Massive Transfusion and Blood Products
Definition
>50% patient’s blood volume at once OR 100% patient’s blood volume over 24 hours
1.
Protocol
2.
3.
PRBC: O negative stat (use O positive if short supply – not if child-bearing female or previous
anti-D)
FFP: give at ratio 1:1 with PRBC from outset; aim INR and APTT <1.5x normal
Platelets: give at ratio 1:5 with PRBC from outset; aim plt >75
In general ratios should be: PRBC : FFP : platelets
5 : 5 :
1-2
In kids doses: 15ml/kg FFP; 10ml/kg PRBC
Give CF if: >5-6iu PRBC transfused
Prognosis
Survival 45-67%
Indications: Hb <7, Hb <10 and symptoms or active bleeding
O negative low titre: available immediately
Group specific: available in 10 minutes (O 46% > A 39% > B 11% > AB 3.5%; Rh +ive 80%, Rh-ive 20%)
Cross-matched: available in 30 minutes; clinically significant antibodies present in 2% ED patients (5%
haematology/oncology patients),  with age
Effects of storage: : pH, rigidity of cell membrane, K
: T, calcium (due to citrate), i 2,3,DPG  L shift
Contents: No factor V/VIII activity, no platelets
Technique: infuse no faster than 5ml/min for 1st 15mins; compatible only with N saline and 4% albumin;
slowest rate is 1iu/4hrs
Pros: longer life, less storage problems, less antigens
Cons: slower flow, smaller volume, higher viscosity; can’t give meds through same line
Packed Red
Blood Cells
Complications:
Microaggregates: activate coagulation cascade and complement, impairs microcirculation and O2
delivery
ABO incompatibility: usually misidentification error
Citrate toxicity: if >100ml/min;  ionised calcium, metabolic acidosis, metallic taste / perioral
paraesthesia
Hyperkalaemia: usually if blood >2/52 old;  Na
Hypothermia: shifts curve to L,  CO
Febrile non-haemolytic reaction: incidence 0.1-1%; often in multiparous women / multiple transfusions;
recipient antibody aimed to donor RBC; dose related, occurs towards end of transfusion (30-120
minutes in or after transfusion)
Management: stop transfusion, check patient and blood details
 if mild (T change <1.5°C, no rash)  restart
 if moderate (T  >1.5°C, urticarial  give anti-histamines and paracetamol 
restart after 20mins
 if severe  stop  send repeat sample (more common with platelets)
Allergy: recipient reaction to plasma proteins in donor blood; most common with FFP; 1-3% incidence
mild reaction, 1:20-50,000 anaphylaxis; treat as fever
Haemolysis: 1:12-77,000; shock, fever, headache, pain, haemoglobinuria, ARF, DIC
Tranfusion related acute lung injury: 1:5-10,000; can be fatal; WBC antibodies react with patient’s
WBC’s  pulmonary damage  SOB, cough, fever, acute pulmonary oedema within 1-6 hours
Transfusion related disease (eg. HIV 1:5400000, Hep C 1:2700000, Hep B 1:739000, malaria etc..)
GVHD: transfusion of immunocompetent WBC to immunosuppressed patient; onset 10-14/7  fever,
skin rash, pancytopenia, diarrhoea, abnormal LFT’s; prevent by irradiating blood products
Bacterial contamination: 1:500,000; more common with platelets
Others: Immune suppression; jaundice (30% transfused RBC don’t survive)
Fresh Frozen
Plasma
Cryoprecipitate
Platelets
Prothrombinex
Factor VIIa
Available in 30 minutes
Indications: haemorrhage and coagulopathy; reversal of warfarin overdose; factor deficiency; antithrombin III deficiency; TTP; can be used in Haemophilia A and B in emergency if no pure factor
available (although risk of volume overload)
Compatibility requirement: requires ABO compatibility
Contents: all clotting factors and fibrinogen
Technique: give at 10ml/min (ie. Over <1 hour); give 4-6iu per 5L blood
Available in 30 minutes
Indications: bleeding and fibrinogen <1
Compatibility requirement: better if ABO compatibility
Contents: clotting factors VIII and XIII, fibrinogen, von-Willebrand factor; no factor IX (so can be used in
Haemophilia A but not B in emergencies, although would be risk of fluid overload in amounts required)
Technique: give at 10ml/min (ie. Over <1 hour); give 1iu / 10kg body weight
Available in 15-30 minutes; 1iu   platelets by 5
Indications: platelets <10
<20 and fever / antibiotics / evidence of systemic haemostatic failure
<50 and bleeding (or skin bleeding time >2x normal) or surgery
<100 and for eye / neurological surgery
DIC / ITP with life-threatening haemorrhage
Compatibility requirement: does not require ABO compatibility
Technique: give 1-2iu per 5L blood
Cons: can only be stored 3/7
Duration of action 12-24 hours
Indications: congenital clotting factor deficiency, warfarin overdose and significant bleeding
Compatibility requirement: ABO compatibility not required
Contents: clotting factors II, V, VII, IX and X; anti-thrombin and heparin
Technique: give 3ml/min; give 25-50iu/kg (50iu if INR >6, 35iu if INR 4-6, 25iu if INR 2-4)
Pros: small volume, rapid administration, no time delay in thawing (unlike FFP), no ABO typing (unlike
FFP), INR reversal within 15 minutes, no disease transmission
Not demonstrated to improve any clinically significant outcomes in trials;  mortality in blunt trauma in
CONTROL trial, expensive, requires normal pH and T to be effective; 5% absolute  risk of VTE; give 90120mcg/kg
Indications: last resort in generalised bleeding only after control of bleeding obtained; inhibitors to
clotting factors VIII/X; congenital clotting factor VII deficiency; Glanzmann’s thrombasthenia