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 complications
Delayed complications
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 |
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Febrile nonhemolytic transfusion reactions |
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Allergic reaction to blood products |
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Tranfusion-associated lung injury |
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Transfusion-associated circulatory overload |
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Bacterial sepsis |
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Hypocalcemia due to citrate |
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Hyperkalemia due to high PRBC K+ content |
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Acidosis |
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Hypothermia |
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Dilutional coagulopathy |
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Dilutional thrombocytopenia |
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Delayed hemolytic transfusion reactions |
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Transfusion-related immune modulation |
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Microchimerism |
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Transfusion-transmitted diseases |
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Posttransfusion graft-vs-host disease |
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Posttransfusion purpura |
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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.