1. Massive transfusion: New Protocol
Bhavani Shankar Kodali MD
Anesthesiologist-in-Chief, Interim Chairman
Brigham and Women’s Hospital
Associate Professor
Harvard Medical School

2. Goal of this presentation
Are we on the right track?
What is our current practice?

4. “Obstetrics Anesthesia”
For most of us, the most blood loss we see has a medical student was in obstetrics. And this is normal. I still remember seeing about a liter of blood loss in about 2 minutes in my first c/s as the obstetrician cut through the anteriorly located placenta to get to the baby.
So although a significant amount of blood loss is normal and the mother is prepared to lose a significant amount of blood as a result of delivery, some conditions are clearly assoicated with pathologic amounts of blood loss leading to significant morbidity and mortality.

5. “Obstetrics is a bloody business”
For most of us, the most blood loss we see has a medical student was in obstetrics. And this is normal. I still remember seeing about a liter of blood loss in about 2 minutes in my first c/s as the obstetrician cut through the anteriorly located placenta to get to the baby.
So although a significant amount of blood loss is normal and the mother is prepared to lose a significant amount of blood as a result of delivery, some conditions are clearly assoicated with pathologic amounts of blood loss leading to significant morbidity and mortality.

6. - maternal deaths due to bleeding = 13% 1990’s ~ 1.3% Presently
- 1 per 100,000
These numbers show the number of maternal deaths that were attributed to blood loss in America according to the CDC. Unfortunately, in many parts of the developing world, the the number of maternal deaths due to blood loss remains very high. This is due to both the lack of prenatal care as well as a lack of facilities. In the world where facilities for blood/components are not readily available, maternal morbidity/mortality remains high.
25-30% maternal deaths Worldwide
Preventable

7. Conventional Management of Hemorrhage
Fluids Colloids Blood Plasma 3:1 Platelets depending on the number

8. 246

10. 22 Level 1 trauma

13. Obstetric hemorrhage

15. Whole Blood Bedside Assay

19. platelets

20. **Balanced ratios of blood products
**Blood viscoelastic assays

24. Initial Labs

26. How did we achieve these results
1:1:1
Cryoprecipitate Ca
Temperature of the patient
RiaSTAP

27. Massive Transfusion
Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital

28. Massive Transfusion Definition
Transfusion of ≥10 units of blood products in 24 hours
Replacement by transfusion of more than 50% of blood volume in 12 to 24 hours
Hemorrhage is the leading cause of death in the first hour after trauma and accounts for 50% of death in the first 24 hours
Massive transfusion is the transfusion of greater than or equal to 10 units of blood products in 24 hours. It can also defined as the replacement by transfusion of more than 50% of blood volume in 12 to 24 hours. Hemorrhage is the leading cause of death in the first hour after trauma and accounts for 50% of deaths in the first 24 hours. It is responsible for 80% of operating room deaths. Coagulopathy is associated with trauma in 25-38% of patients. It is associated with a 4 fold increase in mortality. Risk factors for acute coagulopathy of trauma include injury severity score, hypothermia, acidosis, and shock.

29. Coagulopathy
Coagulopathy is associated with trauma in 25-38% of patients; it is also associated with a 4-fold increase in mortality
Acute Coagulopathy of Trauma (ACoT)
Associated with severe injury
PT, aPTT, thrombin time >1.5 times normal limit
Coagulopathy: higher mortality (46% vs. 11%)1
1Brohi K et al J Trauma 2003

30. Assessment of Coagulopathy
Early recognition is associated with improved survival
Conventional coagulation testing (PT, PTT, platelet count, fibrinogen)
Rapid Thromboelastography (TEG)
Comprehensive assessment of coagulation abnormalities
Faster results
Correlated with conventional testing
Early recognition of coagulopathy is associated with improve survival. Traditional assessment of coagulation includes PT, PTT, platelet count and fibrinogen. However, conventional tests do not provide immediate results and their interpretation is often useless. The rapid thromboelastography (TEG) test provides faster results of coagulation and fibrinolysis abnormalities (5 minutes for TEG versus minutes for conventional assays) and has been shown to be correlated with conventional testing and predictive of transfusion needs.

31. Activating Massive Transfusion Protocol at BWH
Pharmacy = x27153
Blood bank = x27290
Criteria at BWH
> 4 PRBC in 1 hour
> 10 PRBC in 24 hours