A Case presentation of Massive Transfusion in post LSCS PPH patient

workup at blood centre
components issued
transfusion summary
criteria for massive transfusion
goal of massive transfusion
Indication protocol for massive transfusion for whole blood, prbc, ffp, cryo, platelets
Targets of resuscitation in massive blood loss
Complications of Massive Transfusion
citrate toxicity
lethal triad

1. A Case of Massive Transfusion in P1L1 Post LSCS PPH Patient In Integration with Dept. of Anaesthesiology and Obstetrics & Gynaecology Presenter- Dr. Shiny K. Kajal PG-JR 1, Dept. of IHBT

2. Requisition First requisition of 3 PRBCs, 4 FFPs and 6 PCs was received on 29.08.2023 at 1.10 am

3. Workup at Blood Centre ABO-Rh typing- B positive Hb on First Requisition- 6.2 g/dL The issue slip for PRBC and FFPs were received there and then, EMR Components were arranged within average Turn-around Time of 15-25 minutes The issue slip for PCs was not received until next 12 hours

4. Components Issued on 29/08/2023 Date Time of Requisition Time of issue Component Total volume transfused (ml) 29/08/2023 1.15 am 1.42 am 1 PRBC 393 29/08/2023 1.15 am 1.54 am 1 PRBC 398 29/08/2023 1.15 am 2.09 am 4 FFPs 811 29/08/2023 7.35 am 8.20 am 6 FFPs 1758 29/08/2023 1.15 am 2.35 pm 3 PCs 215 29/08/2023 2.25 pm 3.25 pm 1 PRBC 365 29/08/2023 1.15 am 5.10 pm 3 PCs 195 29/08/2023 5.42 pm 6.25 pm 4 FFPs 726 29/08/2023 6.05 pm 6.45 pm 1 Cryoprecipitate 40 No Donations About 17 hours 3 PRBCs, 14 FFPs 6 PCs, 1 Cryo = 24 components 4901 ml within 17 hrs

5. Components Issued on 30/08/2023 Date Time of Requisition Time of issue Component Total volume transfused (ml) 30/08/2023 8.20 am 9.04 am 1 PRBC 389 30/08/2023 9.25 am 10.50 am 2 PRBC 750 30/08/2023 10.35 am 11.14 am 4 FFPs 838 30/08/2023 5.00 pm 6.15 pm 1 PRBC 360 30/08/2023 5.00 pm 7.10 pm 1 PRBC 360 30/08/2023 5.00 pm 7.30 pm 4 FFPs 740 30/08/2023 6.15 pm 7.30 pm 1 PRBC 380 No Donations About 10 hours 6 PRBCs, 8 FFPs = 14 components 3817 ml within 10 hrs

6. Components Issued 31/08/23 to 01/09/23 Date Time of Requisition Time of issue Component Total volume transfused (ml) 31/08/2023 5.40 pm 6.20 pm 4 FFPs 795 31/08/2023 5.58 pm 7.01 pm 2 PRBC 750 31/08/2023 7.55 pm 8.14 pm 2 PCs 140 31/08/2023 8.25 pm 9.00 pm 4 FFPs 765 01/09/2023 5.58 am 7.00 am 1 PRBC 370 02 Donations About 13 hours 3 PRBCs, 8 FFPs 2 PCs = 13 components 2820 ml within 13 hrs

7. Transfusion summary in 72 hours GRAND TOTAL 51 UNITS Total Packed Red Cell units issued 12 Total Fresh frozen Plasma units issued 30 Total Platelet Concentrate units issued 08 Total Cryoprecipitate units issued 01 Total Fresh Whole Blood units issued 00 Total Volume of Blood components 11538 ml

8. .On further requisitions, Hb of the patient- 5 to 8.4 to 4.2 to 5.6 to 7 to 9.4 g/dL All units were issued with Compatibility testing through Immediate Spin Cross Match and were screened negative for HIV, Hep B, Hep C, Malaria & Syphilis In 72 hours, Donations were arranged by requesting active NGOs and repeated announcements. Donations made by family were 02.

9. Blood Volume Of Patient Calculated By Nalder Equation- 3196 mL As Total Blood volume transfused was 11538 ml- It accounts for replacement of nearly 3.6 Blood volumes of the patient in 72 hours and 1.5 Blood Volume in first 24 hours of transfusion therapy- which implies to Evident episode of Massive Blood Transfusion in the Patient

10. Massive Transfusion- Criteria Massive transfusion is defined as the administration of - 8 to 10 red blood cell units to an adult patient in less than 24 hours or acute administration of 4 to 5 units within 1 hour or replacement of patient’s entire blood volume in 24 hours or replacement of more than 50% of the circulating blood volume within 3 hours.

11. THE CLINICAL POLICY- In 1 pack- T ransfusion of Fresh Frozen Plasma (FFP), then platelets, and then RBCs in a 1:1:1 ratio THE GOAL OF TREATMENT- is to restore blood volume rapidly to a level adequate to maintain hemostasis (management of bleeding and coagulopathies) oxygen-carrying capacity (tissue oxygenation) oncotic pressure (volume status) biochemical parameters (acid-base balance)

12. Indication protocol for massive transfusion 1. F.W.B/Packed red cells Acute loss of blood/ Massive hemorrhage  polytrauma, major surgeries, GI bleeds, obstetric haemorrhages 2. Platelet concentrate platelet count is less than 50,000/ uL 3. Fresh frozen plasma prothrombin time (PT) ratio is greater than 1.5 or the international normalized ratio (INR) is greater than 1.5, or the activated partial thromboplastin time ( aPTT ) exceeds 60 seconds 4. Cryoprecipitate the fibrinogen level is less than 100 mg/dL.

13. Targets of resuscitation in massive blood loss Mean arterial pressure (MAP) around 60 mmHg S ystolic pressure 80-100 mmHg Hb 7-9 g/dl INR <1.5 ; activated PTT <42 s Fibrinogen >150-200 mg/dL Platelets >50000/ uL pH 7.35-7.45 Core temperature >35.0°C

14. Complications of Massive Transfusion The complications of massive transfusion include dilutional coagulopathy, hypothermia, citrate toxicity, and electrolyte disturbances 1. Citrate Toxicity- causing Hypocalcemia which can further lead to perioral and peripheral tingling, fasciculations, hyperventilation and can also depress cardiac function . 2. Transfusion Associated Circulatory Overload (TACO) Acute increase in intravascular blood volume Circulatory overload increases central venous pressure, causes congestion of the pulmonary vasculature, and decreases lung compliance, manifesting as dyspnea, tachycardia, acute hypertension, pulmonary edema and heart failure

15. 3. Hemostatic Abnormalities in Massive Transfusion- hypothermia, metabolic acidosis, coagulopathy 4. Air Embolism- can be fatal if air enters > or if air enters a central catheter while containers or blood administration sets are being changed 5. Metabolic changes- like hypokalemia, hypomagnesemia 6. Immune complications like Acute lung injury (TRALI), Transfusion associated dyspnoea (TAD). The lethal triad of Massive Transfusion consists of hypothermia, acidosis, and coagulopathy Hypothermia during massive transfusion has been shown to induce cardiac arrhythmia and arrest.

16. Special Considerations E arly administration of fresh frozen plasma (FFP) during massive transfusion decreases coagulopathy and improves survival in patients. Medical management by Drugs eg. tranexemic acid may be useful in bleeding complicated by fibrinolysis. This avoids unnecessary fluid overload in the patient. Adjacent Calcium supplementation to avoid citrate toxicity. Invasive arterial pressure and temperature monitoring . (use of In-line warmers) Autologous transfusion in case of massive acute blood loss is being implemented.

17. REFERENCES Rossi’s Principles of Transfusion Medicine, Edition 4 AABB Technical manual 18 th edition Harmening DM. Modern Blood Banking & Transfusion Practices 7 th edition Makroo RN. Principles & Practice of Transfusion Medicine 2 nd edition Thankyou