Overview of Massive Transfusion

A massive transfusion is a treatment where a patient receives 10 units or more of whole blood or packed red blood cells within 24 hours. There’s also something called an ultra-massive transfusion, where a patient needs more than 20 units of blood within a day or two. The main goal of these transfusions is to prevent deadly complications due to severe loss of blood, while trying to control any bleeding.

This treatment may be needed in a wide range of medical specialties. It’s most commonly needed during heart and blood vessel surgeries, but it can also be needed in other situations. These could involve severe bleeding in the digestive tract, complications from pregnancy, liver transplants, or injuries. About 3-5% of civilian patients who have experienced trauma, and 10% of military patients involved in trauma end up needing this treatment. Even though it’s a rare occurrence, the death rate is high for those who require massive transfusions.

Massive transfusions are hard to predict and require lots of blood over a long period. That’s why it’s crucial to have good communication and planning amongst all of the healthcare staff involved. This includes the emergency department, trauma team, surgeons, blood bank, and delivery personnel. They use a tool called the Assessment of Blood Consumption score to predict if a patient might need this treatment.

Throughout the transfusion, it’s important to closely monitor things like blood volume, tissue oxygen levels, bleeding management, coagulation (blood clotting) abnormalities, and balance of acid and base in the body. There are guidelines known as major transfusion protocols (MTPs) that, when properly carried out, can help reduce death rates and lessen the amount of blood used.

Why do People Need Massive Transfusion

If a person loses a large amount of blood quickly, they may need a substantial blood transfusion known as a ‘massive transfusion’. Situations that might lead to this include severe injuries, heavy blood loss during childbirth, surgical procedures, and bleeding in the digestive system.

Doctors use different ways to decide if a person needs a massive transfusion, but these methods can sometimes be unclear. One tool doctors use is called the ‘Shock Index’, which helps doctors assess how severe a patient’s condition is, but its assistance is somewhat limited.

Another more useful tool is the ABC score. This system takes into account four things: if a person’s heart rate is over 120 beats per minute, if their blood pressure is under 90 mm Hg, whether ultrasound scans (also known as Focused Assessment with Sonography for Trauma or FAST exam) show any issues, and if the person has been injured in the torso. Each of these factors is scored 1 point. If the total score is 2 or more, this suggests a massive transfusion may be needed.

However, the ABC score isn’t perfect. If a patient has an ABC score that suggests they need a massive transfusion, only 50-55% of them will actually need one. This means that 45-50% of the time, the score might incorrectly suggest a person needs a massive transfusion. Although, the ABC score is good at identifying over 95% of the patients who will need a massive transfusion.

In general, doctors consider a massive transfusion if a patient has:

  • An ABC score of 2 or more points
  • Unstable vital signs like heart rate and blood pressure
  • Active bleeding that requires surgery or a procedure that blocks the blood vessels (angioembolization)
  • Requirement of a blood transfusion immediately after a trauma

When a Person Should Avoid Massive Transfusion

There aren’t any hard-and-fast reasons a patient cannot receive a large amount of blood transfusion.

Equipment used for Massive Transfusion

When someone needs a lot of blood very quickly, a massive transfusion, two important things need to be set up. First, there need to be enough blood supplies on hand. Second, there needs to be a way to get the blood into the patient’s body quickly, such as through a vein (intravenous or IV access) or through the bone (intraosseous access).

There’s a scientific equation that shows larger, shorter tubes can deliver fluid faster. This principle applies here, that’s why larger and shorter tubes known as catheters are used. The amount of fluid that can pass through these catheters depends on the size of the catheter, its length and the thickness (viscosity) of the fluid, being it is blood, flowing into the patient.

For most patients who need a lot of blood fast, getting the blood into the body as quickly as possible is crucial. This is why large catheters, usually sizes from 14 to 18 gauge, are used. They are either inserted into a vein close to the surface of the skin (peripherally) or towards the center of the body (centrally), or through the bone, depending on what’s best for the patient.

The medical team might also need:

  • To keep in touch with the blood bank about changes in the situation.
  • Enough people on hand to collect blood samples and get blood supplies from the bank.
  • Something to warm up the blood.
  • A fridge in the urgent care area stocked with universal donor blood. Ideally, this would be at least 8 packets of O-negative red blood cells and 8 packets of AB or B group blood plasma.
  • Heaters for the fluid and the patient’s body.
  • Constant checks of the patient’s inner body temperature.
  • Repeated measurements of blood pressure through arteries.
  • Enough supplies to provide drip-by-drip and crystal-clear fluid sets.
  • Medications containing calcium that are given into veins.

In addition, point-of-care testing could be used to quickly measure various bodily functions, such as blood gas (balances of oxygen and carbon dioxide), hemoglobin (a protein in your blood cells that carries oxygen), electrolytes (minerals that help balance the amount of water in your body), lactate (which is a measure of how much oxygen your body is using), and clotting function of the blood (thromboelastography or TEG).

You may also see rapid infusion pumps or pressure bags that speed up the rate at which fluids are given.

You can see an example of a set up for giving patient’s their own blood back (autotransfusion) in the image attached, displaying bags and a collecting chamber (atrium).

Who is needed to perform Massive Transfusion?

When a large amount of blood transfusion is needed, many different people have to come together quickly. These include medical professionals in the emergency room, surgeons, support staff, people who work in the blood bank, and designated helpers. Many hospitals and medical centers have a special alert system for this. It’s very similar to the alert system used for severe injury cases. It quickly tells everyone involved that a big blood transfusion is about to happen or is already happening.

Preparing for Massive Transfusion

The best way to prepare for a medical procedure involves setting up a Massive Transfusion Protocol (MTP), which is a plan for quickly replacing a lot of lost blood. It’s very important to quickly let the blood bank know when the MTP needs to be activated. This allows them to get ready and deliver the necessary blood supplies before they are needed during the procedure.

Healthcare professionals also need to closely monitor the patient’s breathing and heart rate. It’s important to have a good Intravenous (IV) or intraosseous access, which means a way to deliver medicines or fluids directly into the patient’s vein or bone marrow. This is crucial for delivering the blood products quickly when needed.

How is Massive Transfusion performed

If a person needs a large volume of blood quickly – what’s known as a massive transfusion – the main goal is to make sure their heart can pump blood effectively and that the blood can carry enough oxygen. This requires a careful balance of different blood products, like red blood cells, platelets, and plasma (which is part of your blood that carries cells and proteins). This process can be a bit different from one hospital to another, but the key is delivering all these components quickly.

Our bodies normally use about a quarter of the oxygen in our blood. So, if a person loses a lot of blood, you can give them fluids called crystalloids to increase blood pressure, and their body can still get enough oxygen until you can give them more red blood cells. However, in people with serious injuries, giving too much crystalloid can dilute their blood too much and make their blood clot less effectively.

Experience from treating trauma patients and soldiers has shown that giving whole blood, which contains red and white blood cells, platelets, and plasma, can be very helpful. There’s some disagreement about the best ratio of red cells to platelets to plasma to give, but some specialists recommend a 1:1:1 ratio. The goal here is to prevent too much dilution of the blood and its ill effects, like poorer healing and longer stays in the hospital.

There’s also evidence that a medication called tranexamic acid (TXA) can help by preventing breakdown of blood clots. This is particularly beneficial in trauma cases and it’s most effective if given within 3 hours of the injury. Many transfusion protocols now include this medication.

At the start of a massive transfusion, people are given O-negative blood (which can be given to anyone) until the blood bank can provide blood that matches their specific blood type. The patient’s blood type is determined as soon as possible for this. It’s also important to monitor the patient’s vitals closely during the procedure and check for any signs of complications.

During the transfusion, blood tests are performed after about every 5 units of blood given. This includes checks for clotting and platelet count, two factors that can help doctors assess the patient’s response to the transfusion. Other tests are performed every 20 to 30 minutes, including checks on blood pH, oxygen and carbon dioxide levels, and other important markers.

The goal with these transfusions is to maintain the patient’s blood pressure and concentration of different blood components within secure ranges, ensure the blood can clot as it should, and keep the person’s temperature above 35°C (or 95°F) among other things.

Possible Complications of Massive Transfusion

When a patient needs a large amount of blood transfused due to injury or illness, there can be several potential side effects or complications. It’s important to closely monitor the patient’s bodily functions such as acid and base levels, minerals, body temperature, and the blood’s ability to clot. More than half of the patients who received more than 5 units of blood might see some complications.

One common issue is ‘coagulopathy’, which means the blood is having trouble clotting. This can be caused by the condition that led to the transfusion, tissue damage from the injury, and the processes that happen in the body during a transfusion. To limit the impact of this issue, doctors can provide additional support, like plasma, fibrinogen, and platelets. It’s also known that the body can struggle to clot with a lower pH level, an issue known as acidosis.

Another potential side effect from a massive transfusion is ‘metabolic abnormalities’. When blood products are stored, chemicals are added to prevent clotting, which can sometimes result in a type of imbalance called metabolic alkalosis and a calcium deficiency called hypocalcemia. Symptoms of severe hypocalcemia can include weird sensations like tingling and irregular heartbeats. Another common issue is an excess of potassium in the blood, called hyperkalemia, which is more likely to occur when blood is transfused rapidly and can potentially cause irregular heartbeats.

Hypothermia, or a dangerously low body temperature, is also a concern for patients receiving large amounts of transfused blood. Colder room temperatures and a need for a larger blood supply can make the patient more prone to hypothermia. As a response, many transfusion devices are equipped with warmers to maintain a safe body temperature during the procedure.

Two respiratory complications, TRALI and TACO, are associated with large blood transfusions as well. TRALI, or Transfusion-Related Acute Lung Injury, is a condition where the lungs suddenly become damaged, leading to fluid build-up. TACO, Transfusion-Associated Circulatory Overload, is a condition where there is fluid build-up in the lungs due to too much volume being transfused too quickly.

Other potential complications include acute hemolytic transfusion reaction which is where the immune system attacks the transfused blood cells, causing symptoms like fever, chills, and bleeding. Transfusion-associated sepsis, where the blood being transfused contains a harmful microorganism, and allergic or anaphylactic reactions, where the body responds negatively to the transferred blood, are other possible side effects.

What Else Should I Know About Massive Transfusion?

Bleeding is the second most common reason for death in trauma patients during their first hour at a trauma center. Often, administering a large amount of blood (a procedure known as massive transfusion) is crucial to save lives. Thanks to using protocols for massive transfusions, the rate of deaths linked to bleeding has dropped from 38% to 25% in certain centers.

Massive transfusions are often used in different medical fields like maternity care, digestive system care, trauma care, and surgical procedures. Although the cause of bleeding might differ in each case, the same rules for massive transfusions apply. Importantly, these transfusions can sometimes lead to serious problems.

Having a set plan or protocol for starting a massive transfusion and checking the patient’s response during the transfusion greatly helps to improve the patient’s outcome, reduce the usage of blood products and decrease waste. It’s a critical intervention that doctors use in emergency situations, especially when there’s severe bleeding.

Frequently asked questions

1. How do you determine if I need a massive transfusion? 2. What are the potential complications or side effects of a massive transfusion? 3. What steps will be taken to monitor my vital signs and ensure the transfusion is going smoothly? 4. Are there any specific blood products or ratios that will be used during the transfusion? 5. How will you ensure that the blood being transfused is compatible with my blood type?

Massive transfusion refers to the rapid administration of a large amount of blood products to a patient who has experienced significant blood loss. This procedure is typically done in emergency situations such as trauma or major surgery. Massive transfusion can help restore blood volume and prevent life-threatening complications, but it also carries risks such as transfusion reactions, infections, and fluid overload.

There aren't any hard-and-fast reasons a patient cannot receive a large amount of blood transfusion.

There are no specific reasons why someone should not get a massive blood transfusion, as there are no hard-and-fast restrictions for this procedure.

The text does not provide information about the recovery time for Massive Transfusion.

To prepare for a Massive Transfusion, it is important to set up a Massive Transfusion Protocol (MTP) and quickly activate it by notifying the blood bank. Close monitoring of the patient's breathing and heart rate is crucial, as well as ensuring good Intravenous (IV) or intraosseous access for delivering blood products quickly. Additionally, having enough blood supplies, communication with the blood bank, and necessary equipment such as warmers and rapid infusion pumps are essential for a successful transfusion.

The complications of Massive Transfusion include coagulopathy (difficulty clotting), metabolic abnormalities (such as metabolic alkalosis and hypocalcemia), hyperkalemia (excess potassium in the blood), hypothermia (dangerously low body temperature), respiratory complications (TRALI and TACO), acute hemolytic transfusion reaction, transfusion-associated sepsis, and allergic or anaphylactic reactions.

Symptoms that require Massive Transfusion include unstable vital signs like heart rate and blood pressure, active bleeding that requires surgery or angioembolization, and a requirement of immediate blood transfusion after a trauma. Additionally, an ABC score of 2 or more points suggests the need for a massive transfusion.

The safety of Massive Transfusion in pregnancy depends on the specific circumstances and risks involved. Massive Transfusion may be necessary in cases of severe bleeding during pregnancy, such as in cases of placenta previa, placental abruption, or postpartum hemorrhage. However, it is important to consider the potential risks and benefits of the procedure for both the mother and the fetus. During a Massive Transfusion, close monitoring of the mother's vital signs, blood volume, tissue oxygen levels, bleeding management, and coagulation abnormalities is essential. The goal is to prevent deadly complications due to severe blood loss while trying to control any bleeding. Major transfusion protocols (MTPs) can help guide the process and reduce the risk of complications. It is important to have good communication and planning among all healthcare staff involved, including the emergency department, trauma team, surgeons, blood bank, and delivery personnel. The specific circumstances and risks of each individual case should be carefully considered, and the decision to proceed with a Massive Transfusion should be made in consultation with a multidisciplinary team of healthcare professionals. Overall, while Massive Transfusion can be a life-saving intervention in certain situations during pregnancy, it is not without risks. The potential benefits and risks should be carefully weighed, and the procedure should be performed with close monitoring and appropriate management to ensure the safety of both the mother and the fetus.

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