdominal pain but now of decreased severity (PS 2/10), no recurrence of fever.

Laboratories : (S/P 5units PRBC, 1 unit FFP) Patient’s Results

Previous Results

CBC Hemoglobin 10.9 10.0 Hematocrit 34.1 32.1 WBC 6.55 9.48 Platelet 148 138Prothrombin Time Activity 77 71 INR 1.19 1.26

+ Transfuse 2 units FFP of patient’s blood type to run for

30 minutes each unit with 30 minute intervals Laboratories:

Patient’s Results

Normal Value

D - Dimer 24.370 < 0.5 ugFEU/mlFibrin Split Products (+) negative ABG pH 7.354 7.35 – 7.45 pCO2 33.2 35 - 45 pO2 166.1 >80 HCO3 18.1 SpO2 99.3 95-98 fIO2 28 BE -6.6

+

IM Clearance No absolute cardiopulmonary contraindication to procedure

per clearance protocol nor does [patient have high risk comorbidities

High risk for perioperative morbidity and risk for adverse events inherent to underlying condition necessitating surgical intervention (ongoing Internal Hemorrhage from probable ruptured cyst)

Advise that surgical interventions that may correct the underlying condition be weighed against perioperative risks

Bleed available donors for additional 2 units FWB Type and screen 2 units FFP

+

Scheduled for Exploratory Laparotomy, Peritoneal Fluid Cytology, Right Salpingooophorectomy with Frozen Section, Total Abdominal Hysterectomy Left Salpingoophorectomy possible Bilateral Lymph Node Dissection, Omentectomy

+Pre-op Assessment Airway Examination

Mouth opening > 4cm Thyromental distance > 6cm Mallampati 1 No missing or loose teeth or dentures

ASA 1 Anesthetic Plan: GA –ETT Anesthesia Orders:

NPO postmidnight Lansoprazole 30 mg IV at 7AM

+4th Hospital Day (OR)

Pt alert, conversant, with reports of abdominal pain (PS 2/10) and occasional dyspnea despite O2 inhalation via nasal prong.

Wheeled to OR with ff vital signs prior to transport: BP: 120/60 mmHg HR: 102 bpm RR: 20 cpm T :36.4 oC 02 sat: 99 % on O2 via nasal prong at 2LPM

+

On arrival at the OR theatre, patient was awake, coheremt, conversant, not in respiratory distress and with the ff vital signs: BP: 115/75 mmHg HR 65 bpm RR 20 cpm O2 sat 100%

Patient positioned supine and standard ASA monitors attached.

Peripheral IV line started with PNSS 500 ml on contralateral arm using IV cath G18.

+

Induction Agents: Midazolam 1mg Fentanyl 100 mcg Lidocaine 40 mg Propofol 40 mg Rocuronium 40 mg Sevoflurane 2%MAC

Atraumatically intubated with ETT 7.0 , lip level 20 on 1st attempt, with equal and clear bibasal breath sounds on auscultation and a positive waveform on capnography

Attached to Mechanical Ventilator with ff settings: TV 350 ml RR 10 cpm PEEP 5 cmH20 Mode: VCV

+ Twenty mins from Induction, Procedure started

Vital signs: BP: 90/50 mmHg HR 68 bpm RR 20 cpm O2 sat 100%

Fentanyl 50 mcg IV given and supplemented with 25 mcg IV bolus every 45 mins Rocuronium 10 mg IV given and top up done with 10 mg boluses every 30 mins therafter

45 mins from Induction Stable vital signs EBL: 500 ml 1st unit of PRBC transfused

2 hrs and 30 mins from Induction EBL 2000 ml Infrequwnt hypotensive episodes as low as 80/40 mmHg 2nd unit PRBC transfused 2 addtl units PRBC secured for transfusion

+

3 hrs 15 mins from Induction Stable vital signs 2 units FFP transfused in succession 1 unit FWB transfused on contralateral arm

5 hrs from Induction 2nd unit FWB transfused

6 hrs from Induction Procedure completed Patient extubated Admitted to INT for close monitoring

+

Summary of Medications: Midazolam 1 mg Fentanyl 275 mcg Propofol 40 mg Lidocaine 40 mg Rocuronium 140 mg Tranexamic Acid 1 gram Paracetamol 600 mg Parecoxib 40 mg Ondansetron 4 mg Sugammadex 120 mg

+

Summary Estimated Blood Loss 3500 mg Peritoneal Fluid 1200 ml Total Fluids administered 4850 ml Total Blood Products Transfused 1460 ml

2 units PRBC 2 units FFP 2 units FWB

Total Urine Output 1280 ml

+

Postop Medications: Cefoxitin (Cefoxitin Bag RTU) 1 gram IV q8 hrs Lansoprazole (Prevacid 30 mg IVTT q12 hrs Tranexamic Acid (Hemostan) 1 gram IVTT q8 hrs x 3 doses Tramadol drip: Tramadol 250 mg in 250 ml D5W at 10 ml/hr x 2

cycles Tramadol 50 mg IVTT q8 hrs PRN for PS>4/10 Paracetamol 600 mg IVTT q4 hrs x 12 doses Parecoxib (Dynastat) 40 mg IVTT q12 hrs x 3 doses Ondansetron (Zofran) 4 mg IVTT q8 hrs PRN for nausea and

vomiting Calcium Gluconate 10 ml amp, 10 ml slow IV over 15 mins x 1

dose

+Immediate Post-op Period (INT)

Patient awake, not in respiratory on continuous 02 via nasal cannula at 2LPM.

Vital signs stable without episodes of hypotension or desaturation.

Diet : NPO Additional 3 units of PRBC secured and transfused over

4 hours per unit with 1 hour interval in between

+

ABG Patient’s Results

Normal Value

ABG pH 7.39 7.35 – 7.45 pCO2 34.9 35 - 45 pO2 173 >80 HCO3 21.0 SpO2 99.5 95-98 fIO2 28.0 BE -3.7

+

Laboratories

Patient’s Results

Previous Results

CBC Hemoglobin 9.9 10.9 Hematocrit 31.9 34.1 WBC 5.6 6.55 Platelet 126 148Prothrombin Time Activity 78 77 INR 1.18 1.19Electrolytes Sodium 136 Potassium 3.4Creatinine 0.8

+5th Hospital Day Patient comfortable with tolerable pain over post-op

site, (+) complaints of dizziness, (-) burp and flatus; no overt bleeding

Diet: Sips of water May turn to sides Laboratories: Patient’s

Results Previous Results

CBC Hemoglobin 13.7 9.9 Hematocrit 40.3 31.9 WBC 11.7 5.6 Platelet 117 126Prothrombin Time Activity 80 78 INR 1.16 1.18

+6th Hospital Day

Pt without subjective complaints, (+) burp and flatus Diet: General liquids with crackers Transout to Regular Room

+7th Hospital Day Patient without subjective complaints Diet: Soft FBC removed and O2 inhalation discontinued Venoclysis shifted to Heplock Mefenamic Acid PO started Laboratories:

Patient’s Results

Previous Results


+9th Hospital Day

Discharged Improved

+Blood Products Transfused

Pre-op: 5 units PRBC 1 unit FFP

Intra-op: 2 units PRBC 2 units FFP 2 units FWB

Post-op: 3 units PRBC

Total: 10 units PRBC 3 units FFP 2 units FWB

+Case DiscussionTransfusion Therapy

+Indications: Allogeneic Blood

To increase oxygen carrying capacity and intravascular volume

ASA Recommendations1. Transfusion is rarely indicated when Hgb > 10 g/dl and is

almost always indicated when it is <6 g/dl, especially when anemia is acute

2. The determination of whether intermediate Hgb concentrations (6 to 10 g/dl) justify or require RBC transfusion should be based on the patient’s risk for complications of inadequate oxygenation

3. Use of a single Hgb “trigger” for all patients and other other approaches that fail to consider all important physiologic and surgical factors affecting oxygenation is not recommended

+

4. When appropriate, preoperative autologous blood donation, intraoperative and postoperative blood recovery, acute normovolemic hemodilution, and measures to decrease blood loss (i.e. deliberate hypotension and pharmacologic agents) may be beneficial

5. The indications for transfusion of autologous RBCs may still be liberal for allogeneic RBCs because of less frequent (but still significant) risks associated with the former.

+

Rule of Thumb: Administration of 1 unit PRBCs will increase Hct value by

3% to 5%:1. Blood loss greater than 20% of blood volume when more

than 100 ml2. Hgb level <8g/dl3. Hgb level <10 g/dl with major disease (i.e emphysema,

ischemic heart disease)4. Hgb level <10 g/dl with autologous blood5. Hgb level <12 g/dl and ventilator dependent

* Anesthesia 6th ed

+ Drag picture to placeholder or click icon to add

Drag picture to placeholder or click icon to add

WHAT IS MASSIVE

TRANSFUSION?

+Definition Traditional:

>20 units RBCs in 24 hours (Approximately 1 blood volume in a 70 kg patient)

Trauma : > 10 units RBCs in 24 hours

Others: Loss of 0.5 blood volume within 3 hours use of 50 units of blood components in 24 hours use of 6 units RBCs in 12 hours.

Practical standpoint Requirement for > 4 RBC units in 1 hour with ongoing need

for transfusion Blood loss > 150 ml/min with hemodynamic instability and

need for transfusion

+

COMPATIILITY TESTING



+Compatibility Testing

Include: ABO-Rh type Crossmatch Antibody Screen

Designed to demonstrate harmful antigen –antibody interactions in vitro so that harmful in vivo antigen-antibody reactions could be prevented

+Compatibility Testing

ABO – Rh typing Most serious and tragic

reactions are caused by accidental transfusion of ABO incompatible blood Result from naturally

occurring antibodies which activate complement and lead to rapid intravenous hemolysis

Antigen D most likely to cause immunization

+Compatibility Testing Crossmatching

A trial transfusion within a test tube in which donor RBC are mixed with recipient serum to detect a potential for serious transfusion reaction

Phases:1. Immediate Phase

Conducted at room temperature Check against errors in ABO typing Detects ABO incompatibilities and those caused by naturally

occurring antibodies in the MN, P and Lewis systems 1 – 5 mins to complete

2. Incubation Phase First phase reactions are incubated at 37oC in albumin or low-ionic

strength salt solution Primarily detects antibodies in the Rh system Incubation: 30 to 45 mins (Albumin) 10 to 20 mins ( Salt soltn)

3. Antiglobulin Phase (Indirect Antiglobulin Test) Addition of antiglobulin sera to incubated test tubes Detects most incomplete a ntibodies in the blood group systems

including Rh, Kell, Kidd and Duffy blood group systems

+

Antibody Screening Carried out in 3 phases A trial transfusion between the recipient’s serum and

commercially supplied RBCs that are specifically selected to contain optimal numbers of RBC antigens or those antigens that will react with antibodies that are commonly implicated in hemolytic transfusion recations

+

Component Use



+Schema for Separation of Whole Blood for Component Therapy

+Packed RBC

Contain same amount of Hgb as FWB but much of the plasma has been removed

Administration is facilitated y reconstituting them with a crystalloid or colloid, however not all crystalloids are suitable If Calcium containing

soltn, clotting occurs. Impt factor is whether

diluent is hypotonic with respect to plasma; if so RBCs swell and lyse

+Platelet Concentrate Great demand for hemato-oncology patients Types:

Apheresis Leukocyte-depleted Ultraviolet B-irradiated

High risk of bacterial contamination (1 in 12 000) in platelets stored for 3 days or more: Bacteria can enter pack from donor skin at the time of collection Platelets are stored in oxygen permeable bag kept at 22oC to help

preserve platelet function but also encourage bacterial growth

High incidence of Transfusion Related Acute Lung Injury (TRALI) Interaction between leukocyte antibodies and in donor plasma and

corresponding antigen in the patient

+Platelet Concentrate

Preparation: Prepared by differential centrifugation from freshly drawn units of

blood or from donors who specifically donate large amounts of platelets by plateletpheresis techniques

From pooled buffy coats of the whole blood donated by four donors to make one adult pack

Individual donor apheresis (from a previously tested donor) can yield up to three adult packs

Storage: Stored for up to 5 days on an agitator at 22oC Volume: 250-350 ml Platelet count in pack: >2.4 x 1011 per adult dose


Dose 1 Platelet Concentrate produces an increase of

approximately 7000 to 10000 platelets/mm3 at 1 hour after transfusion to ave 70 kg adult

10 units Plt Concentrate required to increase platelet count by 100 000 cells/mm3

+Platelet Concentrate ASA Recommendations:

1. Prophylactic platelet transfusion is ineffective and rarely indicated when thrombocytopenia is due to increased platelet destruction (e.g. Idiopathic Thrombocytopenic Purpura)

2. Prophylactic platelet transfusion is rarely indicated in surgical patients with thrombocytopenia because of decreased platelet production when the platelet count is greater than 100 x 109/L and is usually indicated when the platelet count is less than 50 x 109/L. The determination of whether patients with intermediate platelet counts ( 50-100 x 109/L) require therapy should be based on the patient’s risk for bleeding.

3. Surgical and Obstetric patients with microvascular bleeding usually require platelet transfusion if the platelet count is less than 50 x 109/L and rarely require therapy if it is greater than 100 x 109/L. With intermediate platelet counts ( 50-100 x 109/L) the determination should be based on the patient’s risk for more significant bleeding.


4. Vaginal Deliveries or operative procedures ordinarily associated with insignificant blood loss may be undertaken in patients with platelet counts less than 50 x 109/L.

5. Platelet transfusion may be indicated despite an apparently adequate platelet count if there is known platelet dysfunction and microvascular bleeding.

+Fresh Frozen Plasma Most frequently used plasma product Contains all the plasma proteins particularly factors V

and VIII which gradually decline during the storage of blood

Frequently used in cases of excessive bleeding or to prevent bleeding in those patients with abnormal coagulation

NO documentation exists that FFP has a beneficial effect when used as part of transfusion management of patients with massive hemorrhage.

Preparation Centrifugation of whole blood from previously tested donor

and frozen to achieve Factor VIII concentration >0.7 iu.ml

+Fresh Frozen Plasma

Storage: Collected plasma from donated packs or plasmapheresis

and frozen to -30oC Thawed using a dry oven (10 mins), microwave (2-3 mins)

or in a waterbath (20 mins) Once thawed is best used immediately but may be stored

at 4oC and infused within 24 hours

Dose: 12 – 15 ml/kg

+Fresh Frozen Plasma ASA Recommendations :

1. For urgent reversal of warfarin therapy2. For correction of known coagulation factor deficiencies for which

specific correlates are unavailable3. For correction of microvascular bleeding in the presence of

increased (>1.5x normal) PT and aPTT4. For correction of microvascular bleeding secondary to coagulation

factor deficiency in patients transfused with more than 1 blood volume and when PT and aPTT cannot be obtained in a timely fashion

5. FFP should be given in doses calculated to achieve a minimum of 30% of plasma factor concentration (usu. 10 to 15 ml/kg) except for urgent reversal of warfarin anticoagulation (5 to 5 ml/kg)Four to five platelet concentrates, 1 unit of single donor apheresis platelets, or 1 unit of whole blood provides a quantity of coagulation factors similar to that contained in 1 unit of FFP.

6. FFP is contraindicated for augmentation of plasma volume or albumin concentration

+Cryoprecipitate

Is the cryoglobulin fraction of plasma obtained by thawing a single donation of FFP at 4oC

No virally-inactivated preparation Are rich in factor VIII, von Willebrand factor (VWF), factor XIII,

fibronectin and fibrinogen Indications:

In those with acquired coagulopathy related to hemorrhage, trauma or sepsis, to correct a fibrinogen level <1 g/dl

Frequently administered as ABO compatible Should be administered through a filter and as rapidly as

possible; rate: 200 ml/hr; completed within 6 hours of thawing

+Prothrombin Complex

Complex of Factors II, VII, IX and X Commercial Preparations available:

Konyne Proplex Aphanine SD

Indication: Mainly for treatment of Factor IX deficiency Acquired Hypothrombinemic bleeding disorders principally

sodium warfarin overdose

+Fibrinogen Concentrates

Derived from human plasma and does not contain relevant levels of other coagulation factors

Does not have complications associated with blood transfusions Reduces the required need for allogeneic blood components RCTS: may be first line therapy to reduce transfusion requirements

improves hemostasis more rapidly and at lower risk for immunologic reactions, infection and intravascular volume overload than conventional allogeneic blood products

Single dose of 4g would achieve a blood level approximately 200 mg/dl reducing incidence of platelet administration and number of donor exposures

NOT superior to conventional blood components for treatment of perioperative coagulopathy in bleeding patients

+Single Donor Plasma

Plasma that has been removed from stored blood without any effort being made to preserve coagulation factors

Very effective as a volume expander

+

OTHERS



+Albumin

Prepared commercially from albumin fractions from large pools of plasma reconstituted in isotonic electrolyte solutions

Given without regard to ABO blood type and crossmatch

Primarily used as volume expanders Risk: Bacterial Contamination

Administered within 4 hours of initiation of the infusion

Use should be restricted in cases of hypoprotinemia bec expansion of vascular space occurs for a longer period than does balanced electrolyte solutions

+Synthetic Colloid Solutions

Synthetic Hydroxyethyl Starch Dextrans

Infusion > 20 ml/kg in 24 hrs: interferes with normal blood clotting causing deficiency with cross matching and a bleeding diathesis

Major concern: anaphylaxis

Hypertonic Saline Na conc: 250 to 1200 meq/L Theoretical advantage: the greater the Na concentration,

the less total volume required for adequate resuscitation

+

Pharmacologic Management Options



+Antifibrinolytics

Tranexamic Acid Inhibits plasminogen activation and at high concentration

inhibits plasmin Loading dose: 1 gram over 10 mins then 1 gram every 8

hrs Use with CAUTION in patients with renal impairment as the

drug is predominantly excreted unchanged by the kidneys CONTRAINDICATIONS:

Subarachnoid hemorrhage cerebral edema and infarction

+

Aprotinin Serine protease inhibitor, inhibiting trypsin, chymotrypsin,

plasmin and kallikrein Reduces blood loss associated with accelerated fibrinolysis

in surgery (cardiothoracic or transplant surgery) Adverse Effects:

Anaphylaxis 1:200 first time use Risk of Acute Renal Failure, Myocardial Infarction and

Heart Failure, as well as Stroke and Encephalopathy Should only be used when benefits outweigh any risks to

individual patients

+

Desmopressin Synthetic analogue of antidiuretic hormone vasopressin Increases the levels of factor VIII and von Willebrand factor

and reduces blood loss and transfusion requirements in patients with normal preoperative coagulation status who are undergoing spinal or cardiac surgery

Adverse effects: hypotension, hyponatremia, increased platelet adhesion

Factor Concentrates For patients with Inherited bleeding disorders such as

haemophilia or von Willebrand disease

+

EMERGENCY TRANSFUSION



+

1. Type Specific Partially Crossmatched Blood Patient’s serum added to donor RBCs at room temp, centrifuged and

read for microscopic agglutination Duration: 1-5 mins Eliminates serious hemolytic reactions resulting from errors that

may occur in ABO typing Only a few unexpected antibodies outside ABO system are

detected, most of which are not clinically significant

2. Type Specific Uncrossmatched Blood

3. Type O Rh negative (Universal Donor), Uncrossmatched Blood

• PRBC preferrably as opposed to Whole Blood bec of smaller volume of plasma

+

Equipment to Aid Transfusion



+Infusion Devices

Administration sets should incorporate an integral mesh filter (170 -300um)

+Pressure Devices

Exert pressure evenly over the entire bag

Have a gauge to measure the pressure

Not exceed 300 mmHg of pressure

Be monitored at all times when in use

+Blood Warmers

In all adults undergoing elective or Emergency surgery under general or regional anesthesia, Intravenous fluids and blood components should be warmed to 37oC

Greatest benefit : controlled warming of red cells (stored at 4oC) rather than platelets (stored at 22+/- 2oC) or FFP/cryoprecipitate (thawed to 37oC)

+

Massive Transfusion



+Principle

Massive Transfusion protocol (MTP) is activated by a clinician in response to a patient that is experiencing massive bleeding.

Once a patient is in the protocol, the blood bank is able to insure rapid and timely availability of blood components to facilitate resuscitation.

+Rationale

Transfusion of packed red cells (RBCs), plasma, and platelets in a similar proportion as whole blood may minimize the effects of dilutional coagulopathy and hypovolemia

Retrospective studies demonstrate a survival advantage of increased plasma: red cell ratio on mortality in massive transfusion after trauma. optimal ratio of plasma to red cells appears to be in the

range 1:2.4 or higher

+Definition Traditional:

>20 units RBCs in 24 hours (Approximately 1 blood volume in a 70 kg patient)

Trauma : > 10 units RBCs in 24 hours

Others: Loss of 0.5 blood volume within 3 hours use of 50 units of blood components in 24 hours use of 6 units RBCs in 12 hours.

Practical standpoint Requirement for > 4 RBC units in 1 hour with ongoing need

for transfusion Blood loss > 150 ml/min with hemodynamic instability and

need for transfusion

+

Practice Guidelines for Perioperative Blood Management Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood ManagementAnesthesiology Vol V, No 2February 2015



+Patient Evaluation

Review previous medical records and intervoew the patient or family to identify : Previous blood transfusion History of drug induced coagulopathy (e.g warfarin, clopidogrel,

aspirin and other anticoagulants, as well as vitamins or herbal supplements that may affect coagulation)

Presence of congenital coagulopathy History of thrombotic events (e.g. DVT, pulmonary embolism) Risk factors for organ ischemia (e.g cardiorespiratory disease)

which may influence the ultimate transfusion trigger for red blood cells (e.g hemoglobin level

Inform patients of the potential rrisks versus benefits of blood transfusion and elicit their preference

+

Review available laboratory test results including hemoglobin, hematocrit, and coagulation profiles

Order additional laboratory tests depending on a patients medical condition (e.g coagulopathy, anemia)

Conduct a physical examination of the patient (e.g ecchymosis, petechiae, pallor)

If possible, perform the preoperative evaluation well wnough in advance to allow for proper patient preparation

+Preadmission Patient Preparation Erythropoeitin with or without Iron may be administered when

possible to reduce the need for allogeneic blood in selected patient populations (e.g renal insufficiency, anemia of chronic disease)

Administer Iron to patients with Iron Deficiency Anemia if time permits

In consultation with an appropriate specialist, discontinue anticoagulation therapy for elective surgery. Transition to short acting drugs (LMWH) may be appropriate in

selected patients

If clinically possible, discontinue nonaspirin antiplatelet agents (thienopyridines) for a sufficient time in advance of surgery, except for patients with a history of percutaneous coronary intervention Aspirin may be continued on a case by case basis

+

Risk of thrombosis versus the risk of increased bleeding should be considered when altering anticoagulation status

Assure that blood and blood components are available for patients when significant blood loss or transfusion is expected

When autologous blood is preferred, the patient may be offered the opportunity to donate blood before administration only if there is adequate erythropoeitic reconstitution.

+Preprocedure Preparation Restrictive red blood cell transfusion strategy may be safely

used to reduce transfusion administration: The determination of whether Hgb hemoglobin concentrations

between 6 and 10g/dl justify or require red blood cell transfusion should be based on potential or actual ongoing bleeding (rate and magnitude), intravascular volume status, signs of organ ischemia, and adequacy of cardiopulmonary reserve.

Red blood cells should be administered unit-by-unit, when possible, with interval reevaluation

A protocol for avoidance of transfusion may be used as a strategy to reduce blood loss for patients in whom transfusion is refused or is not possible.

A massive (i.e., hemorrhagic) transfusion protocol may be used when available as a strategy to optimize the delivery of blood products to massively bleeding patients.

Use a maximal surgical blood order schedule, when available and in accordance with your institutional policy, as a strategy to improve the efficiency of blood ordering practices

+ Reversal of Anticoagulants

For urgent reversal of warfarin, administer PCCs in con- sultationwiththeappropriatespecialist,oradministerFFP.

Administer vitamin K for selected patients for nonurgent reversal of warfarin, except when rapid restoration of anticoagulation after surgery is required.

Antifibrinolytics for Prophylaxis of Excessive Blood Loss Use antifibrinolytic therapy for prophylaxis of the use of

allogeneic blood transfusion in patients undergoing cardiopulmonary bypass.

Consider using antifibrinolytic therapy for prophylaxis in certain orthopedic surgery.

Consider using antifibrinolytic therapy for prophylaxis in liver surgery and other clinical circumstances at high-risk for excessive bleeding.

Acute Normovolemic Hemodilution (ANH) Consider ANH to reduce allogeneic blood transfusion in patients

at high-risk for excessive bleeding (e.g., major cardiac, orthopedic, thoracic, or liver surgery), if possible

+Intraoperative and Postoperative Management of Blood Loss Allogeneic Red Blood Cell Transfusion

Administer blood without consideration of duration of storage.

Leukocyte-reduced blood may be used for transfusion for the purpose of reducing complications associated with allogeneic blood transfusion.

Reinfusion of Recovered Red Blood Cells Reinfuse recovered red blood cells as a blood sparing

intervention in the intraoperative period, when appropriate.

+ Intraoperative and Postoperative Patient Monitoring

Periodically conduct a visual assessment of the surgical field jointly with the surgeon to assess the presence of excessive microvascular (i.e., coagulopathy) or surgical bleeding

Use standard methods for quantitative measurement of blood loss, including checking suction canisters, surgical sponges, and surgical drains.

Monitor for perfusion of vital organs using standard ASA monitors (i.e., blood pressure, heart rate, oxygen saturation, electrocardiography) in addition to observing clinical symptoms and physical exam features Additional monitoring may include echocardiography,

renal monitoring (urine output), cerebral monitoring (i.e., cerebral oximetry and NIRS), analysis of arterial blood gasses, and mixed venous oxygen saturation.

+

If anemia is suspected, monitor hemoglobin/hematocrit values based on estimated blood loss and clinical signs.

If coagulopathy is suspected, obtain standard coagulation tests (e.g., INR, aPTT, fibrinogen concentration) or viscoelastic assays (e.g., thromboelastography [TEG] and ROTEM), if available, as well as platelet count.

During and after transfusion, periodically check for signs of a transfusion reaction including hyperthermia, hemoglobinuria, microvascular bleeding, hypoxemia, respiratory distress, increased peak airway pressure, urticaria, hypotension and signs of hypocalcemia.

If signs of a transfusion reaction are apparent, immediately stop the transfusion, give supportive therapy, and initiate supportive care.

Notify the blood bank of the transfusion reaction case.

+ Treatment of Excessive Bleeding Obtain a platelet count before transfusion of platelets, if possible

In addition, obtain a test of platelet function, if available, in patients with suspected or drug- induced (e.g., clopidogrel) platelet dysfunction.

Obtain coagulation tests (i.e., PT or INR and aPTT) before transfusion of FFP, if possible

Assess fibrinogen levels before the administration of cryoprecipitate, if possible

Desmopressin may be used in patients with excessive bleeding and platelet dysfunction. Consider topical hemostatics such as fibrin glue or thrombin gel.

Consider the use of antifibrinolytics (i.e., ɛ-aminocaproic acid, tranexamic acid) if fibrinolysis is documented or suspected and if these agents are not already being used

PCCs may be used in patients with excessive bleeding and increased INR.

Consider recombinant activated factor VII when traditional options for treating excessive bleeding due to coagulopathy have been exhausted.

Fibrinogen concentrate may be used

massive transfusion

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