of blood products, the NBA guidelines statement on massive
Deranged Physiology » Required Reading » Haematology and Oncology
Massive blood product transfusion
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e contents and properties of packed red blood cells, the
physiology of acute haemorrhage and the physiological
responses to a moderate-volume blood transfusion are
detailed in other chapters. CICM have asked about this only
in estion 1 from the first paper of 2005.
Definition of a "massive transfusion"
A "massive transfusion" is defined by the volume of blood
lost. Most people are happy to call the replacement of one's
entire blood volume a massive transfusion. at would be
about 7% of a person's body weight, or about 10 units of
PRBCs in a normal-looking adult. Others use time-defined
criteria (the replacement of half of one's blood volume over
4 hours) or bleeding-defined criteria (rate of blood loss in
excess of 150ml/min).
A brief word on the management of massive haemorrhage
Apart from the recommendations strictly related to the use
transfusion also offers its 2 cents worth to the management
of severe trauma.
Use permissive hypotension (SBP 80-100)
Correct acidosis
Correct hypothermia
Correct hypocalcemia
is- in brief summary - is the essence of haemostatic
resuscitation, the new dogma of managing traumatic
haemorrhage, which is well explored in another chapter
from the Trauma section.
Ratio of blood prodcts in massive
transfusion
One specific feature of the NBA document is that no
recommendation is made for any specific ratio of PRBCs to
other blood products. However, a massive transfusion
protocol template is offered, which can be downloaded and
printed; it suggests that the senior clinicial officer order
packages of 2 units of FFP and 4 units PRBCs, and continue
doing so until the bleeding is controlled. Platelets and
cryoprecipitate are also recommended, and though a "ratio"
is not specified, doses are suggested.
us, a single "massive transfusion resuscitation volume"
would include:
 4units of PRBCs circulatory overload Administer a diuretic
2 units of FFP (15ml/kg) Consider a venodilator (eg. GTN) to
1 adult dose of platelets decrease preload
3-4g of fibrinogen (in cryoprecipitate). Ventilate with a higher PEEP

Bacterial sepsis Management of sepsis as per usual routine

e evidence behing various transfusion ratios is explored
more thoroughly in the chapter on haemostatic Inform blood bank regarding contaminated

resuscitation. blood products

Perform a blood culture and Gram stain on
the bag of PRBCs

Management of massive transfusion- Keep the bag and giving set

associated complications Hypocalcemia due to Calcium replacement

Acute hemolytic
transfusion reactions
citrate
Hyperkalemia due to Routine management of hyperkalemia (eg.
+
high PRBC K content calcium gluconate, bicarbonate)
Stop transfusion
Acidosis Tincture of time, if your liver is normal
Re-crossmatch
Maintain blood pressure with vasopressors Dialysis, if the clearance mechanisms are

(there may be cytokine shock) impaired

Maintain adequate urine output to prevent Hypothermia Aggressive rewarming

Febrile nonhemolytic
transfusion reactions
Allergic reaction to
blood products
haem-associated ATN You should have used a blood warmer
Stop transfusion Dilutional coagulopathy Blood products will need to be replaced -
Antipyretic agents FFP and cryoprecipitate to start with
Stop transfusion Dilutional Platelet transfusion
Antihistamine and corticosteroid thrombocytopenia

Tranfusion-associated Stop transfusion

lung injury Ventilate like ARDS Delayed hemolytic Maintain blood pressure with vasopressors
transfusion reactions (there may be cytokine shock)
Transfusion-associated Stop transfusion
 Maintain adequate urine output to prevent
haem-associated ATN
References
Transfusion-related You should have used leukodepleted
immune modulation Goodnough, Lawrence T., Jerrold H. Levy, and Michael F.
PRBCs
Murphy. "Concepts of blood transfusion in adults." The
Microchimerism Using leukodepleted PRBCs, surprisingly, Lancet 381.9880 (2013): 1845-1854.
is not protective.
Monitor for GVHD and autoimmune Spahn, Donat R., and Lawrence T. Goodnough. "Alternatives
diseases to blood transfusion." The Lancet 381.9880 (2013): 1855-1865.

Transfusion-transmied Councelling of the affected ere is also a rescinded document from the NHMRC (2001)
diseases Post-exposure prophylaxis, if relevant which has been used to guide practice: Clinical Practice
Antiviral therapies Guidelines on the Use of Blood Components.
Posransfusion gra- Immunosuppression To some extent this document has been superceded by the
vs-host disease
Australian and New Zealand Society of Blood Transfusion
Posransfusion purpura IV immunoglobulin GUIDELINES FOR THE ADMINISTRATION OF BLOOD
Plasmapheresis PRODUCTS.
Generally, management resembles the
management for TTP e Patient Blood Management Guidelines from the
National Blood Authority of Australia is another series of
documents worth looking at - it contains several important
Previous chapter: ABO modules which have been reviewed and which act as
blood grouping and successors to the 2001 NHMRC guidelines.
transfusion compatibility
Treleaven, Jennie, et al. "Guidelines on the use of irradiated
Next chapter: Storage blood components prepared by the British Commiee for
lesions of banked red Standards in Haematology blood transfusion task
blood cells force." British Journal of Haematology 152.1 (2011): 35-51.

Aoun, Elie, et al. "Transfusion‐associated GVHD: 10 years’

experience at the American University of Beirut—Medical Australian Red Cross - Blood Service Policy on "e Age of
Center." Transfusion 43.12 (2003): 1672-1676. Red Cells"

Heddle, Nancy M., and Morris A. Blajchman. "e Hess, John R. "Red cell changes during storage." Transfusion
leukodepletion of cellular blood products in the prevention and Apheresis Science 43.1 (2010): 51-59.
of HLA-alloimmunization and refractoriness to allogeneic
Benne-Guerrero, Ellio, et al. "Evolution of adverse
platelet transfusions [editorial]." Blood 85.3 (1995): 603-606.
changes in stored RBCs."Proceedings of the National
Sharma, R. R., and Neelam Marwaha. "Leukoreduced blood Academy of Sciences 104.43 (2007): 17063-17068.
components: Advantages and strategies for its
Sihler, Kristen C., and Lena M. Napolitano. "Complications
implementation in developing countries."Asian journal of
of massive transfusion." CHEST Journal 137.1 (2010): 209-
transfusion science 4.1 (2010): 3.
220.
Dzik, Walter H. "Leukoreduction of blood
components." Current opinion in hematology 9.6 (2002): 521-
526.

Corwin, Howard L., and James P. AuBuchon. "Is

leukoreduction of blood components for
everyone?." JAMA 289.15 (2003): 1993-1995.

Blajchman, M. A. "e clinical benefits of the

leukoreduction of blood products."Journal of Trauma-
Injury, Infection, and Critical Care 60.6 (2006): S83-S90.

Rosenbaum, Lizabeth, et al. "e reintroduction of

nonleukoreduced blood: would patients and clinicians
agree?." Transfusion 51.12 (2011): 2739-2743.

Bilgin, Y. M., L. M. van de Watering, and A. Brand. "Clinical

effects of leucoreduction of blood transfusions." Neth J
Med 69.10 (2011): 441-450.
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