Massive blood product transfusion

By Alex Yartsev - 29/06/2015

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The 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 Question 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. That 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 of blood products, the NBA guidelines statement on massive 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

This- 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.

Thus, a single "massive transfusion resuscitation volume" would include:

4units of PRBCs
2 units of FFP (15ml/kg)
1 adult dose of platelets
3-4g of fibrinogen (in cryoprecipitate).

The evidence behing various transfusion ratios is explored more thoroughly in the chapter on haemostatic resuscitation.

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

References

Goodnough, Lawrence T., Jerrold H. Levy, and Michael F. Murphy. "Concepts of blood transfusion in adults." The Lancet 381.9880 (2013): 1845-1854.

Spahn, Donat R., and Lawrence T. Goodnough. "Alternatives to blood transfusion." The Lancet 381.9880 (2013): 1855-1865.

There is also a rescinded document from the NHMRC (2001) which has been used to guide practice: Clinical Practice Guidelines on the Use of Blood Components.

To some extent this document has been superceded by the Australian and New Zealand Society of Blood Transfusion GUIDELINES FOR THE ADMINISTRATION OF BLOOD PRODUCTS.

The Patient Blood Management Guidelines from the National Blood Authority of Australia is another series of documents worth looking at - it contains several important modules which have been reviewed and which act as successors to the 2001 NHMRC guidelines.

Treleaven, Jennie, et al. "Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task 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 Center." Transfusion 43.12 (2003): 1672-1676.

Heddle, Nancy M., and Morris A. Blajchman. "The leukodepletion of cellular blood products in the prevention of HLA-alloimmunization and refractoriness to allogeneic platelet transfusions [editorial]." Blood 85.3 (1995): 603-606.

Sharma, R. R., and Neelam Marwaha. "Leukoreduced blood components: Advantages and strategies for its implementation in developing countries."Asian journal of transfusion science 4.1 (2010): 3.

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. "The 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. "The 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.

Australian Red Cross - Blood Service Policy on "The Age of Red Cells"

Hess, John R. "Red cell changes during storage." Transfusion and Apheresis Science 43.1 (2010): 51-59.

Bennett-Guerrero, Elliott, et al. "Evolution of adverse changes in stored RBCs."Proceedings of the National Academy of Sciences 104.43 (2007): 17063-17068.

Sihler, Kristen C., and Lena M. Napolitano. "Complications of massive transfusion." CHEST Journal 137.1 (2010): 209-220.

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