This document discusses protocols for massive transfusion and bleeding. It defines massive bleeding and massive transfusion, and explores ways to predict which patients may experience massive bleeding through the use of predictive scores and clinical/biological parameters. Predictive scores discussed include TASH and ABC scores. The document recommends activating a massive transfusion protocol for trauma patients with an ABC score >2 and decreased clot firmness on viscoelastic tests, or for non-trauma patients transfused with ≥4 RBC within 1 hour. Clinical parameters that could activate a protocol include low SBP/high HR, coagulopathy signs, low temperature, anemia, and lactic acidosis.

2. Intensive Care Unit
Hospital Universitario La Paz. Madrid. Spain
Massive
transfusion
and
massive
bleeding
protocols
Dr. M. Quintana

3. “The
white
rabbit
wore
his
eyeglasses
—¿Where
do
I
start,
your
majesty?
—Start
from
the
biggining
—replied
the
king—.
Follow
unEl
you
get
to
the
end.
Then
stop.”
Alice's
Adventures
in
Wonderland.
Lewis
Carroll.
1865

4. What
we
know……

5. MASSIVE
BLEEDING
-­‐
CAUSES
Cri$cal
Care
2007,
11:R
17(doi:10.1186/cc5686)

6. trauma
=
bleeding

7. MASSIVE
BLEEDING
-­‐
CAUSES
<1%
Elec$v
Surgery
Liver
Transplant
Gastrointes$nal
30%
Neoplasic
9%
30%
Politrauma$zed
Obstetric
Emergencys
12%
Cardiac
Surgery
Cri$cal
Care
2007,
11:R
17(doi:10.1186/cc5686)

8. Massive
Bleeding

9. Transfusion
of
4
RBC
within
1h,
with
high
probability
to
need
more
>
Or
=
10
RBC
within
the
first
24h
or
>
o
=
30
blood
products
in
7
days
MB
definiEon
is
transitory
Transfusion
of
blood
products
in
a
equal
volumen
of
1
or
more
than
1
$me
the
blood
volume
in
24h
Blood
loss
of
more
than
150
ml/min
for
more
than
10min
or
a
50%
replacement
of
the
total
blood
volumen
in
3h
Na$onal
Blood
Authority
(NBA)
(2011).
Pa$ent
blood
management
guidelines:
Module
1
–
Cri$cal
bleeding/Massive
transfusion.
NBA,
Canberra,
Australia
• ≥
10
RBC
within
6
h.
•
≥
5
RBC
within
4
h.
Massive
Bleeding
(MB)
¿DefiniEon?

10. R.10
R.11
R.12
R.13
It
is
recommended
a
full
clinical
asses
to
evaluate
the
severity
and
extension
of
bleeding.
This
must
include:
trauma
mechanism,
pa$ent
phisiology,
anatomic
paern
and
early
response
to
fluid
reanima$on.
Besides
bleeding
quan$fica$on,
it
must
include
a
correct
training
in
external
quan$fica$on
based
in
the
obstetric
bleeding
clinical
context.
It
is
recommend
the
u$lisa$on
of
viscoelas$c
tests
in
ini$al
protocols
of
trauma
pa$ents
to
predict
massive
transfusion
and
bleeding.
Prospec$ve
studies
are
needed
to
confirm
the
use
of
ROTEM
as
a
massive
transfusion
predictor
¿Can
we
predict
wich
paEents
will
receive
massive
transfusion?
¿Risk
factors?
Documento
HEMOMAS

11. and
for
this….
we
nedeed
PredicEve
Factors
and
Scores!!!

12. 1º
SBP
2º
HR
Gasometry
Injury
(severity,
mechanism)
3º
Hb/Htº
FAST
(Focused
Assessment
for
the
Sonography
of
Trauma)
¿INR?
PredicEve
scores
Frequently
used
parameters:

13. PredicEve
Scores
TASH
(Trauma
Associated
Severe
Hemorrhage)
7
independent
variables.
Punctua$on:
0-­‐28.
-­‐
Each
punctua$on
represents
a
%
of
massive
transfusion
(MT).
-­‐Equa$on:
p
=
1
/
[1
+
exp(5.4
–
0.3
x
TASH)]
TASH>
16
→
MT
>
50%
TASH>
27
→
MT
100%
Maegele
M.
Transfusion
Medicine
and
Hemotherapy
2012;
39:85-­‐97.
Maegele
M.
Vox
Sanguinis
2011;
100:231-­‐238.

14. Predic$ve
Scores
ABC
(Assessment
of
Blood
Consump$on):
Punctua$on:
0-­‐4.
Cutoff
point
for
MT
is
2.
4
dicotomic
variables
available
at
the
pa$ent
bed
No
laboratory
results
needed
Maegele
M.
Transfusion
Medicine
and
Hemotherapy
2012;
39:85-­‐97.
Nunez
TC.
The
Journal
of
Trauma
2009,
66:346-­‐352.

15. ¿Which
clinical
/
biological
parameters
must
acEvate
a
MTP?
RECOMENDATIONS
R.16
Based
on
the
published
data
and
personal
experience
it
is
recommended
to
ac$vate
a
MTP
to
have
a
ABC
punctuaEon
>
2
with
a
decreased
clot
firmness
with
TEG
/
ROTEM
in
traumaEc
paEents.
There
is
no
evidence
in
non
trauma$c
pa$ents
but
transfusion
of
4
or
more
RBC
within
1h
could
be
useful
to
iden$fy
those
who
will
need
MT.

17. B-O-F

18. BLOOD
ON
FLOOR

20. • ≥
4RBC
within
1h
•
ABC
Score
≥
2
(Penetra$ng
Mechanism,
FAST
+,
SBP
≤
90
and
HR
≥
120).
• SBP≤90
and
HR≥120.
INR>1.5
TP>18s(<70%),
aTTP>60s,
Fib.<
1.5g/l
• Tª<
35°C
•
Hb
<
11gr/dl,
Platelets
<
100
x
10⁹/l.
•
Lactate
≥
45
mg/dl,
Ca⁺⁺<
0.9
mmol/l,
BE
>
-­‐5
mmol/l,
pH<
7.2.
MT
PredicEve
Factors
for
trauma

21. 21
HU 12 de Octubre. 2011 Chico-Fernández
TASH: better predictive scale than ABC and Emergency transfusion Score (ETS)
Higher negative predictive value
Cutoff point: 16-18
Predictive Tools
¿Non
trauma$c
bleeding?

22. It
is
essenEal
to
have
a
local
agreement
to
acEvate
a
MTP

23. We need
protocols…

24. Massive
transfusion
protocols
have
shown
to
improve
survival
in
massive
bleeding
paEents
RECOMENDACIÓN
R.19
Due
to
survival
improvement
shown
by
the
ac$va$on
of
MTP,
we
recommend
all
centers
that
receive
politrauma$zed
to
create
one
R.20
There
is
no
evidence
that
PTM
improve
prognosis
in
massive
bleeding
different
to
trauma$c.
We
recommend
to
extend
it
to
other
situa$ons
were
coagulopathy
is
suspected
and
bleeding
is
difficult
to
control

25. ¿Steps
required
to
build,
start
and
monitor
a
Massive
Transfusion
Protocol?
RECOMENDACIÓN
R.17
We
recommend
to
build
a
MTP
coordinated,
mulEdisciplinary,
with
algorithms
including
massive
transfusion
packages,
informaEve
campaigns
and
trained
personel
in
equipments
used
with
a
periodical
evaluaEon
of
its
accomplishment
and
efecEvity
R.18
Steps:
1-­‐
Mul$disciplinary
crew
2-­‐
Look
current
literature
and
consider
the
usage
of
massive
transfusion
packages
3.
Iden$fy
and
propose
solu$ons
to
fundamental
logis$c
aspects
to
ensure
a
correct
protocol
func$oning,
such
as:
communica$on
between
different
hospital
services
and
blood
products
transport
4-­‐
Inform
and
train
all
the
crew
5-­‐
Consider
a
training
phase
before
apllying
it
6-­‐
Set
up
quality
controls
of
the
protocol
regarding
to
its
fulfillment
and
communica$on,
problems
and
deficiencys
between
those
who
design
and
control
the
protocol.
7-­‐
Evaluate
the
impact
of
the
protocol
and
share
regularly
results
to
the
crew

26. 2º
5º
4º
3º
6º
1º

28. 28
Curr Opin Anesthesiol 2013,
26:000 – 000

29. Administrar: A. Tranexámico Bolus 1g +bomba infusión
continua (1g/40ml SF) a pasar en 8h (5ml/h)
Mantener: Ta>35oC;Ph>7,2;Ca>1mmol/l;Hb>8 gr/l
Analizar: TP;TTPA; Reptilase;PLQ; Fibrinógeno+EXTEM;INTEM
Normal
Desmopresina 0,3ug/Kg
1 pool Plaquetas
STOP
SANGRADO
Repetir pruebas después de cada tratamiento
¿Antivitaminicos K?
Rotem: ML>15% en 1h y corregido en APTEM
Rotem: MCF [(Extem<45 + Fibtem ≥ 8mm) ó Ex<33mm]
N° PLQ <50 x 109/L
Rotem: MCF (Extem<45 + Fibtem< 8)
Lab: Fibrinógeno<1,5 g/L
Rotem: CT Extem>80 y/o CTIntem>240
Lab: TP/TTPa>1,5Anormal
Coagulopatía
INR > 1,5 15UI/Kg. à CCP
INR >3 ó ? à 30 UI/Kg.
¿Sangrado
quirúrgico?
¿Disfunción Plaquetas?
Revisión
quirúrgica
Diagnóstico
diferencial
P. laboratorio
FIBTEM / HEPTEM / APTEM
Fibrinógeno
Plasma
15-30 mL/Kg
CCP
15-30 UI/Kg
FVII
90 µg/Kg
Plaquetas
1 pool
TMX 1 g
Rotem: CT Heptem < CT Intem
Lab: TTPa>1,5 + Trombina>60 + Reptilase Normal.
Protamina
1:1

30. 30
We
nedeed
protocolos
because….

31. Massive
transfusion
protocol
(MTP)
and
non
massive
Standardized
care
to
improve
prognosis

32. 32
the
best
protocol?

33. 33
The
one
that
you
have
......
the
one
that
you
have
been
able
to
adapt
of
another
place
to
your
reality
As
long
as
it
is
known
by
all
the
parEcipants,
and
it
is
monitored
for
compliance
Coordinated
with
Blood
Bank
and
Hospital
Pharmacy

34. 34
blood
products
or
prohemostaEc
drugs?

35. 35
both!!!!!
quesEonable
the
moment
(early
!!!)
and
the
amount
You
have
to
know
what
blood
products
you
have
You
have
to
understand
that
you
read

36. WHAT DO YOU NEED
TO TAKE HOME?

37. S creen for risk of bleeding/coagulopathty
T reat bleeding coagulopathy
O bserve response to intervention
P revent secondary bleeding / coagulopathy

38. Adaptada
de
Dra
S.
Kozeck

39. Adaptado
de
Dr.
P.
Johansson

40. “If
you
are
looking
for
different
results,
do
not
always
do
the
same
”
Albert Einstein

41. new
approaches

42. Maegele
M.
Transfusion
2016

44. and
this
has
meant
that
....

45. Transfusión
masiva
Transfusión
por
obje$vos
Tratamiento(s)
Técnicas
para
control
del
sangrado
Co-­‐morbilidades
Equipo
mul$disciplinar
(PBM)
Coagulopa{a
Hemostasia
Transfusión
selec$va

46. Without
forgesng
that
....
in
relaEon
to
prohemostaEc
drugs

47. …….
the
perfect
haemostaEc!!!!!
• Quick
effect
• Stop
ac$ve
bleeding
• Do
not
coagulate
bleeding
blood
vessels
• Be
cheap
• Can
be
easily
stored
• Do
not
have
side
effects
Tomada
Dr
Winearls

48. 48
How
far
can
we
get?

49. Ganter MT, Spahn DR

50. near
Grupo SEMICYUC de Transfusiones

51. Gracias por vuestra atención
MQ
manuel.quintana@uam.es