Evolution of Massive Transfusion Strategies

Transcription

1 Evolution of Massive Transfusion Strategies Kerry Gunn Department of Anaesthesia and Perioperative Medicine Auckland City Hospital

2 Conflict of Interest Honorarium for Novo Nordisk to Chair Meetings

3 Summary A small proportion (4%) need an aggressive approach to transfusion Systems that include plasma (FFP) and platelets improve outcome The key component in plasma is fibrinogen The challenge is to develop systems that deliver fibrinogen rapidly enough to these patients The place of Tranexamic Acid in Trauma is evolving Unless we include POC monitoring of coagulopathy we risk replacing exsanguination with thrombosis

4 0 units RBC in 4 hrs No Transfusion Focused Tx DCR 0 units RBC in 24 hrs

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8 Acute Traumatic Coagulopathy

9 The coagulopathy is related to SHOCK plus TISSUE INJURY. Brohi, J Trauma 2003;

10 ADHB Adult Massive Transfusion Protocol (MTP) Massive bleeding with either shock or abnormal coagulopathy Ensure delivery of X-match specimen to Blood Bank Give 3 Units O-neg or type specific RBC Ring Blood Bank to Activate Massive Transfusion Protocol REQUEST, DELIVER AND TRANSFUSE AS BELOW: TXA G MTP BOX ONE 2 Whole Blood or 2U RBC and 2U FFP Check Coags / Platelets /FBC ABGs / Ca ++ MTP BOX TWO 4 RBC 4 FFP adult Platelets rviia 90 mcg/kg if indicated MTP BOX THREE 4 RBC 4 FFP + 3U Cryoprecipitate MTP BOX FOUR 4 RBC 4 FFP adult Platelets Check Coags / Platelets /FBC ABGs / Ca ++ Repeat every 30 min and alternate 3 &4... Check Coags / Platelets /FBC ABGs / Ca ++

11 Use of red cells in ADHB RBC used / Patient screen tested before UCL=0.483 LCL= _ P= after Jan-08 May-08 Sep-08 Jan-09 May-09 Sep-09 Jan-0 May-0 Sep-0 Jan- May- Screens, RBC, FFP

12 Use of FFP in ADHB FFP Used / Patient screen tested 0.20 before UCL=0.099 LCL=0.080 _ P= after Jan-08 May-08 Sep-08 Jan-09 May-09 Sep-09 Jan-0 May-0 Sep-0 Jan- May- Absolute volume of RBC and FFP

13 Initiating the Massive Transfusion Protocol ABC TASH 2 McLauchlin 3 ED pulse > 20 > 20 > 05 Systolic BP < 90 < 00 < 0 BE -2 to -0 ph < 7.2 Hb 7-2 < 9.6 FAST + + Male + Penetrating + Unstable pelvic # or femoral #.J Trauma 2009;66: J Trauma 2006;60: J Trauma 2008: 64 S57-S63 +

14 ADHB Adult Massive Transfusion Protocol (MTP) Massive bleeding with either shock or abnormal coagulopathy Ensure delivery of X-match specimen to Blood Bank Give 3 Units O-neg or type specific RBC Ring Blood Bank to Activate Massive Transfusion Protocol REQUEST, DELIVER AND TRANSFUSE AS BELOW: TXA G MTP BOX ONE 2 Whole Blood or 2U RBC and 2U FFP Check Coags / Platelets /FBC ABGs / Ca ++ MTP BOX TWO 4 RBC 4 FFP adult Platelets rviia 90 mcg/kg if indicated MTP BOX THREE 4 RBC 4 FFP + 3U Cryoprecipitate MTP BOX FOUR 4 RBC 4 FFP adult Platelets Check Coags / Platelets /FBC ABGs / Ca ++ Repeat every 30 min and alternate 3 &4... Check Coags / Platelets /FBC ABGs / Ca ++

15 MTP: 86 activations 90 Surgical Medical Obstetrics Vascular Trauma Box Box 2 Box 3 30 Box Boxes Box 5 Box 6

16 Auckland MTP : Lactate

17 Auckland MTP: INR

18 Auckland MTP Audit

19 Auckland MTP : fibrinogen

20 Response time in Auckland to MTP activation Mean - Minutes between events/boxes 0:25 0:23 0:20 0:7 0:4 0: 0:08 0:05 0:02 0:00 Start - Box Box-Box2 Box2-Box3 Box3-Box4 Box4-Box5 Box5-Box6 Minutes 0:07 0:23 0:20 0:0 0:05 0:05

21 Trauma Outcomes Group Prospective but not randomised data 22 Level units 223 patients 645 received >0U

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24 ADHB Adult Massive Transfusion Protocol (MTP) Massive bleeding with either shock or abnormal coagulopathy Ensure delivery of X-match specimen to Blood Bank Give 3 Units O-neg or type specific RBC Ring Blood Bank to Activate Massive Transfusion Protocol REQUEST, DELIVER AND TRANSFUSE AS BELOW: TXA G MTP BOX ONE 2 Whole Blood or 2U RBC and 2U FFP Check Coags / Platelets /FBC ABGs / Ca ++ MTP BOX TWO 4 RBC 4 FFP adult Platelets rviia 90 mcg/kg if indicated MTP BOX THREE 4 RBC 4 FFP + 3U Cryoprecipitate MTP BOX FOUR 4 RBC 4 FFP adult Platelets Check Coags / Platelets /FBC ABGs / Ca ++ Repeat every 30 min and alternate 3 &4... Check Coags / Platelets /FBC ABGs / Ca ++

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27 TXA in elective surgery: metaanalysis Henry DA et al,. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 2007

28 274 hospitals in 40 countries Death at 4 weeks

29 Results 5% reduction in haemorrhagic death NN to avoid one hospital death 68 Vascular occlusive events not increased

30 Male 2/3 blunt Head injuries

31 Mortality per day after injury

32 About 2 %

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34 What s good Large Mortality endpoint Well constructed Safely profile confirmed Makes sense Huge implications for third world and us?

35 What s confusing? What is this group of patients and is 6% mortality OK? Who should we give it to here? Where is its place with an MTP and factor VIIa?

36 ISS MTP Shock No Transfusion Tranexamic Acid Focused Tx DCR Red Cells ISS >6 Lactate >2 x normal PT >.5 Pulse >20 Systolic <90 Ongoing bleeding Red Cells plus FFP Add cryo or fibrinogen?pcc?factor VIIa?Factor XIII