Massive Transfusion Copy

8/11/2019 Massive Transfusion Copy

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Massive Transfusion


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Definition

>= 10 RBC units within 24 h

> 4 RBC units in 1 hr with anticipation

of continued need for transfusion

Replacement of > 50% of TBV within 3

hr


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Epidemiology of MT

Variety of clinical settings

Trauma, obstetric, major surgery

Uncontrolled bleeding

40% trauma related mortality

#1 cause of maternal mortality worldwide


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Pathophysiology changes


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3 components

ETIC (early trauma-induced coagulopathy) Tissue injurytissue factorcoagulationDIC

Hyperfibrinolysis Hypoperfusionthrombomodulin expression EC

enhance plasmin formationfibrinolysis

Prominent in obstetric haemorrhage

Infusion of crystalloid, bloods -> dilutionalcoagulopathy, acidosis, hypocalcemia &hypothermia


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Clinical Mx of MT

Massive transfusion protocol

Early recognition of pt requiring MT, facilitate

communications between different services

and avoid delay in clinical care

Demonstrated to improve patients survival,

reduced rates of organ failure.


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Blood products

Optimal transfusion ratio

Blood: plasma :platelets = 1: 1: 1 (645ml)

Resembles whole blood

Haematocrit 26%, coag activity 50% & plt

count of 90 000microL

Evidence supported by US military & then

civilian studies

Pragmatic Randomized Optimal Platelet&

Plasma Ratios (PROPPR)


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Trigger level for blood

components transfusion

Insufficient data to identify an INR,

fibrinogen level or platelet count to

trigger a blood component transfusion

NBA guidelines

Suggested doses

FFP 15ml/kg Platelets: 1 adult therapeutic dose

Cryoprecipitate 3-4 g


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Values indicative of critical

physiologic derangement

Temperature < 35

pH < 7.2, BE >-6, lactate >4

Ionised calcium < 1.1mmol/L

Plt count < 50x109/L

PT > 1.5 x normal

INR > 1.5

APTT > 1.5xnormal

Fibrinogen level < 1.0


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Pharmacological therapy

rFVIIa No effect on 48hr or 30 day mortality

Blunt trauma reduced RBC transfusion req& ARDS

Penetrating trauma no effect on morbidity

90mcg/kg

Prothombinex Indicated for warfarin reversal

Insufficient evidence to support the generaluse in MT


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Pharmacological therapy

TXA

CRASH 2 trial international multicentre RCT Improved survival in trauma patients

Obstetric setting Suggested reduces blood loss @ CS & the risk of progression

to severe PPH

RCT is currently investigating the effect of TXA in treatingPPH


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Laboratory monitoring

Assessment of status O2 carrying capacity, haemostasis, metabolic

Conventional testing has limited utility Coagulation panel

Not available in real time fashion

Do not detect all haemostatic abnormalities such ashyperfibrinolysis

Use of Point-of-care testing is increasing


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Laboratory monitoring

Thromboelastograph (TEG)

Point- of- care Haemostasis assay

Shorter turn-around time (15 mins)

Detect hyperfibrinolysis

Detect coagulopathy due to hypothermia

Shown to reduce transfusion requirement /MTin major surgery


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R = reaction time (s); time of latency from start of test to initial fibrin formation

K = kinetics (s); time taken to achieve a certain level of clot strength (amplitude of

20mm)

alpha = angle (slope between R and K); measures the speed at which fibrin build

up and cross linking takes place, hence assesses the rate of clot formationTMA = time to maximum amplitude(s)

MA = maximum amplitude (mm); represents the ultimate strength of the fibrin clot

A30 or LY30 = amplitude at 30 minutes; percentage decrease in amplitude at 30

minutes post-MA and gives measure of degree of fibrinolysis

CLT = clot lysis time (s)


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TEG AS A GUIDE TO TREATMENT

Increased R time => FFP

Decreased angle => cryopreciptate

Decreased MA => platelets (consider

DDAVP)

Fibrinolysis => transexamic acid (oraprotinin)


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Conclusions

MT protocol is important

Early transfusion of blood products in ratio of 1:1:1may reduce mortality & improve patient outcome butfurther RCT needed to determine optimal ratio

TXA improved survival in several RCT and should beused in MT

New laboratory monitoring, such as TEG mightimprove patient outcome when used in combinationwith MTP


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Reference

Update on Massive Transfusion. H.P Pham, B.H Shaz. Br. J. Anaesth. (2013)

111 (suppl 1): i71-i82.

Patient Blood Management Guidelines: Module 1. Critical Bleeding Massive

Transfusion. National Blood Authority, 2011.

Life in the

Fastlanehttp://lifeinthefastlane.com/education/ccc/thromboelastogram-teg/.
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