Massive transfusion: Difference between revisions

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==Background==
==Background==
•There is no universal definition for what a “massive transfusion” is or what a “massive transfusion protocol” should be.  The most common definition (utilized by ATLS) is any transfusion sequence that necessitates >10 units of packed red blood cells within a 24-hour period. <br>
*Although massive transfusion (MTP) does not have a universal definition, it is generally described as transfusion of >10 units of blood products (specifically [[Packed red blood cells]] within a 24-hour period.
•Pure pRBC transfusions in acute hemorrhagic shock do not address the coagulopathy in the “lethal trauma triad” (hypothermia, coagulopathy, acidosis) and has been associated with increased mortality.<br>
*In addition to controlling hemorrhage the greatest concern during MTP is the lethal triad:<ref>Kashuk JL, et al. Major abdominal vascular trauma — A unified approach. J Trauma. 1982;22(8):672–679.</ref>
•Instead, consider a “balanced resuscitation”<ref>Blood Rev. 2009 Nov;23(6):231-40. doi: 10.1016/j.blre.2009.07.003. Epub 2009 Aug 19</ref> which focuses on appropriate blood product ratios, avoidance of hemodilution with crystalloids, avoidance of hypocalcemia (citrate in blood products), and permissive hypotension, among other concerns.
*#Hypothermia
<br>
*#Coagulopathy
*#Acidosis
*During MTP, focus is on "balanced resuscitation" with clotting factors (FFP) and platelets”<ref>Spinella PC. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. Blood Rev. 2009 Nov;23(6):231-40.</ref>  
*The goal of MTP is to resuscitate and temporize management until definitive operative repair can be accomplished.
==Indications==
==Indications==
•Hemorrhagic shock is the only indication for a massive transfusion. <br>
*[[Hemorrhagic shock]] is the only indication for a massive transfusion.  
•[http://www.mdcalc.com/abc-score-assessment-of-blood-consumption-for-massive-transfusion/ ABC] score and the [http://www.mdcalc.com/tash-score-trauma-associated-severe-hemorrhage-for-massive-transfusion/ TASH] score predict need for MTP.
 
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==Management==
==Management==
•PROPPR trial<ref>JAMA. 2015 Feb 3;313(5):471-82. doi: 10.1001/jama.2015.12</ref> examined a 1:1:1 (FFP:PLT:pRBC) vs 1:1:2 protocol.  There was no difference in mortality at 1 or 30 days; however, the 1:1:1 group experienced less death due to exsanguination in the first day. <br>
*MTP should follow should follow local institutional protocols<ref>ACS TQIP Massive Transfusion in Trauma Guidelines [https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/massive%20transfusion%20in%20trauma%20guildelines.ashx fulltext]</ref>
•The goal of MTP is to resuscitate and temporize management until definitive operative repair can be accomplished.
*[[EBQ:PROPPR_Trial|The PROPPR trial]]<ref>Holcomb J. et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma The PROPPR Randomized Clinical Trial  JAMA. 2015 </ref> examined a 1:1:1 (FFP:PLT:pRBC) vs 1:1:2 protocol.  There was no difference in mortality at 1 or 30 days; however, the 1:1:1 group experienced less death due to exsanguination in the first day.  
<br>
==Additional Considerations==
==Additional Considerations==
•Tranexamic acid (TXA) lowers risk of death from exsanguination in trauma patients in the first day after injury (CRASH-2).<ref>J Trauma Acute Care Surg. 2015 Jun;78(6 Suppl 1):S70-5. doi:10.1097/TA.0000000000000640</ref> <br>
•Tranexamic acid (TXA) lowers risk of death from exsanguination in trauma patients in the first day after injury (CRASH-2).<ref>J Trauma Acute Care Surg. 2015 Jun;78(6 Suppl 1):S70-5. doi:10.1097/TA.0000000000000640</ref> <br>
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==See Also==
==See Also==
•[https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/massive%20transfusion%20in%20trauma%20guildelines.ashx FACS Statement on MTP]
 
<br>
•http://www.ncbi.nlm.nih.gov/pubmed/23375220 <br>
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 00:43, 6 September 2015

Background

  • Although massive transfusion (MTP) does not have a universal definition, it is generally described as transfusion of >10 units of blood products (specifically Packed red blood cells within a 24-hour period.
  • In addition to controlling hemorrhage the greatest concern during MTP is the lethal triad:[1]
    1. Hypothermia
    2. Coagulopathy
    3. Acidosis
  • During MTP, focus is on "balanced resuscitation" with clotting factors (FFP) and platelets”[2]
  • The goal of MTP is to resuscitate and temporize management until definitive operative repair can be accomplished.

Indications

Management

  • MTP should follow should follow local institutional protocols[3]
  • The PROPPR trial[4] examined a 1:1:1 (FFP:PLT:pRBC) vs 1:1:2 protocol. There was no difference in mortality at 1 or 30 days; however, the 1:1:1 group experienced less death due to exsanguination in the first day.

Additional Considerations

•Tranexamic acid (TXA) lowers risk of death from exsanguination in trauma patients in the first day after injury (CRASH-2).[5]
•Ongoing research focuses on using a strict ratio of blood products versus other laboratory values (ex: thromboelastography, TEG) to guide resuscitation with blood products. TEG has been extensively studied in cardiac surgery and was shown to out-perform physician preference for blood replacement [6] with respect to not over-administering blood.
•Factor VII, studied in the CONTROL trial, [7] showed no mortality benefit – in fact, to this effect, the study was terminated early. Other studies of Factor VII have raised concerns for MI and adverse thrombotic events.

See Also

References

  1. ↑ Kashuk JL, et al. Major abdominal vascular trauma — A unified approach. J Trauma. 1982;22(8):672–679.
  2. ↑ Spinella PC. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. Blood Rev. 2009 Nov;23(6):231-40.
  3. ↑ ACS TQIP Massive Transfusion in Trauma Guidelines fulltext
  4. ↑ Holcomb J. et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma The PROPPR Randomized Clinical Trial JAMA. 2015
  5. ↑ J Trauma Acute Care Surg. 2015 Jun;78(6 Suppl 1):S70-5. doi:10.1097/TA.0000000000000640
  6. ↑ Heart Lung Circ. 2009 Aug;18(4):277-88. doi: 10.1016/j.hlc.2008.08.016. Epub 2008 Dec 31.
  7. ↑ J Trauma. 2010 Sep;69(3):489-500. doi: 10.1097/TA.0b013e3181edf36e.
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