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PAH M&M 10-24-13

PAH M&M 10-24-13. Attending/CRNA/SRNA: Springstead /Feeney/Garcia Operation: PSF T10-Pelvis, L2-L3 Lami Complication: massive blood loss. History. 66 yo female presents for her 9 th back surgery PSH: Lumbar Lami x2, Intrathecal thoracic pain pump, THR, Lumbar Fusions, Rotator Cuff

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PAH M&M 10-24-13

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  1. PAH M&M 10-24-13 Attending/CRNA/SRNA: Springstead/Feeney/Garcia Operation: PSF T10-Pelvis, L2-L3 Lami Complication: massive blood loss

  2. History • 66 yo female presents for her 9th back surgery • PSH: Lumbar Lami x2, Intrathecal thoracic pain pump, THR, Lumbar Fusions, Rotator Cuff • PMH: GERD, RLE DVT, Vertigo • Meds: protonix, amtriptyline, clonazepam, vicodin, pyridium, zolpidem, tizanidine • Allergies: Bactrim, Percocet, NSAIDs, Cipro, Terazosin • Wt: 47kg

  3. Pre-op Labs CBC: WBC 6.5, Hgb 11.2, Hct 33.2, Plt 307 CMP: WNL Coags: WNL Estimated Blood Volume: 3,055cc

  4. Case Management • 2 large bore IVs, RIJ triple lumen, CVP, A-line • Smooth IV induction, ETT with TIVA • Prone on jackson table • Neuromonitoring

  5. Issues… • No T&C morning of surgery • No IVC filter placed pre-op • (20% recurrence risk) • 4,700cc of blood loss over 5hours

  6. Interventions • T&C sent • Requested PRBCs, FFP, Plts, Cryo • Level 1 infuser obtained from 3rd floor

  7. Intraoperative I&O Totals EBL: 4,700cc UO: 1,100cc Crystalloid: 4,500cc Colloid: 1,250cc Cell Saver: 875cc PRBCs: 10units (3,000cc) FFP: 4units (1,200cc) Platelets: 3 six packs (750cc) Cryoprecipitate: 10units (100cc) (1:2.5:0.5)

  8. Postoperative Labs • ABG: • pH 7.42, pCO2 35, pO2 248, HCO3 22.7, BE -1.4 • CBC: • WBC 12.2, Hgb 10.4, Hct 29.7, Plt 134 • CMP: • Glucose: 157, BUN/Creat: 6/0.52, Na/K: 139/3.4, Ca: 7.8 • Coags: • PT 16.4, PTT 39, INR 1.5

  9. Post-Op Course: • Day 1: extubated in ICU • Day 3: ileus/nausea, bilateral L3 pedicle fx • Day 4: DOE, CT chest to r/o PE. • Large left pleural effusion

  10. Key Points Factors that contributed to outcome: Pt was relatively healthy, no cardiac hx, extra hands, anticipated large blood loss and preemptively placed central line. Ways to improve: Massive transfusion protocol -PAH only has one for OB patients

  11. Basics Review • Coagulation Abnormalities with Massive Blood Transfusions: • Transfused blood lacks platelets, Factors 5 and 8 • Diffuse bleeding s/p transfusion is caused by thrombocytopenia • Treatment = platelets, FFP, Cryo • Platelets in stored blood are nonfunctional after 1-2 days. • All procoagulants are present in FFP – EXCEPT PLATELETS! • Cryoprecipitate contains factors concentrated factors 8, 1, 13 • One unit PRBCs increases Hct 3-4% or 1g/dL • 1cc/kg RBCs will increase Hct 1% • One unit of platelets increases plt count 5,000-10,000. • Massive transfusion = one complete blood volume within 24 hours.

  12. HUP Exsanguination Protocol - 2011 • Initial activation response: (1:1.6:1.6) • PRBCs – 10 • FFP – 6 • Plts – 1 six pack • Continued activation: (1:1.5:1) • PRBC – 6 • FFP – 4 • Plts – 1 six pack • Factor VIIa • 90mcg/kg • After 2nd dose must be approved by pharmacy

  13. Identifying who needs MTP… • 2012 AAST - Prospective Observational Multicenter Major Trauma Transfusion Study (PROMMTT) • Involved 1,245pts from 10 Level I trauma centers • 297 patients received massive transfusion • CITT & ABC triggers • ABC: penetrating injury, + FAST, SBP <90, HR >120 • 2 or more points = pt likely to receive MT • CITT: SBP <90, Hgb <11, INR >1.5, BD >6, Temp <35.5 • “Parameters that can be obtained early in the initial evaluation are valid predictors for determining the likelihood of massive transfusion” • Penetrating injury and HR least valid, INR most valid • Cannot currently link ABC/CITT to nontrauma patients

  14. First 6 hours… • (2009) Retrospective study involving 16 Level 1 Trauma Centers • 1,489 pts – of which 466 were MT pts • Looked at outcomes in patients who received high ratio transfusions within first 6 hours • 6hr mortality lowest in patients who received > or = 1:1:1 PRBC:FFP:PLT • <1:4 37% and >1:1 2% 6hr mortality • No difference in pulmonary complications s/p resuscitation • In fact, pts who received highest PRBC:PLT ratio had fewer ventilator dependent days • Advocate for early FFP and Platelet administration

  15. Resuscitation Strategies… • (2010) 4 year retrospective study • Included trauma pts requiring DCL & >10units PRBCs • Damage Control Resuscitation vs. Conventional Resuscitation Efforts • Compared pt variables, labs, intraop resuscitation, 30 day survival rate and LOS between DCR and CRE pts • Included 196 pts with blunt/penetrating injuries at Level 1 trauma center

  16. CRE vs. DCR • Damage Control Resuscitation (DCR) • “Close ratio massive transfusion protocol” • 1:1 FFP to PRBCs • 1:2 Platelets to PRBCs • Minimal crystalloids (4L) – counterproductive • Conventional Resuscitation Efforts (CRE) • Aggressive crystalloid resuscitation (14L) • 1:4 FFP to PRBCs • 1:6 Platelets to PRBCs

  17. Findings… • ICU LOS: • DCR = 11 days • CRE = 20 days • 30 Day Survival: • DCR = 73.6% • CRE = 54.8% • CRE patients arrived to ICU volume overloaded with tissue hypoperfusion, hypothermia, coagulopathy and increased mortality

  18. Massive Transfusion Activation in GMS Patients…. • 2013 – Retrospective study from U. Pitt • 164pts = 100 trauma and 64 GMS • Current MTP = 1:1:0.5 PRBC:FFP:PLT • MTP activation automatically provides set ratio from the blood bank (Based on ABC – similar to HUP) • MTP accelerates delivery of blood products from BB ~ 7-17min faster • Overactivation affects resource allocation • 53% in GMS vs. 19% Trauma • Both GMS and Trauma waste significant amount of plts • Despite overactivation – still advocates for MTP in GMS patients to improve delivery time and patient outcome

  19. Massive Transfusion & Organ Failure • (2008) Journal of Trauma, Injury, Infection and Critical Care • High ratios of FFP:PRBC associated with increased risk of organ failure? • 264 pts • Postop complications/organ failure reduced when blood products delivered asap via predetermined protocol. • No change in renal failure or inflammatory response • Decreased pneumonia, pulmonary failure, open abdomens, abdominal compartment syndrome

  20. Storage Duration of Erythrocytes • (2013) Anesthesiology – Cleveland Clinic • Retrospective study examined association between storage duration and postop mortality in general surgery patients • What are the concerns: • Changes in erythrocyte membrane, decreased 2,3 DPG, Nitric oxide, K+ • Increased mortality, LOS, intubation time, infections, multi organ failure • Patient vs. Transfusion? • Current limited data among noncardiac surgical patients

  21. Oxy-hemoglobin Dissociation Curve

  22. The goods. • 63,319 patients from 2005-2009 • 10,090 transfused • 6,994 patients • 1-41units given per patient • ASA 1-5 (80% were ASA 3 or higher) • 3 groups of storage duration • <14 days • 14-28 days • >28 days • This study excluded patients who had units with a difference storage duration greater than 5 days.

  23. The outcomes. • 19,462 units of allogenicPRBCs administered • 1,178 deaths • No association found between length of storage and post-op mortality over 2 years • This data cannot be extrapolated to cardiac surgery. • Did not look at morbidity. • Several prospective studies are currently ongoing…

  24. References • Brenner, M., Bochicchio, G., Bochicchio, K., Ilahi, O., Rodriguez, E., Henry, S., et al. (2011). Long-term impact of damage control laparotomy. Archives of Surgery, 146, 395-399. • Callcut, R. A., Cotton, B. A., Muskat, P., Fox, E. E., Wade, C. E, Holcomb, J. B., et al. (2012). Defining when to initiate massive transfusion: A validation study of individual massive transfusion triggers in PROMMTT patients. Journal of Trauma and Acute Care Surgery, 74, 59-68. • Cotton, B. A., Au, B. K., Nunez, T. C., Gunter, O. L., Robertson, A. M., Young, P. P. (2009). Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. The Journal of Trauma, Injury, Infection, and Critical Care, 66, 41-49. • Duchesne, J. C., Kimonis, K., Marr, A. B., Rennie, K. V., Wahl, G., Wells, J. E., et al. (2010). Damage control resuscitation in combination with damage control laparotomy: a survival advantage. Journal of Trauma, Injury, Infection and Critical Care, 69, 46-52. • McDaniel, L. M., Neal, M. D., Sperry, J. L., Alacron, L. H., Forsythe, R. M., Triulzi, D., et al. (2013). Use of a massive tranfusion protocol in nontrauma patients: activate away. Journal of the American Collage of Surgeons, 1103-1108. • Saager, L., Turan, A., Dalton, J. E., Figueroa, P. I., Sessler, D. I., Kurz, A. (2013). Erythrocyte storage duration is not associated with increased mortality in noncardiac surgical patients. Anesthesiology, 118, 51-58. • Zink, K. A., Sambasivan, C. N., Holcomb, J. B., Chisholm, G., Schreiber, M. A. (2009). A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. The American Journal of Surgery, 197, 565-570.

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