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Massive Transfusion in the New Era

Massive Transfusion in the New Era. JHSGR 17 Apr 2010 Dr J Leung CMC. Outline. Massive transfusion (MT) Definition, conditions, outcomes Coagulopathy Hemostatic resuscitation Transfusion of FFP, Platelet and PRBC Hypotensive resuscitation Massive transfusion protocol

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Massive Transfusion in the New Era

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  1. Massive Transfusion in the New Era JHSGR 17 Apr 2010 Dr J Leung CMC

  2. Outline • Massive transfusion (MT) • Definition, conditions, outcomes • Coagulopathy • Hemostatic resuscitation • Transfusion of FFP, Platelet and PRBC • Hypotensive resuscitation • Massive transfusion protocol • Outcome, complications

  3. Massive Transfusion - definition

  4. Massive Transfuion - Conditions • Trauma • e.g Pelvic fracture, Liver lacerations • Non Trauma • Abdominal Aortic Aneurysm repair • Gastrointestinal Hemorrhage • Liver Transplant • Obstetrics Conditions eg ectopic pregnancy, postpartum hemorrhage

  5. Trauma The most common reason for massive transfusion Hemorrhage: 40% of all trauma deaths The leading cause of death for Americans under 35 years old

  6. MT and Outcome Massive Transfusion - Outcomes • Trauma patient: 19-84% mortality

  7. MT and Outcome (cont’d)

  8. Coagulopathy • Hemorrhage -> Massive Transfusion-> coagulopathy upon or soon after admission • Exacerbated by resuscitation with crystalloid & PRBC

  9. Hemostatic Resuscitation • Hemorrhage control • Normalization of body temperature • Early transfusion of FFP, platelets

  10. FFP : Plt : PRBC

  11. Multicentre retrospective study • 16 major Level 1 trauma centres in the US • 466 required MT trauma patient • FFP:PRBC, Platelet: PRBC & ISS • independent predictors of 30-day mortality • 4 groups • High FFP:RBC ≥ 1:2 vs Low FFP:RBC <1:2 • High Plt:RBC ≥ 1:2 vs Low Plt:RBC <1:2

  12. Mortality Survival is associated with increased FFP & Platelet ratio Best ratio 1:1:1

  13. FFP : Plt : PRBC

  14. Survivial Early transfusion of high ratio of FFP:Platelet:PRBC improved survival

  15. Hemostatic Resuscitation No consensus yet More fluid: risk of hemodilution & disruption of early hemostatic clots Vs Limit fluid: prolonging shock & cellular ischemia may become irreversible • Hypotensive resuscitation: • Aggressive crystalloid fluid resuscitation in patient with uncontrolled hemorrhage -> increase hemorrhage & coagulopathy • Target SBP >90mmHg or Heart rate <130 bpm until hemorrhage is controlled

  16. Massive Transfusion Protocol • In the past: • Crystalloid -> PRBC • FFP / Platelets: upon request when there is lab evidence of coagulopathy • Current era: • prevention of coagulopathy & thrombocytopenia • PRBC: FFP: Platelet = 1:1:1

  17. MTP J Am Coll Surg 2009;209: 198–205

  18. Retrospective review, cohorts • Stanford University Medical Center • Level I trauma Center • MTP since July 2005 • 6 PRBC: 4 FFP: 1 apheresis pack of Platelet • 2 yrs pre (n=40), post MTP (n=37) • FFP:PRBC ratio the same: 1:1.8 (p=0.97) • Plt : PRBC ratio: 1:1.8 -> 1:1.3 (p=0.05)

  19. MTP -> Prompt availability of blood products -> improves survival

  20. Complications from MTP? • More multi-organ failure / ARDS?

  21. Retrospective Cohort • Single Level 1 trauma centre • Trauma Exsanguination Protocol in 1 Feb 2006 • PRBC: FFP: Plt = 6:4:2 • 2 years pre-TEP (n=141), 2 years TEP (N=125)

  22. Conclusion • Prevention of coagulopathy • Predefined ratio of FFP: Platelets: PRBC • Applicable to non trauma cases? • Availability of blood products

  23. Thank You

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