Transcript Massive Transfusion Protocol in Trauma Why

Management of Massive
Bleeding in the ICU
Ibrahim Al-Sanouri, MD, FCCP, FAAAAI
Key Discussion Points
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Definition
Complications of massive transfusion:
coagulopathy.
Therapy goals
Haemostatic resuscitation
Introduction of Massive Transfusion (MMT)
protocol and RBC:FFP:Plts ratio.
Bleeding in the ICU
Bleeding in the ICU: massive or not
massive.
 Mucosal or several.
 Immediate or delayed.
 GI bleed, Trauma or post surgical
intervention
 Massive blood transfusion: control the
source
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Definition of Massive Transfusion
Importance of Massive Transfusion
 39% of trauma related deaths – uncontrollable bleeding
(Leading cause of preventable death)
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2% of trauma patients – need massive transfusion
Bleeding 2 main causes
Vascular injury (surgical)
Coagulopathy (non-surgical)
Massive Blood Transfusion complications
Fluid overload
 Thrombocytopnea
 Hypocalcemia
 Decreased oxygen release by transfused
red cells due to 2,3-bisphosphoglycerate
(2,3-BPG) levels (left shift in Hg-O2
curve).
 Hypothermia
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Coagulopathy in massive bleeding:
Coagulopathy
Hypothermia
Haemorrhage
Complications of
massive
transfusion
Hypotension
Haemodilution
Resuscitation
Massive Blood Transfusion Management
Haemostatic Resuscitation
 Fluid management
 Metabolic acid base correction
 Normal temperature
 Calcium management
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Therapeutic goals:
Maintenance of tissue perfusion and
oxygenation by restoration of blood
volume and haemoglobin.
 Arrest of bleeding by treating any
traumatic, surgical or obstetric source
 Judicious use of blood component therapy
to correct coagulopathy
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Massive bleeding management
Treating
team
Lab
services
Blood
products
supplying
service
1-Restore circulating volume:
Insert wide bore peripheral or central
cannulae
 Give pre-warmed crystalloid or colloid as
needed, keep patient warm.
 Avoid hypotension or urine output <0.5
ml/kg/h
 Concealed blood loss is often
underestimated
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2- Contact key personnel
A named senior person must take
responsibility for communication and
documentation.
 Consultant anaesthetist
 Blood transfusion Biomedical Scientist
 Haematologist
 Arrange Intensive Care Unit bed
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3- Stop the bleeding:
Early surgical or obstetric intervention
 Interventional radiology
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4-Labs investigation:
CBC, PT, APTT, Thrombin time,
Fibrinogen, DIC profile.
 Blood gases and pulse oximetry
 Ensure correct sample identification
 Repeat tests after blood component
infusion
 Results may be affected by colloid infusion
 May need to give components before
results available
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5-Maintain Hb> 8 g.dl
Assess degree of urgency
 Employ blood salvage to minimize
allogeneic blood use
 Give red cells
 Group O Rh D negative In extreme
emergency Until ABO and Rh D groups
known
 Use blood warmer and/or rapid infusion
device if flow rate >50 ml/kg/h in adult
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6- Maintain adequate coagualtion
Anticipate platelet count <50 after 2 blood
volume replacement.
 Maintain PT & APTT < 1.5 · mean control
 Give FFP 12–15 ml/kg guided by tests
 Anticipate need for FFP after 1–1.5 blood
volume replacement
 Allow for 30 min thawing time
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6-Maintain adequate coagulation
Maintain Fibrinogen > 1.0 g/l
 If not corrected by FFP give
cryoprecipitate (Two packs of pooled
cryoprecipitate for an adult)
 Allow for 30 min thawing time
 Keep ionised Ca2+ > 1Æ13 mmol/l
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7-Hospital protocol:
Multidisplinary services: Hospital
Transfusion Committee.
 Improve awareness and confidence and
ensure that the blood transfusion chain
works efficiently.
 Rapid communication cascade.
 Safe and jusdicious use of blood
components.
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What is Haemostatic Resuscitation?
Prevents post massive transfusion
coagulopathy.
 Aims to reduce use of blood products in the
intensive care phase.
 With 5-7 unitis PRBC’s Plt count decreases to
less than 50 %
 With 5 units PRBC PT is increased to more
than 1.5 control.
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Haemostatic Resuscitation: RBC
Erythrocytes promote marginalization of
platelets so the platelet concentrates along
the endothelium and remains almost
seven times that of the average blood
concentration
 Erythrocytes support thrombin generation
by activating platelets by liberating ADP.
 Oxygenation delivery.
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Haemostatic Resuscitation: FFP
It remains controversial when and in what
dose plasma should be transfused to
massively bleeding trauma patients.
 The optimal ratio of FFP to RBCs remains
to be established: FFP:RBC ratio greater
than 1:2 is associated with improved
survival compared to one lower than 1:2.
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Haemostatic Resuscitation: FFP
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Meta-analysis from 2010-2012: Patients
undergoing massive transfusion, high FFP
to RBC ratios was associated with a
significant reduction in the risk of death
(odds ratio (OR) 0.38 (95%CI 0.24-0.60)
and multiorgan failure (OR 0.40 (95%CI
0.26-0.60).
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Murad MH, Stubbs JR, Gandhi MJ, Wang AT, Paul A, Erwin PJ, Montori VM, Roback
JD: The effect of plasma transfusion on morbidity and mortality: a systematic review
and meta-analysis. Transfusion 2010, 50:1370-1383
Haemostatic Resuscitation: FFP
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Meta-analysis from 2012 reports of
reduced mortality in trauma patients
treated with the highest FFP or PLT to
RBC ratios.
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Johansson PI, Oliveri R, Ostrowski SR: Hemostatic resuscitation with
plasma and platelets in trauma. A meta-analysis. J Emerg Trauma Shock
2012, 5:120-125.
Coagulopathy of Massive Transfusion
Mortality Vs FFP/RBC ratio
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Retrospective review of 246 patients
receiving a massive transfusion (> 10 units of
blood)
80%
65%
34%
60%
19%
40%
20%
1:8
1:2.5
1:1.4
0%
Borgman MA. et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a
combat support hospital J trauma, 2007. 66:805-813
Haemostatic Resuscitation: Plts
Platelets are also pivotal for hemostasis:
low Plts increases mortality.
 The highest survival was established in
patients who received both a high
PLT:RBC and a high FFP:RBC ratio.
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Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA,
Gonzalez EA, Pomper GJ, Perkins JG, Spinella PC, Williams KL, Park MS: Increased
plasma and platelet to red blood cell ratios improves outcome in 466 massively
transfused civilian trauma patients. Ann Surg 2008, 248:447-458.
Haemostatic Resuscitation: plt
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Retrospective study of massively
transfused patients: As apharesis platelet
to RBC ratio increased, a stepwise
improvement in survival was seen and a
high apheresis PLT:RBC ratio was
independently associated with improved
survival.
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Zink KA, Sambasivan CN, et al: 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. Am J Surg 2009,
197:565-570.
Massive transfusion protocols and
ratios:
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10 RBC, 4 FFP and 2 apheresis PLT for trauma patients.
211 trauma patients of who 94 received TEP and 117 were historic
controls.
The TEP patients received more RBC (16 vs. 11), FFP (8 vs. 4),
and PLT (2 vs. 1) intraoperatively than the controls.
The protocol group displayed lower 30-day mortality (51% vs. 66%).
After controlling for age, sex, mechanism of injury, Trauma and
Injury Severity Score (TRISS), and 24-hour blood product usage, a
74% reduction in the odds ratio of mortality was found among
patients in the TEP group.
Cotton BA, Gunter OL, Isbell J, Au BK, Robertson AM, Morris JA: St Jacques P, Young PP:
Damage control hematology: the impact of a trauma exsanguination protocol on survival and
blood product utilization. J Trauma 2008, 64:1177-1182.
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Pre-defined Massive Transfusion Protocols are associated with REDUCTION of organ
failure and post injury complication J Trauma 2009 Jan ; 66(1) 41-48
Ratio 10-4-2: RBC-FFP-PLts
Pre-MMT (n-141)
MMT (n=129)
P-values
24hr survival (%)
61
69
0.185
30d survival (%)
37.6
56.8
0.001
Hospital length of stay d (+/-SD)
16.4(+/-12.1)
12 (+/-12.1)
0.049
ICU stay, (days)
6.6(+/-9.4)
5.0 (+/- 8.3)
0.239
Ventilator (days)
8.2 (+/-9.7)
5.7 (+/-7.2)
0.017
IO crystalloid, Litres
7L
4.8L
<0.001
IO blood products units
11U
14.7U
0.001
24hr blood products
38.7U
31.2U
0.05
Complications comparison
Pre-MMT (n-141)
MMT (n=129)
P-values
Systemic inflammatory
response syndrome
SIRS (%)
55.3
52.8
0.682
Severe sepsis/septic
shock (%)
19.8
10
0.019
Ventilator-dependent
respiratory failure(%)
62.4
60.8
0.787
VAP(%)
39
27.2
0.041
Abdominal compartment
syndrome(%)
9.9
0
<0.001
Open abdomen(%)
30.5
6.4
<0.001
Need of Renal
replacement therapy(%)
2.8
3.2
0.826
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Pre-defined Massive Transfusion Protocols are associated with REDUCTION of
organ failure and post injury complication J Trauma 2009 Jan ; 66(1) 41-48
Ratio 10-4-2: RBC-FFP-PLts
Fresh Whole Blood:
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Routine use of fresh whole blood (FWB) for resuscitation
of bleeding patients was abandoned in the civilian
setting.
In the combat setting, however, FWB has been used.
In a report of US military patients in Iraq and Afghanistan
from January 2004 to October 2007, those with
hemorrhagic shock, a resuscitation strategy that included
FWB was associated with improved 30-day survival
(95% vs. 82%, p=0.002).
Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB: Warm fresh whole blood is
independently associated with improved survival for patients with combat-related traumatic
injuries. J Trauma 2009, 66:S69-S76.
Haemostatic Agents:
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Antifibrinolytis: Shakur H, et al: CRASH-2 Trial collaborators: Effects of
tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients
with significant hemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet 2010,
376:23-32.
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Recombinant factor VII: Hauser CJ at al: Results of the
CONTROL trial: efficacy and safety of recombinant activated Factor VII in the
management of refractory traumatic hemorrhage. J Trauma 2010, 69:489-500.
Fibrinogen concentrate
 Prothrombin complex concentrate
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Hospital Alert:
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Active Hemorrhage
SBP < 90
HR > 100
Ph < 7.35
BE < - 2
Uncontrollable active bleeding
Poor responder to fluid
Activation of MMT by team leader only- Registrar or
above.
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MANAGEMENT of MASSIVE TRANSFUSION (MMT) for TRAUMA
Hospital MMT alert confirmation
(patient requiring urgent transfusion)
- SBP < 90, - HR > 100
- Ph < 7.35
- BE < - 2
- Obvious signs of uncontrollable active
bleeding
- Poor responder to fluid resuscitation
Pre-hospital MMT alert:
•Systolic BP < 90
•Poor response to initial
fluid resuscitation
•Suspected active
haemorrhage
MMT ACTIVATION
For Trauma
(Trauma Team leader must declare
MMT Activation to blood bank ,
If so activate MMT (match 3 of the ocriteria)
HAEMOSTASIS
Co-ordinate Porter urgently to standby for
Collection of MMT pack one
PATIENT ARRIVAL
Take bloods (FBC, U&E, Clotting,
fibrinogen and X-match and ABG)
Send pink bottle with X-match form to
blood bank urgently ( please obtain 2
samples for x-match at different time if
possible)
THERAPY TARGET end point:
HAEMORRHAGE CONTROL:
Surgery
Stabilize fractures
Pelvic brace
PREVENT HYPOTHERMIA
HAEMOSTATIC DRUGS:
Consider the following if bleeding persist
despite surgical interventions:
Activated factor VII
Beriplex (consider when patient who is on
anti-coagulant)
Antifibrinolitic agents
Please discuss any of these therapeutic
measures with Haematologist on call)
MMT PACK 1
4 x O –ve RBC ( female) or
O+ve(Male)
2 FFP
(or Group specific if possible)
RE-ASSESSMENT
ABCDE
If haemorrhage continue
Activate MMT PACK 2
Please, specify location of
patient
Fail to
reach
targets
Hb: 8-10 g/dl
Platelets > 100
PT&APTT (INR)< 1.5
Fibrinogen > 1.0 g/l
Ca²⁺ > 1 mmol/l
pH: 7.35-7.45
BE: ± 2
Tª > 36 °C
2 x packs of Cryoprecipitate if Fibrinogen is < 1.0 g/l
INTRA-OPERATIVE CELL SALVAGE:
Transfuse 1 x FFP every 250 ml of blood
Transfuse 1 x ATD platelets every 1000
ml of blood
Notify blood bank
MMT PACK 2
4 X RBC
4 X FFP
1 pharased
Platelets
When MMT stops
Return any unused products
Once administered check:
FBC, Clotting, fibrinogen and ABG
Resume standard ordering practices
Summery:
Immediate labs service is important to
identify coagulopathy, and guide ongoing
transfusion therapy.
 Massive hemorrhage could results in
serious life threatening complications
 Massive bleeding and massive transfusion
could lead to severe coagulaopthy which
tight a viscous cycle that could cause
mortality
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Summery:
While resuscitation your patient keep
patient warm with normal calcium level
 Identify and correct source of bleeding.
 Implementation of a homeostatic control
resuscitation strategy to massively
bleeding patients seems both reasonable
and lifesaving.
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Thank You!
Questions?
Ibrahim Al-Sanouri, MD.