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Massive-transfusion.pptx
- 1.
- 2. Massive transfusion protocol(MTPs) • Established to provide rapid blood replacement in a setting of severe hemorrhage • Early optimal blood transfusion is essential to sustain organ perfusion and oxygenation
- 3. What is Massivetransfusion? 10 units of red cells in 24 hours Total blood volume is replaced within 24 hours Three units over one hour 50% of total blood volume is replaced within 3 hours
- 4. Massive Transfusion-Clinical Settings •Trauma • Surgery (e.g. Liver, Cardiovascular) • Less frequent • abdominal aortic aneurysm • liver transplant • obstetric catastrophes • GI bleeding
- 5. • Cardiac surgery— Most common cause of massive transfusion • Obstetric hemorrhage — Gravid and parturient women are hypercoagulable with compensatory hyperfibrinolysis. • Liver disease — • leads to the reduced production of normal coagulation factors • production of abnormal factors
- 6. Types of Shock •Cardiogenic – MI, cardiomyopathy • Obstructive – Tamponade, PE • Distributive – Sepsis, Anaphylaxis •Hypovolemic – Hemorrhage
- 7. Challenges • Types ofcomponents to be administered • Selection of the appropriate amounts • TIME
- 8. Blood Products • RBC •Plasma • Platelets • Cryoprecipitate
- 9. Emergency blood issue ImmediateWithin an hour Minutes Group O Rh neg Packed RBCs ABO & Rh D type Group specific blood (5-10 min) ABO & Rh D type Complete crossmatch If units are issued without X match – written consent of physician to be taken, -complete X match protocols followed after issue Immediate spin crossmatch ( 15-20) min)
- 10. Emergency Release Blood- Universal Donor • O, RhD neg/pos RBCs – 5 min • AB or A Plasma/Platelets
- 11. Recommendations • “Damage control”approach • Improved survival when the ratio of transfused Fresh Frozen Plasma (FFP, in units) to platelets (in units) to red blood cells (RBCs, in units) approaches 1:1:1 Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007; 62:307.
- 12. Important If uncorrected, concurrenthypothermia and acidosis can further exacerbate coagulopathy and lead to irreversible multiorgan failure (MOF). Untimely or incomplete control of massive bleeding- systemic consumptive coagulopathy with hemodilution and endothelial damage At the onset - aggressive fluid replacement and bleeding control can reduce the tissue injury, inflammation, and hypoperfusion
- 13. • Borgman MA,Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63:805. • Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447. • Cotton BA, Au BK, Nunez TC, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009; 66:41. • Shaz BH, Dente CJ, Nicholas J, et al. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion 2010; 50:493. • Inaba K, Lustenberger T, Rhee P, et al. The impact of platelet transfusion in massively transfused trauma patients. J Am Coll Surg 2010; 211:573. • de Biasi AR, Stansbury LG, Dutton RP, et al. Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma (CME). Transfusion 2011; 51:1925. Patients who have sustained severe traumatic injuries and/or who are likely to require massive transfusion should receive a 1:1:1 ratio of FFP to platelets to RBCs at the outset of their resuscitation and transfusion therapy
- 14. Important! Uncrossmatched group ORh D negative RBCs /Whole blood Residual plasma with both antibodies (Anti A & B) can accumulate when large quantities are transfused Repeat the blood group and do antibody titres before resuming transfusion of RBCs of the patient’s own blood group.
- 15. Fibrinogen concentrate • Europeanguidelines recommend fibrinogen concentrate when the level falls below 1.5g • Cost of fibrinogen concentrate is much more than cryoprecipitate • Availability
- 16. Cryoprecipitate • Most commonblood product used to replace fibrinogen • Contains approximately 200–250 mg of fibrinogen per unit • Standard dose of two 5-unit pools should be administered early in major obstetric haemorrhage. • Subsequent cryoprecipitate transfusion should be guided by fibrinogen results, aiming to keep levels above 1.5 g/l.
- 17. Platelet Transfusion • Itbecomes necessary after two volumes of blood loss. • 10 to 12 units of transfused RBCs- 50 percent fall in the platelet count • Platelet concentrates should be transfused as 1 pack/10 kg body weight.
- 18. Example Regional West MedicalCenter, Nebraska
- 19. Massive Transfusion Protocol RegionalWest Medical Center • Six units RBC’s • Four units FFP • Deliver first “package” within 35 minutes of the initial order. Immediately prepare first transfusion “package” : • Six units RBC’s • Four units FFP • One Single Donor Platelet or one “six-pack” random platelets Have second “package” ready within 35 minutes of issue of first “package”. • Six units RBC’s • Four units FFP • One “ten-pack” pooled Cryoprecipitate Have third “package” ready within 35 minutes of issue of second “package.”
- 21. Complications of MassiveTransfusion • Hypothermia • Acid/base derangements • Coagulopathy • Citrate toxicity • Electrolyte abnormalities • hypocalcemia • hypomagnesemia • hypokalemia • hyperkalemia • Transfusion-associated acute lung injury
- 23. Acidosis and hypothermia Acidosis Interferes with formation of coagulation factor complexes Hypothermia Reduces enzymatic activity of coagulation factors Prevents activation of platelets
- 24. Hypothermia RBCs that arestored at 4C are transfused rapidly Lowers the recipient’s core temperature and further impairs haemostasis. Reduces the metabolism of citrate and lactate Increases the likelihood of hypocalcaemia, metabolic acidosis and cardiac arrhythmias. Shifts the oxyhaemoglobin dissociation curve to the left, reducing tissue oxygen delivery 10 units of cold blood products and an hour of surgery can lead to a 3°C drop in core temperature and hypothermic coagulopathy
- 25. Prevention of hypothermia •A high capacity commercial blood warmer should be used to warm blood components
- 26. Coagulopathy • Dilutional coagulopathy •Disseminated intravascular coagulation. • Consumption of platelets and coagulation factors
- 27. ALTERATIONS IN HEMOSTASIS •Acute DIC • microvascular oozing • prolongation of the PT and aPTT in excess of that expected by dilution • significant thrombocytopenia • low fibrinogen levels • increased levels of D-dimer
- 28. Hypocalcaemia • Citrate bindscalcium • Results in hypotension, small pulse pressure, flat ST-segments and prolonged QT intervals on the ECG. • Slow i.v. injection of calcium gluconate 10%
- 29. Hyperkalaemia • The potassiumconcentration of blood increases during storage, by as much as 5–10 mmol u1 . • Hyperkalaemia rarely occurs during massive transfusions unless the patient is also hypothermic and acidotic
- 30. Monitoring recommendations • PT,aPTT • Platelet count • Fibrinogen • Electrolytes • Viscoelastic test • after the administration of every five to seven units of red cells.
- 31. Goals Investigation Target value Haemoglobin10 gm/dl Hematocrit 32% Platelet count > 50 x 10 9 /l PT < 1.5 x control PTT < 1.5 x control Fibrinogen > 0.8 g/l
- 32. Viscoelastic whole-blood assays •TEG® and ROTEM® • provide information on the coagulation process through the graphic display of clot initiation, propagation and lysis. • used to guide transfusion of blood components
- 34. • Costeffective -sinceit reduces inappropriate transfusions, thus improving transfusion management and patients’ clinical outcome
- 35. Depletion of fibrinogenand coagulation factors • PT prolonged – FFP in a dose of 15 ml/kg • aPTT prolonged – factor VIII/fibrinogen concentrate
- 36. Summary and recommendations •Need to define protocol triggers , an algorithm for preparation and delivery of blood products, including continued support • The protocol should be updated annually and practised in ‘skills drills’ to inform and train relevant personnel.