Complications following massive blood transfusion

1. COMPLICATIONS OF MASSIVE
BLOOD TRANSFUSION
AND THEIR MANAGEMENT

2. Definition
• Transfusion of large volume of blood products over a short period of
time to a patient who has severe or uncontrolled hemorrhage
Adults
Replacement of one entire blood volume (70mls/kg) within 24h
Transfusion of >10 units of packed red blood cells in 24h
Transfusion of >4 units of PRBCs in 1h when ongoing need is
foreseeable
Replacement of 50% of total blood volume within 3hrs

3. Paediatric population
Transfusion of 100% TBV within 24hrs
Transfusion to replace ongoing hemorrhage of 10% TBV per minute
Replacement of 50% TBV by blood products within 3 hrs

4. Massive blood transfusion

5. Complications of massive blood transfusion
• Volume overload
• Tissue hypoxia
• Coagulation abnormalities
• Electrolyte imbalance: hypokalemia, hypocalcemia
• Acid base imbalance ;metabolic acidosis/ alkalosis
• Hypothermia

6. Electrolyte imbalance
• Metabolic complications are usually seen after massive transfusion.
Hyperkalemia: Stored blood has high potassium levels because of hemolysis and
irradiation
Hypocalcemia: Citrate chelates calcium
• Risk is substantially greater in a patient with preexisting liver disease or ischemia
induced hepatic dysfunction
o The indications for calcium replacement during transfusion are:
• Blood given at a very fast rate (Liver does not get sufficient time to metabolize
citrate)
• Liver diseases.
• Massive blood transfusion (citrate load is too high)
• Severe hypothermia (decreases citrate metabolism).

7. Hypomagnesemia because of large volume of poor magnesium fluid
and citrate overload
Hypokalemia because of reentry into transfused red blood cells,
release of stress hormones, or metabolic alkalosis

8. Management of electrolyte imbalances
• Laboratory monitoring
potassium, free calcium, sodium and chloride abnormalities
• Hypocalcemia replaced with either calcium chloride (2 to 5 Ml per
500mL of blood given) or calcium gluconate (10 to 20 ml per 500 ml
of blood transfused)
• Hyperkalemia – insulin, glucose

9. Acid base abnormalities
• Blood gases show variable results.
• Acidic pH of stored blood causes acidosis while citrate metabolism
causes alkalosis.
• pH falls 0.1 pH unit/week due to the production of lactic acid and
pyruvic acids by the red cells
• In massive transfusion alkalosis is more common due to citrate
intoxication (one molecule of citrate generates 3 molecules of
bicarbonate).

10. Management of acid base abnormalities
• Blood gas analysis – base deficits and lactate levels are monitored to
assess adequacy of resuscitation in restoring oxygen delivery and
tissue perfusion

11. Coagulation abnormalities
• Massive blood transfusion causes dilutional coagulopathies especially
dilutional thrombocytopenia (stored blood has no platelets and
concentration of other clotting factors is also less).
• Dilutional coagulopathies leading to disseminated intravascular
coagulation (DIC) is the usual cause of death after massive blood
transfusion
• Tissue trauma causes activation and consumption of coagulation
factors( consumptive coagulopathy)

12. • Prolonged shock, hypoxia and hypothermia result in reduced activity
of coagulation factors
• Renal dysfunction: failure to clear activation peptides that act as
competitive inhibitors
oLaboratory monitoring
CBC( platelet count)
PT, Aptt, INR, fibrinogen levels

13. management
• Treatment should be initiated only if (not prophylactically after 3-4 units as practiced in past)
• There is bleeding from surgical site which is not getting controlled by surgical hemostasis or there
is bleeding from intravenous site, mucous membranes or petechial hemorrhages.
• PT, APTT > 1.5 times of normal
• Fibrinogen < 75 mg/dL
• Platelet count < 50,000
Treatment includes
• Fresh blood (collected and used within 6 hours without refrigeration)- best modality of treatment.
(Provides all coagulation factors and platelets)
• Fresh frozen plasma.
• Specific blood component therapy.
• Platelets.

14. Hypothermia
• Significant hypothermia is only seen with massive transfusion.
• Blood should be warmed to 37°C before infusion
• Reduce rate of infusion

15. Volume overload
• Overzealous resuscitation
• Transfusion associated circulatory overload is characterized by acute
respiratory distress, tachycardia, increased blood pressure, acute
pulmonary edema etc
• Common in the elderly, children, patients with compromised left
ventricular function
• The intravenous infusion of blood product significantly raises the
central venous pressure, resulting in increased trans-vascular fluid
extravasation and pulmonary edema

16. Tissue hypoxia
• Decrease in 2,3 DPG in stored blood can shift oxygen dissociation
curve to left and at least theoretically can produce tissue hypoxia
• 2,3 DPG decreases hemoglobin’s affinity for oxygen, thereby shifting
the entire oxygen-binding curve to right

17. Volume overload/tissue hypoxia intervention
• Fluid (colloids/crystalloids resuscitation) only until blood available
• Typed/cross-matched RBCs is ideal
• Administering PRBCs, FFP and platelet concentrate in a 1:1:1 ratio
for example: 6PRBCs : 6 units of FFP and 6 units of pooled platelets.

18. Transfusion related acute lung injury
• Manifest as hypoxia within 6hrs of transfusion
• Probably due to damage alveolar capillary membrane by to anti-HLA
antibodies or anti-leukocytic antibodies
• Managed like ARDS : oxygen therapy, clearing of the airway, ensuring
adequate breathing and circulation

19. Targeted lab values
Laboratory investigations: BGAs, Electrolytes, Coagulation profile (PT,
APTT,INR, fibrinogen levels, CBC
 Hb 7-9 g/dl
 INR <1.5
 Activated PTT < 42 seconds
 Ph 7.35 – 7.45
 Body temp > 35.0 C
 Base deficit < 3.0
 Lactates <2 mEq/L