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Massive Transfusion and Coagulopathy.ppt
- 1. Massive Transfusion And MassiveTransfusion And Coagulopathy Coagulopathy Christine Mai, MD Christine Mai, MD Faculty Advisor: Mauricio Gonzalez, MD Faculty Advisor: Mauricio Gonzalez, MD Department of Anesthesiology Department of Anesthesiology Boston University Medical Center Boston University Medical Center
- 2. Guidelines to BloodProduct Guidelines to Blood Product Transfusions Transfusions In 1994, the ASA established the Task Force on In 1994, the ASA established the Task Force on Blood Component Therapy to develop evidence- Blood Component Therapy to develop evidence- based guidelines for transfusing blood products in based guidelines for transfusing blood products in perioperative and peripartum settings perioperative and peripartum settings 22 million blood components transfused yearly 22 million blood components transfused yearly Benefits: improved tissue oxygenation and decreased Benefits: improved tissue oxygenation and decreased bleeding bleeding Risks: Transmission of infectious diseases, Risks: Transmission of infectious diseases, hemolytic and nonhemolytic transfusion reactions, hemolytic and nonhemolytic transfusion reactions, immunosuppression, alloimmunization, coagulopathy immunosuppression, alloimmunization, coagulopathy
- 3. Massive Transfusion Massive Transfusion AmericanAssociation American Association of Blood Banks of Blood Banks definition: replacement definition: replacement of one blood volume of one blood volume (equivalent to 10 units (equivalent to 10 units of blood) in any 24 hr of blood) in any 24 hr period, or half of the period, or half of the blood volume (5 units blood volume (5 units of blood) in any four- of blood) in any four- hour period hour period
- 4. American College ofSurgeon’s Classes of Acute Hemorrhage American College of Surgeon’s Classes of Acute Hemorrhage Class Class I I II II III III IV IV Blood loss (ml) Blood loss (ml) ≤ ≤750 750 750-1500 750-1500 1500-2000 1500-2000 ≥ ≥ 2000 2000 Blood loss (% Blood loss (% blood volume) blood volume) ≤ ≤15% 15% 15-30% 15-30% 30-40% 30-40% ≥ ≥40% 40% Pulse rate Pulse rate <100 <100 >100 >100 >120 >120 ≥ ≥ 140 140 Blood pressure Blood pressure Normal Normal Normal Normal Decreased Decreased Decreased Decreased Pulse pressure Pulse pressure (mmHg) (mmHg) Normal or Normal or increased increased Decreased Decreased Decreased Decreased Decreased Decreased Capillary refill Capillary refill test test Normal Normal Positive Positive Positive Positive Positive Positive Respiratory rate Respiratory rate 14-20 14-20 20-30 20-30 30-40 30-40 >35 >35 Urine output Urine output (ml/hr) (ml/hr) ≥ ≥ 30 30 20-30 20-30 5-15 5-15 Negligible Negligible CNS-mental CNS-mental status status Slightly anxious Slightly anxious Mildly anxious Mildly anxious Anxious and Anxious and confused confused Confused, Confused, lethargic lethargic Fluid replacement Fluid replacement (3:1 rule) (3:1 rule) Crystalloid Crystalloid Crystalloid Crystalloid Crystalloid + Crystalloid + Blood Blood Crystalloid + Crystalloid + Blood Blood
- 5. Parameters For FluidReplacement Parameters For Fluid Replacement Maintenance Maintenance Deficits Deficits Insensible loss Insensible loss Estimated blood loss Estimated blood loss
- 6. Maintenance Maintenance 4:2:1 Rule orCalculate Wt +40 cc 4:2:1 Rule or Calculate Wt +40 cc Calculated weight: (IBW + ABW)/2 Calculated weight: (IBW + ABW)/2 IBW male: 110 lbs + 7 lbs * in > 5’ IBW male: 110 lbs + 7 lbs * in > 5’ female: 100 lbs + 6 lbs * in > 5’ female: 100 lbs + 6 lbs * in > 5’ Deficits Deficits NPO status NPO status Calculated Wt x hrs NPO x 0.7 Calculated Wt x hrs NPO x 0.7 Bowel prep ~ 1200cc Bowel prep ~ 1200cc Diuretics/ Urine output Diuretics/ Urine output NGT drainage NGT drainage CT drainage CT drainage
- 7. Insensible Loss Insensible Loss CaseType Case Type Volume Volume Non-open Non-open 2-3 cc/kg/hr 2-3 cc/kg/hr Open Open 4-6 cc/kg/hr 4-6 cc/kg/hr Major Abdominal 6-10 cc/kg/hr Major Abdominal 6-10 cc/kg/hr Trauma Trauma > 10 cc/kg/hr > 10 cc/kg/hr (Volume based on Calculated Weight) (Volume based on Calculated Weight)
- 8. Estimated Blood Loss EstimatedBlood Loss The 3: 1 Rule, replace 3 cc crystalloid : 1 The 3: 1 Rule, replace 3 cc crystalloid : 1 cc blood loss cc blood loss The 1:1 Rule, replace 1 cc colloid : 1 cc The 1:1 Rule, replace 1 cc colloid : 1 cc blood loss blood loss Allowable Blood Loss Allowable Blood Loss ( (Hct present - Hct allowable Hct present - Hct allowable) + EBV ) + EBV Hct present Hct present Estimated Blood Estimated Blood Volume Volume Adults: 75 cc/kg Adults: 75 cc/kg Infants: 80 cc/kg Infants: 80 cc/kg Neonates: 85cc/kg Neonates: 85cc/kg
- 9. Fluid Resuscitation Crystalloids FluidResuscitation Crystalloids Na Na (mEq) (mEq) Cl Cl (mEq) (mEq) K K (mEq) (mEq) Ca Ca (mEq) (mEq) Mg Mg (mEq) (mEq) Lactate Lactate Acetate Acetate Gluconate Gluconate pH pH mOsm mOsm Other Other NS NS (0.9%) (0.9%) 154 154 154 154 5.0 5.0 308 308 Indicated in Indicated in neurosugery neurosugery cases cases LR LR 130 130 109 109 4 4 2.7 2.7 28 28 6.5 6.5 273 273 Contraindicated Contraindicated in liver and in liver and kidney failure kidney failure PL PL 140 140 98 98 5 5 3 3 27 27 23 23 7.4 7.4 294 294 Physiologic Physiologic pH pH
- 10. Type and Screen Typeand Screen Screen for ABO-Rh type and most common antibodies Screen for ABO-Rh type and most common antibodies ABO incompatibility is a tragic and severe reaction, resulting ABO incompatibility is a tragic and severe reaction, resulting in rapid intravenous hemolysis in rapid intravenous hemolysis Ordered during elective cases when the probability of blood Ordered during elective cases when the probability of blood loss and transfusion are high loss and transfusion are high If blood is needed for emergent transfusion, a crossmatch can If blood is needed for emergent transfusion, a crossmatch can be performed to reconfirm ABO-Rh typing be performed to reconfirm ABO-Rh typing Reactions against lower-incident antigens may still occur Reactions against lower-incident antigens may still occur Emergency trauma cases: Type O Rh-Negative (Universal Emergency trauma cases: Type O Rh-Negative (Universal Donor) Uncrossmatched Blood transfused until a Type and Donor) Uncrossmatched Blood transfused until a Type and Cross clot is tested Cross clot is tested
- 11. Type and Crossmatching Typeand Crossmatching Crossmatching Crossmatching -Trial transfusion within a test tube between donor RBCs and recipient serum to -Trial transfusion within a test tube between donor RBCs and recipient serum to detect a potential for serious transfusion reaction detect a potential for serious transfusion reaction - 3 Phases: - 3 Phases: -Reconfirm ABO-Rh typing -Reconfirm ABO-Rh typing - Detect antibodies that are incomplete or do not agglutinate - Detect antibodies that are incomplete or do not agglutinate easily easily - Detect antibodies in other blood group systems (ie. Rh, Kell, - Detect antibodies in other blood group systems (ie. Rh, Kell, Kidd, Duffy) Kidd, Duffy) Antibody screening Antibody screening - Trial transfusion between the recipient’s serum and commercially supplied RBCs Trial transfusion between the recipient’s serum and commercially supplied RBCs with antigens that will react with antibodies commonly implicated in non-ABO with antigens that will react with antibodies commonly implicated in non-ABO hemolytic transfusion reactions hemolytic transfusion reactions - Donor’s serum also screened for unexpected antibodies to prevent their Donor’s serum also screened for unexpected antibodies to prevent their introduction to the recipient’s serum introduction to the recipient’s serum - Otherwise known as the Coomb’s test. Otherwise known as the Coomb’s test.
- 12. Blood Products Transfusion BloodProducts Transfusion Packed Red Blood Cells Packed Red Blood Cells Fresh Frozen Plasma Fresh Frozen Plasma Platelets Platelets Cryoprecipitate Cryoprecipitate
- 13. Packed Red BloodCells Packed Red Blood Cells Approx. 12 000 000 units of RBC are transfused yearly in the US Approx. 12 000 000 units of RBC are transfused yearly in the US Indicated for patients needing red cells for oxygen carrying Indicated for patients needing red cells for oxygen carrying capacity rather than for volume replacement (ie. CHF patients) capacity rather than for volume replacement (ie. CHF patients) 70% Hct in pRBC compared to 40% Hct in whole blood 70% Hct in pRBC compared to 40% Hct in whole blood Each unit contains 250-350 cc of red cells, increases Hct 3-4% or Each unit contains 250-350 cc of red cells, increases Hct 3-4% or increases Hgb 1g/dL increases Hgb 1g/dL Large amount of transfusions should be warmed to 37 Large amount of transfusions should be warmed to 370 0 C C Dilute pRBCs with either normal saline or plasmalyte when Dilute pRBCs with either normal saline or plasmalyte when giving massive transfusions giving massive transfusions Avoid Lactated Ringers because calcium can chealate with citrate Avoid Lactated Ringers because calcium can chealate with citrate
- 14. Citrate Toxicity Citrate Toxicity Calcium binding to citrate preservative in Calcium binding to citrate preservative in transfused blood transfused blood → → Hypocalcemia Hypocalcemia Signs of citrate intoxication: hypocalcemia, Signs of citrate intoxication: hypocalcemia, hypotension, narrowed pulse pressure, hypotension, narrowed pulse pressure, increased end-diastolic pressure increased end-diastolic pressure Cardiovascular depression can occur if Cardiovascular depression can occur if transfusion rate > 1 unit of blood per 5 mins transfusion rate > 1 unit of blood per 5 mins Risk factors: hypothermia, liver disease, liver Risk factors: hypothermia, liver disease, liver transplantation transplantation
- 15. Fresh Frozen Plasma FreshFrozen Plasma Portion of whole blood Portion of whole blood that remains after cellular that remains after cellular elements and platelets are elements and platelets are removed removed Each unit contains 250cc Each unit contains 250cc plasma plasma Contains coagulating Contains coagulating factors and fibrinogen factors and fibrinogen Increases level of each Increases level of each clotting factor by 2-3% clotting factor by 2-3% Needs to be ABO- Needs to be ABO- compatible but does not compatible but does not require crossmatching Rh require crossmatching Rh typing typing
- 16. Fresh Frozen Plasma FreshFrozen Plasma Indications: Indications: 1) urgent reversal of Warfarin therapy 1) urgent reversal of Warfarin therapy 2) correction of isolated coagulation factor deficiencies 2) correction of isolated coagulation factor deficiencies 3) correction of microvascular bleeding when INR and 3) correction of microvascular bleeding when INR and pTT >1.5 x normal pTT >1.5 x normal 4) correction of microvascular bleeding due to 4) correction of microvascular bleeding due to coagulation factor deficiency in patients transfused with coagulation factor deficiency in patients transfused with > one blood volume and when PT and pTT can not be > one blood volume and when PT and pTT can not be obtained obtained 5) Antithrombin III deficiency 5) Antithrombin III deficiency 6) Treatment of immunodeficiencies 6) Treatment of immunodeficiencies 7) Treatment of thrombotic thrombocytopenia purpura 7) Treatment of thrombotic thrombocytopenia purpura
- 17. Platelets Platelets Indicated for thrombocytopeniaplatelet count < 50 x 10 Indicated for thrombocytopenia platelet count < 50 x 109 9 /L /L Pooled from donated blood (ie. 5 donors=5000 plt/microL) Pooled from donated blood (ie. 5 donors=5000 plt/microL) Each 10-12 units of pRBC decrease plt count by 50%, for Each 10-12 units of pRBC decrease plt count by 50%, for replacement therapy, 5-10 units of plt (ie. 5000 – 10 000 replacement therapy, 5-10 units of plt (ie. 5000 – 10 000 plt/microL) should be given when 10-20 units of pRBC has plt/microL) should be given when 10-20 units of pRBC has been transfused been transfused Transfuse SLOWLY to avoid hypotension Transfuse SLOWLY to avoid hypotension
- 18. Cryoprecipitate Cryoprecipitate Collected bythawing FFP at 4 Collected by thawing FFP at 40 0 C, contains von Willebrand C, contains von Willebrand factor, factor VIII, XIII, fibrinogen, and fibronectin factor, factor VIII, XIII, fibrinogen, and fibronectin One unit of cryoprecipitate will increase fibrinogen One unit of cryoprecipitate will increase fibrinogen concentration by 50mg/dL concentration by 50mg/dL Indicatation: Indicatation: Patients with von Willebrand’s Dz unresponsive to Desmopressin Patients with von Willebrand’s Dz unresponsive to Desmopressin Bleeding patients with vWD Bleeding patients with vWD Bleeding patients with fibrinogen levels < 80-100mg/dL Bleeding patients with fibrinogen levels < 80-100mg/dL Hemophilia A Hemophilia A Administer rapidly through a filter (ie. 200 cc/hr, infusion Administer rapidly through a filter (ie. 200 cc/hr, infusion should be completed within 6 hrs of thawing) should be completed within 6 hrs of thawing)
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- 20. Pathophysiology of Coagulopathyin Pathophysiology of Coagulopathy in Massive Transfusions Massive Transfusions Coagulopathy results from: Coagulopathy results from: hemodilution hemodilution hypothermia hypothermia unfractionated blood products unfractionated blood products DIC DIC
- 21. Hemodilution Hemodilution Crystalloids Crystalloids -1/4 staysintravascularly, 3/4 -1/4 stays intravascularly, 3/4 goes into interstium goes into interstium -Dilute platelet and coagulating -Dilute platelet and coagulating factors factors Colloids Colloids -Hespan and Dextran impair -Hespan and Dextran impair platelet adhesion by decreasing platelet adhesion by decreasing von Willebrand factor activity von Willebrand factor activity -Impair thrombin and clot -Impair thrombin and clot formation formation
- 22. Hypothermia Hypothermia Hypothermia (<35 degrees): Hypothermia(<35 degrees): slows activity of coagulation cascade slows activity of coagulation cascade reduces synthesis of coagulation factors reduces synthesis of coagulation factors increase fibrinolysis increase fibrinolysis decrease platelets and affects platelet decrease platelets and affects platelet function function Hypothermia and acidosis cause Hypothermia and acidosis cause significant bleeding despite adequate significant bleeding despite adequate blood, plasma and plt replacement blood, plasma and plt replacement
- 23. Blood Components Blood Components Red Blood Cells-contribute to thrombosis and hemostasis Red Blood Cells-contribute to thrombosis and hemostasis -Contain ADP that activates platelets, activate platelet -Contain ADP that activates platelets, activate platelet cyclooxygenase, increase generation of thromboxane A2, cyclooxygenase, increase generation of thromboxane A2, increase thrombin increase thrombin -Abnormalities of Prothrombin time (PT) and activated -Abnormalities of Prothrombin time (PT) and activated partial thromboplastin time (aPTT) occur after transfusion partial thromboplastin time (aPTT) occur after transfusion of 12 units of pRBC of 12 units of pRBC Coagulation Factors-Blood loss greater than EBVx2 Coagulation Factors-Blood loss greater than EBVx2 resulted in deficiency of prothrombin, factor V, factor VII, resulted in deficiency of prothrombin, factor V, factor VII, and platelets and platelets Platelet- Thrombocytopenia occur after transfusion of 20 Platelet- Thrombocytopenia occur after transfusion of 20 units of pRBC units of pRBC
- 24. Disseminated Intravascular Disseminated Intravascular Coagulation Coagulation Anacquired syndrome secondary to systemic and excessive An acquired syndrome secondary to systemic and excessive activation of coagulation. activation of coagulation. Tissue trauma, brain injury, shock, tissue anoxia, Tissue trauma, brain injury, shock, tissue anoxia, hypothermia contribute to DIC hypothermia contribute to DIC Diagnosis: D-dimer>500mcg/L, increased INR, Diagnosis: D-dimer>500mcg/L, increased INR, thrombocytopenia, microvascular bleeding +/- thrombosis thrombocytopenia, microvascular bleeding +/- thrombosis Risk factors: acidosis, hypothermia, hypotension, increase in Risk factors: acidosis, hypothermia, hypotension, increase in injury severity injury severity
- 25. Transfusion Service Protocolat Transfusion Service Protocol at Parkland Memorial Hospital, Texas Parkland Memorial Hospital, Texas Cooperative effort between Pathology, Anesthesiology Cooperative effort between Pathology, Anesthesiology and Trauma Surgery and Trauma Surgery Goal: to support rapid transfusion in ER and OR with Goal: to support rapid transfusion in ER and OR with regular shipments of blood products released regular shipments of blood products released automatically on a timed basis automatically on a timed basis Design for massive transfusion protocol is based on Design for massive transfusion protocol is based on patterns of coagulopathy that may develop during trauma patterns of coagulopathy that may develop during trauma care care Patient survival to date appox. 50% with the protocol Patient survival to date appox. 50% with the protocol
- 26. Transfusion Service Protocol TransfusionService Protocol Shipments Shipments #1 #1 #2 #2 #3 #3 #4 #4 5 units pRBC + 5 units pRBC + 2 units FFP 2 units FFP q30mins q30mins X X X X X X X X Platelets (5 Platelets (5 pooled units) pooled units) X X X X Cryoprecipitate Cryoprecipitate (10 pooled unit) (10 pooled unit) X X rFVIIa rFVIIa (sent at pRBC (sent at pRBC units 11-15) units 11-15) X X
- 27. Human Recombinant FactorVIIa Human Recombinant Factor VIIa Vitamin K-dependent glycoprotein Vitamin K-dependent glycoprotein Indications: treatment of bleeding in Indications: treatment of bleeding in hemophilia A and B, acquired inhibitors hemophilia A and B, acquired inhibitors (e.g. anti-VIII), and congenital factor (e.g. anti-VIII), and congenital factor VII deficiency bleeding VII deficiency bleeding Site of action: extrinsic coagulation Site of action: extrinsic coagulation cascade cascade Promotes activation of factor X to Xa, Promotes activation of factor X to Xa, and factor II (prothrombin) to IIa and factor II (prothrombin) to IIa (thrombin) - bypassing the intrinsic (thrombin) - bypassing the intrinsic pathway pathway Promotes clot formation and hemostasis Promotes clot formation and hemostasis at the site of injury at the site of injury Shorten the prothrombin time (PT) Shorten the prothrombin time (PT) Extent of PT shortening does not Extent of PT shortening does not correlate with clinical efficacy of rFVIIa correlate with clinical efficacy of rFVIIa → need for → need for monitoring blood loss, monitoring blood loss, transfusion requirement, and transfusion requirement, and hemoglobin hemoglobin Image from: www.itxm.org/images/coag1.jpg
- 28. Human Recombinant FactorVIIa Human Recombinant Factor VIIa Efficacious adjuvant therapy in managing hemorrhage due to Efficacious adjuvant therapy in managing hemorrhage due to trauma trauma Reduce the need for massive blood transfusions in blunt trauma Reduce the need for massive blood transfusions in blunt trauma No increased risk for thromboembolic event, DIC, allergic rxn No increased risk for thromboembolic event, DIC, allergic rxn or thrombocytopenia or thrombocytopenia Reduced risk assoc. with plasma transmission of virus Reduced risk assoc. with plasma transmission of virus Less frequent complications associated with microthrombus Less frequent complications associated with microthrombus generations such as multi-organ failure and ARDS generations such as multi-organ failure and ARDS Frequent dosing needed due to short half-life (2-3hrs) Frequent dosing needed due to short half-life (2-3hrs) Recommended dose: 90 mg/kg, continued every 2-3 hours. Recommended dose: 90 mg/kg, continued every 2-3 hours. Once bleeding and hemoglobin have stabilized, taper to every Once bleeding and hemoglobin have stabilized, taper to every 6-8 hours, then every 12-24 hours, and then stop 6-8 hours, then every 12-24 hours, and then stop
- 29. Management of Coagulopathyin Management of Coagulopathy in Massive Transfusions Massive Transfusions Maintain core body temp > 35 Maintain core body temp > 35o o C C Correct Acidosis by re-establishing adequate tissue perfusion Correct Acidosis by re-establishing adequate tissue perfusion and oxygenation and oxygenation Check labs (ie. ABGs, lytes, coags, plt, fibrinogen, lactate) Check labs (ie. ABGs, lytes, coags, plt, fibrinogen, lactate) Replete electrolytes (ie. Calcium) Replete electrolytes (ie. Calcium) Early administration of FFP and platelets during massive Early administration of FFP and platelets during massive transfusion with pRBC transfusion with pRBC Stay ahead of the game to prevent coagulopathy Stay ahead of the game to prevent coagulopathy in the first instance in the first instance