1. Massive Transfusion in Trama By R1 彭育仁

2. Brief History(1) 26 y/o male came to our ER due to massive bleeding from cutting wound over right neck and left head. Cons: irritable T/P/R:36.7/155/30, BP 120/59 mmHg Active bleeding was noted from cut r’t external and internal jugular vein and l’t temperal area.

3. Brief History (2) Wound was pressured and IV catheters were set up using r’t femoral double lumen (12x12) and peripheral line with 20# catheter. After IV fluid replacement with L/R x 5 bottles and blood transfusion with whole blood 5 unit, he was sent to OR for surgical treatment.

4. Definition of massive transfusion(1) The replacement of patient’s entire blood volume in a 24-hour period. The transfusion of more than 20u of whole blood or 40u of PRBC. The replacement of over 50% of circulating blood volume in 3 hour or less. Loss of blood or more than 150ml/min

5. Definition of massive transfusion(2) Massive transfusion is accompanied most frequently with significant blood loss or shock. Although the volume of blood transfused may lead to a variety of potentially serious problems, the duration and severity of shock (hypoperfusion, acidosis, hypoxia) appears to be the primary derterminant of mortality and morbidity.

6. Initial Management(1) Initual fluid resuscitation with colloid or crystalloid, which begins to replete intravascular volume. Restoration of tissue oxygenation with RBC transfusion. Primary surgical treatment of bleeding source to achieve hemostasis. Replacement of hemostatic components diluted during massive transfusion.

7. Initial Management(2) DO 2 = CO x CaO 2 = CO x {1.34 x Hb x SaO 2 + 0.003 x PaO 2 } Initial fluid resuscitation can increase CO by Frank-Starling law. RBC transfusion can increase Hb.

8. Initial Fluid Resuscitation(1) Crystalloid (N/S, L/R): * Most common fluid used due to cheaper and available. * Due to low colloid oncotic pressure, only 20% remain within IV space. Volume approximately 3 to 4 times of blood loss must be infused to maintain IV volume.

9. Initial Fluid Resuscitation(2) Colloid: * Greater oncotic pressure and greater half life, so better volume expansion. * Less used due to cost and unavailability. * Large dose can impair hemostasis. * Which one is better has come into question.

10. Blood component Whole blood: 250ml. containing PRBC 1u, FFP 1u and 30ml preservatives. PRBC: ~100ml. Hct 70~80%. PRBC 1u can increase Hb 0.5 (Hct 1.5) FFP: ~125ml. Containing coagulation factor, protein and plasma. PLT: ~25ml. PLT 12u can increase PLT 60000.

11. Indications for blood transfusion Whole blood: blood loss > 1500ml, better than PRBC + FFP. PRBC: blood loss < 1000ml. FFP: deficiency of coagulation factor and protein, massive transfusion. PLT: thrombocytopenia, massive transfusion.

12. Emergency Transfusion If blood type is known, an abbreviated cross match (<5min) can be done. If blood type is not known, only PRBC of type O Rh (-) can be used, and further transfusions should be type O Rh (-) until anti-A and anti-B titers are determined in patient’s serum.

13. Role of Hb in blood transfusion In young and healthy p’t, CO may increase enough to maintain adequate DO 2 even Hb is 3g/dL if IV volume is sufficient. In practice, Hb as low as 7 can be compensated by increasing CO. Patient with known heart or lung disease should keep Hb > 10. RBC transfusion decision should be made on a case-by-case basis according to ongoing blood loss, symptoms of impaired DO2 and signs of impending failure.

14. Monitoring patient Vital signs are the most important indicator: HR, BP, RR, capillary perfusion time, Hb, estimated blood loss….etc. More invasive monitor: CVP, A-line, U/O, pulmonary wedge pressure.

15. Anesthesia consideration(1) Hypovolemia should be corrected prior to induction. Rapid sequence for endotracheal intubation due to inadequate NPO and delayed gastric emptying. Drugs should be choiced to minimize cardiovascular depression. Administer small incremental dose to titrate effect.

16. Anesthesia consideration(2) Hypnotics: Thiapental 0.3~1mg/kg, Midazolam 0.1~0.3mg/kg, Ketamine 1mg/kg, Etomidate 0.1~0.2mg/kg. Muscle relaxant: SCC 1.5mg/kg, Rocuronium 1.2mg/kg. Analgesics: Fentanyl 1-2ug/kg Amnesia: Midazolam 1~2mg if not used for hypnotics.

17. Complications of blood transfusion(1) Acute/chronic hemolytic reaction. Infections. Volume overload. Transfusion-related acute lung injury. GVHD. Nonhemolytic febrile reaction. Urticaria.

18. Complications of blood transfusion(2) Hypothermia: Will induce arrhythmia. Warming all blood product is absolutely indicated. Hypocalcemia (Citrate intoxication): Cardiac depression, aggravated by hepatic disease. Hyperkalemia Coagulopathy: Dilutional thrombocytopenia and decreased coagulation factor.

19. Factors Improving Survival Survival following massive transfusion in past 10 years has significantly increased. Factors associated with good outcome included aggressive correction of coagulopathy, more efficient use of warming measures, increased use of component therapy (blood bank available) and improved op skills.

20. Thank You