Massive Transfusion In Trauma

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Massive transfusion in trauma

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Massive Transfusion In Trauma

  1. 1. Massive transfusion in trauma R.Sinha, D.Roxby, R.Seshadri Flinders Medical Centre, SA
  2. 2. Massive transfusion <ul><li>Massive transfusion – a response to uncontrollable haemorrhage </li></ul><ul><li>Must be timely and directed at volume replacement ,oxygen delivery, prevention and correction of coagulopathy </li></ul><ul><li>Opportunities and risks </li></ul>
  3. 3. Who needs massive transfusion <ul><li>In a study of 5646 trauma patients by Como & colleagues - </li></ul><ul><li>2.5% received more than 10 units of red cells during their admission </li></ul><ul><li>American military casualty study </li></ul><ul><li>8% received massive transfusion </li></ul><ul><li>Como JJ,Dutton RP,Scalea TJ,Edelman BB Hess JR.Blood transfusion rates in the care of trauma deaths. Transfusion 2004;44:809-813 </li></ul><ul><li>Borgman et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusion at a combat support hospital. J trauma 2007;63:805-813 </li></ul>
  4. 4. Aspects of massive transfusion <ul><li>Identifies a group with severe injury </li></ul><ul><li>Use a large resource </li></ul><ul><li>Focus of research </li></ul><ul><li>damage control surgery </li></ul><ul><li>1:1:1 ratio of RC:FFP:PLT </li></ul><ul><li>thawing of plasma </li></ul><ul><li>transfusion protocols </li></ul>
  5. 5. Aims of the study <ul><li>Evaluate the massive transfusion practice </li></ul><ul><li>Factors associated with massive transfusion </li></ul><ul><li>Outcomes </li></ul><ul><li>Methods </li></ul><ul><li>Trauma patients admitted during 1998 to 2006 </li></ul><ul><li>Patients who received ≥10 units of red cells in the first 24 hours of injury </li></ul><ul><li>Linked with other databases </li></ul>
  6. 6. Results <ul><li>TOTAL </li></ul><ul><ul><li>6488 trauma patients </li></ul></ul><ul><ul><li>438 (7%) received transfusion </li></ul></ul><ul><ul><li>358 received 1-9 red cells and 80 received ≥10 red cells. </li></ul></ul><ul><ul><li>Major trauma (ISS>15) - 1021 patients </li></ul></ul><ul><ul><li>313 (30%) were transfused </li></ul></ul><ul><ul><ul><li>ISS [16-24] - 19% </li></ul></ul></ul><ul><ul><ul><li>ISS [25-49] - 45% </li></ul></ul></ul><ul><ul><ul><li>ISS [50-75] - 8% </li></ul></ul></ul>
  7. 7. Massive Transfusion - Demographics <ul><ul><ul><ul><ul><li>Median </li></ul></ul></ul></ul></ul><ul><li>Patients 80 </li></ul><ul><li>Age (years) 35 (23-51) </li></ul><ul><li>M:F 3.5:1 </li></ul><ul><li>Blunt injury 92% </li></ul><ul><li>Time from accident to hospital 112 minutes </li></ul><ul><li>Coagulopathy 74% </li></ul><ul><li>ICU length of stay 5 (1-13) </li></ul><ul><li>Hospital length of stay 21 (2-50) </li></ul><ul><li>Mortality 33% </li></ul><ul><li>. </li></ul>
  8. 8. Injury Severity Score (ISS) ISS (median) Overall 38 (27-48) Survivors 29 (22-41) Non-survivors 49 (41-57 )
  9. 9. Injury regions 80% of the patients had multiple injuries 08 (10%) Injury to extremities 09 (11%) Facial injuries 47 (59%) Limbs 38 (48%) Injuries to abdomen and pelvis 51 (64%) Chest injuries 42 (53%) Head or neck injuries Patients (%) Different regions
  10. 10. Blood products used Units 24hrs Median,IQR Units 6hrs Median,IQR 1603 18 (12-28) 1221 13 (9-20) Red cells 679 7 (4-11) 431 4 (2-8) FFP 145 2 (1-3) 80 1 (0-2) Platelets 12 0 4 0 Cryo 2.5 (1.8-3.3) 2.8 (2.0-3.8) RC:FFP 11(9-12) 11(9-15) RC:PLT
  11. 11. Blood products used 0.20 21(13-31) 17 (12-23) RC (24hrs) 0.40 8 (5-13) 6 (4-10) FFP (24hrs) 0.41 2(1-3) 1 (1-3) PLTS (24hrs) 0.66 2.4:1 2.5:1 RC:FFP (24hrs) 0.85 11:1 10.5:1 RC:PLT (24hrs) 26 54 Patients 0.01 18(11-26) 12 (9-17) RC (6hrs) 0.03 7(4-9) 4 (2-8) FFP (6hrs) 0.02 1(0.8-2) 2 (0-1) PLTS (6hrs) 0.60 2.6:1 2.8:1 RC:FFP (6hrs) 0.78 11.4:1 11:1 RC:PLT (6hrs) p-value Non-survivors Survivors
  12. 12. Where are they transfused? 21% of the total units transfused –uncrossmatched O negative or group specific units ICU OT Resuscitation Retrieval Location 57 ( 71%) 60 (75%) 56 (70%) 24 (30%) Patients
  13. 13. Can we predict who needs MT? <ul><li>Simple clinical algorithms to allow recognition of patients at the risk of MT </li></ul><ul><ul><li>McLaughlin et al 1 - Heart rate >105 Systolic BP <110 mm of Hg, pH<7.25Hct <32% </li></ul></ul><ul><ul><li>Schreiber et al 2 ≤11g/dl,INR>1.5,penetrating injury </li></ul></ul><ul><ul><li>Yucel et al 3- TASH score- HR,BP,Hb,BEXS,pelvic & femur fracture </li></ul></ul><ul><li>1 J Trauma. 2008;64:S57–S63. </li></ul><ul><li>2 J Am Coll Surg. 2007;205:541–545 . </li></ul><ul><li>3 J Trauma. 2006;60:1228 –1237 . </li></ul>
  14. 14. Risk factors for the need of massive transfusion <ul><ul><li>p-value OR 95%CI </li></ul></ul><ul><li>SBP <90 <0.001 3.8 1.8-7.8 </li></ul><ul><li>(systolic blood pressure) </li></ul><ul><li>Hb <120g/L 0.002 3.6 1.6-8.0 </li></ul><ul><li>ISS>15 < 0.001 5.3 2.8-10 </li></ul>
  15. 15. Outcomes <ul><li>Overall mortality 26/80 (33%) </li></ul><ul><li>Early Mortality 19/26 (73%) </li></ul><ul><li>Discharged home/Rehab 44 (55%) </li></ul><ul><li>Other hospitals 7 (9%) </li></ul><ul><li>Other 2 (3%) </li></ul>
  16. 16. Approaches to massive transfusion <ul><li>No strict guidelines for transfusion practice in major trauma </li></ul><ul><li>Recent military experience - 1:1, FFP: RBC is independently associated with improved survival. </li></ul><ul><li>1:1 or 1:2 for civilian trauma – the optimal ratios yet to be defined. </li></ul><ul><li>Based on these studies institutions have implemented massive transfusion protocols. </li></ul>
  17. 17. Massive Transfusion Pack
  18. 18. Schedule for Massive Transfusion Response Pack RC FFP PLT Cryo rFVIIa 1 5 (O Neg) 2-4 (AB) 1 2 5 4 2 2 3 5 4 2 2 *** 4 5 4 2 5 5 4 2 6 5 4 2 2 7 5 4 2 8 5 4 2 9 5 4 2 2 10 5 4 2
  19. 19. Case study <ul><li>66 yo male: 6m fall, crushed by falling truss </li></ul><ul><li>Injury time-13.05 </li></ul><ul><li>ED arrival- 14.19 </li></ul><ul><li>SBP- 60 </li></ul><ul><li>CT scan-Open book fracture pelvis </li></ul><ul><li>15:01 – angio-embolisation of bilateral bleeders </li></ul><ul><li>OT - 18:14-19:02 -17 packs placed in deep pelvis </li></ul><ul><li>Patient survived </li></ul>5 RC 2 FFP 1 SDP 1 CRYO 5 RC 4 FFP 1 SDP 1 CRYO 5 RC 2 FFP 1 SDP 5 RC (O Neg) 2 FFP (AB) 1 SDP MTP4 16.23 MTP3 16.10 MTP2 15.15 MTP1 14.24
  20. 20. Summary <ul><li>Massive transfusion identifies a group of trauma patients with </li></ul><ul><li>severe injury </li></ul><ul><li>increased risk of coagulopathy </li></ul><ul><li>potential benefit of 1:1:1 blood products </li></ul><ul><li>Simple variables (SBP,ISS, coagulation parameters) can predict the need for massive transfusion for trauma patients </li></ul>
  21. 21. Thank you

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