its sometime difficult to decide in urgent clinical scenarios - Trauma,active bleeding, surgery: What ; when ; how and why to transfuse? answering some of these queries here is my presentation especially made for PG students (will help in answer writing)

1. AIM FOR STABLE PATIENT NOT STABLE HEMOGLOBIN
DR AKSHAYA TOMAR
DEPT OF IMMUNOHEMATOLOGY AND
BLOOD TRANSFUSION
AFMC PUNE

2.  81% of all the trauma-related deaths occur within
the initial 24-hour period.
 Most of them are hemorrhage related
 Most (99%) of the patients receiving <10 RBC
units within the first 24 h survived, whereas only
60% of patients who received >10 RBC units
within the first 24 h survived (J OF TRAUMA 2011)

4. IN ADULTS PEDIATRICS

6. •Dec Fibrinogen synthesis
and inc degradation
•Dec propagation phase
of coagulation : thrombin
•Decreases FVII/TF
interaction
•Dec platelets count and
function

7. • In the past, trauma patients were given colloid or
crystalloid fluid initially.
• Blood products were administered after 2 litre of fluid
resuscitation, usually guided by laboratory results to
keep haemoglobin >10 g/dl, platelet count >50000,
and INR ≤1.5.
• Using these guidelines, blood loss continued because
of delay in laboratory turn around time and dilutional
coagulopathy.

8.  Recent studies with consideration of resuscitation,
and better understanding the pathophysiology of
ETIC has led to early use of RBCs, plasma, and
platelets and reduced crystalloid use.

9.  Administration of RBC:plasma:platelets at 1:1:1 ratio was
first proposed by the US military and subsequently
supported by military and then civilian studies.
 The rationale for the 1:1:1 ratio is that it more closely
resembles whole blood
 Retrospective review of patients receiving MT at a US
combat hospital demonstrated reduced mortality from
66% to 19% when the RBC:Plasma ratio decreased from
8:1 to 2:1.38

10.  randomized trial to evaluate ratios, MT patients
receive either a 1:1:1 (higher ratio) or a 2:1:1
(lower ratio) RBC: Plasma: Platelet
 Outcome studied : survival & LOHS
 More patients in 1:1:1 group achieved hemostasis
and fewer experienced death (no significant differences
in mortality at 24hrs or at 30 days)

11.  Improved patient outcomes when compared with
physician/lab driven protocols
 Addresses coagulopathy(Fundamental in triad of ‘DEATH’ )
 Improves communication among departments, improves
availability of blood products, reduces delay in obtaining
blood products
 MTP is a way to assure good patient care by having a
standard protocol on specific actions to take for each service
involved.

14.  Identifying patients at risk early is a key
difference between damage control resuscitation
and MTP driven resuscitation.
 Patients can arrive in relatively stable condition
 Non lab markers determining need for MTP
 SBP<90mm Hg
 Positive Focused abdominal sonography in trauma
 HR>120 bpm

15.  Liver laceration with hemorrhage
 Emergent abdominal aortic aneurysm
 Pelvic fracture with overwhelming blood loss
 Massive gastrointestinal hemorrhage
 Coronary artery bypass grafting
 Uterine rupture

16.  WB transfusion compared with COMPONENTS use
reduced pulmonary and tissue oedema, which
decreased the ventilation time and also allowed
closure of the abdomen with minimal delay.
 Patients who received both fresh whole blood and
component therapy had better clinical outcomes
 However, concern for transfusion transmitted
infections and TA GvHD remains

17.  LIMITED data
 In the majority of institutions, a single MTP is
used for both adult and pediatric patients
 Published literature showed no improvement in
overall mortality with institutional MTP when
compared to transfusion as recommended by
treating clinician

18. • Group O RBCs and AB plasma products should be given until the
patient’s blood type can be determined.
• Use of D-positive products in D-negative or D-unknown patients
• Thawed plasma units
• Prothrombin complex concentrate (PCC)
• Fibrinogen concentrate/CRYO
• Tranexamic acid given early in the resuscitation process (<3 h from
injury to treatment, preferably within 1 h from injury).
• When to consider rFVIIa?

19.  Time is important
 Group O PRBC/AB plasma can be used
(without pretransfusion testing)
 Test patient sample ASAP (for further demands)
 Helps to preserve inventory/ reduces typing
discrepancies which can occur after multi unit
transfusions

20.  ‘MINUS IS PLUS HERE’
 We can use of D-positive products for men and women
past childbearing age (usually >50 yr old), and after a
set number of D-negative RBC units
 Frequency of anti-D formation after transfusion of D
positive blood products to a D-negative patient is
 20% for RBCs and ,
 4% for platelets (likely lower for apheresis
platelets)

21.  20 min to thaw
 Many institution keep around 20 AB thawed
plasma for emergent use, shelf life 5 days
 Only 4% of the population is of AB group, hence
this approach is challenging

22.  Invented for congenital coagulation disorder/warfarin
reversal/active bleeding
 PCC can be three-factor, such as Profilnine SD (lacking
factor VII), or four-factor, such as Kcentra.
 No prospective RCT to prove efficacy in MTP
 Depends on institutional protocol & resource available

23.  Shown to reduce overall mortality related to
bleeding in Trauma/Peri- operative settings
 Generally used in conjunction with PCC
 Not yet recommended by US FDA

24.  There are a few studies addressing the need for
cryoprecipitate and some suggest that transfusing
with adequate amounts of FFP will obviate the
need for cryoprecipitate.
 Most studies suggest checking fibrinogen levels in
patients who continue to demonstrate
coagulopathic hemorrhage with maintenance of a
level greater than 100 mg/dL

25. 1 unit of cryo 2500mg/150ml
1 unit of FFP 400mg/250ml
1 unit of PRBC <100mg
6 units of WB derived PC 480mg
1 unit of Apheresis derived PC 300mg
1 unit of whole blood 1000mg

26.  Reduce mortality in trauma patients in both civilian and
military settings, especially if given early in the
resuscitation process (<3 h from injury to treatment,
preferably within 1 h from injury)
 In the military setting, the MATTERs study, mortality in
the TXA group was lower than in the group not receiving
TXA (Military Application of Tranexamic Acid in Trauma Emergency Resuscitation)
 TA should be considered for use in bleeding trauma
patients
 No effect on total transfusion rates however

29.  Oxygen carrying capacity & Delivery
 Hemostasis
 Metabolic status
 Electrolytes

30.  No test can judge the hemostasis accurately in bleeding
patient
 Disadvantages of conventional assays:
 PT, aPTT, and fibrinogen levels, are likely not available in real-
time fashion
 Do not detect some haemostatic abnormalities, such as
platelet dysfunction, hyperfibrinolysis, and FXIII deficiency
 Do not quantify the relative contribution of pro-coagulant and
anti-coagulant factors
 Do not predict the future needs in MTP

31.  Short turn around time (15-20min) ; aids in decision
making at an early stage
 Detects hyperfibrinolysis (clot strength)
 It assesses all phases of coagulation even platelet
role in primary hemostasis
 It gives result in real time settings/POC such that
existing temperature and metabolic status effects
can be taken into account

32.  Frequent pathophysiological consequence of
severe injury as well as resuscitation
 66% of trauma patients presents in ER with
hypothermia
 Classified into
 Mild : 36°C to 34°C
 Moderate : 33.9°C to 32°C
 Severe : below 28°C

33.  Body temperatures less than 33°C produces
coagulopathy (functionally equivalent to factor conc. <
50%)
 Thrombin generation on platelets is reduced by 25% at
33°C and platelet adhesion was reduced by 33%
 Other clinical effects
 Cardiac dysrythmias
 Increased systemic vascular resistance
 Left shift in oxygen Hb dissociation curve

34.  Clinical effects not seen until pH < 7.2
 Effects :
 Decreases cardiac contractility and cardiac output
 Reduces activity of coagulation cascade
 Causes platelet dysfunction

35. SCORING SYSTEMS

36.  Clinician discretion can sometimes lead to delay
or failure of resuscitation
 Scoring helps in accurately identifying patients in
need of large volume replacement
 It also aids in restricting unnecessary transfusion
and its adverse effects also save this precious
resource for the more needy one (PBM)

38.  Surgical control of bleeding
 Hemodynamically stable
 Correction of acidosis and coagulopathy
 Signs of sufficient end organ perfusion
 Improvement in mental status
 Improvement in urine output

40. POOLED/10 UNITS

41.  Speed of transfusion is important during MTP
especially when exsanguination occurs at a rate
greater than transfusion
 Pressurized tubing or specialized pressurized rapid
transfusers can augment flow
 Blood and fluid warming is important as to not to
exacerbate hypothermia.
 Adjunctive techniques of warming including forced air
devices, blankets,and high operating room
temperatures

45.  Significant role
 Coagulation
 Platelet adhesion
 Cardiac and smooth muscle contractility
 In the setting of hemorrhagic shock
 Rapid infusion of blood products + decreased hepatic
clearance of citrate (hypoperfusion/hypothermia)
 Causes hypocalcemia
 A threshold ionized calcium [iCa] <0.9 mmol/L proposed as a
trigger for intravenous calcium

48. THEY DO OCCUR AND CAN BE FATAL

49.  Problems secondary to volume resuscitation
 Inadequate : Hypoperfusionlactic
acidosisSIRSMODSDIC
 Overzealous resuscitation : TACO / Interstitial edema
 Dilutional problems
 Dilutional coagulopathy
 Low colloidal osmotic pressure : Interstitial edema
 Problems related to stored blood
 Citrate toxicity (hypoperfused liver)
 Hyperkalemia/magnesemia(existing acidosis worsen this)
 Hypothermia
 Acidosis

50.  Respiratory complications : TRALI
 SIRS
 Sepsis
 Thrombotic complications
 TRIM

51.  Placement of refrigerators in urgent care centers and emergency
rooms
 Stocking up O blood group RBCs and AB plasma
 Maintaining target response time of <30 min once request
initiated(un crossmatched/IS X match)
 prescribe blood and blood products early to allow for delivery time
lag and thawing time (30 min for FFP)
 Collect blood sample for cross match early as colloids may
interfere with cross matching

52. IT INVOLVES ALLOF US
WORK AS A TEAM