Massive Transfusion Protocol Quiz

Cryoprecipitate

• Forms when FFP is thawed slowly at 4°C
• ABO-compatibility not needed
• Viruses can be transmitted
• Contains: FVIII, FXIII, vWF, fibrinogen
• Indications: microvascular bleeding with low fibrinogen, DIC with low fibrinogen and RBCs

Transfusion-Related Mortality

• Leading cause of transfusion-related mortality (5-25%)
• Accounts for 40% of US transfusion-related fatalities
• Activated neutrophils → sequestered in lung
• Donor antibodies (due to alloimmunization) complex with WBC antigens
• Avoid multiparous female donors
• "Two hit model": pre-existing pro-inflammatory state and reactive lipids in stored blood
• Symptoms: dyspnea, fever, pulmonary edema, bilateral infiltrates within 6h of transfusion
• Treatment: supportive ventilator and fluid management
• Prevention: leukocyte reduction, avoid multiparous female donors

Graft-Versus-Host Disease (GVHD)

• Donor lymphocytes establish immune response against the host
• Highest risk: immunocompromised patients, stem-cell or bone-marrow transplants, B-cell malignancies
• Symptoms occur within 4-21 days: fever, rash, diarrhea, liver dysfunction
• Rapidly progresses to pancytopenia, >90% mortality
• Prevent with irradiation – inactivate donor lymphocytes

Transfusion Related Immunomodulation (TRIM)

• Alteration of immune responsiveness and/or pro-inflammatory mechanisms
• Transfused WBCs and other immune mediators
• Effect of transfused RBCs in the microvasculature
• "Two insult" theory: pre-existing trauma/illness is the first "insult"
• Decreased rates of transplant rejection, Crohn’s, and spontaneous abortion
• Increased mortality, accelerated recurrence of malignancy, increased rates of infection, and more rapid progression of HIV/AIDS

Transfusion-Induced Inflammatory Response

• Bioactive substances accumulate during storage
• PRBC age correlates with multi-organ failure and mortality in ICU patients
• May lead to shorter "shelf times," esp. for sickest patients

Other Non-infectious Risks

• Massive Transfusion: hypothermia, TACO, dilutional coagulopathy, decreased 2,3-DPG, acidosis, hyperkalemia, citrate intoxication, iron overload, microaggregates

Transfusion Reactions

• Febrile non-hemolytic transfusion reaction
• Minor allergic reaction
• Anaphylactic reaction – PRBCs
• Anaphylactic reaction – FFP, platelets
• Acute hemolytic transfusion reaction (AHTR)
• Delayed hemolytic transfusion reaction (DHTR)
• Transfusion-related immunomodulation
• Alloimmunization
• Transfusion-related lung injury (TRALI)
• Graft-vs-host disease (GVHD)
• Post-transfusion purpura