Massive Blood Transfusion - utcomchatt.org · • Replacement of total blood volume within 24 hours • Transfusion of ≥10 RBC units in 24 hours • Accounts for 3 and 8% of civilian

2010 Erlanger Trauma Symposium 3/22/2010

UT College of Medicine ChattanoogaNo portion of this handout may be reproduced in any

form without permission in writing from the author.

Massive Blood Transfusion

Liz Culler, MDMarch 17, 2010

Disclosure• Medical Director at Blood Assurance

• Blood Assurance is a not-for-profit organization that provides blood to 56 healthcare facilities in TN, GA, AL, and NC

• Blood Assurance promotes evidence-based transfusion practices

http://www.bloodassurance.org/aboutBA.html. Accessed 2/22/10.

Learning objectives• Review of blood products

• Discuss hemorrhage in trauma patients

• Discuss damage control resuscitation

• Define massive transfusion (MT)

• Discuss the use of a massive transfusion protocol (MTP)

• Describe the experience with using specific ratios of blood products to treat trauma patients

Art from http://www.kyb.mpg.de/de/ernstgroup/learning_logo.jpg. Accessed 2/22/10.

http://images.google.com/imgres?imgurl=http://spectra-eg.com/images/GambroTrimaAccel/Trima_pic.jpg&imgrefurl=http://spectra-eg.com/GambroTrimaAccel.aspx&usg=__sGxnr3DJ1RQVV9OSwQxUDS4KLqA=&h=400&w=200&sz=11&hl=en&start=2&itbs=1&tbnid=nfnCSr0uxXgm5M:&tbnh=124&tbnw=62&prev=/images%3Fq%3Dtrima%2Baccel%26hl%3Den%26gbv%3D2%26tbs%3Disch:1. Accessed 2/22/10.




1 therapeutic dose of platelets

=

“6 pack” 1 Apheresis platelet

=

1 Acrodose platelet

http://www1.pall.com/Japan/images/Acrodose_PL_System_jpg.jpg. Accessed 2/22/10.

Cryoprecipitate• Volume: 15 mL

• Most common indication is fibrinogen deficiency

• Each pool of 10 units of cryoprecipitate increases the fibrinogen level of a 70 kilogram recipient approximately 70 mg/dl

• Always want fibrinogen level to be at least 100 mg/dL

• 10 bags deliver 2500 mg of fibrinogen in 150 mL of volume

• It would take >1 liter of plasma to achieve the same amount

http://www.ams.cmu.ac.th/depts/bloodbank/bbwebpage/Copy_of_cry2.jpg. Accessed 2/22/10.

http://www.cureheartdisease.us/images/fibrinogen.jpg. Accessed 2/22/10.

Trauma: The Scope of the Problem

• Traumatic injuries are leading cause of death in US in patients 1-44 years old

• 120,000 deaths due to unintentional injuries in 2007

http://www.cdc.gov/injuryresponse/index.html. Accessed 2/12/2010.

http://www.cdc.gov/injury/Images/LC-Charts/10lc%20-Unintentional%20Injury%202006-7_6_09-a.pdf. Accessed 2/12/2010.

http://www.nsc.org/news_resources/injury_and_death_statistics/Pages/HighlightsFromInjuryFacts.aspx. Accessed 2/12/2010.

Timing and mechanism of traumatic death

Kauvar DS, Lefering R, and Wade CE. Impact of Hemorrhage on Trauma Outcome: An Overview of Epidemiology, Clinical Presentations, and Therapeutic Considerations. The Journal of Trauma 2006;60:S3-11.

We need to:

1) Identify patients at risk for death due to hemorrhage

2) Treat these patients quickly




Spahn DR, and Rossaint R. Coagulopathy and blood component transfusion in trauma. British Journal of Anaesthesia2005;95:130-139.

3 phases of treatment of trauma patients

1) Initial control and resuscitation – lifesaving stabilization

2) Interventional phase – definitive bleeding control

3) Critical care phase – support

Impact of Hemorrhage on Trauma Outcome: An Overview of Epidemiology, Clinical Presentations, and Therapeutic Considerations. Dauvar DS, Lefering R, and Wade CE. Journal of Trauma-Injury Infection & Critical Care 2008:65;261-271.

Damage control resuscitation (DCR)Early and aggressive prevention and treatment of hemorrhagic shock

for patients with severe life-threatening traumatic injuries

Deployed at ED and progresses throughout system

Includes:• Prediction of massive transfusion• Hypotensive resuscitation• Prevention/treatment of hypothermia• Prevention/treatment of acidosis• Prevention/treatment of coagulopathy• Prevention/treatment of hypocalcemia• Avoidance of hemodilution• Hemostatic resuscitation with transfusion and coagulation factor

products• Surgical control of bleeding• Monitor need for on-going transfusions (labs, thromboelastography)

Spinella PC and Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Reviews2009;23:231-240.

What is massive transfusion (MT)?

• Multiple definitions

• Replacement of total blood volume within 24 hours

• Transfusion of ≥ 10 RBC units in 24 hours

• Accounts for 3 and 8% of civilian and military trauma admissions respectively





What is a massive transfusion protocol (MTP)?

A standardized method of treating patients identified to be at high risk for requiring a MT

Traditional approach to hemorrhage

Spahn DR and Rossaint R . Coagulopathy and blood component transfusion in trauma. British Journal of Anaesthesia2005;95:130-139.

©2006The Shock Society. Published by Lippincott Williams & Wilkins, Inc. 2

Table 1

THE CELLULAR, METABOLIC, AND SYSTEMIC CONSEQUENCES OF AGGRESSIVE FLUID RESUSCITATION STRATEGIES.Cotton, Bryan; Guy, Jeffrey; Morris, John; Abumrad, Naji

Shock. 26(2):115‐121, August 2006.DOI: 10.1097/01.shk.0000209564.84822.f2

Table 1 . Consequences of Aggressive Volume Resuscitation

What is included in a MTP?• Communication between clinical team and lab

• Laboratory monitoring of patient (PT, PTT, INR, platelet count, fibrinogen, hemoglobin)

• Blood product preparation and issuance

• Assessment of hospital inventory of components and prediction of patient’s future needs

• Other issues (prevention/treatment of hypothermia, acidosis, hypocalcemia, etc)




Why use a massive transfusion protocol (MTP)?

• Patients treated with MTP have improved survival and decreased organ failure compared to historical controls

• Provides organization for a potentially chaotic situation

• Prevents errors

• Standardization

• In a worldwide survey of hospitals 45% of respondents used a MTP, 19% sometimes used one, and 34% did not

Hoyt DB, Dutton RP, Hauser CJ, Hess JR, Holcomb JB, Kluger Y, Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, Bouillon B. Management of coagulopathy in the patients with multiple injuries: Results from an international survey of clinical practice. The Journal of Trauma 2009;66:346-352.

Examples of MTPs

1) Order components based on laboratory test results

2) Management by transfusion medicine physician

3) Transfuse predetermined ratios of components

4) Combination of above

Advantages of predetermined ratios

1) Early, aggressive blood product support

2) Decreased overall blood product usage

3) Improved patient outcome

4) Standardization

5) Decreased errors

Prediction of massive transfusion

Equations may include:

• Blood pressure• Heart rate• Base deficit• Gender• INR• Hemoglobin • Focused Assessment with Sonography in

Trauma (FAST) exam

Spinella PC and Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Reviews 2009;23:231-240.




Assessment of Blood Consumption (ABC)

• 1 point assigned for any of the following

• A total of ≥ 2 means activation of massive transfusion protocol

• 75% sensitivity and 86% specificity

1) Penetrating mechanism2) Positive FAST exam3) Arrival systolic BP of ≤ 90 mm Hg4) Arrival heart rate ≥ 120 bpm

Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD and Cotton BA. Early Prediction of Massive Transfusion in Tauma: Simple as ABC (Assessment of Blood Consumption). The Journal of Trauma 2009;66:346-352.

MT protocol• Transfusion of set ratio of RBCs, plasma, and platelets

upon admission

• Some using 1:1:1 ratio because it approximates reconstituted whole blood

• Use of O- or O+ RBCs

• Always use O- RBCs for women of childbearing years

• Use of thawed plasma


Thawed plasma• Takes 30 minutes to thaw plasma

• Shelf-life of plasma is 24 hours after thawing

• If relabel unit “Thawed plasma” can store for 5 days after thawing

• Some hospitals constantly keep thawed plasma on hand

• Smaller hospitals unable to do this due to wastage

• Need special labeling capabilities

• AB plasma is universal but limited availability (4% of donors)

• Some hospitals use A plasma (can be used for about 85% of patients)

Shaz BH, Dente CJ, Nicholas J, MacLeod JB, Young AN, Easley K, Ling Q, Harris RS, and Hillyer CD. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion2010;50:493-500.




© 2008 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 4

Fig. 3.

Postinjury Life Threatening Coagulopathy: Is 1:1 Fresh Frozen Plasma: Packed Red Blood Cells the Answer?Kashuk, Jeffry; Moore, Ernest; Johnson, Jeffrey; Haenel, James; Wilson, Michael; Moore, John; Cothren, C; Biffl, Walter; Banerjee, Anirban; Sauaia, Angela; MD, PhD

Journal of Trauma‐Injury Infection & Critical Care. 65(2):261‐271, August 2008.DOI: 10.1097/TA.0b013e31817de3e1

Fig. 3. Place of death for patients undergoing massive transfusion according to FFP:RBC ratio at 6 hours postinjury. Patients who died in the operating room were more likely to die from penetrating injuries and less likely to receive lower ratios of FFP:RBC.


Table 6

Postinjury Life Threatening Coagulopathy: Is 1:1 Fresh Frozen Plasma: Packed Red Blood Cells the Answer?Kashuk, Jeffry; Moore, Ernest; Johnson, Jeffrey; Haenel, James; Wilson, Michael; Moore, John; Cothren, C; Biffl, Walter; Banerjee, Anirban; Sauaia, Angela; MD, PhD

Journal of Trauma‐Injury Infection & Critical Care. 65(2):261‐271, August 2008.DOI: 10.1097/TA.0b013e31817de3e1

Table 6 FFP:RBC Ratio in Survivors vs. Nonsurvivors. A Comparison of FFP:RBC Transfusion Ratios in All Patients Demonstrates Significance of Additional FFP in the Survivor Group


FIGURE 1.

Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients.Holcomb, John; Wade, Charles; Michalek, Joel; Chisholm, Gary; Zarzabal, Lee; Schreiber, Martin; Gonzalez, Ernest; Pomper, Gregory; Perkins, Jeremy; Spinella, Phillip; Williams, Kari; Park, Myung

Annals of Surgery. 248(3):447‐458, September 2008.DOI: 10.1097/SLA.0b013e318185a9ad

FIGURE 1. Bubble plot of the relationship of mean center plasma to RBC ratio to survival. Size of circles represents the percentage of MT patients contributed by each center. Colors indicate 3 levels of injury severity scores.






FIGURE 2.



FIGURE 2. Kaplan‐Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio >=1:2, low plasma (FFPL) or platelet (PltL) to RBC ratio <1:2).


TABLE 4.



TABLE 4. Survival, Cause of Death, and Clinical Outcomes by Plasma and Platelet Ratio


FIGURE 3.



FIGURE 3. Kaplan‐Meier survival plot for the first 30 days after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio >=1:2, low plasma (FFPL) or platelet (PltL) to RBC ratio <1:2).

Cryoprecipitate• Traditional approach: give cryopool after fibrinogen <

100 mg/dl

• Practice based on expert opinion instead of data

• In retrospective review of military casualties increased transfusion of fibrinogen resulted in decreased death due to hemorrhage

• In military casualties treated with MT the amount of cryoprecipitate transfused within the first 24 hours was independently associated with improved 30-day survival







TABLE 1

Early Predictors of Massive Transfusion in Patients Sustaining Torso Gunshot Wounds in a Civilian Level I Trauma Center.Dente, Christopher; MD, FACS; Shaz, Beth; Nicholas, Jeffery; MD, FACS; Harris, Robert; Wyrzykowski, Amy; MD, FACS; Ficke, Brooks; Vercruysse, Gary; Feliciano, David; MD, FACS; Rozycki, Grace; MD, FACS; Salomone, Jeffrey; MD, FACS; Ingram, Walter; MD, FACS

Journal of Trauma‐Injury Infection & Critical Care. 68(2):298‐304, February 2010.DOI: 10.1097/TA.0b013e3181cf7f2a

TABLE 1 Massive Transfusion Protocol: Package Contents

Copyright restrictions may apply.

O'Keeffe, T. et al. Arch Surg 2008;143:686-691.

Massive Transfusion Protocol



Mortality in Pre- and Post-MTP Patient Populationsa






Differences in Units of Blood Component Transfused Between Groups



Blood Component Charges


Table 2Damage Control Hematology: The Impact of a Trauma Exsanguination Protocol on Survival and Blood Product Utilization.Cotton, Bryan; Gunter, Oliver; Isbell, James; Au, Brigham; Robertson, Amy; Morris, John; Jacques, Paul; Young, Pampee; MD, PhD

Journal of Trauma‐Injury Infection & Critical Care. 64(5):1177‐1183, May 2008.DOI: 10.1097/TA.0b013e31816c5c80

Table 2 Univariate Analyses of Primary and Secondary Outcome Measures


Fig. 1.Damage Control Hematology: The Impact of a Trauma Exsanguination Protocol on Survival and Blood Product Utilization.Cotton, Bryan; Gunter, Oliver; Isbell, James; Au, Brigham; Robertson, Amy; Morris, John; Jacques, Paul; Young, Pampee; MD, PhD

Journal of Trauma‐Injury Infection & Critical Care. 64(5):1177‐1183, May 2008.DOI: 10.1097/TA.0b013e31816c5c80

Fig. 1. Unadjusted initial 24‐hour blood product utilization before and after implementation of TEP. Each bar corresponds to the mean number of units transfused + standard deviation.




What is recombinant factor VIIa (rVIIa)?

http://intmedweb.wfubmc.edu/grand_rounds/2003/coumadindoc_files/image002.jpg. Accessed 2/22/2010.

When should rVIIa be used?

• Trials have been small

• According to Cochrane review: – No outcomes where any advantage or disadvantage

of rFVIIa over placebo– Trend in favor of rFVIIa for reducing mortality– Trend against rFVIIa for increased thromboembolic

adverse events – Use of rFVIIa outside its current licensed indications

should be restricted to clinical trials

Stanworth SJ, Birchall J, Doree CJ, Hyde C. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev:CD005011.

Remaining questions• What is the best method of determining when to activate the MT protocol?

• What is the best ratio of blood products to use?

• Should thawed AB plasma be stored in the ED or ambulances and helicopters? How will transfusion records be maintained? What about wastage?

• Are fresher RBCs associated with a better patient outcome?

• Should whole blood be used?

• When should cryoprecipitate be used? How much?

• How should fVIIa be used?

• Should this approach be used for other surgical patients?

• How is the success of the transfusion monitored?

Conclusion• Trauma patients are at high risk for death by hemorrhage due to the lethal triad of

acidosis, hypothermia, and coagulopathy

• Damage control resuscitation is a method of treating trauma patients

• Massive transfusion is the replacement of the patient’s total blood volume in 24 hours

• Massive transfusion often defined as transfusion of 10 units of RBCs within 24 hours

• Massive transfusion protocols may reduce mortality by identifying and aggressively treating certain patients

• Transfusion of a ratio of RBCs:plasma:platelets may reduce mortality and blood product usage; Some are using a 1:1:1 ratio

• The best use of cryoprecipitate and recombinant fVIIa is yet to be determined




Thank you

Image from http://isabellelorelai.files.wordpress.com/2009/03/donate-blood-2.jpg. Accessed 2/22/2010.

Documents

Massive Blood Transfusion - utcomchatt.org · • Replacement of total blood volume within 24 hours • Transfusion of ≥10 RBC units in 24 hours • Accounts for 3 and 8% of civilian