Transfusions & Surgery
Christopher J. Gresens, M.D.
VP & Medical Director, Clinical Services
BloodSource
Surgical Transfusion
Medicine
Objectives – At the conclusion of this
presentation, participants will be able to …
1. Summarize the best means for optimizing the
transfusion of – and reducing the need to
transfuse – surgical patients;
2. Describe special transfusion considerations
for patients in emergent need of blood.
Surgical Transfusion Medicine –
Outline 1/2
• Preoperative Approaches
– Correcting Anemias Prior to Surgery
– Preventing Unnecessary and Iatrogenic Blood
Loss
– Preoperative Autologous Blood Collections
• Intraoperative Approaches
– Intraoperative Blood Salvage
– Acute Normovolemic Dilution
• Postoperative Approaches
Surgical Transfusion Medicine –
Outline 2/2
•
Transfusions in Emergency
Situations
– Introduction
– What is Shock (Especially, Hemorrhagic
Shock)? And …
– … What Are Its Consequences?
– The Nuts and Bolts of Emergency
Transfusions
– Challenges Associated with Massive
Transfusions
Surgical Transfusion
Medicine
Preoperative
Approaches
1.
2.
3.
Correcting Anemias Prior to Surgery
Preventing Unnecessary and Iatrogenic Blood Loss
Preoperative Autologous Blood Collections
Correcting Anemias
• The surgeon must decide if the level of
anemia and the risk of surgical blood loss
from the planned procedure require specific
action
• Elective surgeries should generally be
delayed until treatable preoperative anemias
can be corrected
• Oral/intravenous iron + erythropoietin (if
practicable) may be warranted in some cases
• In other cases, different approaches may be
required – e.g., to correct a different,
underlying cause of anemia
Preventing Unnecessary Blood
Loss
• Restrict diagnostic phlebotomies via the
ordering of fewer tests and the practice of
lower volume blood draws
• Manage anticoagulation carefully, e.g.,
discontinue or modify the use of anticlotting agents such as:
– Aspirin
– Other anti-platelet agents (e.g., clopidogrel)
– Anticoagulants (e.g., heparin and warfarin)
Preoperative Autologous
Collection
•
•
•
•
•
•
•
“Self-donated” blood
“Target” usually is RBCs
Relaxed donor eligibility criteria
Minimum hematocrit = 33%
No absolute minimum age
No absolute weight limits
Increased donation frequency
Preoperative Autologous Blood –
Contraindications
• Significant cardiac
abnormalities (e.g., aortic
stenosis, severe coronary
artery disease or congestive
heart failure)
• Very recent myocardial infarct
or cerebrovascular accident
• Potential bacteremia
• Hematocrit < 33%
• < 72 hours from time of surgery
Preoperative Autologous
Blood – Risks
• Development of anemia due to
donation process (see Kanter et
al.)
• Small risk of septic & several
other transfusion reactions
• Remote risk of wrong blood unit
being transfused
• Blood will not be immediately
available in an emergency
Preoperative Autologous
Blood – Other Issues
Preop Auto Blood Donations Before Elective Hysterectomy. M.H. Kanter et al. JAMA. 1996; 276: 798-801.
• Design: Retrospective; compared 140 elective hysterectomy patients who gave auto blood with 123 who didn’t.
• Results: 25 of 140 autologous donors were transfused
(3 with allogeneic RBCs); 1 of the other 123 was transfused
(p < 0.001).
• Conclusion: “For hysterectomy patients, donation of
autologous blood causes anemia and is associated with a
more liberal transfusion policy. Elimination of preoperative
autologous donation for these patients should not result in
frequent exposure to allogeneic blood”
Preoperative Autologous
Blood – Other Issues
• Venous access
• Iron
supplementation
• Special handling
• Fees
• Unused autologous
units are destroyed
Preoperative Autologous
Blood – More Issues
• Crossover to allogeneic supply – Virtually never
done
• Transfusion criteria for autologous blood are
sometimes debated – Should they be same as, or
different from, those for allogeneic blood?
• Local hospitals have varying policies regarding
the use of confirmed HBV- and HIV-infected units
• Cost-effectiveness – In many situations, the use
of preoperatively collected autologous blood may
never by cost-effective (per traditionally utilized
criteria)
Autologous Blood
Transfusions in Total
Joint Replacement
Surgery:
The Marshall
Hospital/BloodSource
Experience
C. Gresens et al. Transfusion 2002; 42 (Suppl): 18S-19S.
Marshall Hospital/BloodSource
Total Joint Replacement (TJR)
Surgery Blood Use Study
 Background
Many orthopedic surgeons advise their total joint
replacement surgery patients to consider making
preoperative autologous blood donations (PABDs)
to reduce the need for perioperative allogeneic
transfusions.
We examined the use of blood transfusions by such
patients to understand better the impact of PABDs
on perioperative transfusion requirements.
Marshall Hospital/BloodSource
TJR Surgery Blood Use Study
Methods: Retrospective review of primary, onejoint TJR surgery patient charts (at Marshall
Hospital) and autologous donor charts (at
BloodSource).
– Blood volume was estimated as: Patient mass (kg)
x 0.069 L/kg (male) or 0.065 L/kg (female).
– Autologous blood was transfused as pRBCs.
– Perioperative blood salvage was not used.
– Criteria for transfusion of autologous and allogeneic
blood were identical.
Marshall Hospital/BloodSource
TJR Surgery Blood Use Study
Results
• Date Range: July 2000-March, 2001
• N = 43 (19 male; 24 female)
• Surgical Procedures: Primary, unilateral joint
replacement surgeries:
– Knee--29 (67%); Hip--14 (33%)
• Ages of Patients: Mean = 67.1 (45-86 years)
Marshall Hospital/BloodSource
TJR Surgery Blood Use Study
• Twenty-four patients (57%) made PABDs:
– 17 (71%) were knee surgery patients
– 7 (29%) were hip surgery patients
• PABD Profile
– Mean # of PABDs/patient = 1.9 (1-2) units
– In total, 45 PABDs were made by these 24
patients.
Marshall Hospital/BloodSource
TJR Surgery Blood Use Study
Summary of Hematocrit Data for the
“Autologous Donor/Patients” (n = 24)
Average
Median
Range
Hct Prior to
1st Donation
41.5%
42%
34-46%
Hct Prior to
2nd Donation
38.0%
37%
33-45%
Hct Immediately
Prior to Surgery
36.5%
35.5%
30.1-45.2%
– Summary of hematocrit data for the “nonautologous donor/patients,” immediately
prior to surgery (n = 19)
• Average Hematocrit = 42.2% (35.6-to-49.6%)
Marshall Hospital/BloodSource
TJR Surgery Blood Use Study
• Mean Estimated Blood Volumes
– Autologous Donor/Patients: 5.8 L
– Non-Autologous Donor/Patients: 5.5 L (p > 0.05)
Estimated Perioperative Blood Loss
For Autologous
Donor/Patients
a. Average = 315 mL
b. Median = 250 mL
c. Range = 0-to-1000
mL
For Non-Auto
Donor/Patients
a. Average = 263 mL
b. Median = 250 mL
c. Range = 100-400
mL
Marshall Hospital/BloodSource
TJR Surgery Blood Use Study
• Nine of the 24 autologous donor/patients (39%)
required perioperative autologous RBC transfusions
– Mean = 1.9; Median = 2; Range = 1-2 units;
– Five (56%) were knee and 4 (44%) were hip;
– 17 total auto units transfused.
• Only one of the 19 non-autologous donor/patients
(5%) required a single allogeneic RBC transfusion (p
< 0.05).
Marshall Hospital/BloodSource
TJR Surgery Blood Use Study
Conclusions:
• PABDs prior to TJR surgery were associated
with:
– A moderate reduction in patient hematocrits;
– A large increase in perioperative transfusions;
– 62% of PABDs not transfused.
• PABDs no longer are routinely recommended for
primary, one-joint TJR surgery patients at
Marshall Hospital.
Preoperative Autologous Blood –
Other Issues
The Cost Effectiveness of Preoperative Autologous
Blood Donations. J Etchason, L Petz, et al. NEJM. 1995;
332: 719-724.
• Design: Decision-analysis model for cost effectiveness
assessment (based upon 1992, UCLA data); looked at total
hip replacement, coronary artery bypass grafting, abdominal
hysterectomy, & transurethral prostate resection patients.
• Results: “The cost-effectiveness values ranged from
$235,000 to over $23 million per quality-adjusted year of life
saved.”
• Conclusion: “The increased protection afforded by donating
autologous blood … may not justify the increased cost.”
Surgical Transfusion
Medicine
Intraoperative
Approaches
1)
2)
Intraoperative Blood Salvage
Acute Normovolemic Dilution
Intraoperative Blood Salvage
• Collection and re-infusion of
blood lost during surgery
• Alternative to pre-operative
autologous blood collection
• Can be especially useful for
massively bleeding patients
• Semi-automated systems
are available for this
purpose
Intraop Blood Salvage –
Considerations
• Washed vs. unwashed?
• Guaranteed blood
compatibility
• May be acceptable to
Jehovah’s Witnesses
(particularly if the
collection/reinfusion
circuit is circular)
Intraoperative Blood –
Contraindications
• Infection/contamination
of surgical field
• Cancer involving
surgical field
Perioperative Blood Salvage –
Risks
• Coagulopathy
• Hemolysis
• Air embolism
(Linden et al.)
Perioperative Blood Salvage –
Risks
Fatal Air Embolism Due to Perioperative Blood
Recovery. J.V. Linden et al. Anesth Analg. 1997; 84:
422-426.
• Design: Retrospective review of 127,586 periop blood
salvage procedures (PBSPs) and 8,955,619 conventional
transfusions (CTs); 1990-1995.
• Results: 4 fatal air embolism cases occurred in
association with PBSPs (1 in 30,000-38,000); none with
CTs.
• Conclusion: Even when considering all the other risks
associated with CTs, the risk for a fatal complication
during PBSP is far higher than that for CTs.
Acute Normovolemic Hemodilution (ANH)
• ANH involves collecting blood from
a patient in the OR at the start of
surgery, for re-infusion later in the
surgery or during the immediate
postoperative period.
• > 4 units may be removed (with
simultaneous 3:1 crystalloid or 1:1
albumin replacement).
• In properly selected and monitored
patients, a target Hct of 20-25%
may be acceptable.
Acute Normovolemic
Hemodilution – Considerations
• Lowers blood viscosity
• Reduces RBC loss during
surgery
• No testing required
• Ideal candidate has good
preop hematocrit & will lose
> 1 L intraoperatively
• Exclusion criteria include
anemia, renal failure, significant coronary artery disease,
and others
Acute Normovolemic
Hemodilution – Risks
• Critical organ
ischemia
• Dilutes circulating
coagulation factors
Surgical Transfusion
Medicine
Postoperative
Approaches
Post-operative Blood
Salvage
• Cardiac & orthopedic
surgical patients
• Blood collected from
drainage devices
• Defibrinogenated
• Unwashed
• Can only be stored for
up to 6 hours at room
temperature
Post-operative Blood Salvage
Red Cell Loss Following Orthopedic Surgery: The
Case Against Postoperative Blood Salvage. J. Umlas
et al. Transfusion. 1994; 34: 402-406.
• Design: The volume of salvaged RBCs was measured for
the first 6 hours postoperatively & compared to total RBC
loss and volume of allogeneic RBCs transfused.
• Results: Mean postoperative RBC losses in 31 THR & 20
TKR patients were 55 + 29 and 121 + 50 mL,
respectively.
• Conclusion: “The relatively small red cell loss in the
postoperative period in most arthroplasty patients does
not appear to justify the routine use of this technique.”
Surgical Transfusion Medicine
Transfusions in
Emergency
Situations
1)
2)
3)
4)
5)
Introduction
What is Shock (Especially, Hemorrhagic Shock)? And …
… What Are Its Consequences?
The Nuts and Bolts of Emergency Transfusions
Challenges Associated with Massive Transfusions
Emergency Transfusions –
Introduction
• A variety of indications exists for the use
of blood transfusions in emergency
medicine
• This discussion will focus primarily on
those transfusion indications pertaining to
hemorrhage; however, other reasons for
emergency transfusions exist, including all
of the ones for which patients generally
require transfusions, such as . . .
Emergency Transfusions –
Introduction
… Selected Examples of NonHemorrhagic Indications for Emergency
Transfusions:
• Complications of sickle cell disease or
thalassemia;
• Worsening chronic anemia or thrombocytopenia
in a patient with leukemia, myelodysplasia, etc.;
• Severe hemolysis secondary to warm
autoimmune hemolytic anemia;
• ...
Emergency Transfusions –
Introduction
• Most trauma patients are treated without
transfusions being performed.
• A five-year study at Vanderbilt University
revealed that only 27% of patients
admitted for trauma at their institution
required blood
(Wudel JH et al: Massive Transfusion: “Outcome in
Blunt Trauma Patients.” J Trauma 31: 1, 1991).
Emergency Transfusions –
Introduction
• Another study, looking at 8,000 trauma
patients at Cooper Hospital (Camden, NJ),
over a similar time period, showed that only
8% needed transfusions (Ross S & Jeter E. In:
Clin. Pract. of Transf. Med., 3rd ed. (eds. Petz LD, et
al.), 1995.).
• Still, a significant minority of trauma patients
require transfusions – sometimes MASSIVE
TRANSFUSIONS (usually defined as the
transfusion of one blood volume of RBCs
within 24 hours).
Shock
• The primary indication for the
administration of IV fluids and blood in
trauma/emergency surgery patients is
hemorrhagic shock.
• Definition of shock: Pathophysiologic
inadequacies in both:
– The delivery of substrate and O2 and …
– … The removal of metabolic end-products
from peripheral tissues.
Types of Shock
• Hemorrhagic: Caused by severe blood loss;
• Metabolic: Associated with profound fluid loss due
to injury or illness (e.g., burns or dehydration);
• Septic: Caused by the toxins from severe (usually
bacterial) infections;
• Neurogenic: Usually caused by head/spinal
injuries;
• Psychogenic: Also known as fainting;
• Anaphylactic: Due to severe allergic reactions;
• Cardiogenic: Caused by damage/injury to heart.
Most Common Causes of
Hemorrhagic Shock
•
•
•
•
Penetrating trauma
Blunt trauma
GI bleeding
Ob/Gyn bleeding.
Graphics from MDChoice.com
Shock – Its Coagulopathic
Consequences
• Often in shock, a
coagulopathy results High velocity
due to the activation gunshot wound
and/or consumption (MDChoice.com)
of coagulation
factors.
• Certain crush injuries
(especially cerebral)
Trauma to legs
can lead to DIC
caused by train
(disseminated
(MDChoice.com)
intravascular
coagulation).
Shock – Its Coagulopathic
Consequences
DIC is
coagulation
activation
occurring to an
abnormal
degree, with so
much thrombin
generated that it
overwhelms the
natural thrombin
inhibitors.
From Merck Manual Online (2003)
Shock – Its Coagulopathic
Consequences
Ultimately, DIC results in:
• Activation (and, often, depletion) of other
coagulation factors
• Fibrinolytic bleeding (the major clinical
sign of DIC) and hemolysis
(microangiopathic hemolytic anemia)
• Thromboses (sometimes more subtle,
resulting in CNS deficits, acute renal
failure, and/or other organ ischemia)
Shock – Its Coagulopathic
Consequences
Fibrinolysis predisposes the patient to
bleeding, both directly (via destruction of
fibrin clot) and indirectly (via compromised
platelet
function).
Normal
Blood
Clot Formation
Fibrinolysis naturally allows
for the control and remodeling
of clots, and normally is a
healthy process. When it
occurs in concert with DIC,
however, it can contribute
heavily to bleeding
(MDChoice.com).
Shock – Some of Its Other
Consequences
• Acidosis may result from inadequate O2 delivery
and waste product removal.
• The loss of thermal regulation and a decrease in
heat production (which may be worsened both by
the environment and the use of cold intravascular
fluids) may cause in vivo dysfunction of platelet and
clotting factor function.
• Prolonged shock ultimately can lead to multisystem
organ failure and (eventually) death.
Management of Emergency
Transfusions
Important factors affecting the management
of emergency (especially massive)
transfusions include:
• Experience of trauma care providers;
• Availability and quality of ICUs and ORs;
• Turnaround time for STAT
hematology/coagulation testing;
• Reliability (largely related to staffing experience
and levels) of transfusion service.
Decision to Transfuse
Emergently
The decision to transfuse (urgently or
otherwise) requires a detailed clinical
analysis, looking at:
• The patient’s clinical condition;
• His/her initial hemoglobin level, platelet count,
PT (INR), PTT, and fibrinogen level;
• His/her response to fluid resuscitation;
• Coexisting cardiac, respiratory, and vascular
conditions;
• Measurements of tissue oxygenation.
Emergency Transfusions –
Why/When?
•
Primary Purposes: To:
1) Restore O2 delivery and tissue perfusion
2) Reverse the effects of shock (by maintaining
intravascular volume and blood pressure); and …
3) Reduce bleeding (by maintaining coagulation
function).
•
Initially:
– Observe response to rapid crystalloid/colloid
infusion (if transfusion is not immediately
indicated);
– Evaluate for ongoing, external bleeding;
– Look for injury patterns consistent with large blood
loss.
Emergency Transfusions –
Why/When?
• Monitor clinical signs (e.g., heart rate, blood
pressure, central venous pressure);
• Monitor laboratory values (e.g., hematocrit,
platelet count, PT/PTT, fibrinogen);
• The decision to transfuse typically is made
by emergency room physicians or
anesthesiologists and surgeons;
• Clinical experience and judgment reign
supreme (and may take precedence over
lab values).
Selection of Blood –
Whole Blood Vs. Components
•
Since the 1960’s, most blood in U.S. has been
separated into components, allowing for:
1) Meeting specific needs of patients;
2) Minimizing risk of volume overload; and
3) Benefiting several patients from a single blood
donation.
•
Some physicians prefer whole blood for massive
transfusion cases; however, stored whole blood
completely loses platelet function after 48 hours
and shows progressive loss of factor VIII (rapidly)
and factor V (more slowly).
Emergency Pre-Transfusion
Testing
• Urgently required blood transfusions should
not be withheld solely because compatibility
testing is incomplete.
• Nevertheless, all parties involved in such a
transfusion should remember that they face
certain increased risks when transfusing
blood that has not gone through the “usual”
compatibility testing process.
Group O Vs. Type-Specific RBCs
– How Long Can You Wait?
Time You Can Wait
Type of RBC Available
Comments
< 5 minutes
O-negative, un-crossmatched
0.2–0.6% of population
has RBC antibody(ies)
(though serious hemolysis
is rare)
15 minutes after clots get to
blood bank
Type-specific, uncrossmatched
Risk same as for Onegative
45 minutes after clots get to
blood bank
Type-specific, crossmatched
(unless an RBC antibody is
present)
No RBC antibody found;
blood compatible by
crossmatch
90-minutes-to several-hours
Type-specific, crossmatched,
antigen-selected unit
If blood needed before
testing complete, do not
withhold
From LD Petz et al.’s Clinical Practice of Transfusion
Medicine, 3rd ed. 1995.
Using Rh-Positive Blood for
Rh-Negative Patients
• Only ~ 15% of donor population is Rh(D)-negative.
• If supplies of Rh(D)-negative RBCs are limited,
Rh(D)-positive RBCs often should be used for
male and postmenopausal female patients (once
presence of anti-D has been excluded).
• Decision when to switch from Rh(D)-negative to
Rh(D)-positive RBCs should be made on a caseby-case basis.
• Rh is far less important for platelets, and not at all
important for FFP or cryoprecipitate.
Types of RBC Units
• Generally, transfuse RBCs stored in additive
solutions (e.g., AS-1, AS-3, AS-5)
– More dilute (Hct 50-60%), so flows faster
– Larger volume (approx. 350 mL)
• Rarely, use CPDA-1 RBCs
– More concentrated/lower volume (approx. 250
mL)
– Generally used for larger volume (> 20 mL/kg)
neonatal transfusions or fetal transfusions
Transfusing Your Patient When
Compatible Blood Is Hard to Find
I. Patient Has Multiple Alloantibodies (not all
of which can be immediately honored)
• Group I (ABO, Rh, Kell, Duffy, Kidd, Ss)--Clinically
Significant Antibodies: Antigen-negative RBCs should
be transfused, except in extreme emergencies.
• Group II (Cha/Rga, Xga, Bg, “HTLA,” Csa, Kna, McCa,
JMH)--Benign Antibodies: Antigen-positive RBCs may
be transfused (even if Ab is 37° reactive)
From LD Petz., et al’s Clinical Practice of Transfusion Medicine,
3rd ed. 1995.
Transfusing Your Patient When
Compatible Blood Is Hard to Find
I. Patient Has Multiple Alloantibodies (not all of which
can be immediately honored) – Continued
• Group III (Lea/Leb, M, N, P1, Lua/Lub, A1)--Usually
Benign, Though Possibly Clinically Significant (if Ab is
37° reactive): Crossmatch-negative RBCs may be
used, without need to phenotype blood.
• Group IV (Yta, Vel, Ge, Gya, Hy, Sda, Yka)-Sometimes Clinically Significant: Efforts should be
made to obtain antigen-negative RBCs or use
autologous RBCs.
From LD Petz., et al’s Clinical Practice of Transfusion
Medicine, 3rd ed. 1995.
Transfusing Your Patient When
Compatible Blood Is Hard to Find
II. In the Massive Transfusion Setting – Consider:
• Using some antigen-negative, compatible units up
front; then . . .
• Once the patient’s serum has been diluted
sufficiently such that the antibody screen no longer is
reactive (usually after > 1 blood volume has been
replaced), switch to incompatible units;
• Finally, top patient off, at the end, with the remaining
antigen-negative units (6-8 units, for an adult-sized
patient, if possible).
Transfusing Your Patient When
Compatible Blood Is Hard to Find
III. For Autoimmune Hemolytic Anemia Patients
– Often, all units will be crossmatch-incompatible.
– Numerous special methods for compatibility testing
exist, but sometimes you have no choice other than
to transfuse immediately (consider the “modified in
vivo crossmatch”).
– “Blood should never be denied a patient with a
justifiable need, even though the compatibility test
may be strongly positive. Probably the most
common mistake is reluctance to transfuse even
those patients with severe anemia.” (Larry Petz, MD,
2002)
Transfusing Your Patient When
Compatible Blood Is Hard to Find
IV. Insufficient ABO-Compatible RBCs (Gulp!)
– Use intraoperative salvage device, if available
– Push volume repletion (with crystalloid/colloid)
hard!
– As early as possible, switch plasma infusions to
something compatible with the ABO type of the
incompatible RBCs (best choice: AB plasma)
– Identify “most-nearly-compatible” (ABOincompatible) units (e.g., group A2 RBCs for a
group O patient)
– Hyperhydrate patient, alkalinize urine, etc.
Emergency Blood Orders
• Written standard operating procedures (SOPs) for
providing emergency transfusions should exist
• The physician who requests an uncrossmatched
RBC unit must (eventually) document the
rationale; however, the hospital blood bank should
not allow this “paper requirement” to delay release
of the blood to the patient’s bedside.
• Hospital blood banks must have SOPs for
managing blood supplies in times of shortages
Massive Transfusions –
Dilutional Coagulopathy
Important Note: The “dilutional coagulopathy” is
not related to transfusions, but, rather, to blood
loss. In fact, if a patient is appropriately
transfused with FFP, platelets, and/or
cryoprecipitate, such a coagulopathy need not
develop.
Relationship between the volume
of plasma (or blood) lost and the
patient’s original plasma (or
blood) remaining [from AABB
Technical Manual, 13th ed., 2001]
Massive Transfusions –
Dilutional Coagulopathy
• Approximately 37% of original plasma
constituents remain after rapid exchange of a
single blood volume (after 2 or 3 blood
volumes are exchanged, remaining elements
drop to about 15% and 5%, respectively).
• Coagulation activity usually is adequate after
1 blood volume replacement; platelet counts
rarely drop below 100,000/uL until > 1.5
blood volume replacement.
Massive Transfusions –
Dilutional Coagulopathy
In fact, Hiippala et al., in a controlled clinical
evaluation looking at 60 massively bleeding
patients, demonstrated that:
• The critical (50,000/uL) platelet level was not
reached until an average loss of 2.30 BVs, & . . .
• Critical levels of prothrombin (20%), factor V
(25%), and factor VII (20%) were not reached
until 2.01, 2.29, and 2.36 BVs, respectively, were
lost.
Hiippala ST et al. Anesth Analg. 1995; 81: 360-5.
Massive Transfusions – DIC
• Disseminated intravascular coagulation (DIC) is
reported in 5-30% of massively transfused trauma
patients.
• DIC can be caused by blunt trauma/tissue injury
resulting in tissue and cell fragments entering
blood stream, causing immediate activation of
clotting system.
• DIC also is seen in:
– Severely burned patients (triggered by hemolysis and
tissue necrosis).
– Head trauma patients (due to release of thromplastins
from brain).
Massive Transfusions – DIC
• Microvascular thrombosis plays a major
role in the multisystem organ failure
associated with DIC.
• This problem generally is accompanied
by simultaneous activation of fibrinolytic
pathways; thus, both microthrombi and
hemorrhage may be seen.
Massive Transfusions –
Providing Components with
Hemostatic Factors
•
•
•
Determine patient’s coagulation status, whenever
possible, with appropriate lab tests.
Clinical Guidelines: (1) Extent/location of injury; (2)
Duration of shock; (3) Response to initial fluid
resuscitation; and (4) Risk of complications (e.g.,
intracranial bleeding).
Lab-Based Guidelines for Specific Components – Give:
1) Platelets if platelet count is < 80-100,000/uL
2) FFP immediately (in a 1:1 ratio of FFP to RBCs); and
…
3) Cryoprecipitate if fibrinogen approaches < 100 mg/dL.
Massive Transfusions –
Complications
• Immune Hemolysis: Due either to ABO/other red
cell antigens or nonimmune causes;
• Citrate Toxicity: Ca2+ salts occasionally are
indicated;
• Hyperkalemia: More problematic in tiny patients;
• Reduced Red Cell [2,3-DPG]: ??? How much of
a problem is this in adult patients? May be offset
by increased cardiac output, vasodilation, and
local acidosis).
Massive Transfusions –
Complications
• Reduced Red Cell [ATP]: May cause
reduced deformability (role of this
phenomenon unclear);
• Hypothermia: Degree is proportional to the
number of units transfused;
• The Various Other Adverse Sequelae of
Transfusions.
Rapid Infusion Devices
and Blood Warmers
Rapid-infusion devices can be used to hold
banked RBCs, washed salvage RBCs, FFP,
crystalloid, and colloid.
From LD Petz, et al’s
Clinical Practice of
Transfusion Medicine,
3rd ed., 1995.
Rapid Infusion Devices
and Blood Warmers
Roller pumps transport
the blood through highflow-rate microaggregate filters, and
then through a highcapacity blood warmer,
allowing blood to be
From LD Petz, et al’s Clinical
delivered as fast as 5 Practice of Transfusion Medicine,
L/hour.
3rd ed., 1995.
Rapid Infusion Devices
and Blood Warmers
Platelets and cryoprecipitate are generally
delivered downstream (i.e., not put into the
reservoir)
From LD Petz, et al’s
Clinical Practice of
Transfusion Medicine,
3rd ed., 1995.
Rapid Infusion Devices
and Blood Warmers
Level 1 Technologies’
Hotline™ Blood Warmer
Warms up to 5 L/hour in
35-40° C range
Disclaimer: This is just one
device among several in its
class, and is not meant to serve
as an advertisement for Level 1)
Pros and Cons for Autologous
versus Allogeneic Blood
Benefits
Allogeneic
Autologous
Available 24/7
Fully tested
Your own blood
Fully tested (sometimes
we even identify
heretofore unknown
infections)
Completely compatible (if
correct unit is used)
Pros and Cons for Autologous
versus Allogeneic Blood
Risks
Allogeneic
Infection
Immune reactions
Autologous
Infection (? Less risk)
Remote risk of incompatibility or
allergic or anaphylactic reaction (if
wrong unit or a synthetic allergen
is introduced)
Circulatory overload, Same
citrate toxicity, etc.
Mild anemia
Not often available for
emergency
Pros and Cons for Autologous
versus Allogeneic Blood
One more “risk” of autologous blood:
Cost
Surgical Transfusion Medicine –
Summary 1/2
• Preoperative Approaches
– Correcting Anemias Prior to Surgery
– Preventing Unnecessary and Iatrogenic Blood
Loss
– Preoperative Autologous Blood Collections
• Intraoperative Approaches
– Intraoperative Blood Salvage
– Acute Normovolemic Dilution
• Postoperative Approaches
Surgical Transfusion Medicine –
Summary 2/2
• Transfusions in Emergency Situations
– Introduction
– What is Shock (Especially, Hemorrhagic Shock)?
And …
– … What Are Its Consequences?
– The Nuts and Bolts of Emergency Transfusions
– Challenges Associated with Massive
Transfusions
Thank You …
To all of our friends/colleagues in
the audience…
Chris.Gresens@BloodSource.org