Transcript Blood Transfusion - Gilan University of Medical Sciences

Blood Transfusion in Burned Patients
Haddadi MD
Anesthesiology Department in GUMS
2014
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Need to transfusion is not a major concern
during immediate resuscitation phase
During the acute resuscitation phase a fall in
Hb (hemodilution, escharotomies , other
invasive procedures )
In OR patients have major blood loss
(excision , graft)
Surgical procedure
<24 h since burn injury
Predicted blood loss
0.45ml/cm2 burn area
1-3 days since burn
0.65ml/cm2 burn area
resuscitation phase
injury
2-16 days since burn
injury
0.75ml/cm2 burn area
>16 days since burn
injury
Infected wound
0.5-0.75ml/cm2 burn
area
1-1.25ml/cm2 burn
area
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Hct to drop to 15-20% prior to transfusion
in other healthy patients with minor excision
Hct <25% in pre-existing
Cardiovascular Disease
 Hct near 25% in patients with more
extensive burn
 Hct near 30% in patients with preexisting Cardiovascular Disease
 Hb 6-6.5 gr/dl
 the lowest adverse metabolic or
hemodynamic reactions
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Evaluating the patient’s clinical status
Assessment of ongoing blood loss , preoperative Hb level , vital sign
Evidence of inadequate o2 delivery such as
hypotension, tachycardia ,acidosis
Pulmonary ,cardiovascular D.
ASA , Hb>10 Hb<6 +
Factors
Blood loss
(mL)
Class I
Class II
Class III
Class IV
750
750-1500
1500-2000
2000 or more
Blood loss (%
15
blood volume)
15-30
30-40
40 or more
Pulse
(beats/min)
100
120
140 or higher
Blood pressure Normal
Normal
Decreased
Decreased
Pulse pressure Normal or
(mm Hg)
increased
Decreased
Decreased
Decreased
Respirations
per minute
14-20
20-30
30-40
35
Urine output
(mL/hr)
30
20-30
5-10
Negligible
Central
nervous
Slightly anxious Mildly anxious
system: mental
status
Anxious,
confused
Confused,
lethargic
Fluid
replacement
(3-1 rule)
Crystalloid +
blood
Crystalloid +
blood
100
Crystalloid
Crystalloid
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During excision of major burn wounds ,blood
loss may reach to patient’s blood volume
Massive Hemorrhage
Loss of 1 blood volume in 24 h
50% blood volume in 3 h
Ongoing blood loss of 150 ml/min
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Coagulation factors are lost
Dilution as volume replacement
Resulting coagulopathy
Use of FFP in massive hemorrhage
Recent clinical studies: early use of
FFP+PRBCs in replacement of massive
hemorrhage
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Intravascular volume, with colloid(
Alb,Hetastarch)
O2 carrying capacity with PRBCs until 50% of
est Blood Volume
From this point ,FFP with PRBCs
RBCs enhance homeostasis through effects
on platelet biochemistry and function
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Hypothermia
Hypothermia can contribute to coagulopathy
Blood warmers when flow rate of blood >100
ml/min
Hypocalcemia (rapid flow rate,FFP, citrate)
Hypocalcemia impairs coagulation interferes
with vascular ,myocardial contractility then,
hypotension ( cacl2)
Ca Gluconate requires to hepatic metabolism
Use of tourniquets on limbs(limitations)
 Compression dressings at sites of excision
 Pharmacologic :
epinephrine soaked dressings
topical epinephrine spray
Tachycardia, hypertension
 Systemic Terlipressin (vasopressin analog )
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Whole blood
Packed RBCs
FFP
Platelets
Cryoprecipitate
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Contains all parts of blood
After 24 h ,has not functional WBC ,Plt
For burns, liver transplant, trauma,
hypovolemic shock
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The most common means of replacing blood
loss
50 ml residual plasma
PH
1
7
14
7.1
7
7
21
6.9
PCO2
48
80
110
140
K ( meq/l)
3.9
12
17
21
2,3 DPG
4.8
1.2
1
1
Viable PLT%
10
0
0
0
Factors 5,7
%
70
50
40
20
Days
Of Storage
At
4”c
value
Whole Blood
Packed RBC
Volume(ml)
517
300
Erythrocyte mass(ml)
200
200
Hct %
40
70
Alb (gr)
12.5
4
Plasma K(meq)
15
4
Plasma acid
80
25
Plasma Na (meq)
45
15
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In burn injuries to replace clotting factors
during massive transfusion
Clotting factors, Protein S,C
In massive transfusion, if active bleeding
exists, coagulation factor deficiency
approved
Indications for FFP according to National Health Guidelines
Replacement of isolated factor deficiencies(lab evidence)
Reverse of warfarin effect
Antithrombine III deficiency
Treatment of immunodeficiencies
Treatment of TTP
Massive blood transfusion( V,VIII=25% of normal)
PT,PTT 1.5 times normal
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Stored at room temperature to max viability
Increasing bacterial contamination after 4
days
Refrigerated PLT remain viable only 24-48h
5000-10,000PLT
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Thawing FFP at 4 c ,collecting cryoprecipitate
Rich in factors XIII, VIII, fibrinogen , Von
Willebrand factor
Massive blood transfusion to treat hypofibrinogenemia
Plasma fibrinogen<100 mg/dl
1 unit cryoprecipitate will increase Plasma
fibrinogen by 5-7 mg/dl
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Hemolytic Transfusion Reaction
Delayed Hemolytic Transfusion Reaction
(Immune Extravascular Reaction)
Nonhemolytic Transfusion Reactions
Transfusion-Related Fatalities in the United States,
2004-2006
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Cause of Fatality
TRALI
Other reactions (nonABO hemolytic therapy;
anaphylaxis)
Bacterial contamination
ABO hemolytic
transfusion therapy
Transfusion not ruled
out
2004-06
86
Average per Year
29
67
22
20
7
15
5
31
10
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Sign or Symptom
No. of Patients
Fever
19
Fever and chills
16
Chest pain
6
Hypotension
6
Nausea
2
Flushing
2
Dyspnea
2
Hemoglobinuria
1
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the transfused donor cells may survive well initially
after a variable delay (2 to 21 days) they are
hemolyzed
This type of reaction occurs mainly in recipients
sensitized to RBC antigens by previous blood
transfusions or pregnancy
RBC destruction occurs only when the level of
antibody is increased after a secondary stimulus
(i.e., anamnestic response)
a decrease in the post-transfusion hematocrit
value
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Nonhemolytic reactions to blood transfusions
usually are not serious and are febrile or allergic
in nature.
The most common adverse reactions to blood
transfusions consist of chills, fever, headache,
myalgia, nausea, and nonproductive cough
occurring shortly after blood transfusion caused
by pyrogenic cytokines and intracellular contents
released by donor leukocytes.
Allergic reactions can be minor, anaphylactoid,
or anaphylactic
The most common symptom is urticaria
associated with itching. Occasionally, the patient
has facial swelling.
Percentage Risk of Transfusion-Transmitted Infection with a Unit of
Screened Blood in the United States
Infection Risk Window Period (days)
Infection
Risk
Window Period
(days)
Human
immunodeficiency
virus-1
1/2,135,000
11
Human Tlymphotropic virus
(HTLV-II)
1/2,993,000
51
Cytomegalovirus
(CMV)
Infrequent with leukocytereduced components
Hepatitis C virus
(HCV)
1/1,935,000
40
Hepatitis B virus (HBV) 1/205,000
West Nile virus (WNV) 1/1,100,000
?