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Massive Blood Transfusion Complications

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Exsanguination from trauma, gastrointestinal bleeding, and obstetric hemorrhage remains a major source of mortality across the planet. Continued research into resuscitation strategies and evolving technology and blood product storage has allowed for patient to undergo very large volume transfusions, even to the point of replacing a patient’s blood volume several times over. As massive transfusions have become more common, more studies have been performed delineating the exact patient population that would benefit, start- and stop-points of transfusions, complications and avoidance of the same.

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Blood transfusion remains a life-saving therapy and according to World Health Organization (WHO) guidelines, of 10 units per 1000 population, approximately 8 million units of blood are currently needed to meet the transfusion demand for a population of about 800 million. While in the industrialized world, blood provision and blood safety are well established, in Africa, there is limited access to blood, and provision of unsafe blood renders blood safety a major public health concern. Blood transfusion may be needed in circumstances like obstetric hemorrhage, road traffic accidents, armed conflicts, sickle cell disease, anaemias especially in children, malnutrition, HIV, malaria, and parasitic infections. It is therefore important to always highlight the blood transfusion reactions, possible causes, expected symptoms and signs, preventive measures, and appropriate management. Blood transfusion reaction refers to undesirable, unintended, adverse response to the administration of blood, blood components, or derivatives that are well thought-out to be definitely probable or possibly related to this product. About 0.5–3% of all transfusions result in transfusion reaction. Blood transfusion reactions can basically be categorized as infectious or noninfectious. The majority of blood transfusion reactions are, nonetheless, noninfectious with outcomes ranging from nonsignificant consequences to death. However, the infectious effects are given more prominence than other adverse reactions. For emphasis, when any unexpected or untoward symptom or sign occurs during or shortly after the transfusion of a blood component, a transfusion reaction must be considered as the precipitating event until confirmed otherwise. Although the signs and symptoms of BTR will be fully discussed under each type of blood transfusion reaction, it is important that these features be highlighted as it relates to each system. Circulatory: circulatory changes include changes in blood pressure, tachycardia, arrhythmia, bleeding, blood in urine, and increase in bleeding tendencies. Pulmonary: pulmonary features include shortness of breath, dyspnea, wheezing, cough, and changes on chest X-ray.

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As screening for transfusion-associated infections has improved, non-infectious complications of transfusion now cause the majority of morbidity and mortality associated with transfusion in the United States. For example, transfusion-related acute lung injury, transfusion-associated circulatory overload, and hemolytic transfusion-reactions are the first, second, and third leading causes of death from transfusion respectively. These complications and others are reviewed here and several controversial methods for prevention of non-infectious complications of transfusion are discussed; universal leukoreduction of red cell units, use of male-only plasma, and restriction of red cell storage age. As transfusion-transmitted infections have decreased, awareness and reporting of non-infectious complications of transfusion have increased. Non-infectious complications are now the more common and more deadly group of transfusion-related morbidities. Incorrect blood component transfusion resulting in hemolytic transfusion reactions and transfusion-related acute lung injury (TRALI) remain major sources of morbidity and mortality. The purpose of this review is to characterize non-infectious hazards of transfusions and to discuss several controversial strategies to reduce transfusion-associated morbidity and mortality (Hendrickson JE, 2009). Blood transfusion is an accepted standard of care in a variety of clinical scenarios and is likely to remain so, despite the absence of randomized controlled trials demonstrating improved outcomes after transfusion. Instead of designing studies to answer the question “should we ever transfuse?” investigators have attempted to answer the question “when should we transfuse?” The question is of principal importance, since several studies have suggested that use of human blood products may place patients at increased risk of death. Finally, pro-coagulant products such as prothrombin complex concentrates, cryoprecipitate, recombinant factor seven, amicar or tranexamic acid and others may be indicated in specific clinical situations, although a discussion of these products is beyond the scope of this review. Ultimately minimizing the use of blood products may be the best way to reduce transfusion associated morbidity (Sanders RP, Maddirala SD, 2005).

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Thus, these approaches are in alignment with the findings of Johansson who concluded that the optimal transfusion by proper monitoring improved the survival of massively bleeding patients. Therefore, the blood banks should be encouraged to remove impediments to rapid issuing of blood component. In addition, the medical/surgical department should discuss the feasibility of the fixed blood component ratio and the consequences of its use. Finally, the hospital blood bank should realize that the fixed blood component ratio measures would improve the access to blood components, reduce mortality, and decrease unnecessary blood component utilization.

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Hendrickson JE, Hillyer CD. Noninfectious serious hazards of transfusion. Anesth Analg. 2009;108:759–69. \

Vamvakas EC, Blajchman MA. Universal WBC reduction: The case for and against. Transfusion. 2001;41:691–712.

Hebert PC, Fergusson D, Blajchman MA, Wells GA, Kmetic A, Coyle D, Heddle N, Germain M, Goldman M, Toye B, Schweitzer I, vanWalraven C, Devine D, Sher GD. Clinical outcomes following institution of the canadian universal leukoreduction program for red blood cell transfusions. JAMA. 2003

Wang SE, Lara PN, Jr, Pee-Ow A. Acetaminophen and diphenhydramine as predemication for platelet transfusions: A prospective randomized double-blind placebo-controlled trial. Am J Hematol. 2002

Sanders RP, Maddirala SD, Geiger TL, Pounds S, Sandlund JT, Ribeiro RC, Pui CH, Howard SC. Premedication with acetominophen or diphenhydramine for transfusion with leukoreduced blood products in children. Br J Haematol. 2005

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Massive Blood Transfusion Complications
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