1. In the name of GOD Blood Transfusion in Burned Patients Haddadi MD
Anesthesiology Department in GUMS
2014

3. Need to transfusion is not a major concern during immediate resuscitation phase
During the acute resuscitation phase a fall in Hb (hemodilution, escharotomies , other invasive procedures )
In OR patients have major blood loss (excision , graft)

4. Surgical procedure Predicted blood loss <24 h since burn injury
0.45ml/cm2 burn area
1-3 days since burn injury
0.65ml/cm2 burn area
2-16 days since burn injury
0.75ml/cm2 burn area
>16 days since burn
injury
Infected wound
ml/cm2 burn area
1-1.25ml/cm2 burn area
resuscitation phase

5. Hct <25% in pre-existing Cardiovascular Disease
Hct to drop to 15-20% prior to transfusion in other healthy patients with minor excision
Hct <25% in pre-existing Cardiovascular Disease
Hct near 25% in patients with more extensive burn
Hct near 30% in patients with pre- existing Cardiovascular Disease
Hb gr/dl
the lowest adverse metabolic or hemodynamic reactions
Factors
Class I
Class II
Class III
Class IV
Blood loss (mL)
750
2000 or more
Blood loss (% blood volume) 15
15-30
30-40
40 or more
Pulse (beats/min)
100
120
140 or higher
Blood pressure
Normal
Decreased
Respirations per minute
14-20
20-30 35
Urine output (mL/hr) 30
5-10
Negligible
Central nervous system: mental status
Slightly anxious
Mildly anxious
Anxious, confused
Confused, lethargic
Fluid replacement (3-1 rule)
Crystalloid
Crystalloid + blood

6. Need to blood transfusion
Evaluating the patient’s clinical status
Assessment of ongoing blood loss , pre- operative Hb level , vital sign
Evidence of inadequate o2 delivery such as hypotension, tachycardia ,acidosis
Pulmonary ,cardiovascular D.
ASA , Hb> Hb<6 +

7. Factors
Class I
Class II
Class III
Class IV
Blood loss (mL)
750
2000 or more
Blood loss (% blood volume) 15
15-30
30-40
40 or more
Pulse (beats/min)
100
120
140 or higher
Blood pressure
Normal
Decreased
Pulse pressure (mm Hg)
Normal or increased
Respirations per minute
14-20
20-30 35
Urine output (mL/hr) 30
5-10
Negligible
Central nervous system: mental status
Slightly anxious
Mildly anxious
Anxious, confused
Confused, lethargic
Fluid replacement (3-1 rule)
Crystalloid
Crystalloid + blood

8. During excision of major burn wounds ,blood loss may reach to patient’s blood volume
Massive Hemorrhage
Loss of 1 blood volume in 24 h
50% blood volume in 3 h
Ongoing blood loss of 150 ml/min

9. High blood loss: Coagulation factors are lost
Dilution as volume replacement
Resulting coagulopathy
Use of FFP in massive hemorrhage
Recent clinical studies: early use of FFP+PRBCs in replacement of massive hemorrhage

10. Exp. During burn surgery
Intravascular volume, with colloid( Alb,Hetastarch)
O2 carrying capacity with PRBCs until 50% of est Blood Volume
From this point ,FFP with PRBCs
RBCs enhance homeostasis through effects on platelet biochemistry and function

11. Massive Blood Transfusion
Hypothermia
Hypothermia can contribute to coagulopathy
Blood warmers when flow rate of blood >100 ml/min
Hypocalcemia (rapid flow rate,FFP, citrate)
Hypocalcemia impairs coagulation interferes with vascular ,myocardial contractility then, hypotension ( cacl2)
Ca Gluconate requires to hepatic metabolism

12. Reducing surgical blood loss
Use of tourniquets on limbs(limitations)
Compression dressings at sites of excision
Pharmacologic :
epinephrine soaked dressings
topical epinephrine spray
Tachycardia, hypertension
Systemic Terlipressin (vasopressin analog )

13. Blood components
Whole blood
Packed RBCs
FFP
Platelets
Cryoprecipitate

14. Whole blood Contains all parts of blood
After 24 h ,has not functional WBC ,Plt
For burns, liver transplant, trauma, hypovolemic shock

15. Packed RBCs The most common means of replacing blood loss
50 ml residual plasma

16. Changes during storage in whole blood(CPD)1 7 14 21 PH
7.1
6.9
PCO2 48 80
110
140
K ( meq/l)
3.9 12 17
2,3 DPG
4.8
1.2
Viable PLT% 10
Factors 5,7 % 70 50 40 20
Days
Of Storage
At 4”c

17. Comparison of Whole Blood ,PRBCs
value
Whole Blood
Packed RBC
Volume(ml)
517
300
Erythrocyte mass(ml)
200
Hct % 40 70
Alb (gr)
12.5 4
Plasma K(meq) 15
Plasma acid 80 25
Plasma Na (meq) 45

18. Fresh Frozen Plasma
In burn injuries to replace clotting factors during massive transfusion
Clotting factors, Protein S,C
In massive transfusion, if active bleeding exists, coagulation factor deficiency approved

19. Indications for FFP according to National Health Guidelines
Replacement of isolated factor deficiencies(lab evidence)
Reverse of warfarin effect
Antithrombine III deficiency
Treatment of immunodeficiencies
Treatment of TTP
Massive blood transfusion( V,VIII=25% of normal)
PT,PTT 1.5 times normal

20. Platelets Stored at room temperature to max viability
Increasing bacterial contamination after 4 days
Refrigerated PLT remain viable only 24-48h
,000PLT

21. Cryoprecipitate Thawing FFP at 4 c ,collecting cryoprecipitate
Rich in factors XIII, VIII, fibrinogen , Von Willebrand factor
Massive blood transfusion to treat hypo- fibrinogenemia
Plasma fibrinogen<100 mg/dl
1 unit cryoprecipitate will increase Plasma fibrinogen by 5-7 mg/dl

22. Transfusion Reactions
Hemolytic Transfusion Reaction
Delayed Hemolytic Transfusion Reaction (Immune Extravascular Reaction)
Nonhemolytic Transfusion Reactions Transfusion-Related Fatalities in the United States,
Cause of Fatality
Average per Year
TRALI 86 29
Other reactions (non-ABO hemolytic therapy; anaphylaxis) 67 22
Bacterial contamination 20  7
ABO hemolytic transfusion therapy 15  5
Transfusion not ruled out 31 10

23. Hemolytic Transfusion Reaction
Sign or Symptom
No. of Patients
Fever 19
Fever and chills 16
Chest pain  6
Hypotension
Nausea  2
Flushing
Dyspnea
Hemoglobinuria  1

24. -- Steps in the Treatment of a Hemolytic Transfusion Reaction 1
-- Steps in the Treatment of a Hemolytic Transfusion Reaction      1.  STOP TRANSFUSION.    2.    Maintain the urine output at a 75 to 100 mL/hr    a.    Generously administer fluids intravenously and possibly mannitol (12.5 to 50 g, given over 5 to 15 minutes).    b.    If intravenously administered fluids and mannitol are ineffective, administer furosemide (20 to 40 mg) intravenously.    3.    Alkalinize the urine; because bicarbonate is preferentially excreted in the urine, only 40 to 70 mEq of sodium bicarbonate per 70 kg of body weight is usually required to raise the urine pH to 8, whereupon repeat urine pH determinations indicate the need for additional bicarbonate.    4.    Assay urine and plasma hemoglobin concentrations.    5.    Determine platelet count, partial thromboplastin time, and serum fibrinogen level.    6.    Return unused blood to blood bank for repeat crossmatch.    7.    Send patient's blood and urine sample to blood bank for examination.    8.    Prevent hypotension to ensure adequate renal blood flow.

25. Delayed Hemolytic Transfusion Reaction (Immune Extravascular Reaction)
the transfused donor cells may survive well initially
after a variable delay (2 to 21 days) they are hemolyzed
This type of reaction occurs mainly in recipients sensitized to RBC antigens by previous blood transfusions or pregnancy
RBC destruction occurs only when the level of antibody is increased after a secondary stimulus (i.e., anamnestic response)
a decrease in the post-transfusion hematocrit value

26. Nonhemolytic Transfusion Reactions
Nonhemolytic reactions to blood transfusions usually are not serious and are febrile or allergic in nature.
The most common adverse reactions to blood transfusions consist of chills, fever, headache, myalgia, nausea, and nonproductive cough occurring shortly after blood transfusion caused by pyrogenic cytokines and intracellular contents released by donor leukocytes.
Allergic reactions can be minor, anaphylactoid, or anaphylactic
The most common symptom is urticaria associated with itching. Occasionally, the patient has facial swelling.

27. Infectivity of Blood
Percentage Risk of Transfusion-Transmitted Infection with a Unit of Screened Blood in the United States Infection Risk Window Period (days)
Infection
Risk
Window Period (days)
Human immunodeficiency virus-1
1/2,135,000 11
Human T-lymphotropic virus (HTLV-II)
1/2,993,000 51
Cytomegalovirus (CMV)
Infrequent with leukocyte-reduced components
Hepatitis C virus (HCV)
1/1,935,000 40
Hepatitis B virus (HBV)
1/205,000
West Nile virus (WNV)
1/1,100,000 ?