What is the most adverse effect that can occur after a massive blood transfusion of cold blood, such as Hypocalcemia, Febrile Non-Haemolytic Transfusion Reaction (FNHTR), or Haemolytic Transfusion Reaction (HTR)?

From the Guidelines

The most adverse effect that can occur after massive transfusion of cold blood is hypocalcemia (option A). When large volumes of cold blood are rapidly transfused, the citrate preservative in stored blood binds calcium, leading to decreased ionized calcium levels in the recipient. This hypocalcemia can cause serious cardiac complications including decreased myocardial contractility, prolonged QT interval, arrhythmias, and in severe cases, cardiac arrest. Additionally, the cold temperature of the blood itself can contribute to cardiac dysfunction and hypothermia.

Key Considerations

• Patients receiving massive transfusions should have their calcium levels monitored, and calcium supplementation (typically calcium gluconate 1-2g IV or calcium chloride 0.5-1g IV) may be necessary to prevent or treat transfusion-associated hypocalcemia, as recommended by the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.
• While febrile non-hemolytic reactions and hemolytic reactions can occur with blood transfusions, they are not specifically associated with the cold temperature of the blood and are not the most concerning adverse effects in massive cold blood transfusion scenarios.
• The risk of fatal hemolysis, as reported to the U.S. Food and Drug Administration, averaged 12.5 deaths per year from 2005 to 2010, with an estimated risk for death due to hemolysis of 1:1 250 000 or 8 per 10 million RBC units 1.

Management

• Ionised calcium levels should be monitored and maintained within the normal range following major trauma and during massive transfusion, with calcium chloride administration to correct hypocalcaemia 1.
• Calcium supplementation should be considered to prevent or treat transfusion-associated hypocalcemia.

From the Research

Adverse Effects of Massive Blood Transfusion

The most adverse effect that can occur after massive blood transfusion of cold blood is:

• Hypothermia, which can lead to coagulopathy and other complications 2, 3
• Other potential adverse effects include:
  • Electrolyte abnormalities, such as hypocalcemia 2, 3
  • Coagulopathy, which can increase the risk of bleeding 2, 4
  • Acid/base derangements 2
  • Transfusion-associated acute lung injury 2, 5
  • Haemolysis 5, 3

Comparison of Options

Comparing the given options:

• A. Hypocalcaemia: This is a potential adverse effect of massive blood transfusion, but it may not be the most severe one 2, 3
• B. Febrile non-haemolytic reaction: This is a type of transfusion reaction, but it is not directly related to the use of cold blood 6
• C. Haemolytic reaction: This is a potential adverse effect of blood transfusion, but it is not specifically related to the use of cold blood 5, 3