Massive Transfusion in the New Era

JHSGR 17 Apr 2010Dr J Leung

CMC

Outline

• Massive transfusion (MT)– Definition, conditions, outcomes– Coagulopathy

• Hemostatic resuscitation– Transfusion of FFP, Platelet and PRBC– Hypotensive resuscitation

• Massive transfusion protocol– Outcome, complications

Massive Transfusion - definition

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

Trauma

• The leading cause of death for Americans under 35 years old

Hemorrhage: 40% of all trauma deaths

Hemorrhage: 40% of all trauma deaths

The most common reason for massive transfusion

The most common reason for massive transfusion

Massive Transfusion - Outcomes

• Trauma patient: 19-84% mortality

MT and Outcome

MT and Outcome (cont’d)

Coagulopathy

• Hemorrhage -> Massive Transfusion -> coagulopathy upon or soon after admission

• Exacerbated by resuscitation with crystalloid & PRBC

Hemostatic Resuscitation

• Hemorrhage control• Normalization of body temperature• Early transfusion of FFP, platelets

FFP : Plt : PRBC

• 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

Mortality

Survival is associated with increased FFP & Platelet ratio

Best ratio 1:1:1

FFP : Plt : PRBC

Survivial

Early transfusion of high ratio of

FFP:Platelet:PRBC improved survival

Hemostatic Resuscitation

• 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

No consensus yetMore fluid: risk of hemodilution &

disruption of early hemostatic clotsVs

Limit fluid: prolonging shock & cellular ischemia may become

irreversible

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

MTP

J Am Coll Surg 2009;209: 198–205

• 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)

MTP -> Prompt availability of blood products -> improves

survival

Complications from MTP?

• More multi-organ failure / ARDS?

• 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)

Conclusion

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

Thank You