Reading your blog for 9-10-05, I was reminded of what I read in your book Patriots a few months back about transfusions. In Patriots blood is drawn off into a sterile bag with no mention of anticoagulation. There is a huge risk here IMO. I am a director with a major university hospital . Here are some things to consider and what I plan on doing for transfusions WTSHTF. You are correct that person to person transfusion is too risky. Depending on vein size and the size of the needle / catheter you could have a flow of 1 ml per minute to 5 or 6. Also, once the line is de-aired, without a optical fluid analyzer you have no way of knowing how fast it is going, let alone if it has stopped -which it can and does. Blood does clot! Moving through a system that has not been anticoagulated will cause many microaggrete clots at best. This is very dangerous IMO. Of course if someone is going to die anyway, why not risk it.
Viable options for anticoagulation drugs:
Citrate: AKA CPDA-1, ACD-A
Ratio: 1ml of either ACD-A or CPDA-1 per 7 ml of blood. These forms of citrate are premixed, unlike Heparin.
Risks: Aside from transfusion reactions, citrate is readily neutralized and absorbed by the body. Calcium negates Citrate. Risk of mis-dosing the PT (via over anticoagulated blood) is minimal. DO NOT use any IV fluid such as LR (lactated ringers) to prime or ‘chase’ this blood because it contains calcium and could clot in the IV line. No worries once the blood is in the patient (PT), LR is fine after the line is cleared. Use .9 NACL during infusion. Once blood is drawn off into a pre-citrated bag, you have 6 hours to reinfuse it at room temp. of 72 degrees.
Bonus: In some areas outside the USA, CPDA-1 blood bags can be purchased without a prescription (RX). The bags store for a printed shelf life of about 24 months. A “must have” if it is legal in your AO.
Heparin: A very distant second choice, EASY to overdose (OD). Basically impossible to properly fix in the field (unless you can wait it out) without PT and PTT tests from a lab or mobile device.
Heparin: Porcine or bovine. (Note: most bovine is expired or nearing expiration, porcine is the current standard)
Ratio: 30 units per 7ML of blood. Here is where it can get VERY confusing. Heparin comes in many different concentrations. From 1,000 units per ML to as high as 20,000 units per ML (some may be around in higher concentrations, but it is rare to see nowadays because of overdosing issues). You must pay strict attention.
Risks: Many. Using Heparin in the field means you must PRECISE. Under anticoagulate and the blood clots before it goes in. Over heparinize the blood and the PT could become anticoagulated. Unlike citrate, heparin attaches to the platelets. You have to wait out the heparin in order for it to go away. Theoretically you could give protamine, but if you knew how much you OD’d your PT you wouldn’t have to give it anyway. NEVER give protamine in the field. Blood can only be stored for an hour once drawn off into heparinized bag.
Negatives: As stated, risk of OD and your PT bleeding out because of it. You must have a pen and paper or calculator to determine how much heparin to use. You also must have a spare bag of .9nacl (preferably) to dilute the heparin in. There is just a lot of room for error at the moment when your most likely to make an error.
Advice: Don’t use it unless it’s truly life or death, make out all you calculations and such ahead of time and keep them with the heparin. Also, heparin requires a RX in the USA.
Afterthoughts:
Blood Volume (in MLs)= Weight in kilograms x 65
6500ml=100Kg x 65
1ML=1CC
1ML=1 gram (if you have a scale and want to weight the transfer pack, that comes in handy).
A full transfer pack looks like it is going to burst.
A 40 micron blood filter would be a big plus to have along with your other transfusion equipment. Running non-anticoagulated blood through one isn’t a good idea.
Keeping iron pills on hand (legal in the USA) is a great idea to boost red blood cell (RBC) production after a transfusion or before it.
I hope this info helps… – Dr. Buckaroo Banzai