List the problems associated with massive transfusion in the critically ill. Outline your principles of management for each.
Massive transfusion (eg. replacement of more than 50% of blood volume in 12 to 24 hours, or one circulation blood volume in 24 hrs [T Oh]) is associated with many potential problems which are related to a number of factors including the volume of resuscitation, factors related to the storage blood, and many other related issues. Problems include:
• Volume overload (careful monitoring of filling pressure, response to volume, diuresis)
• Over-transfusion (monitor Hb regularly, titrate according to needs)
• Hypothermia (use of fluid warmers and general measures to minimise heat loss)
• Dilutional coagulopathy of both clotting factors and platelets (regular and early monitoring of coagulation, and involvement of haematology for replacement therapy [better than according to protocol])
• Transfusion related lung injury (consider use of filters, leukodepletion)
• Excessive citrate causing metabolic alkalosis and hypocalcemia (monitor pH and ionised calcium, replace calcium as necessary)
• Hyperkalaemia (use of “younger” blood, monitor regularly, may require specific therapy)
• Disease transmission (use of products on as needed basis only, standard blood banking precautions)
• Distractions resulting in not controlling source of haemorrhage, and risks of hurried cross-checking and incompatibility (allocation of sufficient resources and personnel, standard programs in place to facilitate process and anticipate needs)
• Other problems include loss of identity (cross matching issues, loss of baseline haematological information etc.)
Massive transfusion is discussed in greater detail elsewhere. Several definitions exist, but the replacement of 1 blood volume is a popular one.
In fact, and excellent article from Chest (2010) has a nice table (Table 1) of complications from massive transfusion. That table was a strong (dominating) influence on the following list of complications:
- Acute hemolytic transfusion reactions
- Febrile nonhemolytic transfusion reactions
- Tranfusion-associated lung injury (TRALI)
- Transfusion-associated circulatory overload (TACO)
- Allergic reactions to blood products
- Bacterial sepsis due to contaminated blood products
- Hypocalcemia due to citrate
- Hyperkalemia due to high PRBC K+ content
- Acidosis due to high PRBC lactate content
- Hypothermia due to use of recently refrigerated PRBCs
- Dilutional coagulopathy due to inappropriate blood product replacement proportions
- Dilutional thrombocytopenia due to lack of platelet replacement
- Delayed hemolytic transfusion reactions
- Transfusion-related immune modulation (TRIM)
- Microchimerism - the persistence of an allogeneic cell population of leucocytes
- Transfusion-transmitted diseases, eg. HIV, Hep C
- Posttransfusion graft-vs-host disease (due to non-leukodepleted PRBCs)
- Posttransfusion purpura
The college allso asks the candidate to "outline your management for each".
This requires a large table. The Australian Red Cross Blood Service have a nice table for management steps of transfusion reactions.
|Acute hemolytic transfusion reactions||
|Febrile nonhemolytic transfusion reactions||
|Allergic reaction to blood products||
|Tranfusion-associated lung injury||
|Transfusion-associated circulatory overload||
|Hypocalcemia due to citrate||
|Hyperkalemia due to high PRBC K+ content||
|Delayed hemolytic transfusion reactions||
|Transfusion-related immune modulation||
|Posttransfusion graft-vs-host disease||
Sihler, Kristen C., and Lena M. Napolitano. "Complications of massive transfusion." CHEST Journal 137.1 (2010): 209-220.
Capon, Stephen M., and Dennis Goldfinger. "Acute hemolytic transfusion reaction, a paradigm of the systemic inflammatory response: new insights into pathophysiology and treatment." Transfusion 35.6 (1995): 513-520.
Perrotta, P. L., and E. L. Snyder. "Non-infectious complications of transfusion therapy." Blood reviews 15.2 (2001): 69-83.
Beauregard, Patrice, and Morris A. Blajchman. "Hemolytic and pseudo-hemolytic transfusion reactions: an overview of the hemolytic transfusion reactions and the clinical conditions that mimic them." Transfusion medicine reviews 8.3 (1994): 184-199.
Reed, William, et al. "Transfusion-associated microchimerism: a new complication of blood transfusions in severely injured patients." Seminars in hematology. Vol. 44. No. 1. WB Saunders, 2007.
Anderson, Kenneth C., and Howard J. Weinstein. "Transfusion-associated graft-versus-host disease." New England Journal of Medicine 323.5 (1990): 315-321.
Yokoyama, Ana Paula Hitomi, et al. "Diagnosis and Management Of POST-Transfusion Purpura-Case Report." Blood 122.21 (2013): 4834-4834.