Welcome to the first edition of the California version of Staten Island Corner. It’ll be similar to the old Staten Island Corner but with more smiles and vegetables.
I think we’ve all been in the following situation: You’re in CCT and in walks an older gentleman with a distended abdomen complaining of blood per rectum x 1 day and vomiting blood x 2 earlier today. Pmhx Cirrhosis/chronic heavy drinker.
VS show HR 130, BP 80/50. Then, the guy vomits forth a volcano of blood and has decreased mental status. What do you do?
If answered ABC’s then great job. You are on your way to being a capable ER doc.
Step 1: IV/ Monitor/Intubate/labs. For an IV, throw a 14 or two somewhere. I’d also recommend a femoral cordis…or two. He looks…pale/bad/like he’s running out of blood.
Step 2: Activate our hospital’s always efficient Massive Transfusion Protocol. This patient needs large amounts of blood and fast. He’s also likely hypocoagulable from liver failure and will become even more so as he’s at risk for hypothermia, acidosis, consumption of platelets and clotting factors. pRBC transfusion or IV crystalloid will also worsen his hypocoag by diluting his platelets and clotting factors).
According to our hospital’s protocol sent to me by the blood bank, you order “massive transfusion protocol”, for which you will get 10 units pRBC, 8 units FFP, and 2 Single Donor Platelets. Call blood bank, and we get all of that in 2 shipments.
Massive Transfusion Protocol
Hx: This whole idea started in Iraq where lots of people were being…trauma’d.
Def: expected > 10 units pRBC or completely replenishing someone’s total rbc in <24 hours.
General goal: give RBC’s, FFP, and platelet’s fast in as close to a 1:1:1 ration as possible.
Data
Borgman’s 2007 paper in The Journal of Trauma was a retrospective analysis of 246 patients divided into three groups by RBC:FFP ration of 1:8, 1:2.5, and 1:1.4. With similar ISS scores (18), the mortality rates were 65%, 34%, and 19% (p<0.001) respectively with Hemorrhage mortality rates of 92.5%, 78%, and 37% (p<0.001). Using logistic regression, the ratio was independently associated with survival (OR 8.6, 95% confidence interval 2.1-35.2. Obviously this is a smaller, retrospective with all the flaws inherent therein, but, the numbers are pretty good. To round nicely, if you give 5 people massive transfusion of 1: 1.4 vs 1: 8, 2 of them will live that otherwise would have died.
Another paper by Holcomb in 2008 reviewed 466 trauma patients across 16 level 1 trauma centers who received >10 units of RBC in 24 hours. They used “multivariate logistic models” to determine <1:2 vs >1:2 ration FFP:rbc resulted in 60% vs. 40% survival respectively. Also, higher ratio leads to decreased hemorrhage, increased 6 hour, 24 hour, and 30 day survival, decreased ICU/ventilator dependent/ hospital length of stay.
And it’s not just the ratio that turns out to be important. Simply having a protocol to speed up blood product delivery can save lives. In Dente’s 2009 article, he reviewed 73 Massive Transfusion Protocol blunt trauma patients after they instituted the protocol were compared to 84 patients with “similar demographics and injury severity score”. By streamlining the process, crystolloid dropped from 9.4L to 6.9L (p=0.006). RBC:FFP went from 22.8:7.6 to 23.7:15.6. Mortality decreased from 36% to 17% (p=0.008) @ 24 hours and also @ 30 days 55% to 34% (p=0.4). Simply by having a protocol, these patients got more FFP per RBC, bled less, and had increased survival. That’s some good data.
Complications to watch out for include: hypocalcemia from increased citrate in pRBC’s, DIC (can also give cryo if fibrinogen < 100) and thrombocytopenia secondary to dilution, consumption or DIC. Also, the usual transfusion problems: TRALI, infection, and transfusion reaction.
Factor VIIa can also be used (off label) as no studies have shown mortality benefit. However, according to a Cochrane review there is a statistically insignificant “trend” towards survival. Risks of FVIIa include an increased incidence of thromboembolic adverse events.
Keep in mind that the platelet’s we get from our blood bank are usually pooled from 5-6 donors. The 1:1:1 ideal is based on individual platelet donors. In our hospital, the 2 units that we order are equivalent to 10 individual donor units.
Back to our case, you instituted massive transfusion protocol and were promptly given lots of blood products in as close a 1:1:1 ratio as possible. GI scoped the patient emergently, banded some varices, and IR even came in for a successful, emergent TIPS procedure. The patient was extubated 3 days later, and, get this, turns out his uncle’s second cousin old college roommate is George Clooney. ER himself. He befriends you, pays off your med school loans, introduces you to the love of your life/becomes the love of your life, and all of your wildest dreams come true.
In short, when people are bleeding , they are losing red blood cells, plasma, platelets, and clotting factors. It seems logical to try to replace those as fast as possible. All the data supports this, in a 1:1:1 ratio. Above we went through some data to show you why it’s important to give RBC:FFP in as close a 1:1 ratio as you can.
- Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63:805.
- Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447.
- Simpson E, Lin Y, Stanworth S, et al. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2012; 3:CD005011.
- Improvements in Early Mortality and Coagulopathy are Sustained Better in Patients With Blunt Trauma After Institution of a Massive Transfusion Protocol in a Civilian Level I Trauma Center, Dente, Christopher J. MD, FACS; Shaz, Beth H. MD; Nicholas, Jeffery M. MD, FACS; Harris, Robert S. MD; Wyrzykowski, Amy D. MD; Patel, Snehal BBA, MS; Shah, Amit BS; Vercruysse, Gary A. MD; Feliciano, David V. MD, FACS; Rozycki, Grace S. MD, FACS; Salomone, Jeffrey P. MD, FACS; Ingram, Walter L. MD, FACS. Trauma and Acute Care Surgery June 2009, volume 66, issue 6.
andygrock
- Resident Editor In Chief of blog.clinicalmonster.com.
- Co-Founder and Co-Director of the ALiEM AIR Executive Board - Check it out here: http://www.aliem.com/aliem-approved-instructional-resources-air-series/
- Resident at Kings County Hospital
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Zehtabchi may have something to say about this enthusiastic plug. See his systematic review.
But in the end, if a fancy name like “massive tranfusion protocol” (also see “stroke code”)gets you past the blood bank-related hurdles, this MAY be beneficial in patients in whom you’re not fearful of volume overload.