1. Emergency & Massive Transfusion
Brian Poirier, MD
UCDavis Medical Center

2. Learning Objectives Define Massive Transfusion.
List the types of shock.
Understand estimations of blood loss and fluid resuscitation.
Discuss the indications for red cells, platelets and plasma in massive transfusion.
Become aware of the risks of emergency release blood.

3. Massive Transfusion 10 or more pRBC units (TBV) in <24 hours.
Others:
Replacement of 50% of TBV within 3 hours.
Blood loss >150 ml/min.

4. Massive Transfusion Clinical Settings
Trauma
Surgery (e.g. Liver, Cardiovascular)
GI bleeding
Obstetrics

5. Storm King Mountain Colorado

6. SHOCK

7. Types of Shock Hypovolemic – Hemorrhage
Cardiogenic – MI, cardiomyopathy
Obstructive – Tamponade, PE
Distributive – Sepsis, Anaphylaxis
Hypovolemic – Hemorrhage

8. Class I <750ml blood loss, 10-15% Pulse <100, BP Normal
Pulse Pressure Normal or Increased
Resp Rate 14-20
Urine Output >30ml/hr
CNS: Slightly Anxious
Fluid Replacement - Crystalloid

9. Class II 750-1500ml 15%-30% Blood Loss Pulse >100, BP Normal
Pulse Pressure Decreased
Resp Rate 20-30
Urine Output ml/hr
CNS Mildly Anxious
Fluid replacement Crystalloid

10. Class III 1500-2000ml 30%-40% Blood Loss Pulse >120, BP Decreased
Pulse Pressure Decreased
Resp Rate
Urine Output 5-15ml/hr
CNS Anxious and Confused
Fluid Replacement - Crystalloid & Blood

11. Class IV >2000ml 40% or more Blood Loss Pulse >140, BP Decreased
Pulse Pressure Decreased
Resp Rate >35
Urine Output Negligible
CNS Confused & Lethargic
Fluid Replacement - Crystalloid and Blood

12. Can Estimate Blood Loss by Response to Fluid Bolus

13. Laboratory Values to Monitor in Trauma
Hgb/Hct
INR/PTT
Fibrinogen
Platelet Count
Blood Gases
Electrolytes

14. Blood Products
RBC
Plasma
Platelets
Cryoprecipitate

15. Blood Products

16. Blood Orders Patient Blood Sample Available
Type & Screen
Type and Crossmatch
Patient Blood Sample Not Available
Emergency Release (Universal Donor/Pink Sheet)
Massive Transfusion Guideline

17. Emergency Release Blood - Universal Donor
O, RhD neg/pos RBCs – 5 min
AB or A Plasma/Platelets

18. Type & Screen Initial sample gets ABO, Rh type and antibody screen.
Time ~ 40min.
When blood is needed an immediate spin crossmatch is done.
Time ~ min.

19. Type & Crossmatch
Initial sample gets ABO, Rh type, antibody screen and crossmatch.
Time ~ 60min.
When blood is needed it has already been fully tested.
Time~5min.

20. Probability of Safe Transfusion

21. Other Emergency RBC Problems
Incomplete compatibility testing
Unexpected antibodies found
Compatible blood not available

23. Washout Curve Y/Y0= e-x Y = Final concentration of substance
Y0 = Initial concentration of substance
X = total number of volumes exchanged
Derksen 1984

24. Coagulation Factors-% Needed for Hemostasis
II %
V %
VII >10%
VIII 30-40%
IX %
X %
XI %

25. Reed 1985
Showed that platelet counts after massive blood loss did not decline according to standard apheresis wash out equations
More platelets became physiologically available
Possible splenic reservoir

26. Platelets & Massive Blood Loss (Toy 1991)
Massive Transfusion Patients
Resuscitated with only RBCs & Crystalloid
After 20 units 75% showed plt count < 50K
No documentation of microvascular bleeding

27. UCD Platelet Usage 1992 1.5% of Trauma patients required platelets
1.43% of blunt injury patients
2.3% of penetrating injury patients

28. UCDMC Non-MTG Indications for Platelets & Hemostatic Factors
FFP if INR> 1.5 or PT >1.5 X Normal
Platelets if Count <50K-100K
Cryoprecipitate if Fibrinogen <100mg/dl (each unit contains ~250 mg)

29. “It saves more lives than you could believe” Gen. George S Patton

30. Massive Exanguination “Triad of Death”
Acidosis
Hypothermia
Coagulopathy

31. Blood Warmer

32. Massive Transfusion Protocol
Mortality in massive transfusion is high – up to 57% (patients transfused >50 RBC units)
Coagulopathy is present early and not only a factor of hemodilution (Gonzalez et al 2007)
A recent retrospective review shows an increase in survival with a 1:1:1 ratio of plasma: platelets: RBCs

33. Massive Transfusion Study (Holcomb 2008)

34. Massive Transfusion Study (Holcomb 2008)

35. Massive Transfusion Study (Holcomb 2008)

36. Massive Transfusion Study (Holcomb 2008)

37. Massive Transfusion Protocol
New Trend to give RBCs, FFP and Platelets to simulate whole blood
Typical Published Ratios of RBC:FFP:Platelets using Typical Products
6 units RBC Adult (250ml/unit)
6 units FFP (~250ml/unit)
6 units Platelet Concentrate (50ml/unit)

38. UCDMC Massive Transfusion Guideline (Established 2008)
Adult Replacement Volumes established based on Acute Blood Loss of 50% and maintenance of a RBC:FFP:Platelet ratio of whole blood AND using the products available at UCDMC
6 units RBC Adult (250ml/unit)
3 units FFP Jumbo (400ml/unit)
1 unit Plateletpheresis (250ml/unit)

39. Massive Transfusion Protocol Example

40. Pediatric MTG
Used Pediatric Growth Charts to determine the weights of children at various age groups and adult dosages were downsized proportionally
MTG specifies what you will receive in the box NOT necessarily the exact dosage for the patient
Each child will need a dosage calculation or estimate based on their size and extent of hemorrhage

41. Problems of the MTG
Is it translatable to civilian practice? Is it needed for all patients or only the most severely injured ?
Wastage of (precious) AB plasma.
Will it increase acute pulmonary events - TACO & TRALI?

43. Potential Adverse Effects of Massive Transfusion
Metabolic Disturbances
Transfusion Reactions
Infectious Disease Risks

44. Massive Transfusion Citrate Toxicity Hyperkalemia
Decreased Oxygen Delivery
Hypothermia

45. Acute/Immediate Transfusion Reactions
Acute Hemolytic Reactions
Bacterial Contamination of Blood Products
Anaphylaxis
Transfusion Related Acute Lung Injury
Severe Febrile Reactions
Transfusion Associated Circulatory Overload
Metabolic Problems of Massive Transfusion
Air Emboli & Microemboli
Hypotensive Response to Plasma

46. Transfusion Mortality FDA Reports

47. Sources of Error (NY Data 1999)
58% Outside blood bank
17% In blood bank & outside
25% In blood bank

48. Sources of Error 58% Outside of the Blood Bank
43% Failure to identify patient
11% Phlebotomy error
3% Incorrect order/No ID at bedside

49. Sources of Error 17% In & Outside of Blood Bank
15% blood issued for another patient/not detected at bedside
2% Inconsistent order sent/not detected in blood bank

50. Sources of Error 25% In Blood bank 1% Used wrong sample
11% wrong blood group issued
7% Incorrect typing-technical
6% incorrect typing - clerical

51. Preventing Errors
Non-punitive error reporting system to uncover systemic/organizational problems
Process Control to Neutralize Human Error
Strict DOE policy (name change requires ABO verification)
ABO Verification on all 1st time recipients
System Audits

52. Phlebotomy Errors Highest Single Source has always been ER
1994 Study showed ER as Major contributor of Mislabelled Specimens
Current Audits still show ER submits many mislabelled specimens but they’ve improved

53. Thank You! მადლობა

54. Thanks to:
Carol Marshall, MD
L. Fernando, MD
Rosemary Howard, CLS

55. References
Gonzalez EA, Moore FA, Holcomb JB, et al. (2007) Fresh frozen plasma should be given earlier to patients requiring massive transfusion. The Journal of Trauma, 62:
Holcomb JB, Wade CE, Michalek JE, et al. (2008) Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Annals of Surgery, 248:
Ho AMH, Dion PW, Cheng CAY, et al. (2005) A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage. Canadian Journal of Surgery, 48(6):
The Face of Mercy: A Photographic History of Medicine at War created and produced by Matthew Naythons, ISBN , New York, NY, Random House/Epicenter Inc, 1993.