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Massive transfusion: New Protocol
Bhavani Shankar Kodali MDAnesthesiologist-in-Chief, Interim Chairman
Brigham and Women’s Hospital
Associate ProfessorHarvard Medical School
Goal of this presentation
• Are we on the right track?
• What is our current practice?
“Obstetrics Anesthesia”
“Obstetrics is a bloody business”
1970’s
- maternal deaths due to bleeding
= 13%
1990’s
- maternal deaths due to bleeding
~ 1.3%
Presently
- 1 per 100,000 25-30% maternal deaths WorldwidePreventable
Conventional Management of Hemorrhage
Fluids
Colloids
Blood
Plasma
3:1
Platelets depending on the number
246
22 Level 1 trauma
Obstetric hemorrhage
Whole Blood Bedside Assay
platelets
**Balanced ratios of blood products**Blood viscoelastic assays
Initial Labs
How did we achieve these results
• 1:1:1• Cryoprecipitate• Ca• Temperature of the patient• RiaSTAP
Massive Transfusion
Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital
Massive Transfusion
• Definition – Transfusion of ≥10 units of blood products in 24
hours – Replacement by transfusion of more than 50% of
blood volume in 12 to 24 hours
• Hemorrhage is the leading cause of death in the first hour after trauma and accounts for 50% of death in the first 24 hours
Coagulopathy
• Coagulopathy is associated with trauma in 25-38% of patients; it is also associated with a 4-fold increase in mortality
• Acute Coagulopathy of Trauma (ACoT)– Associated with severe injury– PT, aPTT, thrombin time >1.5 times normal
limit– Coagulopathy: higher mortality (46% vs. 11%)1
1Brohi K et al J Trauma 2003
Assessment of Coagulopathy
• Early recognition is associated with improved survival• Conventional coagulation testing (PT, PTT, platelet count,
fibrinogen)• Rapid Thromboelastography (TEG)
– Comprehensive assessment of coagulation abnormalities– Faster results– Correlated with conventional testing
Activating Massive Transfusion Protocol at BWH
• Pharmacy = x27153• Blood bank = x27290• Criteria at BWH
– > 4 PRBC in 1 hour– > 10 PRBC in 24 hours