In the name of GOD

1. In the name of GOD Blood Transfusion in Burned Patients Haddadi MD Anesthesiology Department in GUMS 2014

3. Need to transfusion is not a major concern during immediate resuscitation phase • During the acute resuscitation phase a fall in Hb (hemodilution, escharotomies , other invasive procedures ) • In OR patients have major blood loss (excision , graft)

4. resuscitation phase

5. Hct to drop to 15-20% prior to transfusion in other healthy patients with minor excision • Hct <25% in pre-existing Cardiovascular Disease • Hct near 25% in patients with more extensive burn • Hct near 30% in patients with pre-existing Cardiovascular Disease • Hb 6-6.5 gr/dl • the lowest adverse metabolic or hemodynamic reactions

6. Need to blood transfusion • Evaluating the patient’s clinical status • Assessment of ongoing blood loss , pre-operative Hb level , vital sign • Evidence of inadequate o2 delivery such as hypotension, tachycardia ,acidosis • Pulmonary ,cardiovascular D. • ASA , Hb>10 - Hb<6 +

8. During excision of major burn wounds ,blood loss may reach to patient’s blood volume • Massive Hemorrhage • Loss of 1 blood volume in 24 h • 50% blood volume in 3 h • Ongoing blood loss of 150 ml/min

9. High blood loss: • Coagulation factors are lost • Dilution as volume replacement • Resulting coagulopathy • Use of FFP in massive hemorrhage • Recent clinical studies: early use of FFP+PRBCs in replacement of massive hemorrhage

10. Exp. During burn surgery • Intravascular volume, with colloid( Alb,Hetastarch) • O2 carrying capacity with PRBCs until 50% of est Blood Volume • From this point ,FFP with PRBCs • RBCs enhance homeostasis through effects on platelet biochemistry and function

11. Massive Blood Transfusion • Hypothermia • Hypothermia can contribute to coagulopathy • Blood warmers when flow rate of blood >100 ml/min • Hypocalcemia (rapid flow rate,FFP, citrate) • Hypocalcemia impairs coagulation interferes with vascular ,myocardial contractility then, hypotension ( cacl2) • Ca Gluconate requires to hepatic metabolism

12. Reducing surgical blood loss • Use of tourniquets on limbs(limitations) • Compression dressings at sites of excision • Pharmacologic : epinephrine soaked dressings topical epinephrine spray Tachycardia, hypertension • Systemic Terlipressin (vasopressin analog )

13. Blood components • Whole blood • Packed RBCs • FFP • Platelets • Cryoprecipitate

14. Whole blood • Contains all parts of blood • After 24 h ,has not functional WBC ,Plt • For burns, liver transplant, trauma, hypovolemic shock

15. Packed RBCs • The most common means of replacing blood loss • 50 ml residual plasma

16. Changes during storage in whole blood(CPD)

17. Comparison of Whole Blood ,PRBCs

18. Fresh Frozen Plasma • In burn injuries to replace clotting factors during massive transfusion • Clotting factors, Protein S,C • In massive transfusion, if active bleeding exists, coagulation factor deficiency approved

20. Platelets • Stored at room temperature to max viability • Increasing bacterial contamination after 4 days • Refrigerated PLT remain viable only 24-48h • 5000-10,000PLT

21. Cryoprecipitate • Thawing FFP at 4 c ,collecting cryoprecipitate • Rich in factors XIII, VIII, fibrinogen , Von Willebrand factor • Massive blood transfusion to treat hypo-fibrinogenemia • Plasma fibrinogen<100 mg/dl • 1 unit cryoprecipitate will increase Plasma fibrinogen by 5-7 mg/dl

22. Transfusion Reactions • Hemolytic Transfusion Reaction • Delayed Hemolytic Transfusion Reaction (Immune Extravascular Reaction) • Nonhemolytic Transfusion Reactions Transfusion-Related Fatalities in the United States, 2004-2006

23. Hemolytic Transfusion Reaction

24. -- Steps in the Treatment of a Hemolytic Transfusion Reaction    1.  STOP TRANSFUSION.    2.    Maintain the urine output at a 75 to 100 mL/hr    a.    Generously administer fluids intravenously and possibly mannitol (12.5 to 50 g, given over 5 to 15 minutes).    b.    If intravenously administered fluids and mannitol are ineffective, administer furosemide (20 to 40 mg) intravenously.    3.    Alkalinize the urine; because bicarbonate is preferentially excreted in the urine, only 40 to 70 mEq of sodium bicarbonate per 70 kg of body weight is usually required to raise the urine pH to 8, whereupon repeat urine pH determinations indicate the need for additional bicarbonate.    4.    Assay urine and plasma hemoglobin concentrations.    5.    Determine platelet count, partial thromboplastin time, and serum fibrinogen level.    6.    Return unused blood to blood bank for repeat crossmatch.    7.    Send patient's blood and urine sample to blood bank for examination.    8.    Prevent hypotension to ensure adequate renal blood flow.

25. Delayed Hemolytic Transfusion Reaction (Immune Extravascular Reaction) • the transfused donor cells may survive well initially • after a variable delay (2 to 21 days) they are hemolyzed • This type of reaction occurs mainly in recipients sensitized to RBC antigens by previous blood transfusions or pregnancy • RBC destruction occurs only when the level of antibody is increased after a secondary stimulus (i.e., anamnestic response) • a decrease in the post-transfusion hematocrit value

26. Nonhemolytic Transfusion Reactions • Nonhemolytic reactions to blood transfusions usually are not serious and are febrile or allergic in nature. • The most common adverse reactions to blood transfusions consist of chills, fever, headache, myalgia, nausea, and nonproductive cough occurring shortly after blood transfusion caused by pyrogenic cytokines and intracellular contents released by donor leukocytes. • Allergic reactions can be minor, anaphylactoid, or anaphylactic • The most common symptom is urticariaassociated with itching. Occasionally, the patient has facial swelling.

27. Infectivity of Blood  Percentage Risk of Transfusion-Transmitted Infection with a Unit of Screened Blood in the United States Infection Risk Window Period (days)