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Massive Transfusion in the New Era

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Presentation on theme: "Massive Transfusion in the New Era"— Presentation transcript:

1 Massive Transfusion in the New Era
JHSGR 17 Apr 2010 Dr J Leung CMC

2 Outline Massive transfusion (MT) Hemostatic resuscitation
Definition, conditions, outcomes Coagulopathy Hemostatic resuscitation Transfusion of FFP, Platelet and PRBC Hypotensive resuscitation Massive transfusion protocol Outcome, complications

3 Massive Transfusion - definition

4 Massive Transfuion - Conditions
Trauma e.g Pelvic fracture, Liver lacerations Non Trauma Abdominal Aortic Aneurysm repair Gastrointestinal Hemorrhage Liver Transplant Obstetrics Conditions eg ectopic pregnancy, postpartum hemorrhage

5 Trauma The leading cause of death for Americans under 35 years old
The most common reason for massive transfusion Hemorrhage: 40% of all trauma deaths

6 Massive Transfusion - Outcomes
MT and Outcome Massive Transfusion - Outcomes Trauma patient: 19-84% mortality

7 MT and Outcome (cont’d)
How could we mordifiy our resuscitation strategy so as to further reduce the mortality?

8 Coagulopathy Hemorrhage -> Massive Transfusion -> coagulopathy upon or soon after admission Exacerbated by resuscitation with crystalloid & PRBC

9 Hemostatic Resuscitation
Hemorrhage control Normalization of body temperature Early transfusion of FFP, platelets

10 FFP : Plt : PRBC

11 Multicentre retrospective study
16 major Level 1 trauma centres in the US 466 required MT trauma patient FFP:PRBC, Platelet: PRBC & ISS independent predictors of 30-day mortality 4 groups High FFP:RBC ≥ 1:2 vs Low FFP:RBC <1:2 High Plt:RBC ≥ 1:2 vs Low Plt:RBC <1:2

12 Survival is associated with increased FFP & Platelet ratio
Mortality Survival is associated with increased FFP & Platelet ratio Best ratio 1:1:1

13 FFP : Plt : PRBC

14 Early transfusion of high ratio of FFP:Platelet:PRBC improved survival
Survivial Early transfusion of high ratio of FFP:Platelet:PRBC improved survival

15 Hemostatic Resuscitation
No consensus yet More fluid: risk of hemodilution & disruption of early hemostatic clots Vs Limit fluid: prolonging shock & cellular ischemia may become irreversible Hypotensive resuscitation: Aggressive crystalloid fluid resuscitation in patient with uncontrolled hemorrhage -> increase hemorrhage & coagulopathy Target SBP >90mmHg or Heart rate <130 bpm until hemorrhage is controlled Apart from blood transfusion, the traditioal ATLS protocol suggested giving 2L of crystalloid in maintaining the circulating volume

16 Massive Transfusion Protocol
In the past: Crystalloid -> PRBC FFP / Platelets: upon request when there is lab evidence of coagulopathy Current era: prevention of coagulopathy & thrombocytopenia PRBC: FFP: Platelet = 1:1:1

17 MTP J Am Coll Surg 2009;209: 198–205

18 Retrospective review, cohorts Stanford University Medical Center
Level I trauma Center MTP since July 2005 6 PRBC: 4 FFP: 1 apheresis pack of Platelet 2 yrs pre (n=40), post MTP (n=37) FFP:PRBC ratio the same: 1:1.8 (p=0.97) Plt : PRBC ratio: 1:1.8 -> 1:1.3 (p=0.05) Subjects: adm through AED, transfusion of 10 unit in 24hrs



21 MTP -> Prompt availability of blood products -> improves survival

22 Complications from MTP?
More multi-organ failure / ARDS?

23 Retrospective Cohort Single Level 1 trauma centre Trauma Exsanguination Protocol in 1 Feb 2006 PRBC: FFP: Plt = 6:4:2 2 years pre-TEP (n=141), 2 years TEP (N=125)




27 Conclusion Prevention of coagulopathy
Predefined ratio of FFP: Platelets: PRBC Applicable to non trauma cases? Availability of blood products

28 Thank You

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