Use Of Massive Transfusion Protocols Research Articles

Critical Care Services for Pregnant Patients in Ontario: A Province-Wide Survey

Critically ill pregnant patients require advanced critical care support, but access to these services is variable. We surveyed active Ontario obstetric facilities regarding critical care access. Responses were received from 44 of 80 obstetric units (55%), 13 (30%) being rural. Transport to another facility was required by 59% (majority >1 hour transport time), and differences were noted in the availability of specialty support services such as anesthesia and internal/obstetric medicine, as well as radiology and laboratory facilities, and use of massive transfusion protocols. Training in early supportive care of obstetric complications and optimized facility transport are areas for potential improvement.

Accuracy of CHULA (Class-4 Hemorrhage Unresponsive to Lactated Ringer’s) Criteria for Massive Transfusion Protocol Activation in Trauma Patients

Background: In massive bleeding trauma patients, the use of massive transfusion protocol (MTP) has been shown to improve the outcome. However, the triggers for MTP activation vary among institutions. One of the most commonly used scoring systems to predict massive transfusion (MT) is the assessment of blood consumption (ABC) score. The authors’ institution has used a simple clinical criterion, the Class-4 Hemorrhage Unresponsive to Lactated Ringer’s (CHULA criteria), as a trigger for MTP activation. Objective: To identify the accuracy of CHULA criteria for MTP activation in trauma patients. Materials and Methods: Between April 2013 and April 2016, the authors retrospectively collected the data of trauma patients receiving blood transfusion in the first 24 hours at King Chulalongkorn Memorial Hospital, including demographic data, trauma scores, amount of blood transfusion, and mortality. The detail of CHULA criteria included 1) a patient with clinical signs of Class-4 hemorrhage, 2) not responding to one to two liters of Lactated Ringer’s bolus, and 3) had suspected ongoing bleeding. MT was defined as 1) packed red blood cells (PRC) transfusion of equal to or greater than 10 units in 24 hours, or 2) PRC transfusion of more than four units in the first hour. The accuracy of CHULA criteria for MTP activation was analyzed. Comparison between CHULA criteria and ABC score (of equal to or greater than 2) was also performed. Results: Three hundred fifty-eight patients were included in the present study, 292 males and 66 females. The mechanisms of injury were 68% blunt and 32% penetrating, with an average injury severity score of 21. MTP was activated by CHULA criteria in 100 patients and 73 received MT. Of the 258 patients who did not meet CHULA criteria, five received MT. As a trigger for MT activation, CHULA criteria had sensitivity, specificity, and accuracy of 93.6%, 90.4%, and 91%, respectively; while ABC score had sensitivity, specificity, and accuracy of 62.8%, 78.9%, and 75.4%, respectively. Conclusion: CHULA criteria can predict MT in trauma patients with 91% accuracy. When compared with ABC score, CHULA criteria were not inferior to ABC score in predicting MT. Keywords: Massive transfusion, CHULA criteria, ABC score

Amniotic fluid embolism and management of coagulopathy: A case report with successful outcome

Amniotic fluid embolism (AFE) is a rare and potentially catastrophic condition unique to pregnancy. Presentation may range from subtle clinical events to sudden and fatal maternal cardiorespiratory arrest, with a reported incidence of 2–6 in 100,000 deliveries and mortality of 15–60%. Management should include immediate high-grade resuscitation for AFE presenting as cardiac arrest, involvement of multidisciplinary team, provision of adequate ventilator and circulatory support, treatment of coagulopathy precipitated by AFE, and immediate delivery of the foetus in cases of cardiac arrest. The following case report involves a patient with suspected AFE post-induction of labour with favourable maternal and neonatal outcome in our local setting. The management of coagulopathy in AFE is further discussed, including use of massive transfusion protocols, pharmacological agents and recombinant factor VIIa.

Systematic reviews of scores and predictors to trigger activation of massive transfusion protocols.

The use of massive transfusion protocols (MTPs) in the resuscitation of hemorrhaging trauma patients ensures rapid delivery of blood products to improve outcomes, where the decision to trigger MTPs early is important. Scores and tools to predict the need for MTP activation have been developed for use to aid with clinical judgment. We performed a systematic review to assess (1) the scores and tools available to predict MTP in trauma patients, (2) their clinical value and diagnostic accuracies, and (3) additional predictors of MTP. MEDLINE, EMBASE, and CENTRAL were searched from inception to June 2017. All studies that utilized scores or predictors of MTP activation in adult (age, ≥18 years) trauma patients were included. Data collection for scores and tools included reported sensitivities and specificities and accuracy as defined by the area under the curve of the receiver operating characteristic. Forty-five articles were eligible for analysis, with 11 validated and four unvalidated scores and tools assessed. Of four scores using clinical assessment, laboratory values, and ultrasound assessment the modified Traumatic Bleeding Severity Score had the best performance. Of those scores, the Trauma Associated Severe Hemorrhage score is most well validated and has higher area under the curve of the receiver operating characteristic than the Assessment of Blood Consumption and Prince of Wales scores. Without laboratory results, the Assessment of Blood Consumption score balances accuracy with ease of use. Without ultrasound use, the Vandromme and Schreiber scores have the highest accuracy and sensitivity respectively. The Shock Index uses clinical assessment only with fair performance. Other clinical variables, laboratory values, and use of point-of-care testing results were identified predictors of MTP activation. The use of scores or tools to predict MTP need to be individualized to hospital resources and skill set to aid clinical judgment. Future studies for triggering nontrauma MTP activations are needed. Systematic review, level III.

Use of Massive Transfusion Protocol: Maternal Outcomes in Patients With Severe Obstetric Hemorrhage [22K

INTRODUCTION: Obstetrical hemorrhage represents the single-most significant cause of maternal mortality. As hemorrhage rates increase, Massive Transfusions Protocols (MTP) have been adopted for maternal resuscitation. We explored maternal outcomes associated with MTP utilization. METHODS: We retrospectively studied women who delivered with Class III-IV hemorrhage (estimated blood loss [EBL] ≥1,500 mL) at either an urban teaching-hospital serving high-risk patients (HOSP1) or a suburban hospital serving average-risk patients (HOSP2) during 2012–2015. Patient groups included: 1) no transfusion, 2) transfusion without MTP, and 3) transfusion via MTP (implemented at HOSP1 only). Between-group differences in maternal characteristics and outcomes by year and hospital were described. RESULTS: Women totaled 109 at HOSP1 (no transfusion: 30 [28%], transfusion: 56 [51%], MTP: 23 [21%]) and 42 at HOSP2 (no transfusion: 18 [43%], transfusion: 24 [57%]). Transfusion reactions (n=2) occurred in the transfusion group only, and no maternal deaths occurred. No statistically significant patterns were detected in length of stay (LOS) or renal, hematologic, or coagulation indices. However, notable patterns were observed at HOSP1 in mean EBL (no transfusion: 1,720 mL, transfusion: 2,048 mL, MTP: 3,417 mL) and postpartum LOS (no transfusion: 3.0 days, transfusion: 3.2 days, MTP: 4.3 days). Thrombocytopenia improved annually with MTP. Total units transfused were greater with MTP (Total 10.2, PRBC 6.6, FFP 2.6, Platelet 0.9) than transfusion (Total 3.6, PRBC 3.0, FFP 0.4, Platelet 0.1). MTP accounted for the only wasted units (mean 0.52, range 0–4). CONCLUSION: MTP uses more blood products. However, in class III–IV hemorrhages, MTP use may be beneficial without significant adverse outcome.

Obstetric Anesthesia Liability Concerns.

Obstetric practice carries a high risk of medical liability and involves both obstetricians and anesthesiologists. Analysis of data from the Anesthesia Closed Claims Project database shows an increase in the proportion of anesthesia claims for maternal death and brain damage between the 1990s and 2000 and later, primarily due to hemorrhage. The proportion of claims for newborn brain damage remained unchanged while those for maternal nerve injury and minor injuries decreased. Use of massive transfusion protocols and clinical drills have been shown to improve outcomes from hemorrhage. Good communication and teamwork are critical for reducing obstetric liability.

Intrauterine Inflated Foley's Catheter Balloon in the Management of Abnormally Invasive Placenta Previa: A Case-Control Study.

To describe the use of intrauterine inflated Foley's catheter balloon for control of postpartum hemorrhage (PPH) during cesarean section (CS) in cases of abnormally invasive placenta previa aiming to preserve the uterus. Retrospective case-control study of the data of women who underwent elective CS on abnormally adherent placenta previa was carried out. Women in whom inflated Foley's catheter balloon was used for control of PPH during CS (n=40) were compared with a control group of women who underwent elective CS by the same technique but without use of intrauterine catheter balloon (n=38). Use of intrauterine inflated Foley's catheter balloon significantly reduced the estimated amount of blood loss (P=0.008), amounts of crystalloids, colloids and packed red blood cells transfusion (P=0.025, 0.017 and 0.022, respectively), and the need for bilateral internal iliac artery (IIA) ligation (P=0.016). No significant difference was observed between both groups regarding the use of massive transfusion protocol, performing cesarean hysterectomy, relaparotomy, and admission to the intensive care unit. Application of an intrauterine inflated Foley's catheter balloon during CS in cases of morbidly adherent placenta previa helps to control PPH with preservation of the uterus and decreases the need for the invasive IIA ligation.

An Update on the Use of Massive Transfusion Protocols in Obstetrics

(Am J Obstet Gynecol. 2016;214(3):340–344) Peripartum hemorrhage due to increased cesarean deliveries and placental anomalies is a significant cause of maternal mortality worldwide. Alternate pathways have been suggested to play an important role in the pathophysiology of massive hemorrhage. Research evidence suggests that hemostatic resuscitation can improve outcomes compared with traditional resuscitation protocols. Massive transfusion protocols administer blood products early in the resuscitation process and have been adopted widely in the United States for severe hemorrhage treatment. This review aimed to address updates on the use of massive transfusion protocols for obstetrical hemorrhage.

The use of massive transfusion protocol for trauma and non-trauma patients in a civilian setting: what can be done better?

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. 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. 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. 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.

State of the art: massive transfusion.

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.

Let technology do the work

The use of massive transfusion protocols (MTPs) is now common in civilian trauma settings, and early activation of MTP has been shown to increase survival of MTP recipients. Numerous MTP prediction tools have been developed; however, they are often cumbersome to use efficiently or have traded predictive power for ease of use. We hypothesized that a highly accurate predictor of massive transfusion could be created and incorporated into a smartphone application that would provide an additional tool for clinicians to use in directing the resuscitation of critically injured patients. Data from all trauma admissions since the inception of MTP were put in place at Grady Memorial Hospital in Atlanta, Georgia, were collected. A predictive model was developed using the least absolute shrinkage and selection operator (LASSO) and 10-fold cross validation. Data were resampled over 500 iterations, each using a unique and random subset of 80% of the data for model training and 20% for validation. The trauma registry contained 13,961 cases between 2007 and November 2011, of which 10,900 were complete and 394 received MTP. Of 44 input terms, only the mechanism of injury, heart rate, systolic blood pressure, and base deficit were found to be important predictors of massive transfusion. Our model has an area under the receiver operating curve of 0.96 (against data not used during model training) and accurately predicted MTP status for 97% of all patients. The model accurately discriminated full MTPs from MTP activations that did not meet criteria for massive transfusion. While complex to calculate by hand, our model has been packaged into a mobile application, allowing for efficient use while minimizing potential for user error. We have developed a highly accurate model for the prediction of massive transfusion that has potential to be easily accessed and used within a simple and efficient mobile application for smartphones. Prognostic/epidemiologic study, level III.

Use of a Massive Transfusion Protocol in Nontrauma Patients: Activate Away

Recently, concern has been raised that the use of massive transfusion protocols (MTPs) in nontrauma (ie, general medical/surgical [GMS]) patients might be inefficient due to protocol overactivation (activation in patients who do not ultimately receive massive transfusion). The current study was designed to investigate whether an MTP could be used effectively in GMS patients without detrimentally impacting resource allocation. A retrospective analysis was performed using institutional blood bank records from 2011. Trauma and GMS patients who had ≥10 U packed RBC issued to them in a single release were identified and categorized into MTP and no MTP (nMTP) cohorts. The protocol was overactivated in 53.8% of GMS patients. Activation of the MTP accelerated the delivery of component products for all patients. In GMS MTP patients, fresh frozen plasma units were issued a median of 7 minutes earlier than in GMS nMTP patients (MTP: median 1.0 minute; interquartile range [IQR] 0.0 to 2.0 minutes vs nMTP: median 8.0 minutes; IQR 0.0 to 37.5 minutes; p= 0.009), and platelet units were issued 17 minutes earlier (MTP: median 7.0 minutes; IQR 0.0 to 15.0 minutes vs nMTP: median 24.0 minutes; IQR 9.0 to 96.0 minutes; p= 0.010). In GMS MTP patients, there was a statistically significant increase in the percentage of platelet units wasted (MTP 12.8% vs nMTP 8.1%; p= 0.046). This increase was also seen in trauma MTP patients (MTP 12.2% vs nMTP 4.0%; p < 0.001). Despite finding that our MTP is overactivated in GMS patients, we could identify no unique disadvantages to its use with respect to resource allocation. In fact, a potential advantage to MTP activation exists, as products are issued more quickly with less variability. Our findings of increased platelet waste were not unique to GMS patients and should be used as a metric for quality improvement.

Massive Transfusion in Traumatic Shock

BackgroundHemorrhage after trauma is a common cause of death in the United States and globally. The primary goals when managing traumatic shock are the restoration of oxygen delivery to end organs, maintenance of circulatory volume, and prevention of ongoing bleeding through source control and correction of coagulopathy. Achieving these goals may require massive transfusion of blood products. Although use of blood products may be lifesaving, dose-related adverse effects are well described. DiscussionComplications of massive transfusion include interdependent derangements such as coagulopathy, hypothermia, acidosis, and electrolyte abnormalities, as well as infectious and immunomodulatory phenomena. This article explores the pathogenesis, implications, prevention, and treatment of these complications through the use of massive transfusion protocols. Particular attention is given to the optimal ratio of blood products transfused in large volume resuscitation and prevention of secondary coagulopathy. ConclusionsObservational data indicate that the development and use of a massive transfusion protocol may reduce the morbidity and mortality associated with large-volume resuscitation of patients with hemorrhagic shock. Such protocols should include a pre-defined ratio of packed red blood cells, fresh frozen plasma, and platelets transfused; most commonly, the ratio used is 1:1:1. Additionally, such protocols should monitor for and correct hypothermia, hypofibrinogenemia, and electrolyte disturbances such as hypocalcemia and hyperkalemia.

Outcomes after Massive Transfusion in Nontrauma Patients in the Era of Damage Control Resuscitation

There are little data regarding the use of massive transfusion protocols (MTP) outside of the trauma setting. This study compares the use of an MTP between trauma and non-trauma (NT) patients. Data were collected for trauma and NT patients from the prospectively maintained MTP database at a Level I trauma center over a 4-year period. Massive transfusion was defined as ≥ 10 units packed red blood cells (PRBCs) in a 24-hour period. Of 439 MTP activations, 37 (8%) were NT patients (64% male; mean age = 51 years, initial base deficit = -10.8). Activations were for gastrointestinal bleeding (n = 18), bleeding during surgery (n = 13), obstetrical complications (n = 5), and ruptured aortic aneurysm (n = 1). Over-activation of MTP (<10 units PRBCs/24 hours) was higher in NT than trauma patients (19/37, 51% vs 118/284, 29%, P < 0.01). For massive transfusion patients, 24-hour mortality was higher in NT compared with trauma patients (10/17, 59% vs 100/284, 35%, P = 0.05), but there was no difference in 30-day mortality (10/17, 59% vs 144/284, 51%, P = 0.51). With over-activation in 51% of NT patients, MTP usage outside of trauma is inefficient. Outcomes in NT patients were worse than trauma patients, which may be related to the underlying disease processes.

Air Medical Services Must Be Prepared for Massive Transfusion

In 1928, the first Australian civilian air medical service was established in Cloncurry, Queensland. Today, air medical transport of patients in Queensland—a state incorporating a land area of 1.7 million square kilometers and a decentralized population of 4.4 million people—presents significant challenges to the field of retrieval medicine. Retrieval medicine incorporates two fundamental paradigms: the safe and expeditious transfer of the critically injured patient to definitive care; and where necessary the delivery of care at the point of contact between patient and retrieval team. Retrievals often involve large distances and long times, and there is the unfortunate potential for patients to receive little or no intervention besides transport. Ideally the entire continuum of the retrieval process should be directed toward the continuous maintenance, or better, improvement of our patient’s condition. Thus, any period of transport without concurrent appropriate treatment is undesirable. The term therapeutic vacuum, implying lost time that could otherwise be used for patient care, has been used to describe this phenomenon, and its avoidance should be the constant aim of the retrievalist. For trauma patients, the lethal triad of coagulopathy, acidosis, and hypothermia is well established. 1 The use of massive transfusion protocols in the emergency department management of the trauma patient is directed toward secondary prevention of these complications. 2 This standard of care translates to the practice of retrieval medicine and creates a potential requirement for massive transfusion in the retrieval setting. Clearly, prolonged transport of the slowly exsanguinating trauma patient who for lack of blood replacement becomes ever more progressively cold, acidotic, and coagulopathic, is a failure of care for the retrieval service. Case Report

The treatment of traumatic shock: recent advances and unresolved questions.

Uncontrolled bleeding remains a leading cause of potentially preventable death after trauma. Timely, adequate resuscitation in traumatic shock is an essential, lifesaving aspect of polytrauma care. Whilst basic principles in the treatment of traumatic shock remain the same-achieving hemorrhage control and replacing lost volume, the way this is achieved has changed significantly in the last fiveyears. The abandonment of blood pressure driven uncontrolled fluid resuscitation, the introduction of the concept of hemostatic resuscitation, and the increasing use of massive transfusion protocols have all contributed to an improvement in timely access to various blood products. The increase in knowledge regarding the pathophysiology of trauma, the availability of adjuncts, and the array of resuscitation monitoring options available have all contributed to a potentially improved approach to resuscitation. The purpose of this report is to review the most important advances in traumatic shock therapy in the last fiveyears.

Emergency department staff knowledge of massive transfusion for trauma: the need for an evidence based protocol

IntroductionUncontrolled haemorrhage is the leading cause of potentially reversible early in-hospital death following trauma. Approximately 25% of trauma patients arriving in the emergency department have evidence of early coagulopathy. It...