Complications of Massive Blood Transfusion

1. Complications of Massive Blood Transfusion Edgar J. Pierre, M.D. Assistant Professor of Anesthesia, Surgery and Critical Care Ryder Trauma Center University of Miami

2. Someone needs blood every 3 seconds • One in ten hospitalized patients needs blood • 4.5 million lives are saved by blood transfusions/year • One unit of blood saves three lives

3. has about one cup of blood in its body A newborn baby

4. 90% water • albumin – the chief protein • fibrinogen • globulins • other clotting proteins • one white cell • forty platelets • six hundred red cells Blood makes up 7% of the body’s weight 55% plasma 45% cell mass

5. 1 A.D.- roman gladiators drank the blood of slain opponents to harness their strength

6. 1818 – first recorded human transfusion Treats postpartum hemorrhage using patient’s husband as donor James Blundell, MD

7. Karl Landsteiner, MD The breakthrough – blood typing 1901 – Landsteiner discovers the first three human blood groups – A,B,C (later O) 1902 – colleagues Alfred Decastello and Adriano Sturli add AB 1930 – Landsteiner receives the Nobel Prize for Medicine

8. Distribution of blood types for the US population

9. “3” buckets Maintenance Insensible loss Deficit • 4 cc/Kg for 1st 10Kg of weight • 4 cc/Kg for minimal trauma • 2 cc/Kg for 2nd 10Kg of weight • 6 cc/Kg for moderate trauma • 1 cc/Kg for the remaining weight • 8 cc/Kg for severe trauma Crystalloid replacement scheme: Hourly maintenance x number of hours NPO

10. Estimation of Blood Volume • Most commonly used methodology bases estimation on weight, age, and gender

11. Massive blood transfusion • As the replacement of a patient’s total blood volume in less than 24 hours • In a normal adult, this is 10-20 units • As the acute administration of more than half the patient’s estimated blood volume per hour

12. 43 y/o white female s/p uterine rupture with intra-abdominal bleeding for exploratory laparotomy • Starting hematocrit = 43 • Weight = 90 Kg • Allowable hematocrit = 25 ABL = 90 Kg x 70 cc/Kg x [(43-25)/34] = 3,335 cc

13. Hemodynamic stability is the key indicator • If Hgb > 10g/dl transfusion is rarely indicated • If Hgb < 7g/dl transfusion is usually necessary • With Hgb between 7-10 g/dl, clinical status are helpful in defining transfusion requirements • Blood pressure • Heart rate • Extraction ratio

14. Transfusion requirements should be based on the patient’s physiologic needs • Oxygen demand (consumption) • CO × (CaO2-CvO2) • Oxygen delivery • CO × CaO2 • Extraction Ratio • CaO2-CvO2/CaO2

15. Risks of blood component therapy • Transfusion reactions • Hemolytic • Donor blood contains an antibody, usually against the patient's HLA or leukocyte specific antigens • Non-hemolytic • Febrile, urticaria, anaphylactic, purpura

16. Hemolytic reactions Acute hemolytic reactions Are usually due to ABO blood type incompatibility Occur approximately 1 in 25,000 transfusions Often very severe and accounts for 50% of deaths related to transfusions Fatal hemolytic reaction 1:600,000 transfusions Severity of the reaction depends in the amount of blood given

17. Acute hemolytic reactions • Symptoms • Chills, fever, nausea, chest pain in awake patients • Rise in temperature, unexplained tachycardia, hypotension, hemoglobinuria, DIC, shock and renal failure in anesthetized patients • Management • Stop transfusion immediately, re-check the unit, test for hemoglobin in plasma and urine • Facilitate osmotic diuresis and support hemodynamic

18. Hemolytic reactions Delayed hemolytic reactions Caused by antibodies to non-D antigens of the Rh system or foreign alleles 1-1.6% chance of developing antibodies following a normal compatible transfusion Takes weeks or months to happen- and by that time, the original transfused cells have already been cleared Re-exposure can then cause an immune response

19. Delayed hemolytic reactions • Symptoms • Mild and include malaise, jaundice, fever, fall in hematocrit despite transfusion • Diagnosis may be facilitated by the direct Coombs test ( detect antibodies on the membranes of red cells • Management • Generally supportive • Occurs in approximately 1 in 2,500 transfusions and most often in females with previous exposure secondary to pregnancy

20. Non-hemolytic reactions Febrile Urticarial Anaphylactic Graft versus Host Purpura Immune Suppression

21. Febrile reactions 1-3% of all transfusions Rise in temperature without evidence of hemolysis Should receive leukocyte poor transfusions Use of a filter traps most contaminants Urticarial Reactions 1% of all transfusions Erythema, hives without fever PBRC has decreased the likelihood of this problem Treatment is with antihistamines Non-hemolytic reactions

22. Graft vs Host Immunocompromised patients Lymphocyte s can mount an immune response against the recipient Irradiation of transfusions to inactivate the lymphocytes prior to transfusion Post-transfusion purpura Common with the development of platelets antibodies Lead to profound thrombocytopenia Plasmapheresis is the recommended treatment Non-hemolytic reactions

23. Non-hemolytic reactions • Pulmonary edema • Transfusion related acute lung injury – 13% of all transfusion deaths • Donor blood contains an antibody, usually against the patient's HLA or leukocyte specific antigens • Dyspnea, hypotension and fever within 1-2 hours after transfusion • CXR – diffuse, non-specific infiltrates • Treatment involves respiratory support as needed

24. Non-hemolytic reactions • Anaphylactic reaction • Rare and occur in about 1 of 150,000 transfusions • Occur in IgA deficient patients with anti IgA antibodies • IgA deficiency occurs in 1 of 600-800 patients in the general population • Patients should receive thoroughly washed PRBC • Treatment involves fluids, epinephrine, corticosteroids and supportive measures

25. Non-immune complications • Infectious complications • Viral ( hepatitis, HIV, CMV, HTLV) • Parasitic and bacteremia • Physiologic complications • Coagulopathy • Citrate toxicity • Hypothermia • Acid-base disturbances

26. CMV and EBV Asymptomatic or mild systemic disease Immunocompromised patients are susceptible to CMV and should receive CMV negative units only HTLV-1 and HTLV-II Leukemia and lymphoma retro-viruses associated with transfusion Current risk is estimated at 1:250,000 to 2,000,000 Infectious complications

27. Hepatitis Risk of hepatitis A from transfusion is estimated to be 1:100,000 1:30,000 to 250,000 for Hepatitis B 1:30,000 to 1:150,000 for Hepatitis C

28. AIDS All blood is tested for the anti-HIV antibody 6-8 week period required for a person to develop antibody after they are infected therefore infectious units can go undetected Current risk for HIV infection due to transfusion is estimated to be 1:200,000 to 2,000,000

29. Risks of blood component therapy • Infectious risks per unit • Viral contamination • HIV <1:1,900,000 • Hepatitis C <1:1,000,000 • Hepatitis B <1:137,000 • HTLV I + II <1:641,000 • Bacterial contamination • <1:542 six unit platelets pool • <1:777 aphaeresis platelets • <1:38,565 PRBC units

30. Coagulopathy Most common cause of bleeding following large volume transfusion: dilutional thrombocytopenia At least 1.5 times blood volume must be replaced for this to become a clinical problem Thrombocytopenia can occur following smaller transfusions if DIC or there is pre-existing thrombocytopenia

31. Citrate Toxicity Citrate in the transfused blood binds to calcium each unit of blood contains 3 grams of citrate transfusion rates higher than one unit/5 minutes may lead to citrate toxicity At least 1.5 times blood volume must be replaced for this to become a clinical problem Treatment is with intravenous calcium administration if there is biochemical, clinical or electrocardiographic evidence of hypocalcemia

32. Hypothermia Leads to reduction of citrate and lactate metabolism −hypocalcemia and metabolic acidosis Increase affinity of hemoglobin for oxygen, Leads to platelet dysfunction, and increase tendency for cardiac dysrhythmias Massive transfusion is an absolute indication for the warming of all blood to body temperature as it is being given

33. Acid/Base Disturbances Most common abnormality is a metabolic alkalosis −lactic acid in stored PRBC (30-40mmol/l) −citrate and lactic acid metabolized to bicarbonate Final acid/base status being dependent on tissue perfusion, rate of administration and citrate metabolism

34. Hyperkalemia

35. Management of Massive Transfusion Hypotension should be treated speedily. Do not delay fluid administration Initial red cell replacement is in the form of packed red cells Blood should be taken for group and crossmatch, these must be properly labeled and identified in all situations

36. Management of Massive Transfusion For extreme emergencies group O blood should be supplied first Type specific blood should be available in 5-10 minutes and switch promptly Continue transfusing blood on this basis until crossmatch blood is available

37. Guidelines for red blood cell and plasma transfusion for adults and children

38. Complications of Massive Blood Transfusion Edgar J. Pierre, M.D. Assistant Professor of Anesthesia, Surgery and Critical Care Ryder Trauma Center University of Miami