Massive transfusion

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Background

There’s 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.
•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.
•Instead, consider a “balanced resuscitation”[1] which focuses on blood product ratios, avoidance of hemodilution with crystalloids, avoidance of hypocalcemia (citrate in blood products), permissive hypotension, among other concerns.

Indications

•Hemorrhagic shock is the only indication for a massive transfusion.
ABC score and the TASH score predict need for MTP.

Management

•PROPPR trial[2] examined 1:1:1 (FFP:PLT:pRBC) vs 1:1:2 -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.
•Goal of MTP is to resuscitate and temporize management until definitive operative repair can be accomplished.

Additional Considerations

•Tranexamic acid (TXA) lowers risk of death from exsanguination in trauma patients in the first day after injury (CRASH-2).
•Ongoing research focuses on using a strict ratio of blood products versus other laboratory values (ex: thromboelastography, TEG) to guide (ie initiate or terminate) resuscitation with blood products. TEG has been extensively studied in cardiac surgery and was shown to out-perform physician preference for blood replacement with respect to not over-administering blood.
•Factor VII, studied in the CONTROL trial , 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

FACS Statement on MTP

References

  1. Blood Rev. 2009 Nov;23(6):231-40. doi: 10.1016/j.blre.2009.07.003. Epub 2009 Aug 19
  2. JAMA. 2015 Feb 3;313(5):471-82. doi: 10.1001/jama.2015.12