since fever, with or without a chill, also may be the sign of a severe, acute hemolytic transfusion reaction or infection, FNHTRs cannot be ignored.
May occur when a patient with blood group A, B, or AB is transfused with a blood product (eg, apheresis platelets, frozen plasma) containing donor plasma with a high titer of ABO alloantibodies
Avoid dextrose: may initiate hemolysis of remaining cells in the line, RL contains calcium- promotes clotting of remaining blood in IV line
Plasma exchange is more prone to produce anaphylaxis
Commonly seen with platelet transfusions
However ta-GVHD is not reported in HIV-AIDS
Headaches and seizures are also reported in TACO
If blood is mixed with 5 percent dextrose and water, the sugar is rapidly taken up by the red cells, water follows across the red cell membrane, and lysis occurs. ●If lactated Ringers solution is used, the added calcium can cause plasma, if present, to clot in the intravenous line or filter.
if there is no attendant blood (iron) loss, the transfusion of 10 to 12 units of red cells effectively doubles an adult's total body iron burden.
(eg, Babesia, Anaplasma phagocytophilum, Rickettsia rickettsii, Colorado tick fever virus, and tickborne encephalitis virus) (eg, malaria, trypanosomiasis, and leishmaniasis).
Blood transfusion and its reactions in obstetrics
By DR. Momina Zulfeen
The transfer of blood or blood components
from one person (the donor) into the
bloodstream of another person (the
Maternal mortality due to obstetric haemorrhage is
25-30 percent and anaemia is 15percent, both
these conditions require blood transfusion.
Studies show that there is inappropriate
transfusion in 15-45% , either transfusion done in
non indicated cases or too late or too little done in
Rising cost and non availability of blood, risk of
transfusion reaction and transmission of infections
have made us to limit transfusion only in indicated
Anemia in antenatal period
Pregnancy < 36 weeks:
Hb – 5gm % or below
Hb – 5- 7 gm % in presence of established or
incipient cardiac failure or clinical evidence of
hyooxia, pneumonia or any other serious
bacterial infection and malaria.
Pregnancy > 36 weeks:
Hb < 7 – 9 gm % or below in presence of clinical
evidence of hypoxia , pneumonia or any other serious
bacterial infection and malaria.
Anemia in intranatal or postnatal period
Patient needing major surgery and Hb < 8 gm/dl
Ongoing bleeding or risk of further bleeding with Hb <
When hb is <7g/dl in immediate postpartum period,
blood transfusion depends on the medical history, age
and symptoms. Fit and healthy women require no
blood transfusion even with Hb of <7g/dl.
In sickle cell anemia repeated transfusions are
indicated, thus partial exchange transfusion done.
All women should have their blood group and
Rh antibody status checked at booking.
Patient blood samples used for cross
matching should be no more than 7 days old
In pregnancy, pre autologous deposit is not
Compatibility testing is done in two steps
1. ABO-Rh typing
ABO-Rh typing is done by testing RBC for A
and B antigens and the serum for A and B
antibodies. Rh typing follows.
Cross match is essentially a trial transfusion
in which donor cells are mixed with recipient
serum. It takes about 45-60 minutes.
Screening for infectious agents
Every unit of donated blood should be screened for
transfusion- transmissible infections using the most
appropriate and effective tests, in accordance with
both national policies and the prevalence of infectious
agents in the potential blood donor population.
No blood or blood product should be released for
transfusion until all nationally required tests are
shown to be negative.
All donated blood should be screened for
HIV 1 AND HIV 2
Treponema pallidum antibody
WHO prescribes a checklist before prescribing blood
1. What improvement in the patient’s condition am I to
achieve following blood transfusion?
2. Can I minimize the blood loss to reduce the transfusion?
3. Are there any other treatment like IV replacement fluid
4. What are the specific clinical and lab indications for
5. What are the risks of transmitting infectious agent?
6. Do the benefits of transfusion outweigh the risks?
7. What other options are there if no blood is available in
8. Will the trained person monitor and respond
immediately if any acute transfusion reaction occur?
9. Have I recorded my decision and reasons for transfusion
on patients chart and the blood request form?
RCOG Recommends reduction of blood transfusion by
1. Treatment of anemia a must.
2. Hb% of 10.5 gm/dl indicates hematinic deficiency ,
3. Oral iron preferred in the treatment of anemia.
Parenteral iron only in intolerance to oral,
absorption defects, doubtful compliance of patient.
4. Recombinant human erythropoietin used only in
end stage renal disease.
5. Hemoglobinopathies and bone marrow failure
syndrome treated by blood transfusion in close
conjunction with hematologist.
6. Active management of 3rd stage of labour proved to
decrease incidence of blood transfusion.
7. Optimal management of women on anticoagulants.
Blood grouping at Rh typing at booking.
Patients blood sample should ideally be fresh
and save sample in high risk cases, not more
than 7 days.
Only Kell negative blood should be used in
women of child bearing age.
seronegative red cells and platelets for
Autologous transfusion in ruptured ectopic cases
Normal blood volume is 7 % of ideal body weight
and it increases to 8- 9% in pregnancy. Massive
blood loss is loss of one blood volume in 24 hours
or 50 percent blood volume in three hours or loss
at a rate of 150ml /minute.
Red cell replacement in acute blood loss with
Patients needing red cell transfusions where red
cell concentrates or suspensions are not available
Incipient cardiac failure
No functional platelets, no labile coagulation
factors V and VIII.
Components prepared are PRBC, platelet
concentrates, FFP and Cryoprecipitate.
Collected into a sterile disposable plastic
pack containing anticoagulant CPDA(Citrate
Phosphate Dextrose Adenine).
Shelf life – 35 days
One unit of whole blood increases Hb by 0.75
to 1 g/dl and hematocrit by 3-5%.
Transfusion should be started within 30mins
Complete transfusion ideally within 2 hours
not more than 4 hours.
Obst indications- postpartum hemorrhage,
ectopic pregnancy, antepartum hemorrhage,
Packed red cells
Fresh frozen plasma
Human plasma proteins such as albumin,
coagulation factor concentrates,
Specialized products : leukoreduced blood
and HLA matched plateletes.
Quantity – 150 – 200 ml
Hemoglobin approximately 20g/dl
Hematocrit 55-70 percent
Prepared from single blood donor, collected
in plastic bags
Plasma separated by either centrifugation or
Preparation time : 20 mins
Single unit of PRBC raises the hb by 1g and
hematocrit by 3 percent
Contains stable clotting factors, albumin,
immunoglobulin and no platelet.
CBC and coagulation screening advised.
FFP takes 30mins to thaw, once thawed, used
within 6 hours.
Should ideally be of same group, different
group is acceptable.
No anti-d prophylaxis required
Fibrinogen levels should be maintained above
Quantity – 100ml
Contains all the coagulation factors specially
Factor VIII level at least 70% of normal fresh
Plasma separated form one whole blood
donation within 6 hours
Stored at <25*C
1unit raises the fibrinogen level by 5-10mg%
Indications- DIC,TTP,INR>2timesnormal, massive
Infusion of FFP ideally before 1 blood volume
In DIC a combination of FFP, platelets and
FFP indicated when fibrinogen is <100mg/dl
and maintain fibrinogen >1g/dl.
FFP and cryoprecipitate should ideally be of
same group. No need for anti-D prophylaxis.
From FFP by collecting the precipitate during
Frozen within 1hr at <1*C.
Shelf life – 12 months.
Transfuse within 20 mins. Infuse with 6 hours
Each unit increases fibrinogen by 5-10 units
Indicated in DIC, vWD deficiency, factor VIII
The platelet count should not be allowed to
fall below 50,000/dl in acutely bleeding
Should be ideally group compatible
Anti D required.
Indicated in thrombocytopenia due to
ITP,TTP,DIC,HELLP syndrome and massive
1 unit of plt concentrate per 10kg bwt.
Increments will be less if there is
spleenomegaly,DIC or septicemia.
One unit increases the plt count by 6,000 to
Preparation time – 1 hour
Continuous gentle agitation maintained
Shelf life – 72 hours.
4-6 units infused over 30 minutes.
SDP- quantity- 300-350ml.
One unit increases plt by 30,000-60,000.
Is recombinant factor VII.
Dose- 50-100ug/kg IV
Mechanism of action- binds tissue factor at
site of injury. Activates factors X and IX.
Response time- within 20-30 min
Potential complications- thrombosis inculding
Works best in presence of normothermia
Indicated in treatment of coagulopathy in
Check the blood unit details against issue slip
Check patient details against blood unit
Attach unit of blood and remove air column
before connecting, under aseptic precautions.
Ensure blood is flowing at correct rate.
Start transfusion rate at the rate of
Increase the rate half an hourly upto
Complete transfusion with in 4-5 hours.
No recommendations for warming of blood/
routine use of diuretics.
Monitor before starting, at once and 15
minutes after transfusion and then half
Record all the details
Any adverse event attributed to the
introduction of whole blood or blood
components into the blood stream of the
Can occur in any transfusion recipient, but is
more common with hematologic and
*based on time of appearance *based on cause
The most common transfusion reaction
Occurs towards end of transfusion
Occurs in 1/20 platelet and 1/300 RBC
Clinical manifestations: Fever, chills and
sometimes mild dyspnea within one to six
hours after transfusion of red cells or
Cytokines, such as interleukin (IL)-1, IL-6, IL-
8, and tumor necrosis factor-alpha (TNFa),
which are generated and accumulate during
the storage of blood components.
Interaction between donor leukocytes and
recipient antibody leads to interleukin-1
release from donor leukocytes or recipient
monocytes, which stimulates PG-E2
production in the hypothalamus.
Stopping the transfusion
Antipyretics and meperidine
Ruling out hemolytic reaction
Leukoreduction of transfused blood
A medical emergency that results from the rapid
destruction of donor erythrocytes by preformed
Usually due to ABO incompatibility
Some acquired alloantibodies like anti-Rh and anti-
Jka are also implicated
Can occur with as low as 20-30 RBC.
Most fatal complication, followed by TRALI and
Typical triad: Fever, flank pain, and red or
brown urine (ie, hemoglobinuria)
Fever and chills may be the only
DIC may be the presenting mode, with oozing
of blood from puncture sites and
Pink plasma and direct Coomb’s positive
Stop the transfusion, but leave the intravenous line
The bag containing transfused cells, along with all
attached labels should not be discarded to repeat
typing and cross-matching of this unit, if required.
Maintain airway, blood pressure, and heart rate
Initiate IV normal saline (100-200 mL/hr)
From the other arm, obtain a sample for a direct
antiglobulin test, plasma free hemoglobin, and
repeat type and cross-match.
Urine sample for hemoglobin testing.
Alert blood bank immediately and search for
Follow hospital protocol for evaluating
In massive hemolysis or DIC
Early heparinization (10 units/kg/hour) for 12 to
24 hours may be of value
low-dose dopamine as vasopressor
Look for hyperkalemia, cardiac and renal
function monitoring, coagulation profile
monitoring and hemodialysis
Seen generally within 3 to 30 days after transfusion
Anamnestic antibody response occurring after re-
exposure to a foreign red cell antigen previously
encountered by transfusion, transplantation, or
The antibody, often of the Kidd or Rh system, is
undetectable on pre-transfusion testing but
increases rapidly in titer following the transfusion.
Hemolysis is usually extravascular, gradual, and less
severe than with acute reactions
Falling hematocrit, slight fever, mild increase
in serum unconjugated bilirubin, and
spherocytosis on the blood smear.
A new positive direct antiglobulin test and a
new positive antibody screen are found when
more blood is ordered.
No treatment is required in the absence of
brisk hemolysis. However, future transfusions
containing the implicated red cell antigen
need to be avoided.
May occur within a few seconds to a few
minutes following the initiation of a
transfusion that contains plasma, red cells,
platelets, granulocytes, cryoprecipitate, or
Not generally seen following the
administration of normal serum albumin,
plasma protein fraction, or coagulation
Manifested by shock, hypotension,
angioedema, and respiratory distress
Patients with prior history of
anaphylaxis/allergy, IgA deficiency are more
Immediate cessation of the transfusion
Epinephrine, 0.3 mL of a 1:1000 solution
Resuscitation of hypotensive patients with
Airway maintenance, oxygenation
Vasopressors (eg, dopamine), if necessary
Occur when soluble allergenic substances in
the plasma of the donated blood product
react with preexisting IgE antibodies in the
recipient causing mast cells to release
The transfusion should first be stopped and if
the urticaria is extensive, 25 to 50 mg
of diphenhydramine can be given orally or
If the urticaria wanes and dyspnea,
hypotension, and anaphylaxis are absent, the
transfusion may be resumed.
Characterized by drop in blood pressure (SBP, DBP, or
both) of </= 30 mmHg, within minutes of onset of
transfusion and returning to baseline once the
transfusion is stopped.
Other types of transfusion reactions like transfusion-
related acute lung injury [TRALI], sepsis, severe allergic
reactions must be excluded.
Mediated by two vasoactive kinins (bradykinin and one
of its derivatives) generated by activation of the
Generally not serious, and rapidly reversible with
cessation of the transfusion, no specific preventative or
Rare transfusion reaction that can occur
after transfusion of any platelet-containing
product (eg, red cells, platelets, or
granulocyte concentrates), commonly in
women (M:F- 1:26).
Caused in Human Platelet Antigen-1a (HPA-
1a) deficient women being sensitized by
previous HPA-1a positive transfusion or
Present with severe thrombocytopenia (eg, platelet
count ≤20,000/microL) that develops approximately 5 to 10
days following transfusion, which often lasts for days to
Mimics idiopathic thrombocytopenic purpura/ drug-induced
Specific tests to determine the platelet antigenic
composition and/or the presence of anti-platelet antibodies
may not be readily available. Hence clinical history has to be
Preferred therapy is intravenous immune globulin (IVIG)
in high doses (400 to 500 mg/kg per day, usually for five
days); 1 g/kg per day for two days can be given for
Rare complication that develops 4 to 30 days after a
GVHD results from an attack by viable
immunocompetent donor lymphocytes on the recipient's
antigen presenting tissues. This immunologic assault is
manifested clinically by dysfunction of the skin, liver,
gastrointestinal tract and bone marrow
Occurs in two settings: when the recipient is
immunodeficient; and when there is a specific type of
partial HLA matching between the donor and recipient.
ta-GVHD has been reported after the administration of
Not induced by frozen, deglycerolized red cells, fresh
frozen plasma, or cryoprecipitate.
Typically fever and rash. Other symptoms include
anorexia, vomiting, abdominal pain, profuse diarrhea,
Pancytopenia due to a strikingly hypocellular marrow,
abnormal liver function tests, and electrolyte
abnormalities induced by diarrhea.
Diagnosis is suggested from biopsy of affected
skin, which classically reveals vacuolization of
the basal layer and a histiocytic infiltrate, which
is also seen in the aplastic bone marrow.
Definitive diagnosis is established if the
circulating lymphocytes are shown to have a
different HLA phenotype from host tissue cells.
Differential diagnosis: Certain infections (HIV,
HBV,HCV), drug reactions, other causes of liver
failure, the patient's underlying illness, and
Ta-GVHD is almost universally fatal; there is
no effective treatment.
Prevention: gamma irradiation
Defined as new acute lung
injury (ALI)/acute respiratory distress syndrome
(ARDS) occurring during or within six hours after
blood product administration
Can be seen following transfusion of any type of
blood component in any patient, especially those
with a high concentration of donor plasma (due
to antibodies to human leukocyte and human
A "two-hit" hypothesis for the pathogenesis of TRALI holds
that recipient neutrophils are primed for activation by virtue
of the patient's underlying clinical condition.
The second hit involves activation of these neutrophils by
pre-formed anti-leukocyte antibodies or biological response
modifiers contained in the transfused product.
Characteristic clinical presentation of TRALI is the sudden
onset of hypoxemic respiratory insufficiency during or shortly
after the transfusion of a blood product.
Often have frothy airway secretions (if intubated), fever,
cyanosis, and hypotension.
Immediate discontinuation of the transfusion
Evaluate the recipient’s vital signs
Assess the extent of hypoxemia,
Obtain a chest radiograph.
Pulse oximetry is often sufficient, but arterial blood
gas analysis may be warranted in more severe
Report to the blood bank that TRALI is suspected
Therapy is supportive, with oxygen
Non-invasive respiratory support with continuous
positive airway pressure (CPAP) or bilevel positive
airway pressure (BiPAP) ,endotracheal intubation
with invasive mechanical ventilation
Fluid resuscitation and/or vasoactive support to
Although the risk for mortality is significant, patients
who survive a TRALI episode are expected to recover
Prevention of TRALI involves deferring donors
implicated in a case of TRALI, donations from
Transfusion associated circulatory overload
Addition of drugs and diluents to blood products
Hyperkalemia, hypokalemia, and metabolic
Common especially in elderly patients, small
children, and/or those with compromised
Where large fluid volumes and some blood
Symptoms include dyspnea, orthopnea,
tachycardia and a wide pulse pressure, often
with hypertension and hypoxemia
Symptoms may begin near the end of the
transfusion, or within six hours
May be difficult to differentiate TACO and
TACO is characterized by elevated N terminal
Pro-BNP (NT Pro-BNP), central venous
pressure, and pulmonary artery wedge
In TACO, the ratio of protein in the edema
fluid to plasma is low, reflecting a transudate
rather than an exudate
Similar to cardiogenic pulmonary edema
Non-invasive ventilation for respiratory distress
Phlebotomy (250ml increments) with/without
reinfusion of the removed red cells.
A transfusion rate of approximately 2.0 to
2.5 mL/kg per hour is acceptable for routine
transfusions of blood components
Patients deemed to be at risk of TACO (eg, small
stature or low body weight, elderly, known or
suspected poor cardiac function) can be safely
transfused at a rate of 1 mL/kg per hour and should
also be monitored more closely during the transfusion
for signs and symptoms of TACO.
Limiting transfusion of red cells to two units
per day in patients who are not actively
Administering packed cells instead of whole
Administering a small dose of diuretic
Isovolemic exchange: One unit of the
patient's blood (with a low hematocrit) is
removed at the same time as a unit of
packed cells (with a hematocrit of 60 to 80
percent) is infused.
No drugs should ever be added to a blood
component or given through an intravenous
line through which blood is flowing, as
osmotic hemolysis can result.
Only 0.9 percent saline is acceptable as an
additive or diluent for a blood transfusion.
Transported, as well as stored, blood products
must be carefully maintained (and monitored) at
temperatures appropriate to the products: 4°C
for packed red cells, 22°C for platelets, -30°C
for frozen plasma.
If red cells are frozen without cryoprotectant or
are too rapidly thawed after appropriate
freezing, they will hemolyze
Blood warmers — carefully calibrated and
continuously monitored to avoid heating of the
blood cells above 40ºC, with resultant hemolysis
Balanced citrate solution is used to chelate
calcium and prevent the blood from clotting
Citrate toxicity is rare.
Symptoms: Sense of heightened anxiety,
carpopedal spasm, tetanic contractions, and
Mild symptoms are more common: Chilliness,
anxiousness, circumoral paresthesias and
tightness of jaw and/or other muscles.
Hyperkalemia and potassium leakage:
Leakage of potassium from red cell products
(eg, prolonged storage, irradiation) may be a
problem in some settings (eg, infants and
patients with renal impairment).
Red cells that have been irradiated to
prevent graft-versus-host disease leak more
potassium than non-irradiated products. As a
result, their shelf life is reduced to 28 days
Hypothermia is occasionally seen in
recipients of large volumes of refrigerated (1
to 6ºC) blood products.
Slowing the infusion, warming the patient, or
warming the blood with properly functioning
blood warmers is helpful
May occur in chronically transfused patients,
such as those with sickle cell disease,
thalassemia major, aplastic anemia,
myelodysplastic syndrome or other illnesses
requiring many red cell transfusions over long
periods of time.
Each unit of red cells contains approximately 250
mg of iron.
Under normal circumstances, total body iron
burdens are 2-4grams, most of which is
circulating as hemoglobin
Free iron is toxic to tissues.
When reticuloendothelial storage sites are
saturated, iron begins to be deposited in organs
such as the liver, heart, endocrine organs, and
pancreas, leading to hepatic fibrosis,
cardiomyopathy, arrhythmias, endocrine
dysfunction (including hypogonadism), and
Since phlebotomy is not an option in anemic
patients with iron toxicity, iron-chelation is used
as treatment for such patients.
With the advent of plastic equipment and
closed blood delivery systems, entry of large
volumes of air into the venous system is no
longer a problem with routine transfusions.
However, significant amounts of air may be
inadvertently transfused following the use of
more complex transfusion systems, such as
apheresis and blood salvage equipments.
Defined as bacterial infection following
transfusion (in the absence of infection prior to
transfusion), with evidence of blood product
contamination or infection in the donor
The organisms causing TTBI can come from donor
blood, donor skin, the phlebotomist's skin, or
environmental contamination during production
or packaging (eg, contaminated water baths
used to thaw blood products)
Cryophilic organisms especially Yersinia enterocolitica
and Pseudomonas fluorescens, Enterobacter,
and Serratia can survive and multiply in cold-stored
Infection with gram-negative organisms has been
associated with the greatest risk of death
Tickborne infections can also be transmitted by
transfusion of blood products.
Transfusion is associated with risk for transmission of
parasitic infection in endemic countries.
Clinical manifestations: Fever >39ºC (or an
increase of >2ºC following transfusion), rigors,
tachycardia (>120 beats per minute or increase
of 40 beats per minute following transfusion),
and rise or fall in systolic blood pressure (>30
Median interval between completion of
transfusion and appearance of symptoms is 30
minutes (range 0 to 5 hours).
Significant overlap with clinical manifestations
of non-hemolytic transfusion reactions, acute
hemolytic reactions, allergic reactions, and
Stop the transfusion immediately.
Resuscitate the patient.
Collect blood from the opposite arm from that used for the transfusion and
send for culture, direct antiglobulin (Coombs) test, plasma-free hemoglobin,
and repeat crossmatch and typing. Urine should be analyzed for free
Check for clerical error. If an error is found, investigate the status of the unit
intended for the recipient (so that it is not administered to another patient
If there is high suspicion for TTBI (eg, in the setting of fever together with
hypotension, shock, or respiratory failure), begin empiric broad-spectrum
antibiotics. The choice of antibiotics should be determined by local resistance
patterns; the combination of vancomycin and a broad-spectrum beta-
lactam or an aminoglycoside should provide coverage for the most likely
Alert the hospital blood bank and microbiology laboratory.
Seal the blood product bag and send to the microbiology laboratory for Gram
stain and culture. A sample from the bag should be obtained using aseptic
technique with a needle and syringe. If there is no residual blood product in
the bag, then culture broth should be added to the bag and an aspirate of the
broth be used for culture.
Co-components from the same donation should be quarantined.
Donor screening – Exclusion of donors with identifiable infectious
diseases and deferral of donors for 24 hours after dental extraction
Skin preparation – Careful donor arm disinfection; the preferred skin
disinfection solution is a product combining 2
percent chlorhexidine in 70 percent isopropyl alcohol.
Sample diversion – Discarding the first aliquot of donor blood has been
proposed in order to prevent infection due to skin contaminants.
Increasing culture volume – In one study, doubling the volume of blood
cultured resulted in a 54 percent relative increase in culture sensitivity.
Preferential use of apheresis – A single donor product (apheresis
platelets) carries a lower risk of TTBI than whole-blood–derived platelet
concentrates, since bacterial contamination may result from a
Reduced storage time – The risk of TTBI increases with storage time
between blood donation and blood product administration.
Bactericidal treatments (eg, ultraviolet light exposure after psoralen
Fever/chills — Fever (ie, increase in
temperature of >1°C), with or without a chill, is
a critical sign of an acute transfusion reaction.
acute hemolytic transfusion reaction (AHTR), a
septic transfusion reaction, transfusion-related
acute lung injury (TRALI), or a febrile
nonhemolytic transfusion reaction (FNHTR)
Significant ATRs not accompanied by fever
include: urticaria, anaphylaxis, primary
hypotensive reactions and transfusion-associated
circulatory overload (TACO)
Respiratory distress — Respiratory
symptomatology characterizes TACO, TRALI,
TACO and TRALI may be difficult to
differentiate because they both present with
●TACO is more often characterized by
hypertension, while TRALI is often associated
●The pulmonary artery wedge pressure is
usually elevated in TACO but not in TRALI.
●TRALI is more often accompanied by fever.
Hypotension — A significant drop in blood pressure
(eg, by >20 mmHg) is characteristic of AHTR,
TRALI, and sepsis. Importantly, hypotension may
also be due to bleeding rather than a transfusion
AHTR may be accompanied by fever, chills, back
pain, pain along the infusion vein, and
disseminated oozing from intravenous catheters.
Dark urine and/or oliguria. Evidence of
intravascular immune hemolysis.
TRALI is accompanied by fever/chills, respiratory
distress, rales on lung exam, and hypoxemia; chest
radiography shows bilateral pulmonary edema.
Sepsis may be accompanied by fever/chills, and
other findings of shock. Laboratory evaluation will
reveal the infectious organism.
Rash- can be isolated reaction or associated
with serious anaphylaxis or anaphylactoid
Anaphylaxis occurs with in three hours,
associated with hypotension, abdominal pain
The massive transfusion protocol is used to
identify and manage patients at risk of
bleeding by standardizing blood orders for
component replacement during the bleeding
Criteria for activation of massive transfusion
Actual or anticipated 4 units of RBC in <4
hours + hemodynamically stable+/- ongoing
In adults > 50ml per kg per hour
Major obstetric hemorrhage
Resuscitation with FFP, platelets, and RBCs at 1:1:1
unit ratios means that the actual blood being given
has a coagulation factor concentration of 65 percent
of normal, a platelet count of 88 x 109/L, and a
hematocrit of 29 percent. Because 30 percent of the
platelets and 10 percent of the RBC administered will
not circulate, the effective concentrations are a
plasma coagulation factor concentration of 65
percent, platelet count of 55 x 109/L, and a
hematocrit of 26 percent.
Tranexemic acid- loading dose 1gm over 10 min, then
infusion of 1gm over 8 hours.
Cryoprecipitate if fibrinogen <1g/l
Monitor CBC, coagulation profile, ionized calcium
,ABG every ½ hour.
Citrate toxicity and hypocalcemia
Depletion of fibrinogen and coagulation
Depletion of platelets
Disseminated intravascular coagulation
Reduced 2,3 diphosphoglycerate
Acidosis- under normal circumstances body can
easily neutralize this acid load. Routine use of
bicarbonate is unnecessary.
hyperkalemia-small increase is rarely of
Inj calcium gluconate 10% , 10 ml over 10 minutes
salbutamol nebulization 15mg every 30 min for first 2
hours and then 4th hourly.
25% dextrose 100ml with 10 units rapid acting insulin
over half hour
Last resort – dialysis.
Prevention- using fresh blood.
Citrate toxicity- citrate is usually rapidly
metabolized, may cause hypocalcemia.
Prophylactic calcium is not recommended
Dilutional coagulopathy by depletion of
fibrinogen and coagulation factors- FFP and
DIC- abnormal activation of coagulation and
fibrinolytic systems- correct underlying cause
and replace coagulation factors.
Hypothermia- warm blood and warm IV fluids
Microaggregates- filters can be used,little
evidence on their efficacy.
Cell free purified hemoglobin solution
Perfluorocarbon emulsions- an inert liquid
with high oxygen solubility , oxygen
delivered by simple diffusion.
Blood cell subsititutes such as flusol, oxigant.