The blood bank: from provider to partner in treatment of massively bleeding patients

Abstract

Continued hemorrhage remains a major cause of mortality in massively transfused patients of whom many develop coagulopathy. Reviewing transfusion practice for these patients, we found that at our hospital more than 10 percent received a suboptimal transfusion therapy and that survivors had a higher platelet count than nonsurvivors. We therefore investigated whether the blood bank could improve its service and hence improve the outcome. The blood bank introduced monitoring of the delivery of blood products and contacted the clinician provided there was an imbalance in the transfusion practice. For massively transfused patients, transfusion packages, including five red blood cells, five fresh-frozen plasma, and two platelet concentrates, were introduced to improve hemostatic competence. The Thrombelastograph (TEG) Haemostatic System (Haemoscope Corp., Niles, IL) was implemented, aiding in the diagnosis and treatment of coagulopathy. The fraction of suboptimally transfused patients declined from more than 10 percent to less than 3 percent. The transfusion package administered intraoperatively to patients operated on for a ruptured abdominal aortic aneurysm resulted in decreased postoperative transfusion requirements and improved 30-day survival (66% vs. 44%) compared with controls. Performing TEG alone in patients with significant bleeding as judged by the anesthetist reduced the number of analyses by approximately 85 percent, while those patients with coagulopathy remained identified. The TEG showed a 97 percent predictability in identifying a surgical cause of bleeding in postoperative patients. Ten percent of the massively bleeding trauma patients had hyperfibrinolysis as the major cause of bleeding, whereas 45 percent were hypercoagulable. The initiative from the blood bank has improved the transfusion practice and, hence, survival in massively transfused patients at our hospital.