Massive transfusion: Difference between revisions
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{{Adult top}} [[massive transfusion (peds)]] | |||
==Background== | ==Background== | ||
[[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>]] | |||
*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) | *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:<ref>Kashuk JL, et al. Major abdominal vascular trauma — A unified approach. J Trauma. 1982;22(8):672–679.</ref> | *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> | ||
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*#[[Coagulopathy]] | *#[[Coagulopathy]] | ||
*#[[Acidosis]] | *#[[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> | *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. | *[[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. | ||
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==Indications== | ==Indications== | ||
*[[Hemorrhagic shock]] is the only indication for a massive transfusion | *[[Hemorrhagic shock]] is the only indication for a massive transfusion | ||
*The [http://www.mdcalc.com/abc-score-assessment-of-blood-consumption-for-massive-transfusion/ ABC score] and the [ | *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 | ||
*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 | |||
*Revised Assessment of Bleeding and Transfusion (RABT) may reach higher sensitivity than ABC score, but not prospectively validated as of 2019 | |||
===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>=== | |||
*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<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== | ==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<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> | *[[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 | *[[Thromboelastography (TEG)]] has been extensively studied in cardiac surgery and quantifies the coagulation cascade | ||
*Factor VII, studied in the CONTROL trial, <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. | *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 | **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== | ==Example Protocol== | ||
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==Complications<ref>Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.</ref>== | ==Complications<ref>Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.</ref>== | ||
*[[Hypothermia]] | *[[Hypothermia]] | ||
*Dilutional coagulopathy | *Dilutional [[coagulopathy]] | ||
*[[Hypocalcemia]] and [[hypomagnesemia]] from high citrate concentration | *[[Hypocalcemia]] and [[hypomagnesemia]] from high citrate concentration | ||
*[[Lactic acidosis]] from inability to breakdown citrate secondary to to hepatic dysfunction | *[[Lactic acidosis]] from inability to breakdown citrate secondary to to hepatic dysfunction | ||
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*[[Air embolism]] | *[[Air embolism]] | ||
*[[Metabolic alkalosis]] from breakdown of citrate | *[[Metabolic alkalosis]] from breakdown of citrate | ||
*[[TRALI]] | |||
==External Links== | ==External Links== | ||
*[http://www.mdcalc.com/abc-score-assessment-of-blood-consumption-for-massive-transfusion/ MDCalc - ABC score] | *[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] | *[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== | ||
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[[Category:Trauma]] | [[Category:Trauma]] | ||
[[Category:Procedures]] | [[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
- 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]
- 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)
- 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[15]
- 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
- MDCalc - ABC score
- MDCalc - TASH score
- Massive Transfusion Protocol on Internet Book of Critical Care
See Also
- Massive transfusion (peds)
- TXA
- Packed red blood cells
- The PROPPR trial
- Coagulopathy (Main)
- Hemorrhagic shock
References
- ↑ Mikhail J. The trauma triad of death: hypothermia, acidosis, and coagulopathy. AACN Clin Issues. 1999;10(1):85-94.
- ↑ Kashuk JL, et al. Major abdominal vascular trauma — A unified approach. J Trauma. 1982;22(8):672–679.
- ↑ http://rebelem.com/ten-trauma-resuscitation-commandments/
- ↑ Spinella PC. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. Blood Rev. 2009 Nov;23(6):231-40.
- ↑ 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
- ↑ ACS TQIP Massive Transfusion in Trauma Guidelines fulltext
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ Cannon CM et al. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma. 2009 Dec;67(6):1426-30.
- ↑ 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.
- ↑ Joseph B et al. Massive Transfusion: The Revised Assessment of Bleeding and Transfusion (RABT) Score. World J Surg 2018 Nov 42(11): 3560-3567.
- ↑ 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.
- ↑ 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.
- ↑ Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.