present

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

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