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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 68-71

Massive blood transfusion: A case report of transfusion of 70 units of blood and blood products in 24 hours


Department of Anaesthesiology and Pain Management, Max Super Speciality Hospital, New Delhi, India

Date of Web Publication5-Apr-2018

Correspondence Address:
Dr. Kompal Jain
Department of Anaesthesiology and Pain Management, Max Super Speciality Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_6_18

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  Abstract 


The mortality of massive blood transfusion is very high ranging from 34% - 40% . Only 60 % of patients receiving more than ten packed red blood cells units within the first 24 hours have survived. We share our experience with massive blood transfusion in which seventy units of blood and blood products were transfused in 24 hours following massive transfusion protocol. To conclude each institute should have massive transfusion protocol to improve the clinical outcome of the patient. Anaesthetist should be aware about local resources and should ensure early communication with laboratory, haematologist and blood bank. In view of cost, increased demand, urgency, availability and risk of infections, blood substitutes are of great concern specially in developing countries. This case study also emphasizes on future research to make blood substitute with more similarities and minimum complication to replace donated blood.

Keywords: Early communication, massive transfusion protocol, 70 units


How to cite this article:
Jain K, Jain S, Sood N, Puri A. Massive blood transfusion: A case report of transfusion of 70 units of blood and blood products in 24 hours. Glob J Transfus Med 2018;3:68-71

How to cite this URL:
Jain K, Jain S, Sood N, Puri A. Massive blood transfusion: A case report of transfusion of 70 units of blood and blood products in 24 hours. Glob J Transfus Med [serial online] 2018 [cited 2018 May 22];3:68-71. Available from: http://www.gjtmonline.com/text.asp?2018/3/1/68/229341




  Introduction Top


Massive transfusion is defined as transfusion of more than one blood volume, i.e., ≥10 (red blood cell [RBC]) units in 24 hours(h) or replacement of >50% of total blood volume by blood products within 3 h or >4 RBC units in 1 h, with anticipation of continued need for blood product support in adults.[1] The mortality of massive blood transfusion is very high ranging from 34%–40%.[2] It can lead to 54% deaths in the first 6 h due to the use of disproportionate blood products.[3] Most (99%) of the patients receiving less than ten units packed RBCs (PRBCs) within the first 24 h have survived whereas only 60% of the patients receiving more than ten PRBC units within the first 24 h have survived.[4] We share our experience with massive blood transfusion.


  Case Report Top


A 43-year-old female known case of Carcinoma ovary grade 2 with peritoneal metastasis and hypothyroidism was posted for hyperthermic intraperitoneal chemotherapy (HIPEC) cytoreductive surgery. General physical and systemic examination revealed no abnormality. Cardiac, renal and liver, and thyroid parameters were in normal limit. Her blood group was AB positive. Her preoperative hemoglobin, hematocrit, total leukocyte count, platelet count, serum sodium, serum potassium, and serum albumin were 12.8 g/dl, 38.4%, 7600/cmm, 202,000/202 × 103/uL, 140 mmol/L, 3.7 mmol/L, and 3.7g/dL, respectively. Her coagulation profile was normal with prothrombin time (PT), international normalized ratio (INR), and activated thromboplastin time of 11.7 s, 1.08, and 31.8 s, respectively. Preoperatively, four PRBC and four fresh-frozen plasmas (FFPs) were arranged. The blood bank was informed regarding the major surgery and the anticipated massive blood loss. She underwent HIPEC surgery under general anesthesia supplemented with epidural anesthesia using ASA standard monitoring, intra-arterial monitoring, central venous catheter cannulation, and two large-bore venous accesses. Hypothermia was prevented by intravenous fluid warmers, foil drapes, and heated air. After allowable blood loss of around 1.5 L, blood transfusion was started. A total of 12 L of crystalloid, 1.5 L of colloids, eight PRBCs, ten FFPs, eight random donor platelet concentrates (RDPCs), and two 100 ml vials of 20% albumin were transfused intraoperatively. The surgery lasted for 10 h, and total blood loss during surgery was 3.5-4.0 litres(l). Intraoperatively, vitals were maintained within normal limits with regular monitoring of arterial blood gases, serum electrolytes, complete blood count, and coagulation profile. In view of prolonged nature of surgery and massive blood loss, the patient was shifted to the Intensive Care Unit where seven PRBCs, ten FFPs and six Random donor Platelets (RDPs) were transfused. Inspite of blood and blood products, hemoglobin was still falling with continuous blood-strained drain, so the patient was reexplored and surgical site bleeding was controlled. During reexploration, four PRBCs, six FFPs, and four RDPs were transfused. A total of 21 PRBCs, 26 FFPs, 18 RDPs and five cryoprecipitate were transfused in 24 hours. The patient was extubated on the 3rd day. After continued intensive care, the patient was ambulated, shifted to room on the 9th postoperative day, and was discharged from the hospital on the 17th postoperative day.

During transfusion, we followed our institute massive transfusion protocol [Figure 1] based on recent recommendations.[1],[5],[6],[7]
Figure 1: Our institute massive transfusion protocol. GDA: General duty assistant, PRBC: Packed red blood cell, FFP: Fresh-frozen plasma, RDPC: Random donor platelet concentrate, BB: Blood bank

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  Discussion Top


Massive blood transfusion is a life-saving and life-threatening process. Bleeding leads to tissue hypoxia causing acidosis, blood transfusion and crystalloid infusion causing hypothermia, dilution of coagulation factors, platelets, thereby leading to coagulopathy. The complications of massive blood transfusion also include immunological, transfusion reactions, metabolic complications, and logistical issues including delay in laboratory reports and release and delivery of blood products.

We could save the patient as a massive transfusion protocol was activated when unanticipated massive bleeding started and lasted for 24 h till surgical bleeding was controlled. We were aware of our local resources and due to early communication and coordination with blood bank and laboratory, the turnover time of laboratory reports and blood products was decreased with no undue delay [Table 1].
Table 1: Turnover time of blood products and tests in our institution

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Hence, to improve the clinical outcome of the patient receiving massive transfusion, a massive transfusion protocol is must.

Massive transfusion protocol is defined as an empirical treatment that optimizes the management of resuscitation and correction of coagulopathy arising from severe hemorrhage.[5] It includes local adaptation, activation, and cessation of massive transfusion with coordination of clinical, hematological, and laboratory team. It leads to the judicious use of blood and blood products decreasing the complications related to unnecessary exposure to blood products and blood wastage. It also facilitates communication between different teams avoiding delay in clinical care, laboratory testing, and blood product transfusion due to variable and poor compliance of guidelines.

Components of massive blood transfusion include when and who should initiate massive transfusion protocol with notification of the transfusion service and laboratory. It also includes laboratory testing algorithm (PT, activated thromboplastin time, arterial blood gas, thromboelastography), blood product preparation, delivery, and other patient care needs.[1]

After the activation of massive transfusion protocol, laboratory staff, hematologist, anesthetist, and general duty attendant have specific described roles. Laboratory staff informs hematologist to prepare and issue blood components as requested, to anticipate repeat testing and blood component requirement, to minimize turnaround time of tests, and to consider staff resources. Hematologist liaises regularly with laboratory and clinical team and assists in the interpretation of results and advises on blood component support.[1],[5] Massive transfusion protocol and the predetermined blood unit packages vary between different institutions. Anesthesiologist should request four units PRBC and two units FFP. They should consider one adult therapeutic dose platelets and include cryoprecipitate if fibrinogen <1 g/L.[5]

The main aim is to optimize cardiac output, tissue perfusion, oxygenation and metabolic state and monitor complete blood count, coagulation screen, and ionized calcium and arterial blood gases every 30–60 min. The goals are to maintain temperature more than 35°C, pH >7.2, base excess <−6, lactate < 4 mmol/L, and ionized calcium >2.1 mmol/L. Platelets should be >50 × 109/L, PT/activated partial thromboplastin time <1.5 × normal with INR <1.5 and fibrinogen >g/L.[5],[6] Testing of blood and blood products in operation theater is must and in case of any disparity or typographic error found in blood product, the blood should be sent back to the blood bank within 30 min of the release of blood product from the blood bank.


  Conclusion Top


Each institution should have a massive transfusion protocol incorporating recommendations and practice points. The clinical team should be aware of their local resources and how components can be delivered to correct patient and location. Adequate laboratory support is must to check the biochemical, metabolic, and coagulation status. Early communication and coordination with hematologist and laboratory is vital to improve the clinical outcome of the patient.

In view of cost, increased demand, urgency, availability and risk of infections, and blood substitutes are of great concern, especially in developing countries. This case study also emphasizes on future research to make blood substitute with more similarities and minimum complication to replace donated blood.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pham HP, Shaz BH. Update on massive transfusion. Br J Anaesth 2013;111 Suppl 1:i71-82.  Back to cited text no. 1
    
2.
Rose AH, Kotzé A, Doolan D, Norfolk DR, Bellamy MC. Massive transfusion – Evaluation of current clinical practice and outcome in two large teaching hospital trusts in Northern England. Vox Sang 2009;97:247-53.  Back to cited text no. 2
    
3.
Snyder CW, Weinberg JA, McGwin G Jr., Melton SM, George RL, Reiff DA, et al. The relationship of blood product ratio to mortality: Survival benefit or survival bias? J Trauma 2009;66:358-62.  Back to cited text no. 3
    
4.
Como JJ, Dutton RP, Scalea TM, Edelman BB, Hess JR. Blood transfusion rates in the care of acute trauma. Transfusion 2004;44:809-13.  Back to cited text no. 4
    
5.
Patient Blood Management Guidelines: Module 1 Critical Bleeding/Massive Transfusion | National Blood Authority; 2018. Available from: https://www.blood.gov.au/pbm-module-1. [Last accessed on 2018 Jan 26].  Back to cited text no. 5
    
6.
Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth 2014;58:590-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Hsu Y, Haas T, Cushing M. Massive transfusion protocols: Current best practice. Int J Clin Transfus Med 2016;4:15-27.  Back to cited text no. 7
    


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