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MASSIVE TRANSFUSION

MASSIVE TRANSFUSION. OB ROUNDS, JAN 23 2008. RECOMMENDATIONS FOR MASSIVE TRANSFUSION. Assuming: Previously healthy 70 kg adult No cardiac disease Not anaemic Not anticoagulated. Basics. Multiple large IVs (?Central Line) Urinary catheter Keep as warm as possible

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MASSIVE TRANSFUSION

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  1. MASSIVE TRANSFUSION OB ROUNDS, JAN 23 2008

  2. RECOMMENDATIONS FOR MASSIVE TRANSFUSION Assuming: • Previously healthy 70 kg adult • No cardiac disease • Not anaemic • Not anticoagulated

  3. Basics Multiple large IVs (?Central Line) Urinary catheter Keep as warm as possible Bloodwork – CBC, U&E, Creat, PT/PTT/INR (ABG and Lactate if in shock) Cross match 6 units

  4. First 1 – 2 litres of bloodloss: • Crystalloids 3:1 or Colloids (Voluven, Pentaspan) 1:1 • Transfuse RBC if Hb <70 if stable, <100 if acutely bleeding, higher if CAD • If Hb starts at 150, it will be 100 after 1,700 mls lost and 70 after 2,700 mls • Use HemoQ for rapid bedside Hb estimation • Get ready to transfuse by 1l lost, transfuse before 2l lost in most cases

  5. Maximum Allowable Blood Loss MABL before transfusion= (Hbi - Hbt)/Hbi x 72 x Wt Hbi= Initial Hb (e.g.110) Hbt= Transfusion trigger Hb (e.g 70) Wt= Weight (e.g. 55kg) MABL=(110-70)/110 x 72 x 55 = 1,440 mls

  6. FFP • Indications: INR >1.5, or loss of 1 – 1.5 CBV (5 – 7.5 litres) • Controversial – In Iraq war trauma FFP started with blood, 1:1 • Need ~30% normal level of clotting factors. • Give 10 – 15 ml/kg, roughly 3 – 4 units

  7. Platelets • Indications: Pl < 50 (or <75 and bleeding, or <100 and head trauma) • Expect to need platelets after 2 x CBV or 10 litres • Order early as take time (~ 2hr) to arrive • Give 5 units (one pool) or one apherisis unit

  8. Othertreatments ?Consult haematology, ICU • Cryoprecipitate: If Fibrinogen < 1g/l, give 1 unit per 10 kg or 8-10 units – (large donor pool) • rVIIa: Consider if has had over 8 units and still bleeding

  9. Metabolic Issues • CaCl2 (better than gluconate, which needs metabolizing) 10 ml 10 % • Check for • Acidosis (base deficit), • Hyperkalaemia • Lactate

  10. Endpoints (Sunnybrook): • HR<120, • BP>90 • UO >15ml/hr

  11. Risks of Transfusion #1 ALLERGY • Rash, urticaria 1:50 – 1:100 • Febrile reaction, minor allergy 1:100 – 1:500 • Anaphylaxis 1:25,000 FLUID OVERLOAD 1:700 TRALI 1:1,500 -1:5,000 HAEMOLYSIS • Delayed reaction 1:7,000 • Acute (incompatible blood) 1:40,000 (1:700,000 die)

  12. Risks of Transfusion #2 - INFECTIONS Bacterial Platelets 1:2,500 per pool (1:40,000 die) Blood 1:100,000 per unit (1:1m die) Viral Hep B 1:30,000 – 1:80,000 Hep A 1:2m HTLV 1:2-3m Hep C 1:3m HIV/AIDS 1:5m West Nile ? Other Prions ??? Parasites 1:4m

  13. COMMENTS ? • QUESTIONS ?

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