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Easterday T, Byerly S, Magnotti L, Fischer P, Shah K, Croce M, Kerwin A, Howley I. Performance Improvement Program Review of Institutional Massive Transfusion Protocol Adherence: An Opportunity for Improvement. Am Surg 2024; 90:1082-1088. [PMID: 38297889 DOI: 10.1177/00031348221114036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Given the acuity of patients who receive MTPs and the resources they require, MTPs are a compelling target for performance improvement. This study evaluated adherence with our MTP's plasma:red blood cell ratio (FFPR) of 1:2 and platelet:red blood cell ratio (PLTR) of 1:12, to test the hypothesis that ratio adherence is associated with lower inpatient mortality. MATERIALS AND METHODS The registry of an urban level I trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 hours of presentation. Patients were excluded for interfacility transfer, cardiac arrest during the prehospital phase or within one hour of arrival, or for head AIS ≥5. Univariate analysis and multiple logistic regressions were performed to identify variables associated with early transfusion protocol noncompliance and the effect on inpatient mortality. RESULTS Three hundred and eighty-three patients were included, with mean ISS of 25.9 ± 13.3 and inpatient mortality of 28.5%. Increasing age, ISS, INR, and total units of blood product transfused were associated with increased odds of mortality, while an increase in revised trauma score was associated with a decreased odds ratio of mortality. Achieving our goal ratios were protective against mortality, with OR of .451 (P = .013) and .402 (P=.003), respectively. DISCUSSION Large proportions of critically injured patients were transfused fewer units of plasma and platelets than our MTP dictated; failure to achieve intended ratios at 4 hours was strongly associated with inpatient mortality. MTP processes and outcomes should be critically assessed on a regular basis as part of a mature performance improvement program to ensure protocol adherence and optimal patient outcome.
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Affiliation(s)
- Thomas Easterday
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya Byerly
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Louis Magnotti
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter Fischer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kinjal Shah
- Department of Pathology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Martin Croce
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew Kerwin
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac Howley
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
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2
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Shen A, Di Meo B, Perez IA, Hashim Y, Ko A, Margulies DR, Klapper EB, Barmparas G. Reconsidering Fresh Frozen Plasma Availability to Reduce Blood Product Waste During Massive Transfusion Events in Trauma. Am Surg 2024:31348241248811. [PMID: 38658467 DOI: 10.1177/00031348241248811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Within component therapy of massive transfusion protocol (MTP) in trauma, thawed plasma is particularly susceptible to expiring without use given its short 5-day shelf life. Optimizing the number of thawed products without compromising safety is important for hospital resource management. The goal is to examine thawed plasma utilization rates in trauma MTP events and optimize the MTP cooler content at our Level I trauma center. METHODS Trauma MTP activations from 01/2019 to 12/2022 were retrospectively reviewed. During the study period, blood products were distributed in a 12:12:1 ratio of packed red blood cells (pRBC): plasma: platelets per cooler, with up to 4 additional units of low-titer, group O whole blood (LTOWB) available. The primary measure was percent return of unused, thawed plasma. RESULTS There were 367 trauma MTP activations with a median (IQR) activation call-to-first cooler delivery time of 8 (6-10) minutes. 73.0% of thawed plasma was returned to the blood bank unused. In one third of MTP activations, all dispensed plasma was returned. The majority (74.1%) of patients required 6 or fewer units of plasma. In 81.5% of activations, 10 or fewer units of plasma and 10 or fewer units of pRBC were used. DISCUSSION The majority of trauma MTP requirements may be accommodated with a reduced cooler content of 6 units pRBC, 6 units plasma, and 1 pheresis platelets, buffered by up to 4 units LTOWB (approximates 4 units of pRBC/4 units plasma), in conjunction with a sub-10min cooler delivery time. Follow-up longitudinal studies are needed.
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Affiliation(s)
- Aricia Shen
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brent Di Meo
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ingrid A Perez
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yassar Hashim
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ara Ko
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ellen B Klapper
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Keltner NM, Cushing MM, Haas T, Spinella PC. Analyzing and modeling massive transfusion strategies and the role of fibrinogen-How much is the patient actually receiving? Transfusion 2024. [PMID: 38433522 DOI: 10.1111/trf.17774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable death in trauma, cardiac surgery, liver transplant, and childbirth. While emphasis on protocolization and ratio of blood product transfusion improves ability to treat hemorrhage rapidly, tools to facilitate understanding of the overall content of a specific transfusion strategy are lacking. Medical modeling can provide insights into where deficits in treatment could arise and key areas for clinical study. By using a transfusion model to gain insight into the aggregate content of massive transfusion protocols (MTPs), clinicians can optimize protocols and create opportunities for future studies of precision transfusion medicine in hemorrhage treatment. METHODS The transfusion model describes the individual round and aggregate content provided by four rounds of MTP, illustrating that the total content of blood elements and coagulation factor changes over time, independent of the patient's condition. The configurable model calculates the aggregate hematocrit, platelet concentration, percent volume plasma, total grams and concentration of citrate, percent volume anticoagulant and additive solution, and concentration of clotting factors: fibrinogen, factor XIII, factor VIII, and von Willebrand factor, provided by the MTP strategy. RESULTS Transfusion strategies based on a 1:1:1 or whole blood foundation provide between 13.7 and 17.2 L of blood products over four rounds. Content of strategies varies widely across all measurements based on base strategy and addition of concentrated sources of fibrinogen and other key clotting factors. DISCUSSION Differences observed between modeled transfusion strategies provide key insights into potential opportunities to provide patients with precision transfusion strategy.
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Affiliation(s)
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine and Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Thorsten Haas
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Einerson BD, Healy AJ, Lee A, Warrick C, Combs CA, Hameed AB. Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum. Am J Obstet Gynecol 2024; 230:B2-B11. [PMID: 37678646 DOI: 10.1016/j.ajog.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.
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Hairston HC, Ipe TS, Burdine L, Sexton K, Reif R, Jensen H, Kalkwarf KJ. Incidence of Red Cell Antibody Formation Following Massive Transfusion Protocol: Experience of a Single Institution. Am Surg 2023; 89:4715-4719. [PMID: 36169356 DOI: 10.1177/00031348221129500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack. MATERIALS AND METHODS We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe. RESULTS Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens. DISCUSSION Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells.
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Affiliation(s)
| | - Tina S Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lyle Burdine
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kevin Sexton
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca Reif
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hanna Jensen
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle J Kalkwarf
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Di Mascio N, Walsh D, Higgins N. Thromboelastometry-guided treatment algorithm in postpartum haemorrhage. Comment on Br J Anaesth 2023; 130: 165-74. Br J Anaesth 2023; 130:e456-e458. [PMID: 36925328 DOI: 10.1016/j.bja.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 01/24/2023] [Accepted: 02/13/2023] [Indexed: 03/15/2023] Open
Affiliation(s)
| | - Don Walsh
- National Maternity Hospital, Dublin, Ireland
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Parker MJ, Crowder EW, Miles MVP, Harrell KN, Maxwell RA. Hypofibrinogenemic Massive Transfusion Trauma Patients Experience Worse Outcomes. Am Surg 2023:31348231162711. [PMID: 36908225 DOI: 10.1177/00031348231162711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Uncontrolled hemorrhage accounts for up to 40% of trauma-related mortality. Previous reports demonstrate that decreased fibrinogen levels during traumatic hemorrhage are associated with worse outcomes. Cryoprecipitate is used to replace fibrinogen for patients in hemorrhagic shock undergoing massive transfusion (MT), though the optimal ratio of cryoprecipitate to fresh frozen plasma (FFP), packed red blood cells (PRBCs), and platelets remains undefined. The purpose of this study is to investigate the effect of admission fibrinogen level and the use of cryoprecipitate on outcomes in trauma patients undergoing MT. METHODS A prospective practice management guideline was established to obtain fibrinogen levels on adult trauma patients undergoing MT at a level I trauma center from December 2019 to December 2021. Ten units of cryoprecipitate were administered every other round of MT. Thromboelastography (TEG) was also obtained at the initiation and completion of MT. Patient demographic, injury, transfusion, and outcome data were collected. Hypofibrinogenemic (<200 mg/dL) patients at initiation of MT were compared to patients with a level of 200 mg/dL or greater. RESULTS A total of 96 out of 130 patients met criteria and underwent MT with a median admission fibrinogen of 170.5 mg/dL. Hypofibrinogenemia was associated with elevated INR (1.26 vs 1.13, P < .001) and abnormal TEG including decreased alpha angle (68.1 vs 73.3, P < .001), increased K time (1.7 vs 1.1, P < .001), and decreased max amplitude (58 vs 66, P < .001). Patients with hypofibrinogenemia received more PRBC (10 vs 7 U, P = .002), FFP (9 vs 6 U, P = .003), and platelets (2 vs 1 U, P = .004) during MT. Hypofibrinogenemic patients demonstrated greater mortality than patients with normal levels (50% vs 23.5%, P = .021). Older age, decreased GCS, and elevated injury severity score (ISS) were risk factors for mortality. Increased fibrinogen was associated with lower odds of mortality (P = .001). Age, ISS, and fibrinogen level remained significantly associated with mortality in a multivariable analysis. Overall, fibrinogen in post-MT survivors showed an increase in median level compared to admission (231 vs 177.5 mg/dL, P < .001). CONCLUSION Trauma patients undergoing MT with decreased admission fibrinogen demonstrate increased mortality. Other mortality risk factors include older age, decreased GCS, and higher ISS. Patients with increased fibrinogen levels had lower odds of mortality in a multivariable model. Post-MT survivors demonstrated significantly higher fibrinogen levels than pre-MT patients. Hypofibrinogenemic patients also had worse TEG parameters and required more PRBCs, FFP, and platelets during MT. Further studies are needed to assess the optimal volume of fibrinogen replacement with cryoprecipitate during MT to improve trauma patient mortality.
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Affiliation(s)
- Mitchell J Parker
- Department of Surgery, Division of Trauma and Acute Care Surgery, 70274University of Tennessee Health Science Center, Chattanooga, TN, USA
| | - Elizabeth W Crowder
- Department of Surgery, Division of Trauma and Acute Care Surgery, 70274University of Tennessee Health Science Center, Chattanooga, TN, USA
| | - M Victoria P Miles
- Department of Surgery, Division of Trauma and Acute Care Surgery, 70274University of Tennessee Health Science Center, Chattanooga, TN, USA
| | - Kevin N Harrell
- Department of Surgery, Division of Trauma and Acute Care Surgery, 70274University of Tennessee Health Science Center, Chattanooga, TN, USA
| | - Robert A Maxwell
- Department of Surgery, Division of Trauma and Acute Care Surgery, 70274University of Tennessee Health Science Center, Chattanooga, TN, USA
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Stoneham MD, Barbosa A, Maher K, Douglass P, Desborough MJR, Von Kier S. Intraoperative cell salvage using swab wash and serial thromboelastography in elective abdominal aortic aneurysm surgery involving massive blood loss. Br J Haematol 2023; 200:652-659. [PMID: 36253085 DOI: 10.1111/bjh.18523] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/29/2022]
Abstract
The loss of 50% blood volume is one accepted definition of massive haemorrhage, which ordinarily would trigger the massive transfusion protocol, involving the administration of high ratios of fresh frozen plasma and platelets to allogeneic red cells. We investigated 53 patients who experienced >50% blood loss during open elective abdominal aortic aneurysm surgery to assess allogeneic blood component usage and coagulopathy. Specialist patient blood management practitioners used a tailored cell salvage technique including swab wash to maximise blood return. We assessed the proportion of patients who did not require allogeneic blood components and develop evidence of coagulopathy by thromboelastography (TEG) parameters. Blood loss was 50%-174% (mean [SD] 68% [27%]) of blood volume. The mean (SD) intraoperative decrease in haemoglobin concentration, assessed by arterial blood gas analysis, was 5 (13) g/l. No patient received allogeneic red cells intraoperatively. Four of the 53 (8%) patients received blood components in the first 24 h postoperatively at the anaesthetists' discretion. No patient had intraoperative TEG changes indicative of fibrinolysis or coagulopathy. The 30-day mortality was 2% (one of 53). Reduction of allogeneic transfusion is one aim of patient blood management techniques. We have demonstrated virtual avoidance of allogeneic blood product transfusion despite massive blood loss. These data show possible alternatives to the current massive transfusion protocols to the management of elective vascular surgical patients.
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Affiliation(s)
- Mark D Stoneham
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antonio Barbosa
- Haemostasis and Blood Conservation Service, John Radcliffe Hospital, Oxford, Oxon, UK
| | - Keith Maher
- Haemostasis and Blood Conservation Service, John Radcliffe Hospital, Oxford, Oxon, UK
| | - Paul Douglass
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael J R Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Steve Von Kier
- Haemostasis and Blood Conservation Service, John Radcliffe Hospital, Oxford, Oxon, UK
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Simmons K, Piotrowski M, Kweeder S, Lightcap A, Brown L. Implementation of a Multimodal Interdisciplinary Massive Transfusion Protocol Educational Bundle Improves Knowledge and Self-Efficacy. J Perianesth Nurs 2023; 38:398-403. [PMID: 36631375 DOI: 10.1016/j.jopan.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/25/2022] [Accepted: 08/10/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Critical events in the operative setting require rapid management to prevent adverse outcomes. This article describes a multimodal educational bundle that was designed and implemented to improve readiness to respond to crises involving significant blood loss. Intended outcomes of this project were to increase knowledge and self-efficacy of anesthesia providers and perioperative staff members related to the use of the massive transfusion protocol (MTP). DESIGN This is a quality improvement (QI) project. METHODS A two-part educational bundle consisted of pre-education and low-fidelity simulation (LFS) via computer-based training (CBT) modules followed by hands-on skills sessions. Anesthesia providers, registered nurses, and technicians in the operative suite completed the educational intervention. Knowledge and self-efficacy were measured pre-and-post intervention. FINDINGS After completing the educational bundle, the aggregated mean score on a knowledge test increased by 5.65%. Self-efficacy related to role-specific responsibilities and confidence regarding the team's ability to carry out the MTP significantly increased for all participants (n = 62). CONCLUSIONS This project serves as an example of how a multimodal educational bundle can improve knowledge, confidence, and readiness to respond to critical events. This model demonstrates how pre-education and LFS enable crisis management training to be readily accessible for an entire interdisciplinary team.
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Affiliation(s)
- Kristen Simmons
- College of Nursing, Thomas Jefferson University, Philadelphia, PA.
| | | | | | | | - Lauren Brown
- College of Nursing, Thomas Jefferson University, Philadelphia, PA
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10
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Berková J, Kočí J. Massive transfusion protocol. Rozhl Chir 2023; 102:189-193. [PMID: 37527944 DOI: 10.33699/pis.2023.102.5.189-193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
The management of severe traumatic bleeding includes damage control resuscitation procedures including, in addition to surgical bleeding control, the application of the massive transfusion protocol. The aim of this paper is to present the massive transfusion protocol and selected scoring systems for an early detection of patients with severe post-traumatic bleeding. The use of a standardized protocol to activate the massive transfusion protocol reduces lethality due to severe traumatic bleeding and the consumption of blood products in trauma centers.
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Uchida K, Mizobata Y. Warning about potential incidents of critical hyperkalemia during massive transfusion protocol after the preservation period of red blood cell products was extended in Japan. Acute Med Surg 2023; 10:e882. [PMID: 37577335 PMCID: PMC10413817 DOI: 10.1002/ams2.882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/01/2023] [Accepted: 07/24/2023] [Indexed: 08/15/2023] Open
Abstract
Background Recently, the Japanese Red Cross Society approved extension of the preservation period of red blood cell products. Since then, we have already experienced two cases of critical hyperkalemia during massive transfusion protocol (MTP). Case Presentation Case 1, a 24-year-old man was stabbed in his right posterior chest. Although quick hemorrhage control was completed 35 min after arrival, his potassium level increased from 3.5 to 8.9 mEq/L within 40 min. Case 2, a 44-year-old man was transferred to our hospital after a car hit him. We immediately started resuscitation including MTP and opened his abdomen 24 min after arrival. His potassium level increased from 3.5 to 7.8 mEq/L within 38 min. Conclusion Although several other factors might be causing this rise in potassium, we consider the extended preservation periods of red blood cell products to be one cause of these unexpectedly rapid rises in potassium during MTP.
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Affiliation(s)
- Kenichiro Uchida
- Department of Traumatology and Critical Care Medicine, Graduate School of MedicineOsaka Metropolitan UniversityOsakaJapan
| | - Yasumitsu Mizobata
- Department of Traumatology and Critical Care Medicine, Graduate School of MedicineOsaka Metropolitan UniversityOsakaJapan
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Gatta LA, Weber JM, Gilner JB, Lee PS, Grotegut CA, Herbert KA, Bashir M, Pieper CF, Ronald J, Pabon-Ramos W, Habib AS, Strickland KC, Secord AA, James AH. Transfusion Requirements with Hybrid Management of Placenta Accreta Spectrum Incorporating Targeted Embolization and a Selective Use of Delayed Hysterectomy. Am J Perinatol 2022; 29:1503-1513. [PMID: 35973741 PMCID: PMC10035416 DOI: 10.1055/s-0042-1754321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy. STUDY DESIGN This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition. RESULTS Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts. CONCLUSION A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases. KEY POINTS · An algorithm with delayed hysterectomy had less transfusion in scheduled, but not unscheduled, cases.. · Over time, more cases were managed per algorithm; among scheduled cases, the transfusion rate and volume transfused decreased.. · There were similar transfusion outcomes among off-algorithm cases, regardless if delivery was scheduled..
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Affiliation(s)
- Luke A. Gatta
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, North Carolina
| | - Jennifer B. Gilner
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Paula S. Lee
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Gynecologic Oncology, Duke University Hospital, Durham, North Carolina
| | - Chad A. Grotegut
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | | | - Mustafa Bashir
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Carl F. Pieper
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - James Ronald
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Waleska Pabon-Ramos
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Ashraf S. Habib
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina
| | - Kyle C. Strickland
- Department of Pathology, Duke University Hospital, Durham, North Carolina
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Gynecologic Oncology, Duke University Hospital, Durham, North Carolina
| | - Andra H. James
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
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Kumaraswami S, Butwick A. Latest advances in postpartum hemorrhage management. Best Pract Res Clin Anaesthesiol 2022; 36:123-34. [PMID: 35659949 DOI: 10.1016/j.bpa.2022.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/20/2022]
Abstract
Hemorrhage is the leading cause of maternal mortality worldwide. A maternal health priority is improving how healthcare providers prevent and manage postpartum hemorrhage (PPH). Because anesthesiologists can help facilitate how hospitals develop approaches for PPH prevention and anticipatory planning, we review the potential utility of PPH risk-assessment tools, bundles, and protocols. Anesthesiologists rely on clinical and diagnostic information for initiating and evaluating medical management. Therefore, we review modalities for measuring blood loss after delivery, which includes visual, volumetric, gravimetric, and colorimetric approaches. Point-of-care technologies for assessing changes in central hemodynamics (ultrasonography) and coagulation profiles (rotational thromboelastometry and thromboelastography) are also discussed. Anesthesiologists play a critical role in the medical and transfusion management of PPH. Therefore, we review blood ordering and massive transfusion protocols, fixed-ratio vs. goal-directed transfusion approaches, coagulation changes during PPH, and the potential clinical utility of the pharmacological adjuncts, tranexamic acid, and fibrinogen concentrate.
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14
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Yang CX, Lin PC, Chang CC, Tsai HW, Sun JT. The impact of the COVID-19 outbreak on activation of the massive transfusion protocol in the emergency department. Vox Sang 2022; 117:729-732. [PMID: 34984685 DOI: 10.1111/vox.13238] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES An outbreak of coronavirus disease 2019 (COVID-19) occurred in mid-May of 2021 in Taiwan. After 2 months of hard work, transmissions were successfully prevented and the number of newly confirmed COVID-19 cases fell remarkably. We evaluated the impact of this outbreak on the massive transfusion protocol (MTP) in the emergency department (ED) of a trauma centre. MATERIALS AND METHODS We retrospectively compared the activation and efficacy of MTP before, during and after the outbreak by analysing the clinical data relevant to MTP activations. RESULTS There was no remarkable change in the average number of MTP triggers per month during the outbreak. The interval from an MTP trigger to the first unit of blood transfused at bedside was significantly increased during the outbreak compared to that before the outbreak (22.4 min vs. 13.9 min, p < 0.001); while the 24-h survival rate decreased (57.1% vs. 71.1%, p = 0.938). There were no remarkable changes in blood unit return or wastage during the outbreak. CONCLUSION The COVID-19 outbreak limitedly affected MTP activation and waste of blood products, but significantly increased the interval from an MTP trigger to the first unit of blood transfused at bedside.
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Affiliation(s)
- Cheng-Xin Yang
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Pei-Chin Lin
- Department of Clinical Pathology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Chih-Chun Chang
- Department of Clinical Pathology, Far Eastern Memorial Hospital, New Taipei, Taiwan.,Department of Nursing, Cardinal Tien Junior College of Healthcare and Management, Yilan, Taiwan
| | - Huang-Wen Tsai
- Division of Pediatric Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei, Taiwan.,Division of Trauma, Department of Surgery, Far Eastern Memorial Hospital, New Taipei, Taiwan
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- The Transfusion Committee, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Jen-Tang Sun
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan.,College of Medicine, Tzu Chi University, Hualien, Taiwan
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15
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Williams J, Gustafson M, Bai Y, Prater S, Wade CE, Guillamondegui OD, Khan M, Brenner M, Ferrada P, Roberts D, Horer T, Kauvar D, Kirkpatrick A, Ordonez C, Perreira B, Priouzram A, Duchesne J, Cotton BA. Limitations of Available Blood Products for Massive Transfusion During Mass Casualty Events at US Level 1 Trauma Centers. Shock 2021; 56:62-69. [PMID: 33470606 PMCID: PMC8601667 DOI: 10.1097/shk.0000000000001719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/26/2019] [Accepted: 01/04/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Exsanguination remains a leading cause of preventable death in traumatically injured patients. To better treat hemorrhagic shock, hospitals have adopted massive transfusion protocols (MTPs) which accelerate the delivery of blood products to patients. There has been an increase in mass casualty events (MCE) worldwide over the past two decades. These events can overwhelm a responding hospital's supply of blood products. Using a computerized model, this study investigated the ability of US trauma centers (TCs) to meet the blood product requirements of MCEs. METHODS Cross-sectional survey data of on-hand blood products were collected from 16 US level-1 TCs. A discrete event simulation model of a TC was developed based on historic data of blood product consumption during MCEs. Each hospital's blood bank was evaluated across increasingly more demanding MCEs using modern MTPs to guide resuscitation efforts in massive transfusion (MT) patients. RESULTS A total of 9,000 simulations were performed on each TC's data. Under the least demanding MCE scenario, the median size MCE in which TCs failed to adequately meet blood product demand was 50 patients (IQR 20-90), considering platelets. Ten TCs exhaust their supply of platelets prior to red blood cells (RBCs) or plasma. Disregarding platelets, five TCs exhausted their supply of O- packed RBCs, six exhausted their AB plasma supply, and five had a mixed exhaustion picture. CONCLUSION Assuming a TC's ability to treat patients is limited only by their supply of blood products, US level-1 TCs lack the on-hand blood products required to adequately treat patients following a MCE. Use of non-traditional blood products, which have a longer shelf life, may allow TCs to better meet the blood product requirement needs of patients following larger MCEs.
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Affiliation(s)
- James Williams
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Michael Gustafson
- Duke University Pratt School of Engineering, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Yu Bai
- Pathology and Laboratory Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Emergency Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Samuel Prater
- Department of Emergency Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The Red Duke Trauma Institute at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - Charles E. Wade
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | | | - Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - Derek Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cali, Valle del Cauca, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Bryan A. Cotton
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The Red Duke Trauma Institute at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
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16
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Kolodziej JH, Leonard JC, Josephson CD, Gaines BA, Wisniewski SR, Yazer MH, Spinella PC. Survey to inform trial of low-titer group O whole-blood compared to conventional blood components for children with severe traumatic bleeding. Transfusion 2021; 61 Suppl 1:S43-S48. [PMID: 34269453 DOI: 10.1111/trf.16460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Low-titer group O whole-blood (LTOWB) is being used for children with life-threatening traumatic bleeding. A survey was conducted to determine current LTOWB utilization and interest in participation in a randomized control trial (RCT) of LTOWB versus standard blood component transfusion in this population. STUDY DESIGN AND METHODS Transfusion medicine (TM) directors and pediatric trauma directors at 36 US children's hospitals were surveyed by e-mail in June 2020. Hospitals were selected by participation in the Massive Transfusion Epidemiology and Outcomes in Children Study or being among the largest 30 children's hospitals by bed capacity per the Becker Hospital Review. RESULTS The response rate was 83.3% (30/36) from TM directors and 88.9% (32/36) from trauma directors. The median of massive transfusion protocol activations for traumatic bleeding was reported as 12 (IQR 5.8-20) per year by TM directors. LTOWB was used by 18.8% (6/32) of trauma directors. Survey responses indicate that 86.7% (26/30) of TM directors and 90.6% (29/32) of trauma directors either moderately or strongly agree that a LTOWB RCT is important to perform. About 83.3% (25/30) of TM directors and 93.8% (30/32) of trauma directors were willing to participate in the proposed trial. About 80% (24/30) of TM directors and 71.9% (23/32) of trauma directors would transfuse RhD+ LTOWB to male children, but fewer would transfuse Rh + LTOWB to females [20% (6/30) TM directors and 37.5% (12/32) of trauma directors]. CONCLUSIONS A majority of respondents supported an RCT comparing LTOWB to component therapy in children with severe traumatic bleeding.
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Affiliation(s)
- Julia H Kolodziej
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Julie C Leonard
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Barbara A Gaines
- Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Mark H Yazer
- Division of Transfusion Medicine, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
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17
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Hagen KG, Strandenes G, Kristoffersen EK, Braathen H, Sivertsen J, Bjerkvig CK, Sommerfelt-Pettersen N, Aasheim IB, Lunde THF, Hervig T, Apelseth TO. A whole blood based resuscitation strategy in civilian medical services: Experience from a Norwegian hospital in the period 2017-2020. Transfusion 2021; 61 Suppl 1:S22-S31. [PMID: 34269432 DOI: 10.1111/trf.16490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding. Low titer group O whole blood was introduced as the primary blood product for resuscitation of massive hemorrhage at Haukeland University Hospital, Bergen, Norway, in December 2017. In this report, we describe the whole blood program and present results from the first years of routine use. STUDY DESIGN AND METHODS Patients who received whole blood from December 2017 to April 2020 were included in our quality registry for massive transfusions. Post-transfusion blood samples were collected to analyze isohemagglutinin (anti-A/-B) and hemolysis markers. Administration of other blood products, transfusion reactions, and patient survival (days 1 and 30) were recorded. User experiences were surveyed for both clinical and laboratory staff. RESULTS Two hundred and five patients (64% male and 36% female) received 836 units in 226 transfusion episodes. Patients received a mean of 3.7 units (range 1-35) in each transfusion episode. The main indications for transfusion were trauma (26%), gastrointestinal (22%), cardiothoracic/vascular (18%), surgical (18%), obstetric (11%), and medical (5%) bleeding. There was no difference in survival between patients with blood type O when compared with non-group O. Haptoglobin level was lower in the transfusion episodes for non-O group patients, however no clinical hemolysis was reported. No patients had conclusive transfusion-associated adverse events. Both clinical and laboratory staff preferred whole blood to component therapy for massive transfusion. DISCUSSION The experience from Haukeland University Hospital indicates that whole blood is feasible, safe, and effective for in-hospital treatment of bleeding.
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Affiliation(s)
- Kristin Gjerde Hagen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Sessvollmoen, Norway
| | - Einar Klaeboe Kristoffersen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Hanne Braathen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Joar Sivertsen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Christopher Kalhagen Bjerkvig
- Institute of Clinical Science, University of Bergen, Bergen, Norway.,Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | | | - Irmelin Beathe Aasheim
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Turid Helen Felli Lunde
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway.,Laboratory of Immunology and Transfusion Medicine, Haugesund Hospital, Haugesund, Norway
| | - Torunn Oveland Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Sessvollmoen, Norway
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18
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Rosenberger M, Lo J, Hinika G, Shenouda M, Salibian M. A Case of Aggressive Resuscitation and Timely Surgical Intervention to Reverse Severe Acidosis After Multiple Gunshot Wounds to the Chest, Abdomen, and Left Shoulder With a Bullet Fragment Retained in the Heart. Cureus 2021; 13:e16362. [PMID: 34395139 PMCID: PMC8360325 DOI: 10.7759/cureus.16362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/09/2022] Open
Abstract
The lethal triad of coagulopathy, hypothermia, and acidosis is a well-known cause of severe deterioration and poor prognosis in trauma patients. The presence of this triad complicates the surgical management of a patient suffering from penetrating injury and hemorrhage. Here, we report the case and management of a 44-year-old man with multiple high-caliber gunshot wound (GSW) injuries who became severely acidotic (pH <6.8) with hemorrhagic shock in the setting of massive hemorrhage due to penetrating chest and abdominal trauma. The patient sustained one high-caliber GSW to the left upper quadrant of the abdomen, one high-caliber GSW to the left periumbilical region of the abdomen, one high caliber GSW to the fourth intercostal space of the left chest just medial to the midclavicular line with an expanding hematoma, and one high-caliber GSW to the left shoulder with a floating left shoulder. He arrived at the Emergency Department conscious with a stable pulse but quickly became hemodynamically unstable. He required a thoracotomy and exploratory laparotomy in addition to a massive transfusion protocol. This case demonstrates the reversal of a severely acidotic patient due to massive hemorrhage to a blood pH within normal limits using damage control resuscitation surgery and massive transfusion protocols. The patient has since been discharged home in a stable condition with minimal long-term sequelae.
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Affiliation(s)
| | - Jonathan Lo
- Medical Education, Ross University School of Medicine, Miramar, USA
| | - Gudata Hinika
- Department of Surgery, California Hospital Medical Center, Los Angeles, USA
| | - Monika Shenouda
- Department of Surgery, California Hospital Medical Center, Los Angeles, USA
| | - Moses Salibian
- Department of Surgery, California Hospital Medical Center, Los Angeles, USA
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19
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Abstract
INTRODUCTION Acute hemorrhage is a global healthcare issue, and remains the leading preventable cause of death in trauma. Acute severe hemorrhage can be related to traumatic, peripartum, gastrointestinal, and procedural causes. Hemostatic defects occur early in patients requiring massive transfusion. Early recognition and treatment of hemorrhage and hemostatic defects are required to save lives and to achieve optimal patient outcomes. AREAS COVERED This review discusses current evidence and trials aimed at identifying the optimal treatment for hemostatic defects in hemorrhage and massive transfusion. Literature search included PubMed and Embase. EXPERT OPINION Patients with acute hemorrhage requiring massive transfusion commonly develop coagulopathy due to specific hemostatic defects, and accurate diagnosis and prompt correction are required for definitive hemorrhage control. Damage control resuscitation and massive transfusion protocols are optimal initial treatment strategies, followed by goal-directed individualized resuscitation using real-time coagulation monitoring. Distinct phenotypes exist in trauma-induced coagulopathy, including 'Bleeding' or 'Thrombotic' phenotypes, and hyperfibrinolysis vs. fibrinolysis shutdown. The trauma 'lethal triad' (hypothermia, coagulopathy, acidosis) has been updated to the 'lethal diamond' (including hypocalcemia). A number of controversies in optimal management exist, including whole blood vs. component therapy, use of factor concentrates vs. blood products, optimal use of tranexamic acid, and prehospital plasma and tranexamic acid administration.
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Affiliation(s)
- Lena M Napolitano
- Department of Surgery, University of Michigan Health System, University Hospital, Ann Arbor, Michigan, USA
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20
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Paganini M, Abowali H, Bosco G, Balouch M, Enten G, Deng J, Shander A, Ciesla D, Wilson J, Camporesi E. Quality Improvement Project of a Massive Transfusion Protocol (MTP) to Reduce Wastage of Blood Components. Int J Environ Res Public Health 2021; 18:ijerph18010274. [PMID: 33401395 PMCID: PMC7795105 DOI: 10.3390/ijerph18010274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/11/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022]
Abstract
Massive transfusion protocols (MTPs) facilitate the organized delivery of blood components for traumatically injured patients. MTPs vary across institutions, and ratios of blood components can change during clinical management. As a result, significant amounts of components can be wasted. We completed a review of all MTP activations from 2015 to 2018, providing an in-depth analysis of waste in our single Level 1 trauma center. An interdepartmental group analyzed patterns of blood component wastage to guide three quality improvement initiatives. Specifically, we (1) completed a digital timeline for each MTP activation and termination, (2) improved communications between departments, and (3) provided yearly training for all personnel about MTP deployment. The analysis identified an association between delayed MTP deactivations and waste (RR = 1.48, CI 1.19–1.85, p = 0.0005). An overall improvement in waste was seen over the years, but this could not be attributed to increased closed-loop communication as determined by the proportion of non-stop activations (F(124,3) = 0.98, not significant). Delayed MTP deactivations are the primary determinant of blood component waste. Our proactive intervention on communications between groups was not sufficient in reducing the number of delayed deactivations. However, implementing a digital timeline and regular repetitive training yielded a significant reduction in wasted blood components.
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Affiliation(s)
- Matteo Paganini
- TEAMHealth Anesthesia, Tampa General Hospital, Tampa, FL 33606, USA; (H.A.); (M.B.); (G.E.); (A.S.); (J.W.); (E.C.)
- Emergency Medicine, Department of Medicine (DIMED), University of Padova, 35128 Padova, Italy
- Environmental Medicine and Physiology Laboratory, Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy
- Correspondence: (M.P.); (G.B.); Tel.: +39-049-827-5297
| | - Hesham Abowali
- TEAMHealth Anesthesia, Tampa General Hospital, Tampa, FL 33606, USA; (H.A.); (M.B.); (G.E.); (A.S.); (J.W.); (E.C.)
| | - Gerardo Bosco
- Environmental Medicine and Physiology Laboratory, Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy
- Correspondence: (M.P.); (G.B.); Tel.: +39-049-827-5297
| | - Maha Balouch
- TEAMHealth Anesthesia, Tampa General Hospital, Tampa, FL 33606, USA; (H.A.); (M.B.); (G.E.); (A.S.); (J.W.); (E.C.)
| | - Garrett Enten
- TEAMHealth Anesthesia, Tampa General Hospital, Tampa, FL 33606, USA; (H.A.); (M.B.); (G.E.); (A.S.); (J.W.); (E.C.)
| | - Jin Deng
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA;
| | - Aryeh Shander
- TEAMHealth Anesthesia, Tampa General Hospital, Tampa, FL 33606, USA; (H.A.); (M.B.); (G.E.); (A.S.); (J.W.); (E.C.)
| | - David Ciesla
- Department of Surgery, University of South Florida, Tampa, FL 33606, USA;
| | - Jason Wilson
- TEAMHealth Anesthesia, Tampa General Hospital, Tampa, FL 33606, USA; (H.A.); (M.B.); (G.E.); (A.S.); (J.W.); (E.C.)
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA;
| | - Enrico Camporesi
- TEAMHealth Anesthesia, Tampa General Hospital, Tampa, FL 33606, USA; (H.A.); (M.B.); (G.E.); (A.S.); (J.W.); (E.C.)
- Department of Surgery, University of South Florida, Tampa, FL 33606, USA;
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21
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Abstract
OBJECTIVES: Recent advances in damage control resuscitation have advocated a push for early transfusion to maintain circulating volume and minimization of crystalloid use. While measures such as using rapid-matched group specific blood or uncrossmatched blood have been implemented to shorten this wait, delivery times can still be improved. We explored reducing delivery times by use of a pneumatic tube delivery system already built in our hospital. Few studies have evaluated this using fresh blood samples for one-way transport. We modified and evaluated our pneumatic tube delivery system for delivery timings and quality parameters; designing a robust protocol that also tested aged blood for simulated returns unlike other previous studies. METHODS: Delivery timings of emergency blood products by our present portering system were collected and compared against that of products sent through the pneumatic tube system (PTS). The samples sent through the PTS were also tested and analyzed for temperature, quality, and hemolysis in accordance with established blood banking quality guidelines. RESULTS: Blood products delivered by our PTS showed satisfactory conformance with all parameters of temperature, timing, and hemolysis. We showed a significant reduction in transport delivery times from mean of 8 min 43 s to 2 min 23 s. CONCLUSIONS: Delivery of blood products by our modified PTS is safe and significantly reduces delivery time. This time savings could be clinically significant in resuscitation. Usage of the PTS could also cut down on workforce utilization of porters, freeing them up for other tasks in the hospital.
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Affiliation(s)
- Jian Hao Jaryl Kok
- Department of Laboratory Medicine, Ng Teng Fong General Hospital, Singapore
| | | | - Mee Yin Joanne Lee
- Department of Laboratory Medicine, Ng Teng Fong General Hospital, Singapore
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22
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Vernon T, Morgan M, Morrison C. Bad blood: A coagulopathy associated with trauma and massive transfusion review. Acute Med Surg 2019; 6:215-222. [PMID: 31304022 PMCID: PMC6603326 DOI: 10.1002/ams2.402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 12/14/2022] Open
Abstract
Coagulopathy in trauma patients is a known contributor to death due to hemorrhage. In fact, it seen as frequently as 35% of the time. The complexity of the coagulopathy pathway requires a deliberate and planned approach. The methods used to assess and detect if a patient is coagulopathic remain challenging, but tools have been developed to assist the practitioner to effectively manage and even quickly reverse the coagulopathy. The purpose of this review is to educate trauma and emergency medicine staff on the currently available diagnostic tools to assess coagulopathy, to provide an overview of the coagulopathy pathway, as well as provide examples of how to intervene and treat coagulopathy, including the use of crew resource management during mass transfusion protocol activations.
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Affiliation(s)
- Tawnya Vernon
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
| | - Madison Morgan
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
| | - Chet Morrison
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
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23
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Abstract
As major stakeholders in the labor and delivery suite, obstetric anesthesiologists are frequently called upon to provide their unique skill sets and expertise to the management of postpartum hemorrhage, whether anticipated or not. Essential contributions of the anesthesia team ideally begin in the antenatal period with referral of women at high risk of postpartum hemorrhage to an outpatient obstetric anesthesia clinic where a tailored plan for both urgent or scheduled delivery for women with an anticipated complex delivery can be formulated. Maternal safety can be greatly improved if comorbidities are identified early and strategies to address these issues are proposed and known by the obstetric anesthesia team. Participation of the obstetric anesthesiology team is crucial in the development of systematic approaches that are customized to each institution and should comprise the creation and dissemination of algorithms and guidelines that are anesthesia specific, including detailed protocols for the labor and delivery unit and operating rooms, at large. Because management of postpartum hemorrhage requires a coordinated team effort, and may not always be planned, the anesthesia team should be prepared at all times to provide the appropriate anesthetic management and advanced cardiovascular support. The involvement of the anesthesia team should not only be limited to the immediate intrapartum period, but should also extend to the postpartum period where adequate anesthetic/analgesic plans will enhance maternal safety and recovery.
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Affiliation(s)
- Laurence Ring
- Department of Anesthesiology, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, 630 West 168th St PH-5, New York, NY 10032, United States
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, 630 West 168th St PH-5, New York, NY 10032, United States.
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24
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Rosenfeld EH, Lau P, Cunningham ME, Zhang W, Russell RT, Naik-Mathuria B, Vogel AM. Defining Massive Transfusion in Civilian Pediatric Trauma With Traumatic Brain Injury. J Surg Res 2018; 236:44-50. [PMID: 30694778 DOI: 10.1016/j.jss.2018.10.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 09/25/2018] [Accepted: 10/30/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The purpose of this study was to identify an optimal definition of massive transfusion in civilian pediatric trauma with severe traumatic brain injury (TBI) METHODS: Severely injured children (age ≤18 y) with severe TBI in the Trauma Quality Improvement Program research data sets 2015-2016 that received blood products were identified. Data were analyzed using descriptive statistics, Wilcoxon rank-sum, chi-square, and logistic regression. Continuous variables are presented as median (interquartile range). Massive transfusion thresholds were determined based on receiver operating curves and optimization of sensitivity and specificity RESULTS: Of the 460 included children, the mortality rate was 43%. There were no differences in demographics, heart rate at presentation, or injury severity score between children that lived or died. However, those who died had lower Glasgow coma scores (3 [3, 8] versus 3 [3, 3]; P < 0.01), were more likely to have had a penetrating injury (20% versus 11%; P < 0.01) and were more likely to be hypotensive for age (62% versus 34%; P < 0.01). Total blood products infused were greater in those who died (34 mL/kg/4-h [17, 65] versus 22 [12, 44]; P < 0.01). Sensitivity and specificity for delayed mortality was optimized at 40 mL/kg/4 h, and for the need for a hemorrhage control procedure at 50 mL/kg/4 h. These thresholds predicted delayed mortality (OR 2.12; 95% CI 1.28-3.50; P < 0.01) and the need for hemorrhage control procedures (5.47; 95% CI 2.82-10.61; P < 0.01) CONCLUSIONS: For children with TBI, a massive transfusion threshold of 40 mL/kg/4-h of total administered blood products may be used to identify at-risk patients, improve resource utilization, and guide future research methodology.
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Affiliation(s)
- Eric H Rosenfeld
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Patricio Lau
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Megan E Cunningham
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Wei Zhang
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Robert T Russell
- Department of Pediatric Surgery, Children's Hospital of Alabama, Birmingham, Alabama
| | - Bindi Naik-Mathuria
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.
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Wijaya R, Cheng HMG, Chong CK. The use of massive transfusion protocol for trauma and non-trauma patients in a civilian setting: what can be done better? Singapore Med J 2017; 57:238-41. [PMID: 27211577 DOI: 10.11622/smedj.2016088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Massive transfusion protocol (MTP) is increasingly used in civilian trauma cases to achieve better haemostatic resuscitation in patients requiring massive blood transfusions (MTs), with improved survival outcomes. However, in non-trauma patients, evidence for MTP is lacking. This study aims to assess the outcomes of a newly established MTP in a civilian setting, for both trauma and non-trauma patients, in an acute surgical care unit. METHODS A retrospective cohort analysis was performed on 46 patients for whom MTP was activated in Changi General Hospital, Singapore. The patients were categorised into trauma and non-trauma groups. Assessment of Blood Consumption (ABC) score was used to identify MTP trauma patients and analyse over-activation rates. RESULTS Only 39.1% of all cases with MTP activation eventually received MTs; 39.8% of the MTs were for non-trauma patients. Mean fresh frozen plasma to packed red blood cells (pRBC) ratio achieved with MTP was 0.741, while mean platelet to pRBC ratio was 0.213. The 24-hour mortality rate for all patients who received an MT upon MTP activation was 33.3% (trauma vs. non-trauma group: 45.5% vs. 14.3%). The ABC scoring system used for trauma patients had a sensitivity and specificity of 81.8% and 41.2%, respectively. CONCLUSION MTP may be used for both trauma and non-trauma patients in acute care surgery. Scoring systems to predict the need for an MT, improved compliance to predefined transfusion ratios and regular reviews of the MTP are necessary to optimise MTPs and to improve the outcomes of patients receiving MTs.
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Affiliation(s)
- Ramesh Wijaya
- Department of General Surgery, Changi General Hospital, Singapore
| | | | - Chee Keong Chong
- Department of General Surgery, Changi General Hospital, Singapore
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Abstract
BACKGROUND AND AIMS Massive transfusion protocol seems to improve outcome in massively bleeding trauma patients, but not pelvic fracture patients. The aim of this study was to evaluate the effect of massive transfusion protocol on the mortality and fluid resuscitation of shocked pelvic fracture patients. MATERIAL AND METHODS This is a trauma register study from a single hospital. From the trauma registry patients with pelvic fracture, injury severity score >15, admission base excess below -5, age >15 years, blunt trauma, and primary admission from the scene were identified. Patients were divided into two groups: Group 1-pre-massive transfusion protocol (2006-2009) and Group 2-post-massive transfusion protocol (2010-2013). Basic characteristics and intensive care unit length of stay, mortality, and fluid resuscitation data were retrieved from the registry. Standardized mortality ratio was assessed using revised injury severity classification, version II methodology. RESULTS Altogether, 102 patients were identified. Group 1 ( n = 56) and Group 2 ( n = 46) were comparable in their basic characteristics. The observed mortality was 35.7% and 26.1% in Groups 1 and 2, respectively. The standardized mortality ratio failed to reveal any difference between observed and expected mortality in either group. In the emergency room, the use of crystalloids decreased from 5.3 ± 3.4 to 3.3 ± 1.8 L ( p = 0.002) with increased use of fresh frozen plasma (2.9 ± 4.4 vs 5.1 ± 5.3, p = 0.007). CONCLUSION No improvement in the adjusted survival of shocked pelvic fracture patients is apparent after implementation of massive transfusion protocol. Implementation of massive transfusion protocol is associated with a higher use of fresh frozen plasma and improved ratio of fresh frozen plasma:red blood cell toward the targeted 1:1 and decreased use of crystalloids.
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Affiliation(s)
- T Söderlund
- 1 Trauma Unit, Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Central Hospital and Academic Medical Center Helsinki, Helsinki, Finland
| | - T Ketonen
- 2 Department of Radiology, Töölö Hospital, Helsinki University Central Hospital and Academic Medical Center Helsinki, Helsinki, Finland
| | - L Handolin
- 1 Trauma Unit, Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Central Hospital and Academic Medical Center Helsinki, Helsinki, Finland
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Gregory JA, Huitron SS, George AA, Simon CD. Optimizing Transfusion Ratios in Massive Transfusion Protocols: An Argument Against the 1:1:1 Dogma and Approach to Trauma Resuscitation. Lab Med 2016; 46:e46-52. [PMID: 26169658 DOI: 10.1309/lmjqnoqcfg4gkqrj] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
We believe that the current practice of transfusing red blood cells (RBCs), plasma, and platelets in a 1:1:1 ratio is not optimal in massive transfusion protocols (MTPs) and is based on a simple yet profound misconception regarding the preparation of component blood products. This 1:1:1 approach ignores the additional fluids added for anticoagulation and preservation of the components and assumes that there is a one-size-fits-all ratio that must be used across all types of trauma. In this article, we explain the rationale behind our conclusion with supporting figures and suggest that although the 1:1:1 ratio might be within the range of hemostasis, it falls near the lower cusp of hemostasis, making it less than ideal. The patient in mind was one in whom transfusion was expected to exceed 10 units of packed RBCs (pRBCs) in a combat environment where the situation was too hectic for additional testing. The goal was to keep the patient within a hemostatic range until the crisis phase was averted and the transition could then be made to goal-directed therapy with point-of-care testing.
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Affiliation(s)
- Jason A Gregory
- Department of Pathology, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Sonny S Huitron
- Department of Pathology, William Beaumont Army Medical Center, El Paso, Texas
| | - Alan A George
- Department of Pathology, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Clayton D Simon
- Department of Pathology, Brooke Army Medical Center, Fort Sam Houston, Texas
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Clifford SP, Mick PB, Derhake BM. A Case of Transfusion Error in a Trauma Patient With Subsequent Root Cause Analysis Leading to Institutional Change. J Investig Med High Impact Case Rep 2016; 4:2324709616647746. [PMID: 27231693 PMCID: PMC4871199 DOI: 10.1177/2324709616647746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/10/2016] [Accepted: 04/11/2016] [Indexed: 11/15/2022] Open
Abstract
A 28-year-old man presented emergently to the operating room following a gun-shot injury to his right groin. Our hospital’s Massive Transfusion Protocol was initiated as the patient entered the operating room actively hemorrhaging and severely hypotensive. During the aggressive resuscitation efforts, the patient was inadvertently transfused 2 units of packed red blood cells intended for another patient due to a series of errors. Fortunately, the incorrect product was compatible, and the patient recovered from his near-fatal injuries. Root cause analysis was used to review the transfusion error and develop an action plan to help prevent future occurrences.
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Horst J, Leonard JC, Vogel A, Jacobs R, Spinella PC. A survey of US and Canadian hospitals' paediatric massive transfusion protocol policies. Transfus Med 2016; 26:49-56. [PMID: 26833998 DOI: 10.1111/tme.12277] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 11/25/2015] [Accepted: 07/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Trauma is the leading cause of death in children >1 year of age, with haemorrhage as the most common cause of medically preventable deaths. While massive transfusion protocols (MTPs) have been investigated and used in adults to reduce death from haemorrhage, there are a paucity of published data on MTP practices and outcomes in children. This study aimed to survey current MTP policies and the frequency of activation at paediatric care centres. STUDY DESIGN AND METHODS We conducted a survey of MTPs at hospitals in the United States and Canada, including children's general hospitals, children's specialty hospitals and children's units in general hospitals. We collected information on how the MTP is activated, what therapeutics are given, frequency of its use, and how it is audited for compliance. RESULTS Forty-six survey responses were analysed. Physician discretion was the most common activation criteria (89%). A majority of sites (78%) targeted a 'high' (≥1 : 2) ratio of plasma to red blood cells (RBC). Fifteen percent of sites use antifibrinolytics in their MTPs. Eighty nine percent of sites have type-O RBC units and 48% of sites had thawed plasma units stored in an immediately available location. CONCLUSION There is a wide variation in MTPs among paediatric hospitals with regard to both activation criteria and products administered. This underscores the need for future prospective studies to determine the most effective resuscitation methods for paediatric populations to improve outcomes and therapeutic safety for massive bleeding.
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Affiliation(s)
- J Horst
- Division of Emergency Medicine, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - J C Leonard
- Section of Emergency Medicine, Department of Paediatrics, Nationwide Children's Hospital and the Ohio State University, Columbus, Ohio, USA
| | - A Vogel
- Division of Paediatric Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - R Jacobs
- Division of Critical Care, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - P C Spinella
- Division of Critical Care, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
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Abstract
Trauma is a leading cause of death worldwide, and almost 30% of trauma deaths are due to blood loss. A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. Some recent studies have shown that early volume restoration in certain types of trauma before definite hemostasis may result in accelerated blood loss, hypothermia, and dilutional coagulopathy. This review discusses the advances and changes in protocols in fluid resuscitation and blood transfusion for treatment of traumatic hemorrhage shock. The concept of low volume fluid resuscitation also known as permissive hypotension avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that although lower than normal, is adequate for short periods. Permissive hypotension is part of the damage control resuscitation strategy, which targets the conditions that exacerbate hemorrhage. The elements of this strategy are permissive hypotension, minimization of crystalloid resuscitation, control of hypothermia, prevention of acidosis, and early use of blood products to minimize coagulopathy.
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Affiliation(s)
- Veena Chatrath
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Ranjana Khetarpal
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Jogesh Ahuja
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
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McDaniel LM, Etchill EW, Raval JS, Neal MD. State of the art: massive transfusion. Transfus Med 2015; 24:138-44. [PMID: 24889805 DOI: 10.1111/tme.12125] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/17/2014] [Accepted: 04/25/2014] [Indexed: 11/27/2022]
Abstract
The aim of this article was to review recent developments in the resuscitation of both trauma and non-trauma patients in haemorrhagic shock. Strategies for the resuscitation of massively haemorrhaging patients and the use of massive transfusion protocols (MTPs) have been a major focus of the trauma literature over the past several years. The application of haemostatic resuscitation practices and MTPs to non-trauma populations has long been in practice, but has only recently been the subject of active research. Medline and PubMed were reviewed for 'massive transfusion' (MT) from 2012 to present. Non-English and paediatric articles were excluded. Articles were systematically reviewed for their relevance to MT. There were eight major areas of development identified. In recent MT literature, there was an increased focus on massively haemorrhaging non-trauma patients, the role of acute traumatic coagulopathy, the use of thromboelastography (TEG), and the impact of MTPs on blood product waste and efficiency of product delivery. Other developments included additional MT prediction tools and The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. There was also interest in re-evaluating the clinical relevance of the current MT definition and identifying new foci for MT. These recent developments reflect efforts to better understand and manage non-traumatic haemorrhage and to address prior limitations in the trauma literature. Inevitably, new questions have been raised, which will likely direct ongoing and future research in MT.
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Affiliation(s)
- L M McDaniel
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Abstract
Haemorrhage remains a major cause of potentially preventable deaths. Rapid transfusion of large volumes of blood products is required in patients with haemorrhagic shock which may lead to a unique set of complications. Recently, protocol based management of these patients using massive transfusion protocol have shown improved outcomes. This section discusses in detail both management and complications of massive blood transfusion.
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Affiliation(s)
- Vijaya Patil
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Madhavi Shetmahajan
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Abstract
Resuscitation of a severely traumatised patient with the administration of crystalloids, or colloids along with blood products is a common transfusion practice in trauma patients. The determination of this review article is to update on current transfusion practices in trauma. A search of PubMed, Google Scholar, and bibliographies of published studies were conducted using a combination of key-words. Recent articles addressing the transfusion practises in trauma from 2000 to 2014 were identified and reviewed. Trauma induced consumption and dilution of clotting factors, acidosis and hypothermia in a severely injured patient commonly causes trauma-induced coagulopathy. Early infusion of blood products and early control of bleeding decreases trauma-induced coagulopathy. Hypothermia and dilutional coagulopathy are associated with infusion of large volumes of crystalloids. Hence, the predominant focus is on damage control resuscitation, which is a combination of permissive hypotension, haemorrhage control and haemostatic resuscitation. Massive transfusion protocols improve survival in severely injured patients. Early recognition that the patient will need massive blood transfusion will limit the use of crystalloids. Initially during resuscitation, fresh frozen plasma, packed red blood cells (PRBCs) and platelets should be transfused in the ratio of 1:1:1 in severely injured patients. Fresh whole blood can be an alternative in patients who need a transfusion of 1:1:1 thawed plasma, PRBCs and platelets. Close monitoring of bleeding and point of care coagulation tests are employed, to allow goal-directed plasma, PRBCs and platelets transfusions, in order to decrease the risk of transfusion-related acute lung injury.
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Affiliation(s)
- V Trichur Ramakrishnan
- Department of Emergency Medicine, Sri Ramachandra Medical College Research Institute, Porur, Chennai, Tamil Nadu, India
| | - Srihari Cattamanchi
- Masters in Public Health (MPH) Candidate – May 2015, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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