Question 1

College Answer

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.)

Discussion

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

• 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 complications

• 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.

Management of Massive Transfusion-Associated Complications

Acute hemolytic transfusion reactions	Stop transfusion Re-crossmatch Maintain blood pressure with vasopressors (there may be cytokine shock) Maintain adequate urine output to prevent haem-associated ATN
Febrile nonhemolytic transfusion reactions	Stop transfusion Antipyretic agents
Allergic reaction to blood products	Stop transfusion Antihistamine and corticosteroid
Tranfusion-associated lung injury	Stop transfusion Ventilate like ARDS
Transfusion-associated circulatory overload	Stop transfusion Administer a diuretic Consider a venodilator (eg. GTN) to decrease preload Ventilate with a higher PEEP
Bacterial sepsis	Management of sepsis as per usual routine Inform blood bank regarding contaminated blood products Perform a blood culture and Gram stain on the bag of PRBCs Keep the bag and giving set
Hypocalcemia due to citrate	Calcium replacement
Hyperkalemia due to high PRBC K+ content	Routine management of hyperkalemia (eg. calcium gluconate, bicarbonate)
Acidosis	Tincture of time, if your liver is normal Dialysis, if the clearance mechanisms are impaired
Hypothermia	Aggressive rewarming You should have used a blood warmer
Dilutional coagulopathy	Blood products will need to be replaced - FFP and cryoprecipitate to start with
Dilutional thrombocytopenia	Platelet transfusion
Delayed hemolytic transfusion reactions	Maintain blood pressure with vasopressors (there may be cytokine shock) Maintain adequate urine output to prevent haem-associated ATN
Transfusion-related immune modulation	You should have used leukodepleted PRBCs
Microchimerism	Using leukodepleted PRBCs, surprisingly, is not protective. Monitor for GVHD and autoimmune diseases
Transfusion-transmitted diseases	Councelling of the affected Post-exposure prophylaxis, if relevant Antiviral therapies
Posttransfusion graft-vs-host disease	Immunosuppression
Posttransfusion purpura	IV immunoglobulin Plasmapheresis Generally, management resembles the management for TTP

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.