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Ultrafresh blood for massive transfusion
Publication history, Reflections & comments
IN three cases of massive blood loss, patients received an average of 38 units of blood replacement, of which 12 units were fresh. All received fresh frozen plasma (FFP), but no platelet transfusions. The use of fresh warm blood, rather than banked blood, appears to have been of crucial benefit to the patients in this small series.
Case 1. A man, aged 30 years, was stabbed in the back at Coober Pedy. He was resuscitated and flown to Whyalla, arriving pulseless. At laparotomy, he had two tears both in abdominal aorta and in vena cava. The aorta was repaired, and the vena cava tied off above and below the tears. Eight hours later, he collapsed and had a second laparotomy. The right iliolumbar vein had distended and bled heavily from a previously unnoticed tear. This was ligated.
The patient received 47 units of blood in 24 hours. Of these, 31 units were stored blood and 16 units were ultrafresh blood, which was never cooled after collection. He also received eight packs of FFP.
Throughout his operations and stormy postoperative period, there was no evidence of disseminated intravascular coagulopathy (Table 1).
Table 1
Bleeding and Clotting Studies for Patient 1
|
Days
|
1
|
2
|
3
|
4
|
5
|
6
|
|
| a.m. | p.m. | ||||||
| One-stage PT |
14.0
|
14.5
|
14.0
|
16.0
|
15.0
|
16.0
|
13.5
|
| Control |
13.5
|
14.5
|
14.0
|
14.0
|
14.0
|
14.0
|
14.0
|
| Platelets (x1000) |
115
|
164
|
92
|
56
|
74
|
64
|
150
|
| APTT |
45
|
33
|
33
|
34
|
.5 37
|
40.5
|
28.5
|
| Reference |
45
|
43
|
40
|
37.5
|
42
|
36
|
36.5
|
| Hb (g/L) |
60
|
145
|
139
|
142
|
144
|
150
|
144
|
| PCV |
0.115
|
0.44
|
0.43
|
-
|
-
|
-
|
-
|
PT=partial thromboplastin time.
PCV=packed cell volume.
APTT=activated partial thromboplastin time.
For more gory details of Case 1, see here
Case 2. A 17-year-old woman was admitted semiconscious after a
car accident, with profuse vaginal bleeding. She had multiple compound
leg fractures, fractured pelvis, clavicle, dislocated left hand, and massive
bruising of the whole body.
At laparotomy, there was a long anterior vaginal laceration into the bladder base and urethra. Formal repair was not possible because of bleeding, which also occurred from all lacerations and intravenous infusion sites. Three hours after accident, the laboratory reported that the initial blood sample, taken one hour earlier, and before any blood had been infused, would not clot. The patient's fractures were reduced and splinted, and a short length of devascularized small bowel was resected.
Postoperatively, the patient's condition could not be stabilized, despite apparently adequate blood and fluid replacement. Five hours later, she was taken back to the theatre and both internal iliac arteries were ligated. Bleeding persisted from near the obturator foramen and ischiorectal fossa, and this was packed with gauze. Both ureters were catheterized.
The patient's condition improved, but she developed adult respiratory distress syndrome. Four days later, a routine tracheostomy was performed, and the patient's pelvic pack was removed. The patient was transferred to the intensive care ward at the Queen Elizabeth Hospital, Adelaide, but unfortunately died six weeks after the accident with persisting respiratory distress syndrome which was complicated by an episode of anuria.
In the first 18 hours after accident, the patient received 43 units of blood, including 18 ultrafresh units, and six units of FFP.
Although fibrin degradation products were not measured, there was no doubt that this patient developed a bleeding dyscrasia about three hours after her accident. Normal clotting resumed after correction of the patient's severe shock and useof fresh blood (Table 2).
Table 2
Bleeding and Clotting Studies for Patient 2
|
Days
|
1
|
2
|
3
|
4
|
5
|
|
| a.m. | p.m. | |||||
| One-stage PT |
19.5
|
16
|
19
|
15
|
16.5
|
15.5
|
| Control |
13
|
13
|
14
|
13
|
13.5
|
13.5
|
| Platelets (x1000) |
86
|
90
|
70
|
64
|
96
|
|
| APTT |
43
|
39
|
27
|
25
|
38
|
43
|
| Reference |
42
|
40
|
30
|
37
|
32
|
40
|
| Hb (g/L) |
70
|
146 to 152
|
139
|
121
|
109
|
|
| PCV |
0.27
|
0.41
|
0.45
|
0.43
|
0.38
to 0.31 |
|
PT=partial thromboplastin time.
PCV=packed cell volume.
APTT=activated partial thromboplastin time.
No more blood was given after the second laparatomy, and no significant bleeding occurred after the pelvic pack was removed.
Case 3. A woman, aged 21 years, who was transferred from Port Augusta after a motor cycle accident, was severely shocked and had fractures of the pelvis, both femurs and lower parts of legs, as well as lacerations and friction burns all over her body.
She was resuscitated, and then both femurs and tibias were reduced and fixed internally. Large lacerations were sutured, some requiring flat repairs. Two toes of the left foot were amputated.
The patient was transfused with 22 units of blood, of which two units were ultrafresh. She also received four packs of FFP.
Clinically, there was no evidence of bleeding and clotting abnormalities (Table 3).
TABLE 3
Bleeding and Clotting Studies for Patient 3
|
Days
|
1
|
2
|
3
|
5
|
10
|
|
One-stage PT
|
18
|
14
|
|||
|
Control
|
13
|
13
|
|||
|
Platelets (x 1000)
|
48
|
64
|
52
|
140
|
normal
|
|
APTT
|
45
|
45
|
|||
|
Reference
|
38
|
43
|
|||
|
Hb (g/L) (85 on admission)
|
107
|
107
|
120
|
92
|
121
|
|
PCV
|
0.34
|
0.34
|
PT=partial thromboplastin time.
PCV=packed cell volume.
APTT=activated partial thromboplastin time.
This patient received the least blood, and, in particular, only two units of ultrafresh blood. Her thrombo-cytopenia was more pronounced than that of the other two patients.
The above cases are typical of those admitted to major metropolitan trauma units. Invariably, replacement of blood loss is by banked blood, with added fresh frozen plasma and platelet transfusions. Often there are problems with bleeding diathesis and the maintenance of normal clotting.
However, in base hospitals throughout Australia, it is difficult to maintain banks of fresh frozen plasma, and platelets are even harder to stock. The clinical experience reported above suggests the value of emergency blood donor panels, not only for country areas but for city areas as well. For many donors, the inconvenience would be outweighed by the knowledge of helping the seriously ill patient. In addition to spare donors for emergencies, it is recommended that banked autologous blood, with its attendant benefits, be used more widely for elective surgery. There may also be a place for scavenged autologous blood, though we have no experience of this technique.
Labile factors, especially Factor 5, deteriorate rapidly. It is, therefore, likely that ultrafresh blood has better clotting properties than FFP. A separate advantage is that the red blood cells in fresh blood are more effective at transporting oxygen. In major trauma, shock is common, hypoxia is frequent, and oxygen transport in the microcirculation is critical. It seems valid to conclude that massive transfusion is an indication for ultrafresh blood.
We are grateful to Mr A. R. Girgis and Mr G. B. Markey for permission to present Cases 2 and 3. Essential for survival of the patients were St John Ambulance and the Flying Doctor Service, nurses, dedicated laboratory staff, and blood donors in Whyalla.
______________________________________________
Early one Saturday morning I got a phone call from the GP at Coober Pedy, an opal mining town about 3hours away from Whyalla by ambulance plane.
A man had been stabbed in the back shortly after midnight, and he wasn't very well. He had the small laceration titched, and could he be transferred.
When he arrived he was practically dead, deeply shocked and with a hugely distended abdomen. Generally I would have been quite frightened to deal witha problem like this, except that he was so ner death that it seemed more like a sporting challenge than a patient to be worrying badly about.
Richard Davis, the stalwart anaesthetist, got him started with blood transfusions and in the operting theatre I started with a full-length abdominal incision.
Inside there was a belly quite full of blood and clot. My memories are a little hazy, but scooping, packs, suction and irrigation eventually disclosed three small bleeding lacerations of the aorta and vena cava.
My experience of vascular surgery was limited, but it was relatively straightforward to stitch two small lacerations of the aorta, just above the bifurcation, with watertight closure. The one or two lacerations in the collapsed inferior vena cava were more of a challenge, but I remembered reading it was good treatment to tie off the vena cava above and below the damage, and with some trepidation and difficulty I did this successfully, something I had never seen before.
There had been a transfusion of about 20 units of blood, but the patient had survived. I went home exhausted and drained, to sleep.
That afternoon I was woken by a phone call. The patient had collapsed, with a hugely distended abdomen again, and was if anything sicker than when he had arrived first early that day.
There was no alternative but to take him back to the operating theatre and re-open the abdomen.
The bleeding was coming from a laceration I hadn't noticed earlier in a right ilio-lumbar vein, hugely distended as it was now carrying all the blood from the lower half of the body which had previously returned through the inverior vena cava, now tied off.
This I tied off as well, and again retired to bed a second time that day, exhausted and quite spent.
The patient actually did surprisingly well, though on day 3 he developed huge oedema of the legs, not surprising after the tying of his vena cava and the main alternative bypass.
Worried by this, I had him transferred in otherwise safe condition to the Royal Adelaide Hospital 400 km away.
This was treated with diuretics, and with more patience and confidence than I had. He survived well, apart from a little leg oedema.
I saw him 6 months later, ouside the port Augusta Courthouse where his assailant was on trial for attempted murder.
Through his limited English, the story emerged. He, a small man, had been having it off with the wife of his big-built assailant, who had stabbed him in the back in the main street of Coober Pedy, at about 1 am, while he was talking to one of the town's policmen. He was now quite well, except that - poetic justice - he was now impotent.
In the Court-house, I was quizzed by Robin Layton, first wife of premier John Bannon, assisting committed Communist Elliot Johnson QC, and a formidable court-room lawyer only recently honoured by appointment to the Bench.
First, the path of the knife. It had passed through the narrow space between two transverse processes of lumbar vertebrae to hit the two major blood vessels in this part of the body with no other injury apart from the right ilio-lumbar vein.
Then, some softening up. Didn't it take unusual skill to deal with this injury? I was on oath. I had to agree.
Next, wasn't it bad luck it had taken this path and not been held up on the bone? No, because it might have instead gone outside the bone to hit the hepatic veins at the back of the liver, bleeding fromwhich would have been irretrievable. Oh.
I thought I could feel the angry eyes of the rather frightening accused bring into my back, and was only a little comforted by the thought he would be in jail for several years.
What an adventure!
One sequel: in about 2003 I was at a surgical grand round at the Royal Adelaide Hospital, addressed by an Israeli haematologist involved in treatment of victims of the Palestinian Inifada for horrific injuries. One of his challenges was massive blood loss, treated as in our cases by fresh warm donor blood from special volunteer "Yeshivah Bochers" These were the typical bearded black-suited tieless whiteshirted religious students at seminaries, who were presumed not to be subject to AIDS or hepatitis, Speaking with him after his lecture, the paper by Richard Davis and me was one of the earliest sources they used for their own clinical practice.
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Contents
Reports of 3 cases
Discussion
Acknowledgements
THE MEDICAL JOURNAL OF AUSTRALIA MARCH 10, 1979 Med. J. Aust., 1979,1:172-174.
ULTRAFRESH BLOOD FOR MASSIVE TRANSFUSION
RICHARD W. DAVIS MICHAEL PATKIN
Richard W. Davis, F.F.A.R.A.C.S., is an anaesthetist, and Michael Patkin,
F.R.C.S., F.R.A.C.S., is a surgeon at The Whyalla Hospital, Whyalla, South
Australia. Address for reprints: Richard W. Davis, Whyalla Hospital, Whyalla,
S.A. 5600.
______________
A prequel was the habit of D'Arcy Sutherland, who pioneered cardiac surgery at the Royal Adelaide Hospital, of ensuring that one of the units of blood administered to his patients was freshly taken so it might still have various clotting factors undecaed by the passage of time.
All along the various blood transfusion services resisted the use of fresh warm blood, because it meant rousing various stff out of bed at night. They maintained that inability to screen donor blood for intections was a reason against this. They refused to consider a scheme whereby a pool of "safe" emergency donors could be maintained. They had the confident arrogance to think they knew all the factors necessary for clotting, like engineers who insist their untested plans will solve particular problems. Karl Popper had stressed the falsifiability of hypotheses years earlier.
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