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

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Presentation on theme: "Massive Transfusion in the New Era JHSGR 17 Apr 2010 Dr J Leung CMC."— Presentation transcript:

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

2 Outline Massive transfusion (MT) – 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 Hemorrhage: 40% of all trauma deaths The most common reason for massive transfusion

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

7 MT and Outcome (cont’d)

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

13 FFP : Plt : PRBC

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

15 Hemostatic Resuscitation 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 No consensus yet More fluid: risk of hemodilution & disruption of early hemostatic clots Vs Limit fluid: prolonging shock & cellular ischemia may become irreversible

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)

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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)

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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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