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HEMORRHAGE RESUSCITATION AND MASSIVE TRANSFUSION PROTOCOLS CAPT William C. Brunner, MC, USN Senior Medical Officer, BSRF-2013 Assistant Professor, Department of Surgery Disclosures The speaker has no relevant financial relationships with commercial interests that pertain to the content of this presentation Objectives • • • • • Review History of Trauma Resuscitation Discuss Coagulopathies in Trauma Discuss Integrated Damage Control Review Blood Component Preparations Discuss Individual Component Transfusion Guidelines • Discuss Massive Transfusion Protocols • Discuss Future Research Areas History of Trauma Resuscitation • World War I – Little or no systematic resuscitation after injury – Blood banking developed • World War II – Widespread use of blood and albumin – Long, slow evacuation – Significant organ failure – renal, pulmonary – Late deaths from sepsis History of Trauma Resuscitation • Korean War – Forward Surgical Care – Rapid Care – Evacuation to Definitive Treatment – Blood and albumin as in WWII • Vietnam War – Rapid evacuation – Large-volume resuscitation with blood/crystalloid – Da Nang Lung (ALI/ARDS) History of Trauma Resuscitation • Civilian Experience – Trauma Registries and Research – Empiric high-volume crystalloid resuscitation – Iatrogenic Coagulopathy after Trauma recognized – Directed Component Therapy • Requires Laboratory evidence • Empiric therapy limited – Massive Transfusion Protocols History of Trauma Resuscitation • Military Experience – Iraq and Afghanistan • Limited Component availability • Recognition of crystalloid inflammatory response • Whole blood transfusion • Walking Blood Bank – Simple technology – Screened donor population readily available Acute Traumatic Coagulopathy • Recognized in patients with significant tissue injury and hypotension • Distinct from iatrogenic coagulopathy after trauma – Dilutional coagulopathy • Present prior to resuscitation in rapidly evacuated severe trauma • Mortality rate increased 4x • Modulated through protein C activation Integrated Response • Damage Control Surgery • Hemostatic Resuscitation – Rapid, limited, forward surgical care • • • • Control bleeding Control spillage Control contamination Restore perfusion – Avoid unnecessary interventions – Allow for resuscitation – Rapid evacuation – Limited volume – Permissive hypotension – Balanced transfusion • High FFP:PRBC ratio – Colloid vs. crystalloid – Attenuate ATC – Expand resource availability • Walking blood bank • Freeze-dried plasma Blood Components Component Indication Storage Time Disadvantage Whole Blood Volume deficit, O2 carrying capacity, massive transfusion 35 days (2°-6° C) 24 hrs fresh Short shelf life PRBCs Volume deficit, O2 carrying capacity 42 days Immunomodulation Leukocyte-reduced PRBCs Cardiac surgery, prevent CMV infection, reduce febrile reaction and alloimmunization 42 days Cost Washed PRBCs Prevention of allergic reactions 24 hrs Plasma depletion FFP Coagulopathy, warfarin reversal 1 year Cryoprecipitate Von Willebrand disease, Fibrinogen deficiency 1 year Platelets Microvascular bleeding, thrombocytopenia 5-7 days Risk of transfusionassociated sepsis Component Therapy • Advantages – Wider use of limited resources • 1 donated unit – multiple products – Longer storage life – Lower costs in elective use – More predictable availability • Disadvantages – Multiple donor antigen exposure – Less efficacy in high volumes, Lab costs Component Transfusion Guidelines • Fresh Frozen Plasma – Prothrombin Time (PT) > 17 sec – Clotting Factor Deficiency (<25% of normal) – Massive Transfusion (1 unit/5units RBCs) or clinically bleeding – Severe Traumatic Brain Injury • Cryoprecipitate – Fibrinogen < 100mg/dL – Hemophilia A, von Willebrand disease – Severe Traumatic Brain Injury Component Transfusion Guidelines • Platelets – Platelet count < 10,000/uL – Platelet count 10,000 to 20,000 with bleeding – Platelet count < 50,000 after severe trauma – Bleeding Time > 15 mins – Platelet concentrates (5.5 x 1010 in 50ml) – Platelet apheresis (3 x 1011 in 300ml) Component Transfusion Guidelines • Packed Red Blood Cells (PRBCs) – Hemoglobin < 7g/dL – Acute blood volume loss > 15% – > 20% decrease in BP, or BP <100mm Hg due to blood loss – Hemoglobin < 10g/dL with significant cardiac disease or symptoms (chest pain, dyspnea, fatigue, orthostatic hypotension) – Hemoglobin < 11g/dL in patient at risk for MOF Massive Transfusion • Defined as > 10 units PRBCs within 24 hrs • 25-30% of trauma patients requiring massive transfusion will present with Acute Traumatic Coagulopathy (ATC) – Penetrating mechanism – Positive FAST – Arrival SBP < 90mm Hg, HR > 120 bpm – Unstable pelvic fracture – pH < 7.25, base deficit Massive Transfusion Protocol • Advantages – More closely replicate whole blood physiology with components – Retain shelf-life advantage of components – 25-30% reduction in PRBCs used – Predictable workload • Disadvantages – Processing time limitations – Limited applicability Massive Transfusion Protocol Package PRBCs (Units) FFP (Units) 1 6 6 2 6 6 3 6 6 4 6 6 5 6 6 6 6 6 Platelets (Units) Other 1 apheresis Cryoprecipitate rFVIIa 1 apheresis 1 apheresis Cryoprecipitate rFVIIa Data from O’Keeffe T, Refaai M, Tchorz K, et al: A massive transfusion protocol to decrease blood component use and costs, Arch Surg 143:686-691, 2008. Massive Transfusion Protocol • Typically start with 2-6 units Type O blood – Initial “emergency-release” – Subsequent units type-specific, cross-matched • FFP processing time – ER prestaging thawed plasma, shelf-life 4-5 days • Protocols can enhance effective use of staffing and resources Special Situations • Autotransfusion – Limited applicability due to capture, possible contamination • Blood salvage – Intraoperative or postoperative – Labor intensive, expensive, limited utility • Autologous donation, Hemodilution not applicable to trauma setting Areas for Future Study • Determine optimal therapeutic ratio of PRBC:FFP – PROPPR Study - 1:1:1 vs. 1:1:2 PRBC/PLT/FFP • Further delineate ATC physiology and identify clinically useful modulators • Delineate impact of high-ratio therapy on subMT trauma population • Blood component substitutes • Crystalloid alternatives References • McIntyre RC Jr., Moore FA; Blood Transfusion Therapy, Chapter 212, Current Surgical Therapy, 10th Edition, Philadelphia, PA, 2011. • Adams CA Jr., Stephen A, Cioffi WG; Surgical Critical Care, Chapter 23, Sabiston Textbook of Surgery, 19th Edition, Philadelphia, PA 2012. • Chovanes J, Cannon JW, Nunez TC; The Evolution of Damage Control Surgery, Surg Clin N Am 92 (2012) 859-875. References • Cohen MJ. Towards Hemostatic Resuscitation: The Changing Understanding of Acute Traumatic Biology, Massive Bleeding, and Damage-Control Resuscitation. Surg Clin N Am 92 (2012) 877-891. • Committee on Trauma, American College of Surgeons. ATLS: Advanced Trauma Life Support Student Course Manual, 9th Edition. Chcago: American College of Surgeons; 2012.