Massive Transfusion in the Severely Wounded*
Report of a Case Receiving 23,350 cc. of Blood in the First Twenty-four Hours
Lieutenant Colonel Curtis P. Artz,MC, USA
Captain Yoshio Sako, MC, USA
Captain Alvin W. Bronwell, MC,USA
The experiences of World War II pointed out the value of whole blood in the management of the severely wounded. During the Korean conflict, it became apparent that large amounts of blood should be administered to the battle casualty. Replacement of an amount equal to twice the blood volume was not uncommon. As time went on, reports came from various hospitals of the tremendous amounts of blood given to some casualties. The case herein reported received 23,350 cc. of stored, type-O, low-titer blood in the first 24 hours after injury.
A 22-year-old American airman was injured by mortar-shell fragments on June 26, 1953, at 1145 hours. He sustained a penetrating wound of the right upper quadrant of the abdomen, a perforating wound of the left hip and right leg. He arrived at the clearing station 20 minutes after injury. At that time his blood pressure was 0/0 and he was cold, clammy, and semiconscious. Blood transfusion was started 10 minutes later; and, in the next 30 minutes, 1,700 cc. of blood were administered. The patient`s color improved; he became responsive; and a blood pressure of 130/? was obtained. He was then moved to a surgical hospital by ambulance, arriving 2.67 hours after injury.
Upon admission, his blood pressure was 140/80 and his pulse rate 120. Thirty minutes after admission, 1,000 cc. additional blood had been administered through a cannula in the left leg; but blood pressure fell to 90/48, pulse rate 142, respiration 42. Transfusion was continued during the time roentgenograms were. taken. There was a metallic fragment in the right lower quadrant at the level of S-I. There was an open fracture of the body of the left ilium, with metallic fragments lying lateral to the greater trochanter and an open fracture of the upper portion of the right tibia.
*Previous1y published in Surgery 37:469, 1955.
A catheter was inserted into the bladder and the urine was found to be clear. Since there was a fall in blood pressure and a pulse rate of 160, in spite of the infusion of blood, it was believed there was continued intra-abdominal hemorrhage. There was progressive rigidity and distention of the abdomen. An additional cannula was inserted into a vein in the left arm since vena cava injury was suspected. The patient was taken to surgery 4.75 hours after injury. He had received 5,700 cc. of blood at this time; but his blood pressure was 66/0.
After pentothal induction and endotracheal ether anesthesia, an exploratory laparotomy was performed through a right rectus incision. Upon incision of the bulging peritoneum, approximately3,000 cc. of blood was found. The abdomen was rapidly explored, beginning with the iliac region. Pressure was then placed in the region of the celiac axis and the entire area was observed for bleeding points. A 7-inch, through-and-through tear of the inferior half of the right lobe of the liver was bleeding. A gauze pack was inserted; and it appeared that the hemorrhage was under control. Until 2,000 cc. additional blood was administered under pressure, further surgery was withheld. The patient?s blood pressure rose to 100/64;and his pulse rate was 120. Although gelfoam was placed in the laceration of the liver, bleeding did not cease. Through-and-through sutures of chromic catgut (No.1) in round, curved needles were placed widely in the liver to pull the laceration against the gelfoam pack. Finally hemorrhage was controlled by placing two figure-of-eight sutures with gelfoam under the structure on the anterior and posterior aspects of the liver.
The abdomen was explored thoroughly, and no further intraperitoneal damage was observed. The cecum and ascending colon were reflected medially; and the missile tract in the right psoas muscle was located. The muscle was débrided; a 2 cc.-square, metallic fragment was removed; and the bleeding points were ligated. Four drains were placed about the liver and brought out through a stab wound in the right flank. Two large drains were placed in the retroperitoneal area, around the damaged psoas muscle, and brought out through a separate stab wound. A final examination showed that bleeding was under control. The abdominal wall was closed in layers. The wound of entrance to the abdomen and wounds of the extremities were débrided. During the operation which lasted 1.25 hours the blood pressure was around 100/60 for approximately half of the time; and it went as low as 60/0 at other times. During the operation, the patient received a total of 4,500 cc. of blood, making a total of 20 pints administered following injury. He left surgery with a blood pressure of 80/60, pulse rate 120, and respiration 40.
For the first few hours postoperatively, the patient`s pulse rate increased to 150; and his blood pressure fluctuated between 80 and 100
(systolic) in spite of transfusion of an additional 2,000 cc. of blood. During the first 3 hours after surgery, he excreted only 7 cc. of urine. A great deal of oozing could be seen from the wounds, and considerable loss of blood was occurring through the two drainage sites. Three gin. of calcium gluconate were given intravenously with no noticeable effect on the oozing or blood pressure.
Four hours after surgery, the patient`s pulse continued to be 150 and his blood pressure 90/68. A total of 3,500 cc. of blood had been administered following operation, making a total of 27 pints since injury. It was believed that this patient continued to ooze from all wound surfaces, and possibly from the liver. A secondary exploration was thought advisable, inasmuch as the administration of 875 cc. of blood each hour did not compensate for the blood loss.
The patient was taken to the operating room again 11 hours after injury. His blood pressure was 50/40, and his pulse 130. An intra-arterial transfusion was started in the right femoral artery and blood was also pumped into the arm and leg cannulae. The abdomen was re-entered through the previous incision and a massive amount of blood was found in the peritoneal cavity. The liver laceration was not bleeding. A large amount of blood was seen in the depths of the right psoas muscle wound and retroperitoneal area. No definite bleeding point could be found. A large gelfoam pack and two 5-yard gauze packs were inserted into the retroperitoneal area and the ends brought out through an incision in the right flank. Four drains were again placed around the liver. The abdomen was closed with through-and-through wire sutures.
Twelve pints of blood were given during the 1-hour operation, three of them into the femoral artery, making a total of 39 pints. During the operation, the blood pressure was 60/40 and, after administration of 1 ampule (4 mg.) of norepinephrine, the blood pressure rose to 110/80. With discontinuance of norepinephrine, the patient`s pulse was 140 and his blood pressure was 0/0. An additional 4 gin. of calcium gluconate were given with no discernible effect.
After the completion of the operation, the patient remained on the operating table under the care of the anesthesiologist for some time. The patient continued to ooze; and it was decided that freshly drawn blood might be of value in stopping the oozing. By 0200 hours, 40pints of blood had been given (1 pint of fresh blood) ; the patient`s pulse was 140, respiration 48, blood pressure 110/70. Vitamin K-1 oxide (100mg.) was given intravenously and 3 additional pints of freshly drawn blood were given slowly. It was estimated that the patient continued to ooze at the rate of approximately 300 cc. per hour. Following the operation and administration of 43 pints of blood (4 of which were freshly drawn),the output of urine was 150 cc. on the third hour and approximately 70 cc. per hour thereafter. At this time the patient`s general condition appeared to be good.
At 0500 hours, the patient experienced an acute gastric distention because of malfunction of an indwelling stomach tube and respiration increased to more than 60 per minute. This was relieved by the introduction of a larger stomach tube and the respiratory rate fell immediately to 40.
Between the 24th and 30th postoperative hours, the patient improved remarkably; he appeared to have stopped bleeding. Blood pressure was 120/40, pulse 120, respiration 40. Output of urine was 60 cc. per hour. He had received a total of 46 pints of blood (7 pints of freshly drawn blood) and 2,600 cc. of 5 per cent glucose in water within 24 hours following injury.
During the early postoperative period, the patient`s course was somewhat stormy. His temperature rose to 103o F. on the first day and slowly fell to normal by the fourth day. He received one million units of penicillin every 4 hours and 1 gm. of Terramycin every 12 hours intravenously. One-half of the pack was removed on the third postoperative day and the remainder on the fourth day. Although there was a great deal of drainage, there was no bleeding. He was sitting in a chair and eating well by the tenth postoperative day, at which time he was evacuated to the 25th Station Hospital.
In a follow-up letter from the Osaka Army Hospital in Japan, it was stated that the patient was admitted on the 12th postoperative day in surprisingly good condition. His hematocrit was 39, total proteins 6.7 gin., albumin 3.2, globulin 3.5. On the 23rd postoperative day, secondary closure of soft-tissue wounds of the leg was carried out. By the 37th postoperative day, he was walking about and was feeling quite well. He had occasional bouts of distention and diarrhea; but it was felt that he was ready for transfer to the United States.
After a long evacuation by litter jeep, this severely wounded casualty arrived at the clearing station with a blood pressure that was too low to be obtained by the cuff method. After administration of 1,700 cc. of blood, the patient improved and withstood further evacuation to a surgical hospital. This demonstrates the value of resuscitative measures at the division level. It is wise to delay transportation of a severely wounded soldier for infusion of resuscitative fluids and thus prepare him for further transport, rather than to rush him to a hospital in extremely poor condition.
Although the patient`s blood pressure on admission to the hospital was 140/80, it soon fell to 90/48 in spite of continuous infusion of blood. Failure of the patient to maintain a normal blood pressure and a rapidly expanding abdomen were evidences of profuse hemorrhage intra-abdominally.
Since vena cava injury was suspected, an additional cannula for administration of resuscitative fluids was inserted into an arm vein because leg cannulae are of little value in the presence of such injuries.
An operation was carried out immediately in order to control hemorrhage. At operation, a large amount of blood came from the damaged retroperitoneal muscles. Blood loss from this area is always much greater than is apparent. After the brisk hemorrhage was controlled by gauze packs, further operation was delayed until additional blood had been given. This illustrates an important point in resuscitation, namely, when a surgeon suspects continued, profuse, intra-abdominal hemorrhage, it is an indication for immediate exploration. As soon as the hemorrhage is controlled, further manipulation should be delayed until the patient`s condition is improved by further replacement of blood.
Although continued oozing was obvious after operation in spite of administration of 876 cc. of blood per hour, hypotension with the accompanying low output of urine was further indication of serious hemorrhage. The second operative procedure was started when the patient was in very poor condition. Blood pressure was 50/0. The patient was reopened under minimal anesthesia; and further restoration with blood was carried out. In this instance, it is doubtful if the intra-arterial transfusion was of particular value because of the slow rate at which it was given--1,500 cc. in 1 hour.
At the first operation, the liver hemorrhage was controlled by large sutures over gelfoam. Bleeding occurred from multiple points in the damaged retroperitoneal muscle. It is not uncommon for oozing to occur after massive transfusion of stored blood. This is believed to be due to a deficiency in the clotting mechanism, the exact nature of which has not been determined. Administration of multiple, large doses of calcium gluconate or vitamin K-1 oxide was of no apparent benefit. Previous experience has established the beneficial effects of fresh blood in patients who have a bleeding tendency after the administration of large amounts of stored blood. In this patient, it is believed that the use of fresh blood was lifesaving. However, a large quantity of blood (7 pints) was required before there was evidence that clotting occurred.
In the postoperative period, nasal oxygen was administered. About 3 hours after operation, respiration increased to 60 per minute. An intragastric tube was in place, but not functioning; and acute gastric distention occurred. This is not an uncommon occurrence in severely wounded patients. A larger tube was inserted; the distention was relieved; and the respiratory rate decreased to 40 per minute.
Postoperatively the patient made a rapid recovery. The pack was partially removed on the second day, and the remainder on the fourth day without further bleeding.
This case emphasizes the value of replacement of blood loss with whole blood.
The use of massive quantities of blood may be required in the management of severely wounded patients. A case is reported in which a patient received 23,350 cc. of blood in the first 24 hours after injury. Discussion includes several interesting factors in the initial care of patients who have sustained severe injury, accompanied by unusually great blood loss.
In a follow-up letter it was learned that this patient developed a subcutaneous evisceration while waiting to be evacuated to the Zone of Interior. At operation, the bowel was inadvertently entered and he developed a jejunal fistula. From then on, his course was steadily downhill and he expired on the 76th day following injury.
Postmortem examination revealed jejunal fistula, peritonitis, bronchopneumonia and cerebrospinal leptomeningitis.