Blood Management

Transfusion Reactions

Allergic Reaction

  • Most common.
  • Occurs towards the end of a transfusion.
  • Management:
    • Settles spontaneously.
    • Supportive medical treatment.

Febrile Reaction

  • Occurs after the first 100 ml.
  • Cause: Antibody formation against foreign RBCs.
  • Management:
    • Stop transfusion.
    • Treat fever supportively.

Haemolytic Reaction

  • Most severe.
  • Occurs early in the transfusion.
  • Symptoms:
    • Chest tightness.
    • Flank pain.
    • Tachycardia.
    • Fever and chills.
  • Management:
    • Stop transfusion immediately.
    • Administer IV fluids.
    • Perform coagulation screening.
    • Transfer to ICU for monitoring.

Transfusion Infection Transmission Risks

  • Hepatitis C: 1 in 2 million (rarest).
  • Hepatitis B: 1 in 200,000.
  • CMV:
    • Most common.
    • Carried by 70% of donors.
    • Clinically irrelevant.
  • HIV: 1 in 1.2 million.

Alternatives to Blood Transfusion

Autologous Deposition

  • Description: Storage of autologous donated blood weeks before surgery.
  • Indications:
    • Anticipated significant blood loss during surgery.
    • Patient preference.
  • Contraindications:
    • Low Hb (<11).
    • Coronary artery disease.
    • Low haematocrit (<33%).
  • Hepatitis C-containing blood can be transfused back to the patient.

Cell Saver

  • Description: Collection, washing, and re-transfusion of blood intra-operatively.
  • Requirements:
    • Blood loss >1 unit expected.
    • Minimum of 400 ml blood loss needed to produce 1 unit.
    • Maximum usage time: 4 hours.
  • Process:
    1. Blood is collected and passed through a filter.
    2. Washed to remove cytokines and debris (also removes clotting factors and platelets).
    3. Re-transfused into the patient.
  • Disadvantage:
    • Sub-standard blood quality.
    • Residual cytokines may cause SIRS, TRALI, etc.

Autotransfusion

  • Description: Direct re-introduction of lost blood back into the bloodstream.
  • Requirements:
    • Must begin within 6 hours of blood loss to avoid transfusion reaction.
  • Advantages:
    • Contains clotting factors and platelets.
  • Disadvantages:
    • Risk of reactions due to unremoved cytokines and debris.
    • May not be of optimal quality.

Blood Product Storage

Product Storage Duration Temperature
Whole Blood 24 hours Room Temperature
Packed Red Cells 35 days 4°C
Platelets 5 days Room Temperature
Cryoprecipitate 12 months -25°C

Massive Transfusion Protocols

Definition

  • Massive Transfusion:
    • Transfusion of >4 units of blood in 1 hour.
  • Statistics:
    • Leading cause of preventable trauma deaths (39%).
    • 2% of trauma victims require massive transfusion.
  • Main Complication: Post-transfusion coagulopathy.

Global Recommendations

  • Debra L. Malone, Journal of Trauma (2006):
    • Equivalent use of packed cells and platelets.
    • Early use of platelets and FFP reduces coagulopathy.
    • Early use of FFP reduces mortality.

Practical Guidelines

  • Identify at-risk patients based on:
    • Injury mechanism.
    • Biochemical parameters:
      • HR > 100.
      • Acidosis.
      • Raised lactate.
      • Poor response to fluid resuscitation.
  • Goals:
    • Normothermia.
    • Urine output ≥ 35 ml/hr.
    • Hb ≥ 10 g/dL.
    • PT & APTT ratio < 1.5.
    • Platelets > 100,000.
    • Normal lactate.

General Protocol

  • Use a 1:1 ratio of FFP and RBC.
  • Start with 4 units of each.
  • Add platelets for every 4 units given after the first batch.
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