1. Consultant in Haematology and Transfusion Medicine
Massive Transfusion
Dr. Dupe Elebute
MRCP, MRCPath, MD
Consultant in Haematology and Transfusion Medicine

2. Massive Blood Loss Definitions:
Loss of one blood volume within 24 hour period
50% blood volume loss within 3 hours
Rate of blood loss  150ml/min
Any blood loss >2L (SGH)

3. Presentation Medical emergency
Usually occurs in A&E, operating theatre or obstetric department
High morbidity & mortality from:
Underlying cause of haemorrhage
Pre-existing disease (liver, renal)
Complications of massive blood transfusion

4. SGH: Massive Transfusion by specialty
TRAUMA
CARDIO
THORACIC
9.5%
26%
OBSTETRIC
24%
ANEURYSM
7.1%
SURGICAL
GI BLEED
9.5%
24%

5. Complications of Massive Tx
Circulatory overload/ARDS
Hypothermia  Acidosis
Hyperkalaemia
Rare
Exacerbated by keeping blood at RT for long periods
Increased risk with -irradiated blood

6. Complications of Massive Tx (2)
Citrate toxicity  hypocalcaemia
Massive transfusion with whole blood or FFP
Massive transfusion in newborn infants
Depletion of platelets, coagulation factors
Other transfusion reactions (infections!)

7. Haemostatic complications
Replacement of TBV in short period of time
Thrombocytopenia
Dilution effect
Increased consumption
Results in microvascular bleeding when <50x109/L
Coagulation Factors
Deficient in red cell concentrates

8. Massive Blood Loss:A Vicious Cycle
Haemorrhage
Dilution of clotting factors/DIC;
thrombocytopenia
Massive Blood Transfusion

9. Management Resuscitation
rapid infusion of crystalloid; maintain blood volume
Optimise oxygen carrying capacity
maintain PCV>0.20
Maintain haemostasis
platelet count (>50 x 109/l),
coagulation factors
Correct or avoid metabolic disturbances

10. Management (2) Monitor Blood component therapy FBC, clotting screen
U & Es including Calcium, arterial pH
ECG, CXR
Blood component therapy
effective communication between clinicians, lab staff
urgent review of results

11. Red Cells ‘Flying squad’ – O RhNeg CMV neg
If >30-40% of blood volume lost
In extreme situations:
Group O un-crossmatched red cells
ORh (D) Neg for pre-menopausal women
ORh (D) Pos for men, post menopausal women
‘Flying squad’ – O RhNeg CMV neg

12. Platelets Essential to keep platelets >50x109/l
Higher target of 100x109/l for:
Multiple high-energy trauma
Central nervous system injury
Prophylactic use in platelet dysfunction e.g. CABG

13. Coagulation Factors FFP Cryoprecipitate
Provides replacement for most coagulation factors
Essential to give adequate volume
Dose: 12-15ml/kg
Cryoprecipitate
For treatment of DIC
Required if Fibrinogen <1.0 g/L

14. Code Red Procedure Inform blood bank: ‘Code Red!!!’
If ‘flying squad’ blood used
Send 2 group & X-match samples
Transfusion Nurse/SpR informed

15. Code Red: blood components
First stage:
6 units blood
1 litre FFP
2 pools platelets
Second Stage:
10 units cryo if fibrinogen <0.8g/l
2 pools platelets if count <100 x 109/L
Send blood for repeat FBC, coag, chemistry

16. Adjunctive therapy
Tranexamic acid, Aprotinin have been shown to reduce transfusion requirements in CABG
Desmopressin (DDAVP) and aprotinin can reduce antiplatelet effect of Aspirin
Coagulation factors:
Prothrombin Complex Concentrate (Beriplex)
Fibrinogen concentrate
Factor VIIa (NovoSeven)

17. Recombinant FVIIa : NovoSeven® Mode of Action
Tissue factor (TF)/FVIIa,
is necessary to initiate haemostasis
rFVIIa directly activates
FX on the surface of activated platelets
This activation initiates
the ”thrombin burst”
independently of FVIII and FIX
This step is independent of TF
The “thrombin burst” leads to formation of a stable clot

18. Novoseven Recombinant human factor VIIa Activates extrinsic pathway
Licensed for:
Congenital/acquired haemophilia
Factor VII deficiency
Glanzmann’s thrombasthenia

19. Role in non-haemophilia patients?
Anecdotal reports:
Control of haemorrhage in traumatic and post-surgical bleeding
Controlled trials
Prophylaxis prior to elective surgery (prostatectomy)
Treatment of intracranial haemorrhage

20. NovoSeven Audit 18 ‘non-haemophilia’ patients on database
12/16 under surgical speciality
Increasing use over 12 months by cardiothoracic and vascular surgery
67 vials used in total
2 patients given novoseven twice – neither survived!

21. NovoSeven audit: outcome
7/16 patients survived to discharge
Survival unrelated to age or sex
Trend of improved survival when used in patients with haemorrhage complicating a procedure
Marked reduction in blood product support
BUT at a cost…

24. NovoSeven Audit:Cost Analysis
Dose: 90g/kg
1.2 units = £820 (inc VAT)
Total units of Novoseven : 147
Average units per patient: 9
Total cost of Novoseven: £119,326
Average cost per patient: £7458

25. SGH Blood components Projected spend £3.5 million
Platelets £198.76
Red cells £120.22
Cryoprecipitate £35.62
FFP £30.89

26. Alternatives to allogeneic blood transfusion

27. Autologous pre-deposit
Useful in elective surgery for fit patients
Maximum of 4 units
Requires sufficient time prior to surgery for collection (done by NBS)
begins 3-5 weeks pre-op; last unit >72hours pre-op
Does not remove all potential hazards
infections: no different from allogeneic blood
getting the wrong blood!

28. Acute Normovolaemic Haemodilution
Elective or emergency surgery where blood loss is > 1L
Whole blood removed by anaesthetist
litres (up to 3 units) can be collected
Replaced with crystalloid/colloid
Clearly labelled pack with anticoagulant
“UNTESTED BLOOD: FOR AUTOLOGOUS USE ONLY”
Blood must remain with the patient until re-infused
Re-infused during procedure or immediately post-op

29. Intra-operative Blood Salvage
Shed blood from operative field is collected
Blood is anticoagulated with citrate or heparin
Filtered to remove debris/clots
Suitable for cardiac surgery and trauma
C/I in contaminated operative fields and malignancy

30. Postoperative Blood Salvage
Blood from wound drains collected and re-infused using special equipment
Proven to reduce blood transfusion post hip, knee replacement surgery
Cheap, managed by nurses

31. Erythropoietin Genetically engineered Synthetic form; s/c or iv
Suitable for:
Renal patients
Patients with multiple red cell abs
JW patients
Can be used to boost pre-deposit

32. Intravenous iron Improves bioavailability Rapidly increases stores
Avoids potential gastric irritation and malabsorption
May improve response to EpO