Massive transfusion

Definition

• Traditional: 10U of PRBC in first 24 hours
• More modern definitions include 3U in 1 hour, 5U in 4 hours or 10U in 6 hours
• Predictive rules can be applied

Team leader responsibilities

• Activate Trauma Team if appropriate
• Activate MTP for critically bleeding patient
  • SBP <90;HR >100;BE -6
  • FAST or CT positive for blood
  • Ongoing bleeding
  • Notify if product-based on ROTEM-based algorithm
• Consider medevac products (3U O neg PRBC)
• Consider red blanket
• Notify blood bank if patient transferred to other departments
• Notify blood bank if MTP deactivated

Initial measures

• Control external bleeding/pelvic binder/splint fractures
• Crossmatch – signed paper request
• ABG/FBC/LFT/Lipase/Coags/Calcium
• ROTEM
• Limit crystalloid
• Warm fluid (DO NOT WARM PLATELETS)
• Tranexamic acid 1g IV over 10 min in 100mL N/S then 1g over 8 hours
  • If renal failure, stat dose only

Monitor

• ROTEM
  • 10 minutes after each blood product intervention
• FBC/Coags/Calcium/ABG
  • Every 30-60 min
• Temperature

Targets

• Temp 36-38
• pH >7.2, BE >-6, Lactate <4
• iCa >1.1
• Hb >70
• Plt >50
• Fibrinogen >1.5
• Normal ROTEM
• INR <1.5, PT <20, APTT <60

Component based MTP

• Pack 1: 4 PRBC, 2 FFP, 6 cryoprecipitate
• Pack 2: 4 PRBC, 4 FFP, 1 dose Plt
• Pack 3: 4 PRBC, 4 FFP, 6 cryoprecipitate
• Packs 2 and 3 then continue repeatedly

Special situations

• Warfarin/liver failure
  • Vitamin K 10mg IV
  • Prothrombinex 50U/kg
• Dabigatran
  • Discuss with Haematologist
  • Idarucizumab 2x 2.5g aliquots
• Rivaroxaban/Apixaban
  • Discuss with Haematologist
  • Prothrombinex 50IU/kg
• Antiplatelet agents or renal failure
  • Additional platelets
  • Consider desmopressin

FFP

• Has INR 1.6
• Usual volume is 250mL = Plasma derived from one unit of blood
• Must be ABO compatible
• 10-20mL/kg (4-6U in adults) will increase factors by 20%
• Contains all coagulation factors in physiological concentration
• Free of red cells, leukocytes and platelets
• Rhesus compatibility does not matter
• No risk of CMV or GVHD as no active leukocytes

Cryoprecipitate

• Fibrinogen, vWF, Factor VIII, Factor XIII and fibronectin
• Made from thawing FFP to 1-6 degrees and collecting insoluble precipitate
• 1U = 30-40mL
• Preferably ABO compatible with recipients red cells
• Rhesus compatibility not required
• Give as fast as possible
• 1U/5-10kg should increase fibrinogen by 0.5-1.0 g/L

Novoseven

• Recombinant activated Factor VII
• Requires surgical director/haematologist approval

ROTEM

• EXTEM
  • Extrinsic pathway testing (not affected by heparin)
  • Coagulation activated by tissue factor 
• FIBTEM
  • EXTEM with addition of platelet inhibitor. Comparison with EXTEM identifies effect of fibrinogen concentration and function
• APTEM
  • EXTEM with addition of aprotinin (to inhibit fibrinolysis). Comparison with EXTEM identifies hyperfibrinolysis
• INTEM
  • Intrinsic pathway and heparin sensitive
• HEPTEM
  • INTEM with addition of heparinase. Comparison to INTEM identifies heparin effect

ROTEM

• Targets
  • FIBTEM A5 >10mm
  • EXTEM CT < 80s
  • EXTEM A10 >40mm
• Indications
  • Haemodynamic instability from suspected or proven haemorrhage
  • Traditionally used in cardiac surgery, liver transplant and trauma
  • Some evidence of benefit exists for any patient with active haemorrhage and haemodynamic instability including patients with hepatic coagulopathy
• Normal values of EXTEM
  • Clotting time (CT) <80s (time to initiation of clotting)
  • Clot formation time (CFT) <160s (time to clot firmness of 20mm)
  • Amplitude at 5 min (A5) >35mm
  • Amplitude at 10 min (A10) > 45mm
  • Maximum clot firmness (MCF) 50-72mm
  • Maximum lysis (ML) <15% (% of MCF)

ROTEM

• Systematic review (Bugaer et al.) found in trauma over 7 studies the use of ROTEM/TEG-guided haemostatic resuscitation reduced PRBC (RR 0.74), adverse effects, number of people requiring platelet transfusion and overall mortality (RR 0.75)
• Hunt et al. 2015 Cochrane review found no evidence on the accuracy of TEG and scant evidence on the accuracy of ROTEM in diagnosing trauma-induced coagulopathy and advised their use to be limited to research studies
• The RCT by Gonzalez et al. 2016 found in 111 severely injured patients that TEG-guided MTP reduced the risk of death at both 6 hours (21.8% conventional vs. 7.1% in TEG-guided) and 28 days (36.4% conventional vs. 19.6% TEG-guided)
  • No difference in overall transfusions between groups but more FFP/Platelets in the first hours of resuscitation
• ITACTIC
  • Multicentre RCT involving injured patients suspected of suffering haemorrhage who required at least one PRBC transfusion
  • Compared outcomes in those who received an empiric MTP supplemented by viscoelastic haemostatic assay vs. augmentation with conventional coagulopathy testing.
  • All patients received 1:1:1 ratio MTP and limited infusion of crystalloids
  • Primary outcome was 24 hour alive and free of massive transfusion
  • Secondary outcomes were all-cause mortality up to 90 days, total blood components, ICU-free days, total hospital LOS and serious adverse events/VTE/MODS
  • 411 patients randomised in total
  • 2/3 blunt trauma
  • Overall median ISS 26
  • No overall difference in primary or secondary outcomes between groups
  • Only 1/4 of patients were coagulopathic on arrival and very few developed this
  • The VHA group had trauma-induced coagulopathy diagnosed more commonly and subsequently had more interventions
    • The VHA group received study interventions 67% of the time, 1.8x more likely than the conventional coagulation testing groups

ROTEM

• Limitations
  • Platelet inhibitors
    • No detection of antiplatelet effects
    • No detection of von Willebrand syndrome
    • No detection of functional platelet impairment in renal failure
  • Anticoagulants
    • Poor sensitivity to LMWH
    • Poor sensitivity to oral anticoagulants

ROTEM

• Hyperfibrinolysis = ML % > 15% = TXA 1g
• Hyperfibrinolysis + low fibrinogen = 
  • FIBTEM cT >600s AND EXTEM A5 < 35mm = 
  • TXA 1g + Fibrinogen concentrate 4g (one off) OR CRYO 20U
• Low fibrinogen
  • FIBTEM A5 <8mm = Fibrinogen concentrate 4g one off or Cryo 20U
  • FIBTEM A5 8-10mm = Cryo 10U
• Low platelets
  • EXTEM A5 <35mm & FIBTEM A5 >10mm = 1 dose of platelets
• Factor deficiency
  • EXTEM-CT >90s & EXTEM A5 <35mm = 2-4U FFP

Transfusion ratios

• PROMMTT Study (2013)
  • Higher plasma and platelet ratios early in resuscitation associated with reduced mortality in patients receiving at least 3U of PRBC over 24 hours
  • Ratios <1:2 were 3 to 4 times more likely to die than those with ratios of 1:1 or higher
  • After 24 hours the association is lost
• PROPPR study
  • No statistical difference in mortality between 2:1:1 and 1:1:1
  • Currently 1:1:1 (PRBC:FFP:Platelets) is used
    • Equates to 5U PRBC:5FFP:5 units of platelets
    • 5U of platelets = 1 pooled bag

Likelihood of transfusion

• Prehospital SBP <100
  • Require transfusion in 40-60%
• Prehospital SBP >100
  • 5-10% require transfusion
  • Group and hold should be ordered on arrival

Emergency transfusion score (ETS)

• Age
  • 20-60: 0.5
  • >60: 1.5
• Direct from scene – 1
• Traffic accident – 1.5
• Fall >3m – 1
• SBP
  • 0-90 – 2.5
  • 90-120 – 1.5
• Unstable pelvic ring disruption – 1.5
• + FAST – 2

ETS

• <3: 60% of patients, 5% probability of transfusion, specificity 68%
• ETS 6: 50% probability of transfusion
• + FAST and SBP <90: 95% sensitive and 55% specific for transfusion

ABC score

• SBP<90: OR 13.0
• + FAST: OR 8.2
• HR >120: OR 3.9
• Penetrating mechanism: OR 1.9

Predictors of need for immediate surgery

• Haemothorax > 1.5L
• IVC expiratory diameter <7mm
• Largely + FAST
• Transient fluid response: IVC increase <3mm following resus
• Leaking AAA
• Ectopic pregnancy

Traumatic coagulopathy (Brohi et al. 2003)

• Incidence of coagulopathy rises with increasing severity of injury
• Coagulopathy on arrival to ED carries a significantly higher mortality (46% vs. 10.9%)
• The incidence of coagulopathy was not associated with the amount or volume of IV fluid administered
• Tissue trauma known to activate multiple neurohormonal pathways including coagulation, fibrinolytic, complement and kallikrein cascades
• May be exacerbated by resuscitation-associated coagulopathy

Platelet function tests in trauma (Paniccia et al. 2015)

• Scant evidence for use of platelet function tests in trauma
• Appears that trauma-induced platelet dysfunction is relatively common but unclear if specific treatment of this provides benefit/harm

Blood warmers

• Should be utilised for rapid transfusions or in patients who are hypothermic
• Most commonly used are dry heat plate warmers (e.g. 3M Ranger) that can increase temperature up to 41 degrees in a cassette between heat plates

Last Updated on June 13, 2022 by Andrew Crofton