Massive Blood Transfusion

1. Massive Blood TransfusionMassive Blood Transfusion
Definition, IndicationsDefinition, Indications
ComplicationsComplications
Dr. Maha AL-MadiDr. Maha AL-Madi
Urology ResidentUrology Resident

2. - Massive Blood Transfusion Defined- Massive Blood Transfusion Defined
- Indications of Blood TransfusionIndications of Blood Transfusion
- Clinical Practice Guidelines of Blood TransfusionClinical Practice Guidelines of Blood Transfusion
- Complications of Blood TransfusionComplications of Blood Transfusion
- Alternatives to Blood TransfusionAlternatives to Blood Transfusion
ObjectivesObjectives

3. Definition of MBT…Definition of MBT…
Massive BT is loosely defined as the transfusion of more
than 10 units of PRBCs in a 24-hour period. (ARCH SURG/VOL
143 (NO. 7), JULY 2008)

Massive BT , defined as the replacement of more than 50 %
of a patient's blood volume in 12 to 24 hours, (Massive blood
transfusion by Steven Kleinman, MD up to date article Sept. 2009)


•
•

4. Definition of MBT…Definition of MBT…
Massive BT is defined as a volume equivalent or exceeding
the patients own volume transfused within a 12 hour period (
Clinical Surgery ,A.Cuscheieri, 2
nd
ed)
Massive transfusion implies a single transfusion greater
than 2500 mL or 5000 mL transfused over a period of 24
hours (Schwartz’s Principles of Surgery, 8
th
ed)

5. Definition of MBT…Definition of MBT…

Massive transfusion is defined as replacement of the
patient's blood volume with packed RBCs in 24 hours or
transfusion of more than 10 units of blood over a period of a
few hours (Sabiston Textbook of surgery, 8
th
ed.)

6. General Indications …General Indications …
•In Hemorrhagic shockHemorrhagic shock and ongoing hemorrhage
and anemiaanemia (to increase oxygen carrying capacity)
•In hemorrhage, the goal of transfusion is
restoration of the oxygen-carrying capacity and
NOT restoration to a specific hemoglobin level.

7. General Indications ……General Indications ……
•Anemia in critical illness is a distinct clinical entity
resulting from:
1) excessive phlebotomy for labs
2) active hemorrhage
3) reduced erythropoiesis
Most BT in ICU patients is used for treatment of
anemia.

8. General Indications ……General Indications ……
•40-50% of ICU patients receive at least 1, and on
average close to 5 units of RBCs
•Transfusion is not risk free and there is little
evidence that routine BT is beneficial to
hemodynamically stable critically ill patients*
* Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med 2009 vol.37
No.12

9. General Indications …General Indications …
Perioperative Transfusion
•Several factors are involved in the decision to
transfuse a patient before surgery
•Are generally not recommended when the
hemoglobin is ≥10 g/dL should be given when less
than 7 g/dL *
•No specific hematocrit is an indication for
preoperative transfusion in a stable patient
* Indications for red cell transfusion in the adult, by Steven Kleinman, MD
Addison K May, MD, Sept 2009 uptodate article.

10. Indication for MBT …Indication for MBT …
•There is no clear indication for MBTMBT in any
case
•The decision to transfuse in poly trauma or
other critical cases is based on
- the physiological state of the patient,
- evidence of amount of blood loss
- potential for ongoing hemorrhage

11. General Indications …General Indications …
No single criterion should be used as an indication
for RBC transfusion and that multiple factors
related to the patient's clinical status and
oxygen delivery needs should be considered*
* Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med
2009 vol.37 No.12

12. Clinical Practice Guidelines and Clinical Practice Guidelines and
RecommendationsRecommendations
* Clinical practice guideline: RBC transfusion in adult trauma and
critical care. Crit Care Med 2009 vol.37 No.12

13. Clinical practice guidelines..Clinical practice guidelines..

14. Clinical practice guidelines..Clinical practice guidelines..

15. Clinical practice guidelines..…Clinical practice guidelines..…

16. Clinical practice guidelines..Clinical practice guidelines..

17. Clinical practice guidelines..Clinical practice guidelines..

18. Benefits of BTBenefits of BT
•Increase DO2 tissues, but no evidence of increased
oxygen consumption
•Increase cell mass post acute hemorrhage or blood
loss;
• Alleviate symptoms of anemia

19. Complications of BT…Complications of BT…
•Donated blood is collected and separated into
various components. CPD-A 1 added to whole
blood can be stored for up to 42 days.
•Storage changesStorage changes
- Leakage of intracellular K
- Reduced levels 2,3-DPG
- Degeneration of functional granulocytes and platelets
- Deterioration of clotting factors V and VIII
- Ammonia concentration rises
- Decrease in pH
- Decrease in RBC deformability and viability

20. Complications of BT…Complications of BT…
Transfusion
Rxns
Infective Massive BT
Acute non-hemolytic rxns
Hemolytic rxns
TRALI
GVHD
1.Hypersensitivity rxn
2.Febrile non hemolytic
1. Acute immune
hemolysis
2. Delayed hemolysis

21. Complications of BT…Complications of BT…
Transfusion
Rxns
Infective
Massive BT
VIRAL
CMV (1:10 to 1:30)
EBV (1:200)
HBV ( 1 : 50,000)
HCV (1 :3000-4000)
HIV ( 1: 150,000)
HTLV-I/
II(1:250,000 to 1:2
mill
PARASITIC
Malaria, (1:4 mill)
BACTERIAL
1:200,000 to 1:4.8
mill
Yersinia Serratia ,
Pseudomonas
Enterobacter

22. Complications of BT…Complications of BT…
Transfusion
Rxns
Infective
Massive BT

23. Transfusion ReactionsTransfusion Reactions
Acute Non hemolytic reactionsAcute Non hemolytic reactions
Hypersensitivity reaction
•The most common.
•A reaction to plasma proteins in blood resulting in
the release of vasoactive peptides and activation of
complement.
•It may be a mild and rarely sever ( anaphylaxis 1 in
20,000 units)

24. Transfusion ReactionsTransfusion Reactions
Acute Non hemolytic reactionsAcute Non hemolytic reactions
Febrile non-hemolytic reaction
•in 3-4% of all transfusions
•development of high fever during or within 24
hours of a transfusion
•Theories:
-alloimmunization to leukocyte or platelet antigens
-formation of cytokines during storage
•Self limiting

25. Transfusion ReactionsTransfusion Reactions
Hemolytic reactionsHemolytic reactions
Acute immune hemolytic reaction
•The most serious transfusion reaction
•Occurs in 1 in 40,000 transfused units.
•Recipient’s antibodies to ABO antigens result in a
rapid intravascularintravascular hemolysis of donor RBCs
mediated by activation of complement.

26. Transfusion ReactionsTransfusion Reactions
Hemolytic reactionsHemolytic reactions
Delayed hemolytic reaction
•Results from an anamnestic Ab response to donor
Rh or non-ABO antigens causing an extravascularextravascular
hemolytic reaction
•Transfused blood cells take days or weeks to
hemolyze and typically there are few signs or
symptoms other than falling RBC count and
elevated bilirubin.

27. Transfusion ReactionsTransfusion Reactions
Transfusion related acute lung injury (TRALI)
•Occurs in 1 in 5000 units transfused
•Its is a clinical syndrome with acute hypoxemia and non-
cardiogenic pulmonary edema.
•Usually occurs within 1 to 2 hours of transfusion (anytime
up to 6 hours later).
•Theories:
- Donor blood containing anti-leukocyte Ab.
- Mediators of inflammation form in stored blood

28. Transfusion ReactionsTransfusion Reactions
•Patient develops fever, SOB, cough and hypoxemia.
CXR shows the picture of ARDS with perihilar
infiltrates.
• Support can vary from supplemental oxygen to
intubation and ventilation. Most cases resolve on
their own but some can be fatal.

29. Clinical practice guidelines..Clinical practice guidelines..
Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med 2009 vol.37
No.12

30. Transfusion ReactionsTransfusion Reactions

GVHDGVHD
• Rare (0.15% incidence) but usually fatal complication
• Donor T lymphocytes mount an immune response against the
recipient's lymphoid tissue.
- When the recipient is immunocompromised or donor
is homozygous and the recipient is heterozygous for
HLA, normal defense mechanisms fail.
• Mortality rate 80%, preventable by irradiation of blood.

31. Complications of BT…Complications of BT…
Role of leukoreduction
•Reduces the number of transfused WBCs.
•Leukoreduction is effective in reducing the
transmission of cell-associated viruses (eg, CMV,
EBV) and post operative infections.

32. Complications of BT…Complications of BT…
Role of leukoreduction
•But studies showed no significant effect on
mortality, febrile episodes or MOF *
•Some studies have suggested it has further reduced
the already low risk of transfusion related GVHD
* Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med
2009 vol.37 No.12

33. Complications of MBTComplications of MBT
A) Alteration in coagulation system
It can be a preexisting or Induced coagulopathy.
Effects of acidosis and hypothermia
•Acidosis interferes with the assembly of coagulation
factor complexes involving calcium
•Hypothermia reduces the enzymatic activity of
plasma coagulation proteins and prevents plt
activation

34. Complications of MBTComplications of MBT
Coagulation proteins
• Resuscitation results in gradual dilution of plasma
clotting proteins
•Bleeding due to dilution can occur when the level of
coagulation proteins falls to 25 % of normal. (8- 10
units)

35. Complications of MBTComplications of MBT
Platelet count
•Each 10 - 12 units can produce a 50 % fall in the
platelet count; thus, significant thrombocytopenia
can be seen
•Also a dilutional effect

36. Complications of MBTComplications of MBT
B) Complications Of Citrate TransfusionB) Complications Of Citrate Transfusion
Metabolic alkalosis
•At collection pH 7.10
•falls 0.1 pH unit/week due to lactic and pyruvic
acids.
•Acidosis does not develop in a massively bleeding
patient even if "acidic" blood is infused.

37. Complications of MBTComplications of MBT
Metabolic alkalosis
Each 1 mmol of citrate 3 mEq of
bicarbonate.
As a result, metabolic alkalosis can occur

38. Complications of MBTComplications of MBT
Hypocalcemia
•Due to citrate binding of ionized calcium
•Clinically significant hypocalcemia does not usually
occur unless the rate of transfusion exceeds one
unit every five minutes.

39. Complications of MBTComplications of MBT
Hypocalcemia
•May exhibit transient tetany and hypotension.
•Calcium should only be given if there is clinical or
ECG or lab evidence of hypocalcaemia

40. Complications of MBTComplications of MBT
Hypothermia
•Blood warmers should be used as the rapid
transfusion of multiple units of may reduce the core
temperature and can lead to cardiac arrhythmias.
•Leads to :
- reduction in citrate and lactate metabolism
- increases affinity of haemoglobin for oxygen,
- impairment of red cell deformability

41. Complications of MBTComplications of MBT
Hyperkalemia
•Potassium levels in stored blood increase by
approximately 1 meq/L per day ( peaks at 30
meq/L)
•Not a problem unless very large amounts of blood
are given quickly
•To minimize the risk:
- Use of < 5 days stored blood
- wash unit before transfusion

42. Complications of MBT…Complications of MBT…
Volume overload
•In patients with poor cardiac or renal function.
•Careful monitoring of volume status and diuretic
therapy can reduce the risk of this complication.

43. Clinical Practice Guidelines.Clinical Practice Guidelines.
Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med 2009 vol.37
No.12

44. Clinical Practice Guidelines.Clinical Practice Guidelines.
Clinical practice guideline: RBC transfusion in adult trauma and critical care. Crit Care Med 2009 vol.37
No.12

46. Alternative to BTAlternative to BT
•Hemoglobin-based oxygen carriers are being
investigated for use in critically ill and injured
patients, not yet approved (level 2).
•Potential uses:
-Elective surgery
-Hemorrhagic shock of trauma
- Vaso-occlusive crises

47. Alternative to BTAlternative to BT
Side effects:Side effects:
•Vasoactivity
•Gastrointestinal side effects
•Immunosuppression
•Myocardial infarction and death
Further phase III trials of HBOCs will not be
conducted until it can be shown that these agents
are at least as effective in reducing mortality or
serious morbidity as the current standards of care

48. …Thank You…

49. References.. References..
•Clinical practice guideline: RBC transfusion in adult trauma
and critical care. Crit Care Med 2009 vol.37 No.12
•ARCH SURG/VOL 143 (NO. 7), JULY 2008
•Massive blood transfusion by Steven Kleinman, MD up to
date article Sept. 2009
•Transfusion Reactions by Eric M Kardon, MD ,eMedicine
Dec 10, 2009
•Indications for red cell transfusion in the adult by Steven
Kleinman, MD up to date September 2009
•Clinical Surgery ,A.Cuscheieri, 2
nd
ed
•Schwartz’s Principles of Surgery, 8
th
ed