Risks of blood transfusion:
Common
- Fever
- Rash / itch
Rare / serious:
- Anaphylaxis
- Fluid overload
- Acute immune haemolytic reaction
- Development of antibodies which may complicate future transfusions
- TRALI
- Blood borne infections – Hep B, Hep C, HIV
(Theoretical) risks of cell saver:
- Non immune haemolysis
- Coagulopathy (due to major blood loss)
- Contamination with drugs or infectious agents
- Air embolism
- Hypersensitivity reaction to anticoagulants
Cell saver in cancer and bowel surgery?
- Malignancy was listed as a contraindication in 1986 – subsequent large retrospective reviews show no oncological disadvantage in RRP or cystectomy – endorsed by NICE guidelines for use in RRP, cystectomy
- Filter effectively removes 97 – 100 % of organisms in in vitro studies, and microbiological contamination seen in 12 – 33 % of salvaged blood during ‘sterile’ procedures
Indications for caval filter?
- Classically – cases of DVT where anticoagulation is contraindicated, inadequate or resulting in complications, aiming for prevent migration and embolism
- g. large DVT in a patient with clot retention and bleeding
Massive transfusion protocol
Activation criteria – actively bleeding with any of:
- 4 units PRBC in < 4 hours, with haemodynamic instability
- Estimated blood loss > 2.5 L
- Clinical or lab signs of coagulopathy
Management:
- Resuscitation combined with ICU/anaesthetist/haematology
- Haemostasis or control of bleeding
- Tranexamic acid
- Oxygenation
- Ensure warmed
- ROTEM if available guides MTP
- RBC / fibrinogen / FFP
- Monitor FBC, fibrinogen, coagulation studies, ionised calcium
- Communicate closely with lab
- Dedicated runners/orderlies in OT
Bleeding diatheses
von Willebrand disease
- Hereditary deficiency in vWF – inadequate platelet adhesion
- Manage in conjunction with haematology – usually load with Biostate perioperatively (recombinant factor 8 and vWF) – other options are TxA and desmopressin
Haemophilia
- Ensure managed at a centre with experience managing these patients
- Pre-operative planning – operate early in day – re-screen as needed and plan factor replacement on individualised basis – may need continuation for up to 2 weeks
Disseminated intravascular coagulopathy
Systemic activation of blood coagulation – leading to countless microvascular thrombi but also consumption of clotting factors and platelets leading to life threatening haemorrhage
Most commonly seen in sepsis, septic shock and trauma