The Hip: Preservation, Replacement and Revision

Complications of Blood Transfusion:

- Blood Product Menu:
      - pRBCs - Fresh Frozen Plasma - Platlets - Cryoprecipitate - Transfusion Therapy - Coag Pathway

- Acidemia and Hyperkalemia: from massive transfusions;
    - massive transfusion: transfusion of pRBC >6-8 units, must also provide platlets;
            - 8 units platlets for ea 10-12 units pRBC's transfused;
            - 2 units of FFP
            - Ca replacement if hypocalcemic (2nd to citrate)
            - references:
                   - Electrolyte and acid-base disturbances caused by blood transfusions.
                   - Hyperkalemia after packed red blood cell transfusion in trauma patients.
- Post-Transfusion Alkalosis:
           - the early net result of succesful resusitation is post-transfusion alkalosis in the patient;
           - the sodium citrate is converted to bicarbonate
           - the alkalosis is associatted with increased potassium excretion;

- Hypocalcemia:
           - some recommend calcium supplementation for patients receiving greater than 100 ml/min;
           - give 0.2 gm of CaCl in a separate line for each 500 ml given;
           - some believe that most patients will tolerate 1 unit pRBC q 5 min without requiring calcium supplementation;

- Hemolysis:
    - non hemolytic reaction:    
           - typically, this reaction occurs after a significant portion of the blood has already been transfused;
           - note: hives + hypotension = anaphylaxis
           - management:
                  - by itself, may continue the transfusion (benadryl 50mg PO/IV);
                  - prior to future transfusions, the patient should be pre-medicated w/ benadryl 50mg PO/IV (not IM);
                  - if this fails to prevent urticarial rxn, washed RBC's should be given;
                  - w/ mild febrile transfusion reactions fever w/o evidence of hemolysis or more severe symptoms), antipyretics can be used;
    - acute hemolytic reaction:
           - most severe and potentially dangerous transfusion reactions;
           - acute intravascular hemolysis occurs during or shortly after transfusion of incompatible blood and is usually due to preformed antibodies;
                  - typically this reaction occurs early w/ as little as 30 cc of transfused blood;
           - manifestations:  
                  - fever, chills, back or chest pain, N/V, and evidence of hemodynamic instability;
           - required labs:
                  - spin a hematocrit to look for a pink plasma layer indicates hemolysis;
                  - pink-red (spun) plasma indicates that greater than 20 mg/dl of free hemoglobin is present;
                  - send off a DIC screen: PT/PTT, fibrinogen, fibrinogen degradation products, serum bilirubin;
                  - culture of the patient and the donor blood is indicated if there is suspicion of bacterial contamination;
                  - repeat cross match;
                  - Coomb's Test, Free Hb;
                  - CBC, RBC morphology;
                  - send Donor's Blood back to the blood back;
                  - repeat cross match;
           - management:
                  - try to preserve intravascular volume and protect against acute renal failure;
                         - NS 500 ml IV "wide open"
                  - monitor the urine output closely and maintain a brisk diuresis (greater than 100 ml/hr);
                  - consider alkalinization of the urine with bicarbonate (1 mEq/kg IV until urine pH =7.5-9.0)
                         - will facilitate the excretion of free hemoglobin 
           - reference:
                  - Extracorporeal hemolysis in orthopedic patients. Report of two cases.

- Transmission of disease:

- Increased infection rate:
    - septic reaction: considered when high fever and hypotension accompany a transfusion reaction;
    - references:
           - Concepts in Emergency and Critical Care: Effect of Stored-Blood Transfusion on Oxygen Delivery in Patients With Sepsis.
           - Perioperative blood transfusions are associated with increased rates of recurrence and decreased survival in patients with high-grade soft-tissue sarcomas of the extremities.
           - Association between blood transfusion and infection in injured patients.
           - Blood transfusion and oxygen consumption in surgical sepsis.
           - Comparison of one dose versus three doses of prophylactic antibiotics, and the influence of blood transfusion, on infectious complications in acute and elective colorectal surgery.
           - Association between blood transfusion and infection in injured patients.
           - Does blood transfusion or hemorrhagic shock induce immunosuppression.
           - Effects of blood transfusion on oxygen transport variables in severe sepsis.
           - Whole blood vs. packed red cells for resuscitation of hemorrhagic shock: an examination of host defense parameters in dogs.

- Citrate toxicity:
   - can be prevented or its effects minimized by the administration of Ca;
   - historically 1gm of CaCl has been given for every four units of blood administered until such time as the pt is normothermic, euvolemic, and is known to have reasonably normal hepatic function;
   - if Ca gluconate is used, dose must be 4 times greater than w/ CaCl;
   - improved approach is to measure the ionized calcium level



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, January 31, 2013 4:41 pm