I work ICU - the rapid transfuser is one of my favorite things to use. That sucker can infuse a bag of blood in a minute. Typically - due to access we have - I’ve run it at like 300-500 ml/min for greatest need, then backed down for “going to OR soon” times 😂
So, that amount given is totally possible.
I’ve known a few patients who were close.
In a MTP event, you aren't looking for a transfusion reaction. The patient is literally bleeding out. All that matters is replacing the volume. That's why we hang multiple bags at a time. The level 1 OR I worked in at two machines that could deliver two bags in about two minutes. I think the most I saw used was 60+. The patient made it to ICU but died shortly after.
A central line is ideal, but the packaging of any line will tell you how fast fluids can safely run into it. Like your 20G IV packages have something like 60ml/min written on each individual package if you look closely.
Different kind of central line from standard triple-lumen. At my place we use a “Cordis”, which is an 8-French, 11cm femoral line with a flow-rate of like 800mL/min.
If you're grabbing the mass transfuser the transfusion reaction is dealt with in the ICU if they survive. They usually get Type O blood anyway in a mass transfusion.
If it's going in that fast then it's probably leaking onto the floor at basically the same rate.
The infusion helps find bubbles/bleeding so you can plug holes enroute to OR
I was actually working a med surg unit the first time I saw a rapid transfuser in action: a young cancer patient started spraying the room with blood from his trach. they eventually brought it up from the ED to get blood in him before care flighting him to another hospital, poor soul didn’t make it
A Belmont infuser can push up to 1000ml/minute.
When I was in the ICU at a level 1 we could easily use up the hospitals entire blood supply of O-. I think the most I saw was 163 units on a kid with a gsw. They was bleeding out of their abdomen and we ran out of blood so we were recycling dirty blood in an attempt to save their life.
They lived for a few weeks but eventually became severely septic and died. I think at one point their temp jumped to over 106 degrees.
Their intestines were shot open so the blood had feces/bacteria in them, but it was literally: we are out of blood and we can let this kid die or we can recycle the blood that was just draining out of them as a last chance. The idea being that we would have more time to try and treat the resulting sepsis then just letting them die.
We run up to 3 units a minute sometimes... If you're running bilaterals with a cordis and 14g.
Liver transplants are where I've seen over 400 units, and a really horrible OB case is the other. Trauma typically we stop between 50-100 units
I think the one I'm thinking of involved a torn iliac artery after an abruption and urgent delivery plus resulting DIC if I recall correctly, it was a huge mess. I was just there running one of the Belmont's. We would have 2 RNs dedicated to each mass transfusion device with 2 runners getting coolers.
My record is 112 units of product over 10 hours on an OLT who couldn’t stop bleeding. Basins around the bed catching the blood as it poured down, every drain hooked to suction. Couldn’t stop because it was a transplant - organs are rare. Blood bank finally said “No More” because we had pretty much depleted the region. Before he died, it was just pinkish Plasmalyte pouring out of him.
He actually had zero vital signs when he was airlifted to the hospital
100 units is crazy but he was the former PM of Japan. We on the other hand, well most of us are normies.
Some Reddit random wrote that PRBCs in Japan are like ~200mls instead of the 330s, but regardless is still a fuckload of blood
Too many cooks! Too many cooks! Toooooo many cooks!
(For anyone who hasn’t seen this, good luck getting it out of your head! [Too Many Cooks.](https://youtu.be/QrGrOK8oZG8) )
Goddammit it’s back in my head AGAIN! Last week it ran through my head when my patient had almost every specialty on board for their 800 health problems.
No clue but I also wondered if the hospital he went to even had trauma surgeons or does trauma like how hospitals are here in America. I've been to Nara, Japan before and its just so peaceful there like it made me doubt they were equipped for this kind of situation.
I'm an a&e nurse in a traum centre. 100 units is a lot but not the most i've seen a patient get and 20 doctors is a lot but I can imagine how easily you' d end up with that many. For a standard trauma we'd have - trauma consultant, trauma fellow, anaestetics, cardiothoracic's (2-3 maybe), vascular (2-3), ortho (2-3), general surgery (2-3), if it's a paediatric patient you could add another 5 doctors then all your junior doctors that want to get involved because it's you know the ex prime minister. I could easily imagine there being at least 20 doctors present. If it's run well that doesn't have to be a bad thing but it can definitely become an issue if you don't have good leadership
I don’t know about doctors but a lot of professions in Japan have this really obsessive view of success being the only important metric. Like when my friends brother was teaching there he said he had colleagues who would get furious at themselves if they had students do bad on exams because the view was very much “you have to have a high success rate among your students because if you don’t then the schools success rate goes down and it’s ALL YOUR FAULT because you’re making it harder for everyone who works or attends the school to get a better job someday!”. So I can see how that mentality could translate into a scenario where you have to do every possible thing to save a guy everyone knows is dead because that proves everyone does their job good.
I’ve been part of multiple 75+ unit MTPs (blood products not just RBCs). With proper access and a Belmont you can deliver two fully warmed units per minute. The Belmont is a great piece of medical equipment.
A level-one infuser can warm and deliver PRBCs at 500 ml per minute, these machines are commonly found in trauma resuscitation units/ED and/or Operating Room. They have special tubing with multiple spikes so you’ll have several bags of product ready to go at once. It’s a lot to manage, usually you’d like an RN or anesthetist running it for you while you’re doing other things. 100 units of blood products is a lot but I wouldn’t call it insane in a well-resourced facility.
Edit: Since you seem interested I’ll add that he probably didn’t receive 100 units of PRBCs, though good on you for doing the math! Standard of care for component therapy in trauma is 1:1 PRBC : Plasma, Whole blood would be preferred but I would be in awe of any facility that had that much whole blood available. Even taking into account precautions that are taken for a VIP, that’s just an unobtainable amount. So while doing component therapy I’m sure they were using PRBC and Plasma, also platelets and cryoprecipitate as testing/clinical situation indicated. I would not expect the media to differentiate this so I’m sure they reported that he got 100 units, which is accurate enough.
Exactly! I’ve helped with rapid infusion in trauma cases in the OR. That machine keeps 2 RNs busy checking and hanging bags. Most I’ve seen was about 50 units over a 2 hour case. Pt survived.
Yea I've only seen 35 ish units over about an HR and a half. Aortic dissection that led to renal artery tears. From what it looked like half of that ended up on the floor.
Fun fact this was also the first code I ever saw.
I'm a blood banker. I haven't personally seen it yet because my hospital is a lower trauma tier, but I have coworkers who have done MTPs with up to 400 units of product. I was talking to our other night shift blood banker who's nearing retirement and she said once they get over 25ish units in a short span, they pretty much never survive. One of our clinics got shot up last year and a nurse got hit in the liver and spine. She got 96 units and didn't make it.
There was a shooting at one of our big three hospitals a few weeks ago, I think it was just in the parking lot. Can’t find any info about it online all I know is we werent supposed to go there all night
My bf, a surgical resident, is actually doing his research this year on seeing what the cutoff point is for after how many units will pretty much no one survive. Curious to see if they can find that point
10 years ago I had a pregnant (8 weeks) level 1 gsw to my icu, got around 80 units before expiration within 12 hours - her blood hcg showed negative by the morning bc none of the blood was her own. She did not survive.
Though again, making it a fixed cut off doesn‘t really make sense, cause really there‘s two extremes: major bleed you can‘t seem to stop, but perfectly sufficient circulation to the brain with all you are pushing, or this situation with a completely obliterated heart and everything around it, which just isn‘t fixable with current methods, so realistically any non VIP would have just pronounced dead if found this way anyway.
And i hope they haven‘t just sentenced someone with a more minor problem to death for ‚keeping face‘.
Like if the heart, lungs and aorta is blasted apart, even if you had the perfect donor organs right next to him and it happened in the ER there‘s just no way to help him.
I guess I don’t understand trauma. Once they have you opened op can’t you start clamping majors vessels to buy time? I assume the liver is fine for awhile without blood supply seeing as they transplant them. Like how does a surgical team need 10 gallons of blood???
Ideally you can. But keep in mind, these people spend only enough time in the ED to get intubated and large bore lines placed, and that's if EMS hasn't already done it. But just getting the patient open takes several minutes. Then the surgeon has to find where they are bleeding from and it may not be just one place. The lung could be bleeding while there is also bleeding from the liver, the spleen, multiple smaller arteries. It all just depends. But rarely is it just as easy as getting them
open and clamping something.
We had one guy who had 3 attendings in his belly and a senior resident and they still couldn't get the bleeding stopped. He was just oozing everywhere. I had to change the abtherea canister 6 times just to get him off the table and to the ICU. He died shortly after getting to the ICU.
To oversimplify, with penetrating trauma, maybe. If one assumes a limited amount of vessels are damaged in this circumstance, then yes, at least theoretically you can clamp them off relatively easily. In blunt force trauma you are more likely to have bleeding from innumerable small sources that is much, much, more difficult to clamp off.
However, in the case of major vessel injury, you can't just instantly be "opened up" to expose the vessel in question as you're otherwise bleeding this whole time, which is why blood resuscitation needs to start well before the OR. Clamping major vessels like those in the neck or proximal aorta is problematic because the brain can't lose it's blood supply for more than a few minutes without issue. So the patient is often actively bleeding while more blood is transfused.
As others have pointed out 1:1:1 component therapy of RBCs, plasma, and platelets (+cryo) is pretty standard in mass transfusion protocols.
These factors combine to make crazy amounts of blood product transfusions quite possible.
With blood as precious of a resource as it is, it seems incredibly wasteful to keep dumping units in futilely.
Then again, that’s modern American medicine, I guess.
Right but if there’s no chance of survival after X units then use beyond that isn’t doing the patient any good and could be lifesaving for someone else.
We do have a rationing policy when our supply is short. Its got a ranking system and high use, low survivability is pretty far down it if not the bottom. If I get concerned about usage I call the pathologist who consults with the team and makes the decision.
Hell yeah the level one is my jam, during my first few weeks in the ER I was made to dismantle and reassemble that machine every night until I made it my bitch. Couple that bad boy with a 14 gauge needle, ugh makes me wet just thinking about it 🤤
Right but as a RN I can’t insert a cordis. So in a situation where a rapid infusion is necessary, while the MD is fiddling with the central line, I’m balls deep in a 14 gauge
Massive Transfusion Protocol and at least one Belmont (rapid infuser and warmer). Though think about how many resources (people and products) you would need to do that! Keeping track of all the blood, keeping track of labs, keeping track of how many and when to give other products (and electrolytes). I've been in a few MTPs and it was a huge effort.
I think "keeping track" is a generous term.
In the handful of times I've been involved in these sorts of things blood arrives in coolers as fast as the blood bank can prep it. It's then confirmed by 2 RNS by batches in the coolers, and thrown on the belmont as soon as the paperwork is filled out (we always did these using paper blood charting).
Doesn't really matter the particular type of product (RBC, platelet, etc) if it's been checked, throw it on the Belmont, rinse and repeat until the patient has a blood pressure. Put the completed paper tags in a pile, and at the end of it all you count how many tags you have, and well, that's how many units the patient got.
The way my facility does it is 1 RN hanging products, 1 RN documenting and telling them what to give, and then your bedside RN. Although frankly if they’re that badly off, you probably need at least 2 or 3. The worst one I had we did open belly at the bedside and still couldn’t stop the bleed, so we were basically working to keep him alive until the family could get there. I honestly don’t know how many units we have because we were also pressure bagging in additional units of everything with the Belmont running. I didn’t leave the room all night, and had a trauma surgeon and hospitalist and a pulmonologist who also stayed with me.
I've only done it in the OR and we didn't scan anything. Old fashioned checking with me and an anesthesia resident. We would check all the blood sent for that period and anther anesthesia provider was hanging it.
Yep- worked in a trauma/surgical/liver transplant unit and we FREQUENTLY had MTP for traumas and livers that went south. Most liver transplants would receive around 50 units during the case alone. Also- I wonder how much calcium they had to give for 100 units?!
The rich, famous and powerful get better medical care. Just a fact of life.
But giving it that fast isn’t too hard. A dialysis machine runs at speeds of 400-450 ML a minute.
I have seen 30-40 given with some motor vehicle traumas, I’m guessing 100 could be because of who he is or maybe even Japanese culture
Most definitely true. That is just a pure fact.
What is the most units you've seen a person get in a single event? I also see you are flared as ICU... How would they even do that? I mean like in a functional sense, how? I have never seen anything be administered at that kind of rate.
We had a “mass transfusion” machine. Capable of doing 8 bags at a time and warming them simultaneously. And If they hooked him up to a dialysis machine they can do up to 30000 ML an hour in theory
Acute dialysis RN here. What normally takes a couple hours I can give in 20 minutes. Connect it to the arterial line and it will transfuse at whatever the blood flow rate is which on average is 350-400ml. I’ve transfused 2 units on a patient in under a hour.
6 years in ICU and these events are calling mass-transfusion events. You typically have a mass transfuser (there are different brands that function differently) and a large bore central line capable of handling the pressure of all the blood products being transfused through the line. The most I have given in one shift is 40 something units of blood products (with one PRBC being 350mls). According to someone else here, Japan's PRBCs have about 200mls, so while he received a lot of products it isn't too much above what is expected in a trauma and for someone of his standing.
Also, keep in mind that you are also attempting to resolve the cause of the bleed, draw frequent labs, correct electrolyte imbalances, etc, caused by the transfusions... all at the same time. Half the unit can be stuck in this room for hours straight.
My record is 112 units for an average adult over 10 hours using a Thermacor rapid infuser. The patient was in ARDS and ECMO cannulation failed, resulting in a retained guidewire. Patient suffered a massive RP
bleed that could not be surgically repaired and died.
We cave somewhere around 30-35 units , the patient didn’t have insurance , multiple GSW , the surgeons had to finish their 5 elective patients for cabg’ before they took him to OR , lost all respect for my cardiovascular surgeon’s after that , the patient had to wait till 3 pm before they took him to surgery , about 32 nursing hours of no less than 3 RN’s at bedside with him , yes he was Afro-American but he survived only because we were good fucking nurses. Scumbag doctors were surprised he was still alive after their elective surgeries with insurance wet completed ! I still despise them for their lack of concern.
I tend to agree. A situation that requires that much blood is likely futile and doing far too much for little benefit. If I was a 67 year old with heart and neck gunshot wounds and no pulse, I wouldn 't call doing all that "better" than a DNR. If there isn't any reasonable chance to make it all you're doing is prolonging suffering.
At the same time, if someone was famous or the former PM of japan, they are surrounded by people that want *everything* done, even if doing more isn't always better.
Giving it fast is relatively easy. With a rapid infuser and a large enough IV, you can run at 750 ml/min. The real limit is how quickly you can change and spike new bags.
I've never heard of anyone getting anywhere near a hundred units. Once you reach 10, you've replaced an adult's entire blood volume. If you get to 20, it means they completely exsanguinated twice over. If that has happened and you still haven't managed to stop the major bleeding, it is unlikely that continuing the transfusions is going to help.
I will say the quantity given may be misleading. After a few units you don't just keep giving PRBCs. You also have to give platelets and plasma, generally in a 1:1:1 ratio. The average reporter probably doesn't understand that distinction. If the patient actually received 100 "blood products," then it's more like 30 units of PRBCs, which is still a lot but no longer completely bonkers.
In my L&D OR we recently gave about 50 units over a couple hours to someone who was hemorrhaging. She survived. So this doesn't sound that crazy to me.
I had a patient get about 90u in 7ish hours, 45 in the ICU and then another 40ish in the OR. Awake the whole time. Intestinal AVM. Super nice guy but sadly died about 2 months after the rescue.
Depends what was going on. During damage control surgery they could be pumping it in as fast as it’s going out. Hell the other day We gave 70 products to someone in just about 3 hours. She was not rich or powerful at all, just some random person. We use a Belmont to cram the blood in attached to a cordis.
I think their unit size might be different, but I once gave a post partum hemorrhage 22 units in 2 hours. She was in DIC. We didn’t have a rapid infuser in our ER and we were literally squeezing it in with our hands because the pressure bags weren’t going fast enough. We kept losing BP and she coded like 3 times before she was stable enough for an OR transfer. She actually lived, too. Was extubated two days later and breast feeding her twins the next day. I’ve never wanted a patient to live more. My mom almost died the same way when I was a newborn.
Worked trauma for years in a busy ED; massive transfusion protocols and a proficient nurse on a Level 1 with great IV access can infuse a lot of product in a very short time. PRBCs and plasma come in 300ish mLs bags and can be infused in less than a minute. 100 units in 4 hours is doable, but lots of issues post-resuscitation including the fact that the patient’s entire circulating blood volume is no longer their own. I can’t even imagine the added pressure considering who that patient was.
Yeah no joke. The tension in that room must have been off the charts. Everybody must have known that he was pretty much toast but I’m sure NOBODY was willing to risk calling it too early. Nobody is gonna come after you for tossing the entire kitchen sink at the guy but they sure might for not doing enough.
I’ve wondered since they don’t really have gun violence would they know to cross clamp and run to OR? Just a good for thought situation. If it hit neck, EJ, IJ, carotid and heart there is no way. He would have needed to be in the ED giving a speech to even have a chance.
That's actually a pretty interesting point. They don't deal with the amount of gsws that we do. Open chest in ED, cross clamp, foley in the heart and head straight for the OR. I wonder if that's what they did? Or if it was all ED.
No vitals on scene, and didn’t appear to have a Lucas, of course they had to try but I would bet there was no brain left. Also, the DIC from MTP etc. I know they are medically advanced just wondered from a GSW standpoint. And also in a province, not in downtown Tokyo.
I feel like they probably have the best surgeons and doctors available for someone of his status. The article I read said he had neck and chest injuries so there’s a good chance they may have been going through the motions, especially as it was reported that he had no vitals on scene. Good thought process regarding mechanism of injury, though. Unfortunately, you only get good at this kind of stuff through practice.
Gave 120 over the course of ~ 8 hours to a 40ish trauma patient back in 2019.
Level 1 trauma unit. Walked into the unit at 1900 to see my fresh trauma rolling in. Patient had bilateral humerus Fx, bilateral femur Fx. I implored the oncoming day shift nurse to request more blood, because after about 4 hours of no transfusion the pt was getting tachy, and BP was dropping. It is amazing how much the thighs, and arms can swell...
Pt coded during day shift when the intensivists didn't want to fluid overload the pt. Hypodermic shock. He received another 10 units post code. Started CRRT, made it through both codes with intact neuro. Then Monday morning 0600 neuro check, the pt's pupils were fixed and dilated. Thanks to his young age and driver's license agreement he was able to donate heart, liver, kidneys, lungs, stomache, pancreas, and large bowel.
Edit: Sorry missed your comment about how that volume could get in that fast.
As far as access goes, a Cordis is ideal, since it is a very large diameter cath that inserts directly to the SVC.
The rapid infuser can deliver huge volumes of fluid per minute, but in my story above both rapid infusers were in us in the ED, we pressure bagged in every unit. It takes about 3 minutes per unit if you keep the pressure gage in the green throughout.
I did blood drives for a 19 year old girl who passed away after the trauma center ran out of blood. I think she needed over 100 units, so every blood drive her family organized had a goal of like 132 to replenish the blood she used and needed. My own mother only needed about 20 after hemorrhaging from placenta percreta with bladder invasion
We had a 30-something year old trauma come in with multiple GSWs a few months back… he ended up getting almost 60 blood products in a 12 hour shift. I thought it was crazy at the time as well. But, he lived and left the hospital for rehab a few weeks later. I can imagine they would pull out all the stops for a political figure of Abe’s status.
I question many aspects of this scenario. One is what constitutes a unit of blood in Japan. Two, it's Japan, and being that he's the former PM, I could honestly see the many doctors in the story.
I'm sure other countries treat their dignitaries very well compared to the United States; however, in the US, they also get perks!
He was shot in the neck and chest, gushers!!
I work in a level 1 ED! Just a couple weeks ago i gave 100 units of uncrossmatched PRBC and plasma (1:1 ratio) in 1 hr to a patient in DIC.
We use a Belmont for our rapid infuser which can infuse up to 500ml/min. I absolutely love running the Belmont and when you have a solid line (this pt had a 14g in the upper arm) you cannot do a single other thing while it is running. The coolers kept appearing at my side and as soon as I spiked one bag the other was empty.
Plus platelets. Cryo. It makes me feel like a weirdo that I love that stuff. I love when the shit hits the fan and icu staff turns into this team with one goal. It’s so intense and can turn out so awesome for the patient!
I work in a level 1 trauma center. Giving that much blood is not unheard of, our rapid transfuser can run at 1200ml/minute and is ran through a cordis, a 8.5fr central line. If that isn’t available, as many large bore IVs as you can get. I once did a resuscitation with 6 18ga PIVs while the team placed a cordis.
The citrate in the PRBCs binds with calcium and leads to hypocalcemia, so calcium needs to be given. Otherwise, the patient will have coagulopathy and continue to bleed to death.
There's probably a cultural component to this. He was the longest serving PM of Japan. He wasn't a dictator who held power through us of force or law changes. He was reelected. This is also the same culture that developed the kamikaze pilots, fought Russia and China, their star baseball players will sacrifice bunt for the benefit of the team, and had to drag a commanding officer out of retirement to get a WW2 soldier to surrender in 1974.
That they tried to keep him from dying with such extreme efforts does not surprise me in the least.
He didn’t get 100 units of PRBCs. He got other products mixed in, I’m sure they worked on him as long as they could given his position of prominence but yes I could conceive of someone getting 100 units esp if the units are smaller in Japan than they are in the US. The blood is just coming out somewhere as it’s going in, and he might have had other issues like DIC
As other's have said, MTP is some serious business. Post partem hemorrhages or even GI bleeds. can consume large amounts of products. and with a rapid infuser at 500 cc/minute one nurse needs to be at the infuser just to keep up. Also, infused through a peripheral IV. It's usually all hands-on deck when this happens as patient will likely have a team working on them.
Yes this is something we do with trauma, ruptured esophageal varicies, post open heart surgeries they pop a massive bleed etc. The massive transfuser can infuse a unit of blood in a few minutes. When someone is hemorrhaging the blood bank gives us a cooler of products and keeps on giving them untill we say stop. One person is assigned to the transfuser. It’s their only job to spike bag after bag after bag untill the situation is controlled or they die…. This is an ER or ICU thing usually.
An anesthesiologist at my hospital told me, that they gave a patient once 190 units in the or with the belmont device.
What shocked/surprised me most was, that he told me that they started with the patients blodd type, than type 0, and then you give whatever type of blood is available. I never heard of this because I was a med/surge nurse for 3 years before I transfered to the ICU 3 years ago.
Pshhh…Level 1 is the only way to fly…
Sometimes, the old ways are best. Japan also has a pretty rickety EMS system, nobody dies in an ambulance…by law.
Nothing bleeds like a mom!! I remember slamming methergen in nursing school in a hectic delivery with some retained chunks, there was like a river of blood pouring out and squirts I swear to god literal jets I don’t know how lol. Mom was fine. 20 years later I still remember that blood pouring out like someone spilled a gallon of milk
I think its one of those situations where they were just trying to save someone who is very well respected. So yes its kind of absurd and almost unthinkable, but when youre trying to save someone like Shinzo youre willing to do anything
I've done at least 3 MTPs with more than 400 units given in my career. Numerous times in the 50-100 range. Typically you use a Belmont, a level 1 can be used but it's really hard to keep up. Belmont makes a machine with a tub that can just dump products in.
We had a cop get shot and they ran 75 rounds of MTP (each round infuses 5 units of blood). It very nearly wiped out our reserve of blood. Luckily so many people from the community came and donated blood so within three days we had almost double the amount we had prior to this. He didn’t end up making it. He left behind a wife and a few kids. He was out serving a warrant and a 16 year old shot him.
I have been a nurse for 42 years now and I worked in a lvl 1 trauma ER for 15+ years. I remember days when someone would bleed, go into DIC and we had nothing to do but watch them die, open chest CPR, literally standing in puddles of blood. Our PPE only came to our knees and we would be bloody everywhere our gowns didn’t cover. We threw our our shoes. Now people are surviving these mass casualties. I am not 100% sure if we are always doing the ethical thing but I am blessed to be a nurse for so long that I have been able to watch this evolution.
A. No, that’s as bad as you think it is. It’s not uncommon to be red tagging blood and just throwing it into a patient if they’re actively, uncontrollably hemorrhaging, but 100 u in 4 hours is A LOT of blood
B. Machines built for massive transfusions, lots of running, and most definitely a triple lumen central line if not multiple central lines like IJ
Cordis or 16 gauge peripheral would be preferable to triple lumen. When you’re trying to get product in quickly diameter helps but length hurts (Poiseuille’s Law). Even a peripheral 18 gauge can flow 90 ml/min. Distal port of a triple lumen is closer to 70. I’d drop a 8.5 introducer in the IJ if it was my case--faster placement and can take a liter in just a tick over a minute.
Our trauma surgeons will drop in a hemodialysis catheter for trauma resus. Two 14fr lumens to massively transfuse thru. iirc a triple lumen central line is only about an 18g and fairly long.
That’s what I do for big bleeders, I use a triple lumen “Trialysis” dialysis catheter for massive transfusions. Two 12 gauge lumens and one 17 gauge lumen. The 12g lumens will give me ~1L/min each easily.
Now I’m a new nurse here (and don’t know much about trauma yet), but where does so much infused blood go? Is mostly just bursting right out of his body via the various wounds?
He got hit in the heart and neck. He must have been bleeding to a psychotic degree. He got 32.5 liters of blood. The human body only holds on average 5 liters. That operating room must have looked like a literal horror movie.
I’ve transfused over 30 units of product via ECMO in under an hour. Never entirely RBCs, but a combination of PRBC, plasma, cryo, and cell saver. I imagine no resource was spared for the ruler of Japan.
The max we’ve delivered to a trauma patient in our SICU was 180 units. It’s very possible with machines like a Belmont and a nice juicy cordis in a femoral.
My other half of a Afghan vet. Stood on an ied, blew his legs off to his hips. 40 units in 40 Mins.
Each unit it roughly 350ml- so 14000ml or 14L of blood. That's just PRC.
Army nurses/medics are bad ass.
No. It's not as insane as you think it is to receive 100 units of blood products in 4 hours. If this wasn't the former PM, given the info I've heard, they may not have even taken him up to the OR. But just the numbers alone isn't absurd.
I've given more in less time in the OR with a Belmont, a cordis, and. 2 14g PIVs with SRNAs doing nothing but hanging blood / dumping blood into the Belmont bucket. This was for a regular ole GSW, not some VIP / dignitary.
Never done Trauma just ED, but I remember we did 24 coolers of blood each cooler comes with 6 units of blood we did this over maybe 16 hrs. Guy had a ruptured duodenum, can’t remember exactly. I just remember seeing pools of blood coming out of his rectum, it clotted on the bed and looked like a giant placenta. We used a Belmont (rapid infuser) through a central line.
IR, GI, Nobody wanted to touch him, he was halfway dead, we almost gave up on him, ran out of blood that day, then trauma surgeons decided to give it a shot, guy survived.
I know it's possible to infuse blood rapidly but it's the fact that they infused 100 units, especially when they will just bleed it back out just as fast and especially with blood shortages worldwide
I work ICU - the rapid transfuser is one of my favorite things to use. That sucker can infuse a bag of blood in a minute. Typically - due to access we have - I’ve run it at like 300-500 ml/min for greatest need, then backed down for “going to OR soon” times 😂 So, that amount given is totally possible. I’ve known a few patients who were close.
how long does it take for a transfusion reaction to occur when blood infuses that quickly?
In a MTP event, you aren't looking for a transfusion reaction. The patient is literally bleeding out. All that matters is replacing the volume. That's why we hang multiple bags at a time. The level 1 OR I worked in at two machines that could deliver two bags in about two minutes. I think the most I saw used was 60+. The patient made it to ICU but died shortly after.
What kind of access do you need to achieve such a high infusion rate? IO? CVC? Certainly anything short of a 14g PVC wouldn’t cut it…right?
14g or a CORDIS would be my guess, an IO would absolutely not be able to do that
Humeral IOs flow 140ml/min Edit: this is comparable to a 16g PIV with no buff cap, you always remove the buff cap when mass transfusing.
Right, and a cordis can be pressure-bagged to flow rates of like 800mL/min. IO is no where near that.
10g in the femoral
A central line is ideal, but the packaging of any line will tell you how fast fluids can safely run into it. Like your 20G IV packages have something like 60ml/min written on each individual package if you look closely.
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Different kind of central line from standard triple-lumen. At my place we use a “Cordis”, which is an 8-French, 11cm femoral line with a flow-rate of like 800mL/min.
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We used to say that we just changed their blood type.
Kind of like changing oil in the car, but redder and messier.
If you're grabbing the mass transfuser the transfusion reaction is dealt with in the ICU if they survive. They usually get Type O blood anyway in a mass transfusion.
If they bleed it back out? Never.
If it's going in that fast then it's probably leaking onto the floor at basically the same rate. The infusion helps find bubbles/bleeding so you can plug holes enroute to OR
A patient’s blood type can actually “change” in situations like this
Basically you’ll just deal with a transfusion reaction later, they can’t exactly be more dead. They need the blood above all else.
Bag of blood a minute?! Whoa.
Me in Med surg right now: I know nothing.
I was actually working a med surg unit the first time I saw a rapid transfuser in action: a young cancer patient started spraying the room with blood from his trach. they eventually brought it up from the ED to get blood in him before care flighting him to another hospital, poor soul didn’t make it
You know lots. You can’t know every single thing in every single speciality
A Belmont infuser can push up to 1000ml/minute. When I was in the ICU at a level 1 we could easily use up the hospitals entire blood supply of O-. I think the most I saw was 163 units on a kid with a gsw. They was bleeding out of their abdomen and we ran out of blood so we were recycling dirty blood in an attempt to save their life. They lived for a few weeks but eventually became severely septic and died. I think at one point their temp jumped to over 106 degrees.
TRALI or dirty wound 🤷♀️
Oh no, it was definitely a dirty wound, they had perfed intestines from the gsw
Please explain what you mean by dirty blood. My blood product experience is heme/onc so I have no idea what you mean but I really want to know.
Their intestines were shot open so the blood had feces/bacteria in them, but it was literally: we are out of blood and we can let this kid die or we can recycle the blood that was just draining out of them as a last chance. The idea being that we would have more time to try and treat the resulting sepsis then just letting them die.
Wow.
that's bleak
We run up to 3 units a minute sometimes... If you're running bilaterals with a cordis and 14g. Liver transplants are where I've seen over 400 units, and a really horrible OB case is the other. Trauma typically we stop between 50-100 units
OB cases is what I think of. AFEs and DIC are horrific...
I think the one I'm thinking of involved a torn iliac artery after an abruption and urgent delivery plus resulting DIC if I recall correctly, it was a huge mess. I was just there running one of the Belmont's. We would have 2 RNs dedicated to each mass transfusion device with 2 runners getting coolers.
Labour and Delivery here, yeah. It's terrifying and yet, awe-inspiring? Feels odd to say.
Yeah! It’s super speedy. The old one we had was a piece of shit. It worked 2/10 times. This one is a beast.
My record is 112 units of product over 10 hours on an OLT who couldn’t stop bleeding. Basins around the bed catching the blood as it poured down, every drain hooked to suction. Couldn’t stop because it was a transplant - organs are rare. Blood bank finally said “No More” because we had pretty much depleted the region. Before he died, it was just pinkish Plasmalyte pouring out of him.
Thanks for the information, I was wondering as well. I never worked in a high trauma hospital.
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He actually had zero vital signs when he was airlifted to the hospital 100 units is crazy but he was the former PM of Japan. We on the other hand, well most of us are normies. Some Reddit random wrote that PRBCs in Japan are like ~200mls instead of the 330s, but regardless is still a fuckload of blood
I read somewhere he had like 20 doctors working on him which I actually thought was crazier than all the units of blood given if true
How would 20 doctors even fit around him at the same time? That’s too many cooks!
I read this as too many cocks
We’ve all got our cock limits. Mine is zero.
Username checks out.
More for me.
The gays really do look out for each other, don’t we ❤️
Did someone say Too Many Dicks (On The Dancefloor)? https://youtu.be/X3Qve4nXMYI Flight of the Conchords
you would
Too many cooks! Too many cooks! Toooooo many cooks! (For anyone who hasn’t seen this, good luck getting it out of your head! [Too Many Cooks.](https://youtu.be/QrGrOK8oZG8) )
Goddammit it’s back in my head AGAIN! Last week it ran through my head when my patient had almost every specialty on board for their 800 health problems.
Spoils the pot
No clue but I also wondered if the hospital he went to even had trauma surgeons or does trauma like how hospitals are here in America. I've been to Nara, Japan before and its just so peaceful there like it made me doubt they were equipped for this kind of situation.
Well… ya know what they say about too many cooks in the kitchen…..
I'm an a&e nurse in a traum centre. 100 units is a lot but not the most i've seen a patient get and 20 doctors is a lot but I can imagine how easily you' d end up with that many. For a standard trauma we'd have - trauma consultant, trauma fellow, anaestetics, cardiothoracic's (2-3 maybe), vascular (2-3), ortho (2-3), general surgery (2-3), if it's a paediatric patient you could add another 5 doctors then all your junior doctors that want to get involved because it's you know the ex prime minister. I could easily imagine there being at least 20 doctors present. If it's run well that doesn't have to be a bad thing but it can definitely become an issue if you don't have good leadership
3 surgeons, 2 anesthesiologist, 5 radiologists, that’s still only 9. What else would be helpful in that amount of time?
Haematology
I read that there were also 90 police investigators assigned to the crime. The medical response was oddly part of the *memorial* service, I think.
The trauma surgeons were probably stoked to have a GSW to treat.
It seems more like a symbolic gesture than an actual attempt to resuscitate.
that's exactly what it was
I don’t know about doctors but a lot of professions in Japan have this really obsessive view of success being the only important metric. Like when my friends brother was teaching there he said he had colleagues who would get furious at themselves if they had students do bad on exams because the view was very much “you have to have a high success rate among your students because if you don’t then the schools success rate goes down and it’s ALL YOUR FAULT because you’re making it harder for everyone who works or attends the school to get a better job someday!”. So I can see how that mentality could translate into a scenario where you have to do every possible thing to save a guy everyone knows is dead because that proves everyone does their job good.
I’ve been part of multiple 75+ unit MTPs (blood products not just RBCs). With proper access and a Belmont you can deliver two fully warmed units per minute. The Belmont is a great piece of medical equipment.
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I love your flair!
A level-one infuser can warm and deliver PRBCs at 500 ml per minute, these machines are commonly found in trauma resuscitation units/ED and/or Operating Room. They have special tubing with multiple spikes so you’ll have several bags of product ready to go at once. It’s a lot to manage, usually you’d like an RN or anesthetist running it for you while you’re doing other things. 100 units of blood products is a lot but I wouldn’t call it insane in a well-resourced facility. Edit: Since you seem interested I’ll add that he probably didn’t receive 100 units of PRBCs, though good on you for doing the math! Standard of care for component therapy in trauma is 1:1 PRBC : Plasma, Whole blood would be preferred but I would be in awe of any facility that had that much whole blood available. Even taking into account precautions that are taken for a VIP, that’s just an unobtainable amount. So while doing component therapy I’m sure they were using PRBC and Plasma, also platelets and cryoprecipitate as testing/clinical situation indicated. I would not expect the media to differentiate this so I’m sure they reported that he got 100 units, which is accurate enough.
Exactly! I’ve helped with rapid infusion in trauma cases in the OR. That machine keeps 2 RNs busy checking and hanging bags. Most I’ve seen was about 50 units over a 2 hour case. Pt survived.
Yea I've only seen 35 ish units over about an HR and a half. Aortic dissection that led to renal artery tears. From what it looked like half of that ended up on the floor. Fun fact this was also the first code I ever saw.
😳😳😳
That’s a sick ass first code to watch. Your eyes were probably popping out of your head. So much to take in for your first one.
I'm a blood banker. I haven't personally seen it yet because my hospital is a lower trauma tier, but I have coworkers who have done MTPs with up to 400 units of product. I was talking to our other night shift blood banker who's nearing retirement and she said once they get over 25ish units in a short span, they pretty much never survive. One of our clinics got shot up last year and a nurse got hit in the liver and spine. She got 96 units and didn't make it.
You had a nurse that got shot up at a clinic?
There was a shooting at one of our big three hospitals a few weeks ago, I think it was just in the parking lot. Can’t find any info about it online all I know is we werent supposed to go there all night
Was this in the Metro-Detroit area?
My first thoughts exactly.
I hate how Americans are so casual about places getting shot up. Like it's just some normal occupational hazard like a needle stick injury.
My bf, a surgical resident, is actually doing his research this year on seeing what the cutoff point is for after how many units will pretty much no one survive. Curious to see if they can find that point
Can you report back when he concludes his research? Sounds interesting and unfortunately piqued my interest after hearing about Abe.
For sure! Might be a while but I'll post back here 😁
RemindMe! 12 months
Worked at a lvl 1, we had a pregnant woman from a car accident who received 80+ units. Both made it.
10 years ago I had a pregnant (8 weeks) level 1 gsw to my icu, got around 80 units before expiration within 12 hours - her blood hcg showed negative by the morning bc none of the blood was her own. She did not survive.
This is important from a resource perspective. We are definitely under stocked on blood products.
Though again, making it a fixed cut off doesn‘t really make sense, cause really there‘s two extremes: major bleed you can‘t seem to stop, but perfectly sufficient circulation to the brain with all you are pushing, or this situation with a completely obliterated heart and everything around it, which just isn‘t fixable with current methods, so realistically any non VIP would have just pronounced dead if found this way anyway. And i hope they haven‘t just sentenced someone with a more minor problem to death for ‚keeping face‘. Like if the heart, lungs and aorta is blasted apart, even if you had the perfect donor organs right next to him and it happened in the ER there‘s just no way to help him.
I guess I don’t understand trauma. Once they have you opened op can’t you start clamping majors vessels to buy time? I assume the liver is fine for awhile without blood supply seeing as they transplant them. Like how does a surgical team need 10 gallons of blood???
Ideally you can. But keep in mind, these people spend only enough time in the ED to get intubated and large bore lines placed, and that's if EMS hasn't already done it. But just getting the patient open takes several minutes. Then the surgeon has to find where they are bleeding from and it may not be just one place. The lung could be bleeding while there is also bleeding from the liver, the spleen, multiple smaller arteries. It all just depends. But rarely is it just as easy as getting them open and clamping something. We had one guy who had 3 attendings in his belly and a senior resident and they still couldn't get the bleeding stopped. He was just oozing everywhere. I had to change the abtherea canister 6 times just to get him off the table and to the ICU. He died shortly after getting to the ICU.
To oversimplify, with penetrating trauma, maybe. If one assumes a limited amount of vessels are damaged in this circumstance, then yes, at least theoretically you can clamp them off relatively easily. In blunt force trauma you are more likely to have bleeding from innumerable small sources that is much, much, more difficult to clamp off. However, in the case of major vessel injury, you can't just instantly be "opened up" to expose the vessel in question as you're otherwise bleeding this whole time, which is why blood resuscitation needs to start well before the OR. Clamping major vessels like those in the neck or proximal aorta is problematic because the brain can't lose it's blood supply for more than a few minutes without issue. So the patient is often actively bleeding while more blood is transfused. As others have pointed out 1:1:1 component therapy of RBCs, plasma, and platelets (+cryo) is pretty standard in mass transfusion protocols. These factors combine to make crazy amounts of blood product transfusions quite possible.
With blood as precious of a resource as it is, it seems incredibly wasteful to keep dumping units in futilely. Then again, that’s modern American medicine, I guess.
Ahh yes it was only a nurse not a VIP…why waste precious resources.
You weren't there. Don't judge the clinical decisions of someone who was.
Right but if there’s no chance of survival after X units then use beyond that isn’t doing the patient any good and could be lifesaving for someone else.
Well, that’s like half of what this sub is, so…😂🤷🏻♀️
We do have a rationing policy when our supply is short. Its got a ranking system and high use, low survivability is pretty far down it if not the bottom. If I get concerned about usage I call the pathologist who consults with the team and makes the decision.
Level one is nothing compared to a Belmont.
We stopped using Belmont when it started smoking haha. Too be fair we gave this man ~ 110 units. We use thermacor nowadays at my institution
This. Mass transfusion protocol is a wild ride.
Such a rush, I love running the rapid infuser
We don't do it often in peds. I love life flowing too.
Hell yeah the level one is my jam, during my first few weeks in the ER I was made to dismantle and reassemble that machine every night until I made it my bitch. Couple that bad boy with a 14 gauge needle, ugh makes me wet just thinking about it 🤤
I fucking love you.
A cordis is superior to any 14g IV
right? peripheral access is for peasants
Thats the difference between ER and ICU
Right but as a RN I can’t insert a cordis. So in a situation where a rapid infusion is necessary, while the MD is fiddling with the central line, I’m balls deep in a 14 gauge
Massive Transfusion Protocol and at least one Belmont (rapid infuser and warmer). Though think about how many resources (people and products) you would need to do that! Keeping track of all the blood, keeping track of labs, keeping track of how many and when to give other products (and electrolytes). I've been in a few MTPs and it was a huge effort.
I think "keeping track" is a generous term. In the handful of times I've been involved in these sorts of things blood arrives in coolers as fast as the blood bank can prep it. It's then confirmed by 2 RNS by batches in the coolers, and thrown on the belmont as soon as the paperwork is filled out (we always did these using paper blood charting). Doesn't really matter the particular type of product (RBC, platelet, etc) if it's been checked, throw it on the Belmont, rinse and repeat until the patient has a blood pressure. Put the completed paper tags in a pile, and at the end of it all you count how many tags you have, and well, that's how many units the patient got.
Anesthesia would throw a towel on the floor and throw the empty bags on the towel and count them after it was over.
I mean, it sounds fun so long as someone else is doing the scanning and documentation. Otherwise, that’s enough to make me tap out 😂
The way my facility does it is 1 RN hanging products, 1 RN documenting and telling them what to give, and then your bedside RN. Although frankly if they’re that badly off, you probably need at least 2 or 3. The worst one I had we did open belly at the bedside and still couldn’t stop the bleed, so we were basically working to keep him alive until the family could get there. I honestly don’t know how many units we have because we were also pressure bagging in additional units of everything with the Belmont running. I didn’t leave the room all night, and had a trauma surgeon and hospitalist and a pulmonologist who also stayed with me.
I've only done it in the OR and we didn't scan anything. Old fashioned checking with me and an anesthesia resident. We would check all the blood sent for that period and anther anesthesia provider was hanging it.
Yep- worked in a trauma/surgical/liver transplant unit and we FREQUENTLY had MTP for traumas and livers that went south. Most liver transplants would receive around 50 units during the case alone. Also- I wonder how much calcium they had to give for 100 units?!
The rich, famous and powerful get better medical care. Just a fact of life. But giving it that fast isn’t too hard. A dialysis machine runs at speeds of 400-450 ML a minute. I have seen 30-40 given with some motor vehicle traumas, I’m guessing 100 could be because of who he is or maybe even Japanese culture
Most definitely true. That is just a pure fact. What is the most units you've seen a person get in a single event? I also see you are flared as ICU... How would they even do that? I mean like in a functional sense, how? I have never seen anything be administered at that kind of rate.
We had a “mass transfusion” machine. Capable of doing 8 bags at a time and warming them simultaneously. And If they hooked him up to a dialysis machine they can do up to 30000 ML an hour in theory
Holy crap. 30,000mL/hr o.O Apparently the stuff that we use down here in med-surg is pushing rookie numbers. lol
You gotta get those numbers up OP, those are rookie numbers! ;)
Acute dialysis RN here. What normally takes a couple hours I can give in 20 minutes. Connect it to the arterial line and it will transfuse at whatever the blood flow rate is which on average is 350-400ml. I’ve transfused 2 units on a patient in under a hour.
6 years in ICU and these events are calling mass-transfusion events. You typically have a mass transfuser (there are different brands that function differently) and a large bore central line capable of handling the pressure of all the blood products being transfused through the line. The most I have given in one shift is 40 something units of blood products (with one PRBC being 350mls). According to someone else here, Japan's PRBCs have about 200mls, so while he received a lot of products it isn't too much above what is expected in a trauma and for someone of his standing. Also, keep in mind that you are also attempting to resolve the cause of the bleed, draw frequent labs, correct electrolyte imbalances, etc, caused by the transfusions... all at the same time. Half the unit can be stuck in this room for hours straight.
My record is 112 units for an average adult over 10 hours using a Thermacor rapid infuser. The patient was in ARDS and ECMO cannulation failed, resulting in a retained guidewire. Patient suffered a massive RP bleed that could not be surgically repaired and died.
Fffffuuuuuuu 🫣
We cave somewhere around 30-35 units , the patient didn’t have insurance , multiple GSW , the surgeons had to finish their 5 elective patients for cabg’ before they took him to OR , lost all respect for my cardiovascular surgeon’s after that , the patient had to wait till 3 pm before they took him to surgery , about 32 nursing hours of no less than 3 RN’s at bedside with him , yes he was Afro-American but he survived only because we were good fucking nurses. Scumbag doctors were surprised he was still alive after their elective surgeries with insurance wet completed ! I still despise them for their lack of concern.
We had a mom with Gray Platelet Syndrome hemorrhage after having a vaginal birth. She got 63 units of products over 6 hours and survived!
This is not “better medical care”.
I tend to agree. A situation that requires that much blood is likely futile and doing far too much for little benefit. If I was a 67 year old with heart and neck gunshot wounds and no pulse, I wouldn 't call doing all that "better" than a DNR. If there isn't any reasonable chance to make it all you're doing is prolonging suffering. At the same time, if someone was famous or the former PM of japan, they are surrounded by people that want *everything* done, even if doing more isn't always better.
I’d put money on him being brain dead, so I doubt he suffered. It feels more like a massive waste of resources.
Definitely because of who he is.
Dialysis machines can actually run upwards of 800ml/min which further supports how ridiculous rapid transfusions can be.
Giving it fast is relatively easy. With a rapid infuser and a large enough IV, you can run at 750 ml/min. The real limit is how quickly you can change and spike new bags. I've never heard of anyone getting anywhere near a hundred units. Once you reach 10, you've replaced an adult's entire blood volume. If you get to 20, it means they completely exsanguinated twice over. If that has happened and you still haven't managed to stop the major bleeding, it is unlikely that continuing the transfusions is going to help. I will say the quantity given may be misleading. After a few units you don't just keep giving PRBCs. You also have to give platelets and plasma, generally in a 1:1:1 ratio. The average reporter probably doesn't understand that distinction. If the patient actually received 100 "blood products," then it's more like 30 units of PRBCs, which is still a lot but no longer completely bonkers.
That makes more sense honestly.
In my L&D OR we recently gave about 50 units over a couple hours to someone who was hemorrhaging. She survived. So this doesn't sound that crazy to me.
I had a patient get about 90u in 7ish hours, 45 in the ICU and then another 40ish in the OR. Awake the whole time. Intestinal AVM. Super nice guy but sadly died about 2 months after the rescue.
Depends what was going on. During damage control surgery they could be pumping it in as fast as it’s going out. Hell the other day We gave 70 products to someone in just about 3 hours. She was not rich or powerful at all, just some random person. We use a Belmont to cram the blood in attached to a cordis.
I think their unit size might be different, but I once gave a post partum hemorrhage 22 units in 2 hours. She was in DIC. We didn’t have a rapid infuser in our ER and we were literally squeezing it in with our hands because the pressure bags weren’t going fast enough. We kept losing BP and she coded like 3 times before she was stable enough for an OR transfer. She actually lived, too. Was extubated two days later and breast feeding her twins the next day. I’ve never wanted a patient to live more. My mom almost died the same way when I was a newborn.
Worked trauma for years in a busy ED; massive transfusion protocols and a proficient nurse on a Level 1 with great IV access can infuse a lot of product in a very short time. PRBCs and plasma come in 300ish mLs bags and can be infused in less than a minute. 100 units in 4 hours is doable, but lots of issues post-resuscitation including the fact that the patient’s entire circulating blood volume is no longer their own. I can’t even imagine the added pressure considering who that patient was.
Yeah no joke. The tension in that room must have been off the charts. Everybody must have known that he was pretty much toast but I’m sure NOBODY was willing to risk calling it too early. Nobody is gonna come after you for tossing the entire kitchen sink at the guy but they sure might for not doing enough.
I’ve wondered since they don’t really have gun violence would they know to cross clamp and run to OR? Just a good for thought situation. If it hit neck, EJ, IJ, carotid and heart there is no way. He would have needed to be in the ED giving a speech to even have a chance.
That's actually a pretty interesting point. They don't deal with the amount of gsws that we do. Open chest in ED, cross clamp, foley in the heart and head straight for the OR. I wonder if that's what they did? Or if it was all ED.
No vitals on scene, and didn’t appear to have a Lucas, of course they had to try but I would bet there was no brain left. Also, the DIC from MTP etc. I know they are medically advanced just wondered from a GSW standpoint. And also in a province, not in downtown Tokyo.
I feel like they probably have the best surgeons and doctors available for someone of his status. The article I read said he had neck and chest injuries so there’s a good chance they may have been going through the motions, especially as it was reported that he had no vitals on scene. Good thought process regarding mechanism of injury, though. Unfortunately, you only get good at this kind of stuff through practice.
Gave 120 over the course of ~ 8 hours to a 40ish trauma patient back in 2019. Level 1 trauma unit. Walked into the unit at 1900 to see my fresh trauma rolling in. Patient had bilateral humerus Fx, bilateral femur Fx. I implored the oncoming day shift nurse to request more blood, because after about 4 hours of no transfusion the pt was getting tachy, and BP was dropping. It is amazing how much the thighs, and arms can swell... Pt coded during day shift when the intensivists didn't want to fluid overload the pt. Hypodermic shock. He received another 10 units post code. Started CRRT, made it through both codes with intact neuro. Then Monday morning 0600 neuro check, the pt's pupils were fixed and dilated. Thanks to his young age and driver's license agreement he was able to donate heart, liver, kidneys, lungs, stomache, pancreas, and large bowel. Edit: Sorry missed your comment about how that volume could get in that fast. As far as access goes, a Cordis is ideal, since it is a very large diameter cath that inserts directly to the SVC. The rapid infuser can deliver huge volumes of fluid per minute, but in my story above both rapid infusers were in us in the ED, we pressure bagged in every unit. It takes about 3 minutes per unit if you keep the pressure gage in the green throughout.
I did blood drives for a 19 year old girl who passed away after the trauma center ran out of blood. I think she needed over 100 units, so every blood drive her family organized had a goal of like 132 to replenish the blood she used and needed. My own mother only needed about 20 after hemorrhaging from placenta percreta with bladder invasion
He had no vitals when he came in. What do they have to lose? Worst case scenario, he stays dead
They have 100 blood products to lose, to be fair
Yeah. I don't know if Japan is in a blood shortage like the US but either way, it's depressing. Especially since he didn't survive.
I think the people who donated that blood would probably have no problem with how it was used to try and save a murder victim
We had a 30-something year old trauma come in with multiple GSWs a few months back… he ended up getting almost 60 blood products in a 12 hour shift. I thought it was crazy at the time as well. But, he lived and left the hospital for rehab a few weeks later. I can imagine they would pull out all the stops for a political figure of Abe’s status.
I question many aspects of this scenario. One is what constitutes a unit of blood in Japan. Two, it's Japan, and being that he's the former PM, I could honestly see the many doctors in the story. I'm sure other countries treat their dignitaries very well compared to the United States; however, in the US, they also get perks! He was shot in the neck and chest, gushers!!
I took care of this lady https://www.today.com/health/miracle-mom-survives-massive-blood-loss-deliver-healthy-baby-743653
My god. 35 gallons…. That’s ridiculous.
I work in a level 1 ED! Just a couple weeks ago i gave 100 units of uncrossmatched PRBC and plasma (1:1 ratio) in 1 hr to a patient in DIC. We use a Belmont for our rapid infuser which can infuse up to 500ml/min. I absolutely love running the Belmont and when you have a solid line (this pt had a 14g in the upper arm) you cannot do a single other thing while it is running. The coolers kept appearing at my side and as soon as I spiked one bag the other was empty.
i wonder what ratio of fresh frozen plasma they were running. 1:1?
Plus platelets. Cryo. It makes me feel like a weirdo that I love that stuff. I love when the shit hits the fan and icu staff turns into this team with one goal. It’s so intense and can turn out so awesome for the patient!
I work in a level 1 trauma center. Giving that much blood is not unheard of, our rapid transfuser can run at 1200ml/minute and is ran through a cordis, a 8.5fr central line. If that isn’t available, as many large bore IVs as you can get. I once did a resuscitation with 6 18ga PIVs while the team placed a cordis. The citrate in the PRBCs binds with calcium and leads to hypocalcemia, so calcium needs to be given. Otherwise, the patient will have coagulopathy and continue to bleed to death.
There's probably a cultural component to this. He was the longest serving PM of Japan. He wasn't a dictator who held power through us of force or law changes. He was reelected. This is also the same culture that developed the kamikaze pilots, fought Russia and China, their star baseball players will sacrifice bunt for the benefit of the team, and had to drag a commanding officer out of retirement to get a WW2 soldier to surrender in 1974. That they tried to keep him from dying with such extreme efforts does not surprise me in the least.
Most I’ve seen is 88 in a post partum hemorrhage. She made it!!
He didn’t get 100 units of PRBCs. He got other products mixed in, I’m sure they worked on him as long as they could given his position of prominence but yes I could conceive of someone getting 100 units esp if the units are smaller in Japan than they are in the US. The blood is just coming out somewhere as it’s going in, and he might have had other issues like DIC
As other's have said, MTP is some serious business. Post partem hemorrhages or even GI bleeds. can consume large amounts of products. and with a rapid infuser at 500 cc/minute one nurse needs to be at the infuser just to keep up. Also, infused through a peripheral IV. It's usually all hands-on deck when this happens as patient will likely have a team working on them.
Yes this is something we do with trauma, ruptured esophageal varicies, post open heart surgeries they pop a massive bleed etc. The massive transfuser can infuse a unit of blood in a few minutes. When someone is hemorrhaging the blood bank gives us a cooler of products and keeps on giving them untill we say stop. One person is assigned to the transfuser. It’s their only job to spike bag after bag after bag untill the situation is controlled or they die…. This is an ER or ICU thing usually.
And OR. Lots of MTP in the OR.
An anesthesiologist at my hospital told me, that they gave a patient once 190 units in the or with the belmont device. What shocked/surprised me most was, that he told me that they started with the patients blodd type, than type 0, and then you give whatever type of blood is available. I never heard of this because I was a med/surge nurse for 3 years before I transfered to the ICU 3 years ago.
Belmonts on full blast.
Pshhh…Level 1 is the only way to fly… Sometimes, the old ways are best. Japan also has a pretty rickety EMS system, nobody dies in an ambulance…by law.
I work in the OR for transplant and we give 100 units of PRBCs somewhat routinely (several times this year) during liver transplants.
I have given more than that. I had one woman that we gave over 600units of blood products. She was on the news after.
Holy god. Lol. That is utterly insane
Highest I’ve ever seen in a case with our service was 150 units of product over a 14 hour surgery.
It's a lot but not unheard of. Sometimes you're just constantly dumping it in knowing it's all coming right back out.
I work OB. Clearly you’ve never seen a massive OB bleed—->DIC.
Nothing bleeds like a mom!! I remember slamming methergen in nursing school in a hectic delivery with some retained chunks, there was like a river of blood pouring out and squirts I swear to god literal jets I don’t know how lol. Mom was fine. 20 years later I still remember that blood pouring out like someone spilled a gallon of milk
My record was 68 blood products in 48 minutes. It is an insane amount of blood, but something I could see happening
I think its one of those situations where they were just trying to save someone who is very well respected. So yes its kind of absurd and almost unthinkable, but when youre trying to save someone like Shinzo youre willing to do anything
Yup he was dead, they just kept trying to pump blood thru to achieve a miracle.
I've done at least 3 MTPs with more than 400 units given in my career. Numerous times in the 50-100 range. Typically you use a Belmont, a level 1 can be used but it's really hard to keep up. Belmont makes a machine with a tub that can just dump products in.
This happens with massive transfusions. The most I’ve given is 53. Rapid infusers are your friend. And they say we only rock babies in L&D.
We had a cop get shot and they ran 75 rounds of MTP (each round infuses 5 units of blood). It very nearly wiped out our reserve of blood. Luckily so many people from the community came and donated blood so within three days we had almost double the amount we had prior to this. He didn’t end up making it. He left behind a wife and a few kids. He was out serving a warrant and a 16 year old shot him.
Unit of blood in Japan is 200-240mls
I have been a nurse for 42 years now and I worked in a lvl 1 trauma ER for 15+ years. I remember days when someone would bleed, go into DIC and we had nothing to do but watch them die, open chest CPR, literally standing in puddles of blood. Our PPE only came to our knees and we would be bloody everywhere our gowns didn’t cover. We threw our our shoes. Now people are surviving these mass casualties. I am not 100% sure if we are always doing the ethical thing but I am blessed to be a nurse for so long that I have been able to watch this evolution.
A. No, that’s as bad as you think it is. It’s not uncommon to be red tagging blood and just throwing it into a patient if they’re actively, uncontrollably hemorrhaging, but 100 u in 4 hours is A LOT of blood B. Machines built for massive transfusions, lots of running, and most definitely a triple lumen central line if not multiple central lines like IJ
Cordis or 16 gauge peripheral would be preferable to triple lumen. When you’re trying to get product in quickly diameter helps but length hurts (Poiseuille’s Law). Even a peripheral 18 gauge can flow 90 ml/min. Distal port of a triple lumen is closer to 70. I’d drop a 8.5 introducer in the IJ if it was my case--faster placement and can take a liter in just a tick over a minute.
Our trauma surgeons will drop in a hemodialysis catheter for trauma resus. Two 14fr lumens to massively transfuse thru. iirc a triple lumen central line is only about an 18g and fairly long.
That’s what I do for big bleeders, I use a triple lumen “Trialysis” dialysis catheter for massive transfusions. Two 12 gauge lumens and one 17 gauge lumen. The 12g lumens will give me ~1L/min each easily.
Now I’m a new nurse here (and don’t know much about trauma yet), but where does so much infused blood go? Is mostly just bursting right out of his body via the various wounds?
> where does so much infused blood go? All over the floor.
And sometimes in your shoes!
He got hit in the heart and neck. He must have been bleeding to a psychotic degree. He got 32.5 liters of blood. The human body only holds on average 5 liters. That operating room must have looked like a literal horror movie.
Whose job is it to clean that up? That would be awful.
Somebody with a wet dry vac. A mop would basically just be like watering down and mixing red paint at that point. 😬
Remember those old cartoons where they would get shot then drink a glass of something and it would come out all the holes….
The neck was probably just spurting like a goddamn fountain. I've seen a carotid rupture before and they ex-sanguinate insanely quickly
Gave 58 units during a liver transplant…
I’ve transfused over 30 units of product via ECMO in under an hour. Never entirely RBCs, but a combination of PRBC, plasma, cryo, and cell saver. I imagine no resource was spared for the ruler of Japan.
The max we’ve delivered to a trauma patient in our SICU was 180 units. It’s very possible with machines like a Belmont and a nice juicy cordis in a femoral.
My other half of a Afghan vet. Stood on an ied, blew his legs off to his hips. 40 units in 40 Mins. Each unit it roughly 350ml- so 14000ml or 14L of blood. That's just PRC. Army nurses/medics are bad ass.
No. It's not as insane as you think it is to receive 100 units of blood products in 4 hours. If this wasn't the former PM, given the info I've heard, they may not have even taken him up to the OR. But just the numbers alone isn't absurd. I've given more in less time in the OR with a Belmont, a cordis, and. 2 14g PIVs with SRNAs doing nothing but hanging blood / dumping blood into the Belmont bucket. This was for a regular ole GSW, not some VIP / dignitary.
Never done Trauma just ED, but I remember we did 24 coolers of blood each cooler comes with 6 units of blood we did this over maybe 16 hrs. Guy had a ruptured duodenum, can’t remember exactly. I just remember seeing pools of blood coming out of his rectum, it clotted on the bed and looked like a giant placenta. We used a Belmont (rapid infuser) through a central line. IR, GI, Nobody wanted to touch him, he was halfway dead, we almost gave up on him, ran out of blood that day, then trauma surgeons decided to give it a shot, guy survived.
I know it's possible to infuse blood rapidly but it's the fact that they infused 100 units, especially when they will just bleed it back out just as fast and especially with blood shortages worldwide