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In the name of GOD Blood Transfusion in Burned Patients
Haddadi MD Anesthesiology Department in GUMS
2014
Need to transfusion is not a major concern during immediate resuscitation phase
During the acute resuscitation phase a fall in Hb (hemodilution, escharotomies , other invasive procedures )
In OR patients have major blood loss (excision , graft)
resuscitation phase
Surgical procedure Predicted blood loss
<24 h since burn injury 0.45ml/cm2 burn area
1-3 days since burn injury
0.65ml/cm2 burn area
2-16 days since burn injury
0.75ml/cm2 burn area
>16 days since burn injuryInfected wound
0.5-0.75ml/cm2 burn area1-1.25ml/cm2 burn area
Hct to drop to 15-20% prior to transfusion in other healthy patients with minor excision
Hct <25% in pre-existing Cardiovascular Disease
Hct near 25% in patients with more extensive burn
Hct near 30% in patients with pre-existing Cardiovascular Disease
Hb 6-6.5 gr/dl the lowest adverse metabolic or hemodynamic reactions
Evaluating the patient’s clinical status Assessment of ongoing blood loss , pre-
operative Hb level , vital sign Evidence of inadequate o2 delivery such as
hypotension, tachycardia ,acidosis Pulmonary ,cardiovascular D. ASA , Hb>10 - Hb<6 +
Need to blood transfusion
Factors Class I Class II Class III Class IVBlood loss (mL) 750 750-1500 1500-2000 2000 or more
Blood loss (% blood volume) 15 15-30 30-40 40 or more
Pulse (beats/min) 100 100 120 140 or higher
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Hg)
Normal or increased Decreased Decreased Decreased
Respirations per minute 14-20 20-30 30-40 35
Urine output (mL/hr) 30 20-30 5-10 Negligible
Central nervous system: mental status
Slightly anxious Mildly anxious Anxious, confused
Confused, lethargic
Fluid replacement (3-1 rule)
Crystalloid Crystalloid Crystalloid + blood
Crystalloid + blood
During excision of major burn wounds ,blood loss may reach to patient’s blood volume
Massive Hemorrhage Loss of 1 blood volume in 24 h 50% blood volume in 3 h Ongoing blood loss of 150 ml/min
Coagulation factors are lost Dilution as volume replacement Resulting coagulopathy Use of FFP in massive hemorrhage Recent clinical studies: early use of
FFP+PRBCs in replacement of massive hemorrhage
High blood loss:
Intravascular volume, with colloid( Alb,Hetastarch)
O2 carrying capacity with PRBCs until 50% of est Blood Volume
From this point ,FFP with PRBCs RBCs enhance homeostasis through effects
on platelet biochemistry and function
Exp. During burn surgery
Hypothermia Hypothermia can contribute to coagulopathy Blood warmers when flow rate of blood >100
ml/min Hypocalcemia (rapid flow rate,FFP, citrate) Hypocalcemia impairs coagulation interferes
with vascular ,myocardial contractility then, hypotension ( cacl2)
Ca Gluconate requires to hepatic metabolism
Massive Blood Transfusion
Use of tourniquets on limbs(limitations) Compression dressings at sites of excision Pharmacologic : epinephrine soaked dressings topical epinephrine sprayTachycardia, hypertension Systemic Terlipressin (vasopressin analog )
Reducing surgical blood loss
Whole blood Packed RBCs FFP Platelets Cryoprecipitate
Blood components
Contains all parts of blood After 24 h ,has not functional WBC ,Plt For burns, liver transplant, trauma,
hypovolemic shock
Whole blood
The most common means of replacing blood loss
50 ml residual plasma
Packed RBCs
1 7 14 21
PH 7.1 7 7 6.9
PCO2 48 80 110 140
K ( meq/l) 3.9 12 17 21
2,3 DPG 4.8 1.2 1 1
Viable PLT% 10 0 0 0
Factors 5,7 %
70 50 40 20
Days Of Storage At 4”c
Changes during storage in whole blood(CPD)
value Whole Blood Packed RBC
Volume(ml) 517 300
Erythrocyte mass(ml) 200 200
Hct % 40 70
Alb (gr) 12.5 4
Plasma K(meq) 15 4
Plasma acid 80 25
Plasma Na (meq) 45 15
Comparison of Whole Blood ,PRBCs
In burn injuries to replace clotting factors during massive transfusion
Clotting factors, Protein S,C In massive transfusion, if active bleeding
exists, coagulation factor deficiency approved
Fresh Frozen Plasma
Indications for FFP according to National Health Guidelines
Replacement of isolated factor deficiencies(lab evidence)
Reverse of warfarin effect
Antithrombine III deficiency
Treatment of immunodeficiencies
Treatment of TTP
Massive blood transfusion( V,VIII=25% of normal)
PT,PTT 1.5 times normal
Stored at room temperature to max viability Increasing bacterial contamination after 4
days Refrigerated PLT remain viable only 24-48h 5000-10,000PLT
Platelets
Thawing FFP at 4 c ,collecting cryoprecipitate
Rich in factors XIII, VIII, fibrinogen , Von Willebrand factor
Massive blood transfusion to treat hypo-fibrinogenemia
Plasma fibrinogen<100 mg/dl 1 unit cryoprecipitate will increase Plasma
fibrinogen by 5-7 mg/dl
Cryoprecipitate
Hemolytic Transfusion Reaction Delayed Hemolytic Transfusion Reaction
(Immune Extravascular Reaction) Nonhemolytic Transfusion Reactions
Transfusion-Related Fatalities in the United States, 2004-2006
Transfusion Reactions
Cause of Fatality 2004-06 Average per Year
TRALI 86 29Other reactions (non-ABO hemolytic therapy; anaphylaxis)
67 22
Bacterial contamination 20 7
ABO hemolytic transfusion therapy 15 5
Transfusion not ruled out 31 10
Hemolytic Transfusion Reaction
Sign or Symptom No. of Patients
Fever 19
Fever and chills 16
Chest pain 6
Hypotension 6
Nausea 2
Flushing 2
Dyspnea 2
Hemoglobinuria 1
-- Steps in the Treatment of a Hemolytic Transfusion Reaction
1. STOP TRANSFUSION. 2. Maintain the urine output at a 75 to 100 mL/hr a. Generously administer fluids intravenously and possibly mannitol (12.5 to 50 g, given over 5 to 15 minutes). b. If intravenously administered fluids and mannitol are ineffective, administer furosemide (20 to 40 mg) intravenously. 3. Alkalinize the urine; because bicarbonate is preferentially excreted in the urine, only 40 to 70 mEq of sodium bicarbonate per 70 kg of body weight is usually required to raise the urine pH to 8, whereupon repeat urine pH determinations indicate the need for additional bicarbonate. 4. Assay urine and plasma hemoglobin concentrations. 5. Determine platelet count, partial thromboplastin time, and serum fibrinogen level. 6. Return unused blood to blood bank for repeat crossmatch. 7. Send patient's blood and urine sample to blood bank for examination. 8. Prevent hypotension to ensure adequate renal blood flow.
the transfused donor cells may survive well initially
after a variable delay (2 to 21 days) they are hemolyzed
This type of reaction occurs mainly in recipients sensitized to RBC antigens by previous blood transfusions or pregnancy
RBC destruction occurs only when the level of antibody is increased after a secondary stimulus (i.e., anamnestic response)
a decrease in the post-transfusion hematocrit value
Delayed Hemolytic Transfusion Reaction (Immune Extravascular Reaction)
Nonhemolytic reactions to blood transfusions usually are not serious and are febrile or allergic in nature.
The most common adverse reactions to blood transfusions consist of chills, fever, headache, myalgia, nausea, and nonproductive cough occurring shortly after blood transfusion caused by pyrogenic cytokines and intracellular contents released by donor leukocytes.
Allergic reactions can be minor, anaphylactoid, or anaphylactic
The most common symptom is urticaria associated with itching. Occasionally, the patient has facial swelling.
Nonhemolytic Transfusion Reactions
Percentage Risk of Transfusion-Transmitted Infection with a Unit of Screened Blood in the United States
Infection Risk Window Period (days)
Infectivity of Blood
Infection RiskWindow Period (days)
Human immunodeficiency virus-1
1/2,135,000 11
Human T-lymphotropic virus (HTLV-II)
1/2,993,000 51
Cytomegalovirus (CMV)
Infrequent with leukocyte-reduced components
Hepatitis C virus (HCV) 1/1,935,000 40
Hepatitis B virus (HBV) 1/205,000
West Nile virus (WNV) 1/1,100,000 ?