Management of Massive Transfusion

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					Management of Massive
     Transfusion
      Massive transfusion
Defined as giving greater than one blood
volume (8-10 units of blood in an adult) in
24 hrs or less.
Practically defined as giving one blood
volume in two hrs or less.
 The replacement of a patient’s
  total blood volume by stored
blood in a relatively short period
              of time
      Patients with massive
transfusion need close attention
 to detail and careful monitoring
        for complications
           Complications
Thrombocytopenia
Hypothermia
Electrolyte imbalance:
    Hypocalcaemia
    Hyperkalaemia
Coagulation defects
       Thrombocytopenia
Occur reasonably quickly.
Usually results from dilution.
Increased consumption may also occur.
When the platelet count is less than 50x10
9/l microvascular bleeding and general

oozing from wounds or venapuncture sites
are likely
           Hypothermia
Most common complication.
Red cells stored at 4° C can cool the
patient.
Core temperatures below 35 ° C have been
associated with development of
coagulopathies and variety of metabolic
disturbances.
        Hyperkalaemia
Rarely seen.
A plasma or additive solution K+ in a
unit of red cells or whole blood
increases with storage period.
Presence of acidaemia, hypothermia
and hypocalcaemia with
hyperkalaemia can lead to cardiac
arrest.
This problem is best prevented by
keeping the patient warm.
        Hypocalcaemia
Due to citrate present in anticoagulant
solution.
As normal liver can metabolize citrate, this
condition is rare.
In neonates and hypothermic patients, the
combined effects of hypocalcaemia and
hyperkalaemia can lead to cardiac arrest.
 If there is clinical or ECG evidence, treat
with IV calcium gluconate (5ml of 10%
solution IV)
        Coagulation defects
Common.
Due to dilution of plasma. (replacement with
packed cells lead to dilutional coagulopathy)
Patient may develop coagulopathy due to
underlying medical condition or trauma.
Hypothermia leads to coagulation defects.
Degree of coagulopathy cannot be predicted
according to the amount of blood replaced.
    Management of massive
         transfusion
Replacement therapy according to the five
basic tests.

Use blood warmers and keeping the patient
warm.
         Five basic tests
Haematocrit
Platelet count
Prothrombin time (INR)
Activated partial thromboplastin time
(APTT)
Fibrinogen level
         Management
Assess need for blood products based on five
basic tests.
Platelets < 50-75000/L : give platelet
concentrates (6-8 packs)
Fibrinogen<125 mg/dl, unusually prolonged
PT and APTT or evidence of DIC: Give
cryoprecipitate 6-8 units of cryoprecipitate
PCV below 30%: give red cells
INR > 2.0 and aPTT abnormal 2-4 units of
FFP
Isolated abnormalities of PT: no specific
replacement is needed.
When laboratory tests are not
         available
Platelet concentrates.
FFP 10-15 ml/kg will replace both
fibrinogen and coagulation factors.
If hypofibrinogenaemia is suspected
consider giving cryoprecipitates.
              Platelets
Largest determinant of microvascular
bleeding in massively transfused patients.
Priority should be directed towards keeping
platelet count about 50-75000/ L.
Each platelet concentrate will increase
platelet count by 5000-7000/L.
Either 6-8 platelet concentrates or single
donor (apharesis) platelets.
        Cryoprecipitate
If there is evidence of DIC cryoprecipitate
transfusion is indicated.
Fibrinogen levels below 125mg/dl needs
cryoprecipitate.
Each unit of cryoprecipitate will increase
fibrinogen level by 10 mg/dl.
When indicated transfuse at least 7-10 units
of cryoprecipitate.
      Fresh frozen plasma
Used only when there is micro-vascular
bleeding with laboratory results showing
abnormal coagulation.
Given 15 ml/kg dosage
    Ongoing haemostatic
treatment should be guided
    by the patients clinical
   response and results of
  repeated laboratory tests
 Indiscriminate use of blood
 component therapy can be
 avoided by routine tests of
haemostasis performed early
  in order to define precise
        abnormalities
   Disseminated intravascular
         coagulation
Clinical manifestation of inappropriate
thrombin generation
Clinically present as asymptomatic, severe
bleeding, thrombosis, purpura fulminans
          Aetiology of DIC
Infection
Shock
Trauma
Penetrating brain injury
Placental abruption
Amniotic fluid embolism
Retained fetus
Adenocarcinoma
Leukaemia
Snake bites
Burns
             Diagnosis
PT, APTT, Fibrinogen assay (non specific)
Specific
– FDP
– D-Dimers
 Consequences of excessive
    thrombin generation
Conversion of fibrinogen to fibrin :
thrombosis and depletion of fibrinogen

				
DOCUMENT INFO
Description: Bleeding disorders and blood transfusion