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8/6/2019 Massive Blood Transfusion by Dr.bhanumurthy
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Massive Blood TransfusionMassive Blood Transfusion
When, What to Care & AlternativesWhen, What to Care & Alternatives
S BhanumurthyS Bhanumurthy
8/6/2019 Massive Blood Transfusion by Dr.bhanumurthy
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Contents:
� Introduction : Definition
Patho-physiology
� When : Types of SituationsImplications
� What to care: Management
� Alternatives : Autologous Blood
HB solution
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Definition
Massive Blood Transfusion:
Replacement equivalent to
pt bl. Volume in 24 hours
Or ½ the Bl vol in 3 hours
UK military: Transfusion of 4u RCC in 1hr Or 10u of RCC in 24 hours
Introduction
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Patho-Physiology
� Trauma & Ops.: Third Space Fluid Loss
& Blood loss
� Leading to: Decreased perfusion
Hypotension & Shock
Tissue hypoxia
� Resulting in: Met. AbnormalitiesMulti- System failure
Introduction
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Situations
� Expected:
i) Specific : Liver Transplant
Open Heart Surgery
ii) Non Specific: Any major Surgery
associated with massive blood loss
� Unexpected:
i) In hospital: Post Op bleed
ii) Out of hospital: Trauma, Blast injury
When
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Implications
Expected Unexpected
� Pt. Prepared
� Elective & Planned
� Social hours & good
Communication� Organised Theatre available
� Senior Team
� Blood products ready
� Monitor & Freq Invest.
� Adeq. Warming devices
� Early slow IV warmtransfusion
� ITU & Post Op care
Ahead in the game
� Moribund, not prepared
� Emerg. & Aggressive
� Often in out of hours so
poor communication� Organised theatre?
� Often junior doctors
� Bl. Products may not ready
� Monitor&Invest. inadequate
� Warming device usage?
� Often IV fluids late & Rapid
� ITU/HDU care may not
Chasing the numbers
When
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What to care for Factors involved in Management
Stop further blood loss
Manage hypovolemia
Maintain Oxygenation
Prevent/ treat coagulopathyPrevent/ treat hypothermia
Judicious monitoring & freq. Invest.
Watch and correct electrolyte
ImbalanceConsider alternatives
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Decreasing the Bl. Loss
� Trauma: C before ABC
Emergency Bandage, CAT
Indirect pressure
Quikclot, HemconPrevent Hypothermia
� In OT: Surgical measures
Anaesthetic measures
Avoid hypothermiaPrevent/treat coagulopathy
Drugs
What to care for
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Field Bandage & Tourniquet
What to care for
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has positively charged chitosan, extracted f rom shrimp shells.
Attracts negatively charged red blood cells and
create a tight-f itting plug over the wound.
"You can have a hole in your heart and 60 secondslater it's sealed," says inventor Kenton Gregory.
What to care for
HemCon
Bandage
Made its
debut in the
2003 Iraq war
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QuikClot
Granulated mineral, non-biological
So minimal or no allergic reaction
Rapid absorption of fluid-µµconc. of clot. Factors & Haemostasis
Stops moderate to severe bleeding by rapid coagulation
Painless
What to care for
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Drugs
Desmopressin: Mild Hemophilia, Uremia
Defective platelets, Ch. Liver disease
Antifibrinolytics: Aprotonin,
Tranexemic acid, Aminocaprioic Acid
in CPB, transplants, ortho &
vascular surgeries
Other specific: Protamine
What to care for
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Hypovolemia
More dangerous than hypoxemia,
So early treatment is essential
Two Big bore IV cannulae, Rapid Infuser Consider Main.& Third space losses as
well
Crystalloids Vs Colloids, Combination is better
Hypotension may be due to other causes
What to care for
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Maintenance of Oxygenation
� Increase FiO2
� Replace the Volume
� RCC transfusion If Hb% <6gm : MustIf Hb% >10g : No
� Based on time available O neg/positive
Gr. Spec. Uncross/Cross Matched RCC� Use Warming device
What to care for
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Prevent/treat coagulopathy
Causes:
� Dilutional
� Hypothermia
� Pre-op patient status
� DIC
� Surgical: CPB, Transplants� Transfusion Reactions
What to care for
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Prevent/ treat coagulopathy
� Prevent hypothermia
� Observe intra-Op bleed
� Frequent investigations
� Liaise with Haematologist� If APTT & PT >1.5
treat with FFP/CPP
Empirical Tt: RCC:FFP= 1:1
DIC? : Additional measures may be needed
What to care for
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Recombinant Factor VIIa
Licensed to treat Hemophilia
Other Indication: Salvageable pt. with Uncontrolled
bleed despite surgical/ Non surgical methods
Correct Acidosis and HypothermiaConsider after 6-8u of PRBC, if bleeding continues
Dose: 100ug kg-1 if needed another in 20-30min.
Contraindication: In last 6 months Thrombo-embolic
events
What to care for
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Thrombocytopenia
� Critical level: 50x109/L
� Trigger level: 75x109/L
� In CNS & major trauma etc aim for 100X109/l
� Don¶t use the same bl. Giving set
What to care for
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Monitor, Investigate, Coms/Records
� Dedicated Coordinator
� Monitoring: Vital Signs, SpO2, Dir. Art. BPCVP, Temp., Urine Output &
Fluid balance, blood loss
� Investigate: Frequent FBC, U&E, Ca++
Clotting Screen, Bl.gases
What to care for
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Electrolyte Imbalance
� Lactates, Citrates & Acidosis
� Hyperkalaemia
� Hypocalcaemia: Ca++, Albumin levels
Freq investigations & Correction
What to care for
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Autologous blood
� Pre-op blood donations/intra-op admin
� Blood Salvage: Replaces only RBC
Limitations: Needs trained &
Dedicated personnel
Equipment & Disposables� PO drained Blood: Anticoagulants++
Alternatives
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Oxygen Carrying solutions
� Hb. Solution: 3 types in Phase iii trials
Long shelf life, No Cross match/infection
� Problems: With earlier versions
Renal failure, Hypertension
With recent versionsTrans-capillary leak
Increased O2 affinity
Alternatives
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Key Learning Points
� Expected and Unexpected massive
transfusions are different
� Prompt and aggressive management is needed
in unexpected group
� New agents: Hemcon, Quickclot
� Volume replacement is vital
� Prevent Hypothermia & Coagulopathy
� Needs multidisciplinary consultant input & Co-
ordination
� Communication & record keeping are imp.
� Alternatives are not yet fully alternative
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Thank You
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Bad Prognostic Indicators at
admission
� INR>1.5
� Base Deficit>6
� Temp: 350C or less
� Sys BP<90mmHg
� HB<11gm/dl� Abnormal Mental status
� Severe Injury
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Complications in Summary
� Haemolytic reactions: Early& Delayed
� Transfusion Transmitted Infections
� Transfusion Related Acute Lung Injury
� Hypothermia, Hyperkalaemia
� Hypocalcaemia, Hypomagnaesemia� Acidosis and Coagulopathy