Massive transfusion: Difference between revisions

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{{Adult top}} [[massive transfusion (peds)]]
==Background==
==Background==
There’s no universal definition for what a “massive transfusion” is or what a “massive transfusion protocol” should be. The most common definition (utilized by ATLS) is any transfusion sequence that necessitates >10 units of packed red blood cells within a 24 hour period. <br>
[[File:lethaltriad.png|thumb|<ref>Mikhail J. The trauma triad of death: hypothermia, acidosis, and coagulopathy. AACN Clin Issues. 1999;10(1):85-94.</ref>]]
•Pure pRBC transfusions in acute hemorrhagic shock do not address the coagulopathy in the “lethal trauma triad” (hypothermia, coagulopathy, acidosis) and has been associated with increased mortality.<br>
*Although massive transfusion (MTP) does not have a universal definition, it is generally described as transfusion of >10 units of blood products (specifically [[Packed red blood cells]] within a 24-hour period)
•Instead, consider a “balanced resuscitation”<ref>Blood Rev. 2009 Nov;23(6):231-40. doi: 10.1016/j.blre.2009.07.003. Epub 2009 Aug 19</ref> which focuses on blood product ratios, avoidance of hemodilution with crystalloids, avoidance of hypocalcemia (citrate in blood products), permissive hypotension, among other concerns.
*In addition to controlling hemorrhage the greatest concern during MTP is the lethal triad:<ref>Kashuk JL, et al. Major abdominal vascular trauma — A unified approach. J Trauma. 1982;22(8):672–679.</ref>
<br>
*#[[Hypothermia]]
*#[[Coagulopathy]]
*#[[Acidosis]]
*Trauma Associated Coagulopathy<ref>http://rebelem.com/ten-trauma-resuscitation-commandments/</ref>
**Platelet defects (worse with [[TBI]]), endothelial injury, and loss of coagulation factors and platelets through hemorrhage consumption of platelets and coagulation factors
*During MTP, focus is on "balanced resuscitation" with clotting factors (FFP) and platelets”<ref>Spinella PC. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. Blood Rev. 2009 Nov;23(6):231-40.</ref>
*[[EBQ:PROPPR_Trial|The PROPPR trial]]<ref>Holcomb J. et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma The PROPPR Randomized Clinical Trial  JAMA. 2015 </ref> examined a 1:1:1 (FFP:Plt:pRBC) vs 1:1:2 protocol.  There was no difference in mortality at 1 or 30 days; however, the 1:1:1 group experienced less death due to exsanguination in the first day.
*The goal of MTP is to resuscitate and temporize management until definitive operative repair can be accomplished.
*MTP should follow should follow local institutional protocols<ref>ACS TQIP Massive Transfusion in Trauma Guidelines [https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/massive%20transfusion%20in%20trauma%20guildelines.ashx fulltext]</ref>
 
==Indications==
==Indications==
•Hemorrhagic shock is the only indication for a massive transfusion. <br>
*[[Hemorrhagic shock]] is the only indication for a massive transfusion
•[http://www.mdcalc.com/abc-score-assessment-of-blood-consumption-for-massive-transfusion/ ABC] score and the [http://www.mdcalc.com/tash-score-trauma-associated-severe-hemorrhage-for-massive-transfusion/ TASH] score predict need for MTP.
*The [http://www.mdcalc.com/abc-score-assessment-of-blood-consumption-for-massive-transfusion/ ABC score] and the [https://www.mdcalc.com/tash-score-trauma-associated-severe-hemorrhage TASH score] predict the need for MTP
<br>
*Newer studies<ref>Accuracy Of Shock Index Versus ABC Score To Predict Need For Massive Transfusion In Trauma Patients Schroll, R., et al, Injury 49(1):15, January 2018</ref> show that the [https://www.mdcalc.com/shock-index Shock Index score] is a better predictor than the ABC score
==Management==
*Revised Assessment of Bleeding and Transfusion (RABT) may reach higher sensitivity than ABC score, but not prospectively validated as of 2019
•PROPPR trial<ref>JAMA. 2015 Feb 3;313(5):471-82. doi: 10.1001/jama.2015.12</ref> examined 1:1:1 (FFP:PLT:pRBC) vs 1:1:2 -no difference in mortality at 1 or 30 days, however, the 1:1:1 group experienced less death due to exsanguination in the first day. <br>
===ABC Score<ref>Nunez TC et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009 Feb;66(2):346-52.</ref>===
•Goal of MTP is to resuscitate and temporize management until definitive operative repair can be accomplished.
*Non-lab scoring system as opposed to TASH:
<br>
**Penetrating mechanism
==Additional Considerations==
**SBP ≤90 in ED
•Tranexamic acid (TXA) lowers risk of death from exsanguination in trauma patients in the first day after injury (CRASH-2). <br>
**HR ≥120 in ED
•Ongoing research focuses on using a strict ratio of blood products versus other laboratory values (ex: thromboelastography, TEG) to guide (ie initiate or terminate) resuscitation with blood products.  TEG has been extensively studied in cardiac surgery and was shown to out-perform physician preference for blood replacement  with respect to not over-administering blood. <br>
**Positive FAST
•Factor VII, studied in the CONTROL trial , showed no mortality benefit – in fact, to this effect, the study was terminated early. Other studies of Factor VII have raised concerns for MI and adverse thrombotic events.
*Scoring interpretation:
<br>
**0-1, not likely to require MTP (≥10 units pRBCs)
**2-4, likely to require MTP, sensitivity 75% and specificity 86% from original study<ref>Schroll R et al. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury 2018 Jan;49(1):15-19.</ref>
*Subsequent studies suggested < 50% sensitivity
 
===Shock Index===
*SI = HR / SBP
*Particularly useful in patients with pre-hospital SBP >90 mmHg
*Pre-hospital SI >0.9 suggestive of need for MTP<ref>Cannon CM et al. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma. 2009 Dec;67(6):1426-30.</ref><ref>Vandromme MJ et al. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma. 2011 Feb;70(2):384-8; discussion 388-90.</ref>
 
===RABT===
*RABT score ≥ 2 of the following predicts need for MTP:
**Shock index > 1.0
**Pelvic fracture
**Positive FAST
**Penetrating injury
*Sensitivity 84%, specificity 77%<ref>Joseph B et al. Massive Transfusion: The Revised Assessment of Bleeding and Transfusion (RABT) Score. World J Surg 2018 Nov 42(11): 3560-3567.</ref>
 
==Adjunctive Agents==
*[[Tranexamic acid|Tranexamic acid (TXA)]] lowers risk of death if administed in less then 3 hours after injury in trauma patients with significant hemorrhage (CRASH-2 trail)<ref>Shakur H, et al. "Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage". The Lancet. 2010. 376(9734):23-32.</ref>
*[[Thromboelastography (TEG)]] has been extensively studied in cardiac surgery and quantifies the coagulation cascade
*Factor VII, studied in the CONTROL trial, showed no mortality benefit and was terminated early<ref>Hauser CJ. et al. Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma. 2010 Sep;69(3):489-500.</ref>
**Other studies of Factor VII have raised concerns for [[MI]] and adverse thrombotic events
*Consider giving calcium and magnesium IV supplementation if approaching > 4 units of pRBCs
 
==Example Protocol==
''MTP pack contains 6 units RBCs and 4 units FFP (O neg uncrossmatched rbc's and AB FFP until completed screen)
#Attending physician activates protocol
#Charge nurse contacts blood bank and sends  runner to pick up MTP pack
#[[TEG]] is drawn
#First MTP pack is delivered within 30min of ordering
#Transfusion continues until patient expires or is hemodynamicallys stable with cessation of bleeding
#If second pack is ordered it contains an additional single donor platelet pack (six-pack)
#The third pack substitutes cryoprecipitate for platelets
#PT, aPTT, and Fibrinogen is ordered q2 hours for the duration of the massive transfusion event
 
==Complications<ref>Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.</ref>==
*[[Hypothermia]]
*Dilutional [[coagulopathy]]
*[[Hypocalcemia]] and [[hypomagnesemia]] from high citrate concentration
*[[Lactic acidosis]] from inability to breakdown citrate secondary to to hepatic dysfunction
*[[Hyperkalemia]]
*[[Air embolism]]
*[[Metabolic alkalosis]] from breakdown of citrate
*[[TRALI]]
 
==External Links==
*[http://www.mdcalc.com/abc-score-assessment-of-blood-consumption-for-massive-transfusion/ MDCalc - ABC score]
*[http://www.mdcalc.com/tash-score-trauma-associated-severe-hemorrhage-for-massive-transfusion/ MDCalc - TASH score]
*Massive Transfusion Protocol on [https://emcrit.org/ibcc/mtp/ Internet Book of Critical Care]
 
==See Also==
==See Also==
[https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/massive%20transfusion%20in%20trauma%20guildelines.ashx FACS Statement on MTP]
*[[Massive transfusion (peds)]]
<br>
*[[TXA]]
*[[Packed red blood cells]]
*[[EBQ:PROPPR_Trial|The PROPPR trial]]
*[[Coagulopathy (Main)]]
*[[Hemorrhagic shock]]
 
==References==
==References==
{{reflist}}
{{Reflist|2}}
<references/>
 
[[Category:Heme/Onc]]
[[Category:Trauma]]
[[Category:Procedures]]
[[Category:Critical Care]]

Revision as of 16:59, 10 December 2020

This page is for adult patients. For pediatric patients, see: massive transfusion (peds)

Background

[1]
  • Although massive transfusion (MTP) does not have a universal definition, it is generally described as transfusion of >10 units of blood products (specifically Packed red blood cells within a 24-hour period)
  • In addition to controlling hemorrhage the greatest concern during MTP is the lethal triad:[2]
    1. Hypothermia
    2. Coagulopathy
    3. Acidosis
  • Trauma Associated Coagulopathy[3]
    • Platelet defects (worse with TBI), endothelial injury, and loss of coagulation factors and platelets through hemorrhage consumption of platelets and coagulation factors
  • During MTP, focus is on "balanced resuscitation" with clotting factors (FFP) and platelets”[4]
  • The PROPPR trial[5] examined a 1:1:1 (FFP:Plt:pRBC) vs 1:1:2 protocol. There was no difference in mortality at 1 or 30 days; however, the 1:1:1 group experienced less death due to exsanguination in the first day.
  • The goal of MTP is to resuscitate and temporize management until definitive operative repair can be accomplished.
  • MTP should follow should follow local institutional protocols[6]

Indications

  • Hemorrhagic shock is the only indication for a massive transfusion
  • The ABC score and the TASH score predict the need for MTP
  • Newer studies[7] show that the Shock Index score is a better predictor than the ABC score
  • Revised Assessment of Bleeding and Transfusion (RABT) may reach higher sensitivity than ABC score, but not prospectively validated as of 2019

ABC Score[8]

  • Non-lab scoring system as opposed to TASH:
    • Penetrating mechanism
    • SBP ≤90 in ED
    • HR ≥120 in ED
    • Positive FAST
  • Scoring interpretation:
    • 0-1, not likely to require MTP (≥10 units pRBCs)
    • 2-4, likely to require MTP, sensitivity 75% and specificity 86% from original study[9]
  • Subsequent studies suggested < 50% sensitivity

Shock Index

  • SI = HR / SBP
  • Particularly useful in patients with pre-hospital SBP >90 mmHg
  • Pre-hospital SI >0.9 suggestive of need for MTP[10][11]

RABT

  • RABT score ≥ 2 of the following predicts need for MTP:
    • Shock index > 1.0
    • Pelvic fracture
    • Positive FAST
    • Penetrating injury
  • Sensitivity 84%, specificity 77%[12]

Adjunctive Agents

  • Tranexamic acid (TXA) lowers risk of death if administed in less then 3 hours after injury in trauma patients with significant hemorrhage (CRASH-2 trail)[13]
  • Thromboelastography (TEG) has been extensively studied in cardiac surgery and quantifies the coagulation cascade
  • Factor VII, studied in the CONTROL trial, showed no mortality benefit and was terminated early[14]
    • Other studies of Factor VII have raised concerns for MI and adverse thrombotic events
  • Consider giving calcium and magnesium IV supplementation if approaching > 4 units of pRBCs

Example Protocol

MTP pack contains 6 units RBCs and 4 units FFP (O neg uncrossmatched rbc's and AB FFP until completed screen)

  1. Attending physician activates protocol
  2. Charge nurse contacts blood bank and sends runner to pick up MTP pack
  3. TEG is drawn
  4. First MTP pack is delivered within 30min of ordering
  5. Transfusion continues until patient expires or is hemodynamicallys stable with cessation of bleeding
  6. If second pack is ordered it contains an additional single donor platelet pack (six-pack)
  7. The third pack substitutes cryoprecipitate for platelets
  8. PT, aPTT, and Fibrinogen is ordered q2 hours for the duration of the massive transfusion event

Complications[15]

External Links

See Also

References

  1. ↑ Mikhail J. The trauma triad of death: hypothermia, acidosis, and coagulopathy. AACN Clin Issues. 1999;10(1):85-94.
  2. ↑ Kashuk JL, et al. Major abdominal vascular trauma — A unified approach. J Trauma. 1982;22(8):672–679.
  3. ↑ http://rebelem.com/ten-trauma-resuscitation-commandments/
  4. ↑ Spinella PC. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. Blood Rev. 2009 Nov;23(6):231-40.
  5. ↑ Holcomb J. et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma The PROPPR Randomized Clinical Trial JAMA. 2015
  6. ↑ ACS TQIP Massive Transfusion in Trauma Guidelines fulltext
  7. ↑ Accuracy Of Shock Index Versus ABC Score To Predict Need For Massive Transfusion In Trauma Patients Schroll, R., et al, Injury 49(1):15, January 2018
  8. ↑ Nunez TC et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009 Feb;66(2):346-52.
  9. ↑ Schroll R et al. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury 2018 Jan;49(1):15-19.
  10. ↑ Cannon CM et al. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma. 2009 Dec;67(6):1426-30.
  11. ↑ Vandromme MJ et al. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma. 2011 Feb;70(2):384-8; discussion 388-90.
  12. ↑ Joseph B et al. Massive Transfusion: The Revised Assessment of Bleeding and Transfusion (RABT) Score. World J Surg 2018 Nov 42(11): 3560-3567.
  13. ↑ Shakur H, et al. "Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage". The Lancet. 2010. 376(9734):23-32.
  14. ↑ Hauser CJ. et al. Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma. 2010 Sep;69(3):489-500.
  15. ↑ Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.
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