HEMORRHAGE RESUSCITATION AND MASSIVE TRANSFUSION PROTOCOLS
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HEMORRHAGE RESUSCITATIONAND
MASSIVE TRANSFUSION PROTOCOLS
CAPT William C. Brunner, MC, USNSenior Medical Officer, BSRF-2013
Assistant Professor, Department of Surgery
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Disclosures
The speaker has no relevant financial relationships with commercial interests that pertain to the content of this presentation
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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
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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
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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)
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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
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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
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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
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Integrated Response• Damage Control Surgery– Rapid, limited, forward
surgical care• Control bleeding• Control spillage• Control contamination• Restore perfusion
– Avoid unnecessary interventions
– Allow for resuscitation– Rapid evacuation
• Hemostatic Resuscitation– Limited volume– Permissive hypotension– Balanced transfusion
• High FFP:PRBC ratio– Colloid vs. crystalloid– Attenuate ATC– Expand resource
availability• Walking blood bank• Freeze-dried plasma
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Blood ComponentsComponent 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-reducedPRBCs
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 transfusion-associated sepsis
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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
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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
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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)
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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
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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
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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
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Massive Transfusion ProtocolPackage PRBCs (Units) FFP (Units) Platelets
(Units)Other
1 6 6
2 6 6 1 apheresis
3 6 6 CryoprecipitaterFVIIa
4 6 6 1 apheresis
5 6 6
6 6 6 1 apheresis CryoprecipitaterFVIIa
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.
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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
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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
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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 sub-MT trauma population
• Blood component substitutes• Crystalloid alternatives
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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.
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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.