1. MASSIVE TRANSFUSION OB ROUNDS, JAN 23 2008

2. RECOMMENDATIONS FOR MASSIVE TRANSFUSION Assuming: Previously healthy 70 kg adult No cardiac disease Not anaemic Not anticoagulated

3. Basics Multiple large IVs (?Central Line) Urinary catheter Keep as warm as possible Bloodwork – CBC, U&E, Creat, PT/PTT/INR (ABG and Lactate if in shock) Cross match 6 units

4. First 1 – 2 litres of blood loss: Crystalloids 3:1 or Colloids (Voluven, Pentaspan) 1:1 Transfuse RBC if Hb <70 if stable, <100 if acutely bleeding, higher if CAD If Hb starts at 150, it will be 100 after 1,700 mls lost and 70 after 2,700 mls Use HemoQ for rapid bedside Hb estimation Get ready to transfuse by 1l lost, transfuse before 2l lost in most cases

5. Maximum Allowable Blood Loss MABL before transfusion= (Hbi - Hbt)/Hbi x 72 x Wt Hbi= Initial Hb (e.g.110) Hbt= Transfusion trigger Hb (e.g 70) Wt= Weight (e.g. 55kg) MABL=(110-70)/110 x 72 x 55 = 1,440 mls

6. FFP Indications: INR >1.5, or loss of 1 – 1.5 CBV (5 – 7.5 litres) Controversial – In Iraq war trauma FFP started with blood, 1:1 Need ~30% normal level of clotting factors. Give 10 – 15 ml/kg, roughly 3 – 4 units

7. Platelets Indications: Pl < 50 (or <75 and bleeding, or <100 and head trauma) Expect to need platelets after 2 x CBV or 10 litres Order early as take time (~ 2hr) to arrive Give 5 units (one pool) or one apherisis unit

8. Other treatments ?Consult haematology, ICU Cryoprecipitate: If Fibrinogen < 1g/l, give 1 unit per 10 kg or 8-10 units – (large donor pool) rVIIa: Consider if has had over 8 units and still bleeding

9. Metabolic Issues CaCl 2 (better than gluconate, which needs metabolizing) 10 ml 10 % Check for –Acidosis (base deficit), –Hyperkalaemia –Lactate

10. Endpoints (Sunnybrook): HR<120, BP>90 UO >15ml/hr

11. Risks of Transfusion #1 ALLERGY –Rash, urticaria 1:50 – 1:100 –Febrile reaction, minor allergy 1:100 – 1:500 –Anaphylaxis1:25,000 FLUID OVERLOAD1:700 TRALI1:1,500 -1:5,000 HAEMOLYSIS –Delayed reaction1:7,000 –Acute (incompatible blood)1:40,000 (1:700,000 die)

12. Risks of Transfusion #2 - INFECTIONS Bacterial Platelets1:2,500 per pool (1:40,000 die) Blood1:100,000 per unit (1:1m die) Viral Hep B1:30,000 – 1:80,000 Hep A1:2m HTLV1:2-3m Hep C1:3m HIV/AIDS1:5m West Nile? Other Prions??? Parasites1:4m

13. COMMENTS ? QUESTIONS ?