Emergency & Massive
Transfusion
Brian Poirier, MD
UCDavis Medical Center
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.
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.
Massive Transfusion
Clinical Settings
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Trauma
Surgery (e.g. Liver, Cardiovascular)
GI bleeding
Obstetrics
Storm King Mountain
Colorado
Types of Shock
• Cardiogenic – MI, cardiomyopathy
• Obstructive – Tamponade, PE
• Distributive – Sepsis, Anaphylaxis
• Hypovolemic – Hemorrhage
Class I
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<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
Class II
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750-1500ml
15%-30% Blood Loss
Pulse >100, BP Normal
Pulse Pressure Decreased
Resp Rate 20-30
Urine Output 20-30ml/hr
CNS Mildly Anxious
Fluid replacement Crystalloid
Class III
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1500-2000ml
30%-40% Blood Loss
Pulse >120, BP Decreased
Pulse Pressure Decreased
Resp Rate 30-40
Urine Output 5-15ml/hr
CNS Anxious and Confused
Fluid Replacement - Crystalloid &
Blood
Class IV
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>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
Can Estimate Blood Loss by
Response to Fluid Bolus
Laboratory Values to
Monitor in Trauma
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Hgb/Hct
INR/PTT
Fibrinogen
Platelet Count
Blood Gases
Electrolytes
Blood Products
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RBC
Plasma
Platelets
Cryoprecipitate
Blood Products
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
Emergency Release Blood
- Universal Donor
• O, RhD neg/pos RBCs
– 5 min
• AB or A
Plasma/Platelets
Type & Screen
– Initial sample gets ABO, Rh type
and antibody screen.
• Time ~ 40min.
– When blood is needed an
immediate spin crossmatch is
done.
• Time ~ 10-15 min.
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.
Probability of Safe
Transfusion
None
64.4%
64.4%
ABO
35.0%
99.4%
Rh
0.4%
99.8%
Antibody
0.14%
Screen
Crossmatch 0.01%
99.94%
99.95%
Other Emergency RBC
Problems
• Incomplete compatibility testing
– Unexpected antibodies found
– Compatible blood not available
Washout Curve
Y/Y0= e-x
Y = Final concentration of substance
Y0 = Initial concentration of
substance
X = total number of volumes
exchanged
Derksen 1984
Coagulation Factors-%
Needed for Hemostasis
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I 12-50%
II 10-25%
V 10-30%
VII >10%
VIII 30-40%
IX 15-40%
X 10-40%
XI 20-30%
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
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
UCD Platelet Usage 1992
• 1.5% of Trauma patients required
platelets
• 1.43% of blunt injury patients
• 2.3% of penetrating injury patients
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)
“It saves more lives than you could
believe” Gen. George S Patton
Massive Exanguination
“Triad of Death”
• Acidosis
• Hypothermia
• Coagulopathy
Blood Warmer
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
Massive Transfusion Study
(Holcomb 2008)
Massive Transfusion Study
(Holcomb 2008)
Massive Transfusion Study
(Holcomb 2008)
Massive Transfusion Study
(Holcomb 2008)
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)
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)
Massive Transfusion Protocol
Example
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
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?
Potential Adverse Effects of
Massive Transfusion
• Metabolic Disturbances
• Transfusion Reactions
• Infectious Disease Risks
Massive Transfusion
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Citrate Toxicity
Hyperkalemia
Decreased Oxygen Delivery
Hypothermia
Acute/Immediate Transfusion
Reactions
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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
Transfusion Mortality FDA
Reports
Sources of Error (NY Data
1999)
• 58% Outside blood bank
• 17% In blood bank & outside
• 25% In blood bank
Sources of Error
• 58% Outside of the Blood Bank
– 43% Failure to identify patient
– 11% Phlebotomy error
– 3% Incorrect order/No ID at bedside
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
Sources of Error
• 25% In Blood bank
– 1% Used wrong sample
– 11% wrong blood group issued
– 7% Incorrect typing-technical
– 6% incorrect typing - clerical
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
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
Thank You!
მადლობა
Thanks to:
• Carol Marshall, MD
• L. Fernando, MD
• Rosemary Howard, CLS
References
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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:
112-119.
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: 447-458.
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):470-478.
The Face of Mercy: A Photographic History of Medicine at War created and
produced by Matthew Naythons, ISBN 0-679-42744-9, New York, NY, Random
House/Epicenter Inc, 1993.