1. 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. resuscitation phase Surgical procedurePredicted 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 0.5-0.75ml/cm2 burn area 1-1.25ml/cm2 burn area

5.  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 6-6.5 gr/dl  the lowest adverse metabolic or hemodynamic reactions Factors Clas s I Class IIClass II Class III Clas s IV Blood loss (mL)750 750-1500750-1500 1500- 2000 200 0 or mor e Blood loss (% blood volume)15 15-3015-30 30-40 40 or mor e Pulse (beats/min)100 100100 120 140 or high er Blood pressure Nor mal NormalNormal Decrease d Respirations per minute 14- 20 20-3020-30 30-4035 Urine output (mL/hr)30 20-3020-30 5-10 Negl igibl e Central nervous system: mental status Sligh tly anxi ous Mildly anxiousMildly anxious Anxious, confused Conf used, letha rgic Fluid replacement (3-1 rule) Crys talloi d CrystalloidCrystalloid Crystalloi d + blood

6.  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>10 - Hb<6 +

7. FactorsClass IClass IIClass IIIClass IV Blood loss (mL) 750750-15001500-20002000 or more Blood loss (% blood volume) 1515-3030-4040 or more Pulse (beats/min) 100 120140 or higher Blood pressureNormal Decreased Pulse pressure (mm Hg) Normal or increased Decreased Respirations per minute 14-2020-3030-4035 Urine output (mL/hr) 3020-305-10Negligible Central nervous system: mental status Slightly anxiousMildly 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.  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.  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.  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.  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.  Whole blood  Packed RBCs  FFP  Platelets  Cryoprecipitate

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

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

16. 1 7 14 21 PH 7.1 7 7 6.9 PCO2 48 80 110 140 K ( meq/l) 3.9 12 17 21 2,3 DPG 4.8 1.2 1 1 Viable PLT% 10 0 0 0 Factors 5,7 % 70 50 40 20 DaysOf StorageAt 4”c

17. 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 4 Plasma acid 80 25 Plasma Na (meq) 45 15

18.  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.  Stored at room temperature to max viability  Increasing bacterial contamination after 4 days  Refrigerated PLT remain viable only 24-48h  5000-10,000PLT

21.  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.  Hemolytic Transfusion Reaction  Delayed Hemolytic Transfusion Reaction (Immune Extravascular Reaction)  Nonhemolytic Transfusion Reactions Transfusion-Related Fatalities in the United States, 2004-2006  Cause of Fatality2004-06Average per Year TRALI8629 Other reactions (non- ABO hemolytic therapy; anaphylaxis) 6722 Bacterial contamination20 7 ABO hemolytic transfusion therapy 15 5 Transfusion not ruled out 3110

23. Sign or SymptomNo. of Patients Fever19 Fever and chills16 Chest pain 6 Hypotension 6 Nausea 2 Flushing 2 Dyspnea 2 Hemoglobinuria 1

25.  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 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. Percentage Risk of Transfusion-Transmitted Infection with a Unit of Screened Blood in the United States Infection Risk Window Period (days) InfectionRisk Window Period (days) Human immunodeficiency virus-1 1/2,135,00011 Human T- lymphotropic virus (HTLV-II) 1/2,993,00051 Cytomegalovirus (CMV) Infrequent with leukocyte- reduced components Hepatitis C virus (HCV) 1/1,935,00040 Hepatitis B virus (HBV)1/205,000 West Nile virus (WNV)1/1,100,000?