Complications of Massive Blood Transfusion

1

• Complications of Massive Blood Transfusion

Edgar J. Pierre, M.D. Assistant Professor of
Anesthesia, Surgery and Critical Care Ryder
Trauma Center University of Miami
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
2

• Someone needs blood every 3 seconds

• One in ten hospitalized patients needs blood

• 4.5 million lives are saved by blood
  transfusions/year

• One unit of blood saves three lives

3
A newborn baby
4
Blood makes up 7 of the bodys weight
55 plasma
45 cell mass
5
1 A.D.- roman gladiators drank the blood of slain
opponents to harness their strength
6
1818 first recorded human transfusion
Treats postpartum hemorrhage using patients
husband as donor
James Blundell, MD
7
The breakthrough blood typing
1901 Landsteiner discovers the first three
human blood groups A,B,C (later O)
1902 colleagues Alfred Decastello and Adriano
Sturli add AB
1930 Landsteiner receives the Nobel Prize for
Medicine
8
Distribution of blood types for the US population
9
Crystalloid replacement scheme
Hourly maintenance x number of hours NPO
10
43 y/o white female s/p uterine rupture with
intra-abdominal bleeding for exploratory
laparotomy

• Starting hematocrit 43

• Weight 90 Kg

• Allowable hematocrit 25

ABL 90 Kg x 70 cc/Kg x (43-25)/34 3,335 cc
11
Hemodynamic stability is the key indicator

• If Hgb gt 10g/dl transfusion is rarely indicated
• If Hgb lt 7g/dl transfusion is usually necessary
• With Hgb between 7-10 g/dl, clinical status are
  helpful in defining transfusion requirements
• Blood pressure
• Heart rate
• Extraction ratio

12
Transfusion requirements should be based on the
patients physiologic needs

• Oxygen demand (consumption)
• CO (CaO2-CvO2)
• Oxygen delivery
• CO CaO2
• Extraction Ratio
• CaO2-CvO2/CaO2

13
Risks of blood component therapy

• Transfusion reactions

• Hemolytic
• Donor blood contains an antibody, usually against
  the patient's HLA or leukocyte specific antigens
• Non-hemolytic
• Febrile, urticaria, anaphylactic, purpura

14
Hemolytic reactions
Acute hemolytic reactions
Are usually due to ABO blood type incompatibility
Occur approximately 1 in 25,000 transfusions
Often very severe and accounts for 50 of deaths
related to transfusions Fatal hemolytic
reaction 1600,000 transfusions
Severity of the reaction depends in the amount of
blood given
15
Acute hemolytic reactions

• Symptoms
• Chills, fever, nausea, chest pain in awake
  patients
• Rise in temperature, unexplained tachycardia,
  hypotension, hemoglobinuria, DIC, shock and renal
  failure in anesthetized patients

• Management
• Stop transfusion immediately, re-check the unit,
  test for hemoglobin in plasma and urine
• Facilitate osmotic diuresis and support
  hemodynamic

16
Hemolytic reactions
Delayed hemolytic reactions
Caused by antibodies to non-D antigens of the Rh
system or foreign alleles
1-1.6 chance of developing antibodies following
a normal compatible transfusion
Takes weeks or months to happen- and by that
time, the original transfused cells have already
been cleared
Re-exposure can then cause an immune response
17
Delayed hemolytic reactions

• Symptoms
• Mild and include malaise, jaundice, fever, fall
  in hematocrit despite transfusion
• Diagnosis may be facilitated by the direct Coombs
  test ( detect antibodies on the membranes of red
  cells

• Management
• Generally supportive
• Occurs in approximately 1 in 2,500 transfusions
  and most often in females with previous exposure
  secondary to pregnancy

18
Non-hemolytic reactions
Febrile
Urticarial
Anaphylactic
Graft versus Host
Purpura
Immune Suppression
19
Non-hemolytic reactions

• Febrile reactions
• 1-3 of all transfusions
• Rise in temperature without evidence of hemolysis
• Should receive leukocyte poor transfusions
• Use of a filter traps most contaminants

• Urticarial Reactions
• 1 of all transfusions
• Erythema, hives without fever
• PBRC has decreased the likelihood of this
  problem
• Treatment is with antihistamines

20
Non-hemolytic reactions

• Graft vs Host
• Immunocompromised patients
• Lymphocyte s can mount an immune response against
  the recipient
• Irradiation of transfusions to inactivate the
  lymphocytes prior to transfusion

• Post-transfusion purpura
• Common with the development of platelets
  antibodies
• Lead to profound thrombocytopenia
• Plasmapheresis is the recommended treatment

21
Non-hemolytic reactions

• Pulmonary edema

• Transfusion related acute lung injury 13 of
  all transfusion deaths

• Donor blood contains an antibody, usually against
  the patient's HLA or leukocyte specific antigens

• Dyspnea, hypotension and fever within 1-2 hours
  after transfusion

• CXR diffuse, non-specific infiltrates

• Treatment involves respiratory support as needed

22
Non-hemolytic reactions

• Anaphylactic reaction

• Rare and occur in about 1 of 150,000 transfusions
  

• Occur in IgA deficient patients with anti IgA
  antibodies

• IgA deficiency occurs in 1 of 600-800 patients in
  the general population

• Patients should receive thoroughly washed PRBC

• Treatment involves fluids, epinephrine,
  corticosteroids and supportive measures

23
Non-immune complications

• Infectious complications
• Viral ( hepatitis, HIV, CMV, HTLV)
• Parasitic and bacteremia
• Physiologic complications
• Coagulopathy
• Citrate toxicity
• Hypothermia
• Acid-base disturbances

24
Infectious complications

• CMV and EBV
• Asymptomatic or mild systemic disease
• Immunocompromised patients are susceptible to CMV
  and should receive CMV negative units only

• HTLV-1 and HTLV-II
• Leukemia and lymphoma retro-viruses associated
  with transfusion
• Current risk is estimated at 1250,000 to
  2,000,000

25
Hepatitis
Risk of hepatitis A from transfusion is estimated
to be 1100,000
130,000 to 250,000 for Hepatitis B
130,000 to 1150,000 for Hepatitis C
26
AIDS
All blood is tested for the anti-HIV antibody
6-8 week period required for a person to develop
antibody after they are infected therefore
infectious units can go undetected
Current risk for HIV infection due to transfusion
is estimated to be 1200,000 to 2,000,000
27
Risks of blood component therapy

• Infectious risks per unit

• Viral contamination

• HIV lt11,900,000

• Hepatitis C lt11,000,000

• Hepatitis B lt1137,000

• HTLV I II lt1641,000

• Bacterial contamination

• lt1542 six unit platelets pool

• lt1777 aphaeresis platelets

• lt138,565 PRBC units

28
Citrate Toxicity
Citrate in the transfused blood binds to
calcium each unit of blood contains 3 grams of
citrate transfusion rates higher than one unit/5
minutes may lead to citrate toxicity
At least 1.5 times blood volume must be replaced
for this to become a clinical problem
Treatment is with intravenous calcium
administration if there is biochemical, clinical
or electrocardiographic evidence of hypocalcemia
29
Hypothermia
Leads to reduction of citrate and lactate
metabolism -hypocalcemia and metabolic
acidosis Increase affinity of hemoglobin for
oxygen, Leads to platelet dysfunction, and
increase tendency for cardiac dysrhythmias
Massive transfusion is an absolute indication for
the warming of all blood to body temperature as
it is being given
30
Acid/Base Disturbances
Most common abnormality is a metabolic
alkalosis -lactic acid in stored PRBC
(30-40mmol/l) -citrate and lactic acid
metabolized to bicarbonate
Final acid/base status being dependent on tissue
perfusion, rate of administration and citrate
metabolism
31
Hyperkalemia
32
Management of Massive Transfusion
Hypotension should be treated speedily. Do not
delay fluid administration
Initial red cell replacement is in the form of
packed red cells
Blood should be taken for group and crossmatch,
these must be properly labeled and identified in
all situations
33
Management of Massive Transfusion
For extreme emergencies group O blood should be
supplied first
Type specific blood should be available in 5-10
minutes and switch promptly
Continue transfusing blood on this basis until
crossmatch blood is available
34
Guidelines for red blood cell and plasma
transfusion for adults and children
 
Summary of the nature and frequency of noninfectious risks associated with red blood cell and plasma transfusion Summary of the nature and frequency of noninfectious risks associated with red blood cell and plasma transfusion Summary of the nature and frequency of noninfectious risks associated with red blood cell and plasma transfusion
Complication Usual cause Frequency
Acute hemolytic reaction121,122,123 ABO incompatibility 1 per 25 000 RBC units
Delayed hemolytic reaction122,123126 Hemolysis due to minor blood group incompatibility 1 per 25009000 RBC units
RBC alloimmunization127 Recipient antibody response to donor antigen About 8 of patients transfused with RBCs
Nonimmune hemolytic reaction122,128 Physical or chemical degradation of RBCs (freezing, heating or addition of a hemolytic drug or solution) Unknown
Febrile, nonhemolytic reaction or chills without fever122,123,129 Recipient antibody to donor WBC or platelet antigen or accumulation of cytokines in blood units during storage or both 1 per 100 RBC units
Anaphylaxis122,123,128 Complement activation 1 per 20 00050 000 units (RBC or plasma)
Urticarial reactions122,123 Antibody-mediated response to donor plasma proteins 1 per 100300 plasma transfusions (probably similar with RBC transfusions)
Transfusion-related acute lung injury122,123 Complement-mediated pulmonary edema Unknown
Graft-versus-host disease79,130,123,131,132 Engraftment of immunocompetent donor lymphocytes in host Unknown
Postransfusion purpura122,133,134 Recipient develops antibodies against donor and recipient platelets Unknown
Passive alloimmune thrombocytopenia135,136 Donor blood contains platelet-specific alloantibody that results in abrupt thrombocytopenia in the recipient Rare
Circulatory overload122,131 Excess intravascular volume 1 of transfused patients
Hypothermia, coagulopathy, acidbase disturbances, hypocalcemia, electrolyte abnormalities and citrate toxicity associated with massive transfusion88,90,94,137140 Loss, consumption or dilution of blood elements Related to volume transfused, unlikely to be seen when lt 1.5 blood volumes replaced
Iron overload Chronic RBC transfusion therapy (each unit contains 200 mg of iron) Variable, according to number of RBC units transfused begins after the transfusion of gt 20 RBC units