HEMORRHAGE RESUSCITATIONAND

MASSIVE TRANSFUSION PROTOCOLS

CAPT William C. Brunner, MC, USNSenior Medical Officer, BSRF-2013

Assistant Professor, Department of Surgery

Disclosures

The speaker has no relevant financial relationships with commercial interests that pertain to the content of this presentation

Objectives• Review History of Trauma Resuscitation• Discuss Coagulopathies in Trauma• Discuss Integrated Damage Control• Review Blood Component Preparations• Discuss Individual Component Transfusion

Guidelines• Discuss Massive Transfusion Protocols• Discuss Future Research Areas

History of Trauma Resuscitation• World War I– Little or no systematic resuscitation after injury– Blood banking developed

• World War II– Widespread use of blood and albumin– Long, slow evacuation– Significant organ failure – renal, pulmonary– Late deaths from sepsis

History of Trauma Resuscitation• Korean War– Forward Surgical Care– Rapid Care– Evacuation to Definitive Treatment– Blood and albumin as in WWII

• Vietnam War– Rapid evacuation– Large-volume resuscitation with blood/crystalloid– Da Nang Lung (ALI/ARDS)

History of Trauma Resuscitation• Civilian Experience– Trauma Registries and Research– Empiric high-volume crystalloid resuscitation– Iatrogenic Coagulopathy after Trauma recognized– Directed Component Therapy• Requires Laboratory evidence• Empiric therapy limited

– Massive Transfusion Protocols

History of Trauma Resuscitation• Military Experience – Iraq and Afghanistan• Limited Component availability• Recognition of crystalloid inflammatory

response• Whole blood transfusion• Walking Blood Bank– Simple technology– Screened donor population readily available

Acute Traumatic Coagulopathy• Recognized in patients with significant tissue

injury and hypotension• Distinct from iatrogenic coagulopathy after

trauma– Dilutional coagulopathy

• Present prior to resuscitation in rapidly evacuated severe trauma

• Mortality rate increased 4x• Modulated through protein C activation

Integrated Response• Damage Control Surgery– Rapid, limited, forward

surgical care• Control bleeding• Control spillage• Control contamination• Restore perfusion

– Avoid unnecessary interventions

– Allow for resuscitation– Rapid evacuation

• Hemostatic Resuscitation– Limited volume– Permissive hypotension– Balanced transfusion

• High FFP:PRBC ratio– Colloid vs. crystalloid– Attenuate ATC– Expand resource

availability• Walking blood bank• Freeze-dried plasma

Blood ComponentsComponent Indication Storage Time Disadvantage

Whole Blood Volume deficit, O2 carrying capacity, massive transfusion

35 days (2°-6° C)24 hrs fresh

Short shelf life

PRBCs Volume deficit, O2 carrying capacity

42 days Immunomodulation

Leukocyte-reducedPRBCs

Cardiac surgery, prevent CMV infection, reduce febrile reaction and alloimmunization

42 days Cost

Washed PRBCs Prevention of allergic reactions 24 hrs Plasma depletion

FFP Coagulopathy, warfarin reversal 1 year

Cryoprecipitate Von Willebrand disease,Fibrinogen deficiency

1 year

Platelets Microvascular bleeding, thrombocytopenia

5-7 days Risk of transfusion-associated sepsis

Component Therapy• Advantages– Wider use of limited resources• 1 donated unit – multiple products

– Longer storage life– Lower costs in elective use– More predictable availability

• Disadvantages– Multiple donor antigen exposure– Less efficacy in high volumes, Lab costs

Component Transfusion Guidelines• Fresh Frozen Plasma– Prothrombin Time (PT) > 17 sec– Clotting Factor Deficiency (<25% of normal)– Massive Transfusion (1 unit/5units RBCs) or

clinically bleeding– Severe Traumatic Brain Injury

• Cryoprecipitate– Fibrinogen < 100mg/dL– Hemophilia A, von Willebrand disease– Severe Traumatic Brain Injury

Component Transfusion Guidelines• Platelets– Platelet count < 10,000/uL– Platelet count 10,000 to 20,000 with bleeding– Platelet count < 50,000 after severe trauma– Bleeding Time > 15 mins– Platelet concentrates (5.5 x 1010 in 50ml)– Platelet apheresis (3 x 1011 in 300ml)

Component Transfusion Guidelines• Packed Red Blood Cells (PRBCs)– Hemoglobin < 7g/dL– Acute blood volume loss > 15%– > 20% decrease in BP, or BP <100mm Hg due to

blood loss– Hemoglobin < 10g/dL with significant cardiac

disease or symptoms (chest pain, dyspnea, fatigue, orthostatic hypotension)

– Hemoglobin < 11g/dL in patient at risk for MOF

Massive Transfusion• Defined as > 10 units PRBCs within 24 hrs• 25-30% of trauma patients requiring massive

transfusion will present with Acute Traumatic Coagulopathy (ATC)– Penetrating mechanism– Positive FAST– Arrival SBP < 90mm Hg, HR > 120 bpm– Unstable pelvic fracture– pH < 7.25, base deficit

Massive Transfusion Protocol• Advantages– More closely replicate whole blood physiology

with components– Retain shelf-life advantage of components– 25-30% reduction in PRBCs used– Predictable workload

• Disadvantages– Processing time limitations– Limited applicability

Massive Transfusion ProtocolPackage PRBCs (Units) FFP (Units) Platelets

(Units)Other

1 6 6

2 6 6 1 apheresis

3 6 6 CryoprecipitaterFVIIa

4 6 6 1 apheresis

5 6 6

6 6 6 1 apheresis CryoprecipitaterFVIIa

Data from O’Keeffe T, Refaai M, Tchorz K, et al: A massive transfusion protocol to decrease blood component use and costs, Arch Surg 143:686-691, 2008.

Massive Transfusion Protocol• Typically start with 2-6 units Type O blood– Initial “emergency-release”– Subsequent units type-specific, cross-matched

• FFP processing time– ER prestaging thawed plasma, shelf-life 4-5 days

• Protocols can enhance effective use of staffing and resources

Special Situations• Autotransfusion– Limited applicability due to capture, possible

contamination• Blood salvage– Intraoperative or postoperative– Labor intensive, expensive, limited utility

• Autologous donation, Hemodilution not applicable to trauma setting

Areas for Future Study• Determine optimal therapeutic ratio of

PRBC:FFP– PROPPR Study - 1:1:1 vs. 1:1:2 PRBC/PLT/FFP

• Further delineate ATC physiology and identify clinically useful modulators

• Delineate impact of high-ratio therapy on sub-MT trauma population

• Blood component substitutes• Crystalloid alternatives

References• McIntyre RC Jr., Moore FA; Blood Transfusion

Therapy, Chapter 212, Current Surgical Therapy, 10th Edition, Philadelphia, PA, 2011.

• Adams CA Jr., Stephen A, Cioffi WG; Surgical Critical Care, Chapter 23, Sabiston Textbook of Surgery, 19th Edition, Philadelphia, PA 2012.

• Chovanes J, Cannon JW, Nunez TC; The Evolution of Damage Control Surgery, Surg Clin N Am 92 (2012) 859-875.

References• Cohen MJ. Towards Hemostatic Resuscitation:

The Changing Understanding of Acute Traumatic Biology, Massive Bleeding, and Damage-Control Resuscitation. Surg Clin N Am 92 (2012) 877-891.

• Committee on Trauma, American College of Surgeons. ATLS: Advanced Trauma Life Support Student Course Manual, 9th Edition. Chcago: American College of Surgeons; 2012.