Transfusion in trauma (original) (raw)
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INDICATIONS FOR MASSIVE TRANSFUSION IN THE CONDITION OF SEVERE TRAUMA: A LITERATURE REVIEW (Atena Editora), 2022
Goal: Dissertation about the effective indications for massive transfusion in patients with severe trauma. Method: Literature review prepared between October and November 2022, through a search in the Scielo and Pubmed databases with the descriptors "massive transfusion", "blood Component transfusion", "protocol" and "indications". 5353 articles were found and, after the inclusion and exclusion criteria, 13 studies were selected. Review: Hemorrhage is a preeminent cause of possibly preventable mortality in cases of trauma and in many cases requires massive transfusions (MT). Thus, in clinical practice it is mainly based on guidelines that determine different TM protocols (MTP). After the appreciation of an abundance of clinical parameters of the patient, one can opt for the massive transfusion that must be performed in a period of 24 hours. Conclusion: The lack of research that standardizes parameters for massive transfusions leads teams to evaluate different clinical standards based on different emergency services.
Transfusion strategies for major haemorrhage in trauma
British Journal of Haematology
Trauma is a leading cause of death worldwide in persons under 44 years of age, and uncontrolled haemorrhage is the most common preventable cause of death in this patient group. The transfusion management of trauma haemorrhage is unrecognisable from 20 years ago. Changes in clinical practice have been driven primarily by an increased understanding of the pathophysiology of trauma-induced coagulopathy (TIC), which is associated with poor clinical outcomes, including a 3-to 4-fold increased risk of death. Targeting this coagulopathy alongside changes to surgical and anaesthetic practices (an overarching strategy known as damage control surgery/damage control resuscitation) has led to a significant reduction in mortality rates over the last two decades. This narrative review will discuss the transfusion practices that are currently used for trauma haemorrhage and the evidence that supports these practices.
Reappraising the concept of massive transfusion in trauma
Critical Care, 2010
The massive-transfusion concept was introduced to recognize the dilutional complications resulting from large volumes of packed red blood cells (PRBCs). Definitions of massive transfusion vary and lack supporting clinical evidence. Damage-control resuscitation regimens of modern trauma care are targeted to the early correction of acute traumatic coagulopathy. The aim of this study was to identify a clinically relevant definition of trauma massive transfusion based on clinical outcomes. We also examined whether the concept was useful in that early prediction of massive transfusion requirements could allow early activation of blood bank protocols. Methods: Datasets on trauma admissions over a 1 or 2-year period were obtained from the trauma registries of five large trauma research networks. A fractional polynomial was used to model the transfusion-associated probability of death. A logistic regression model for the prediction of massive transfusion, defined as 10 or more units of red cell transfusions, was developed.
Massive transfusion in traumatic shock
The Journal of emergency medicine, 2013
Hemorrhage after trauma is a common cause of death in the United States and globally. The primary goals when managing traumatic shock are the restoration of oxygen delivery to end organs, maintenance of circulatory volume, and prevention of ongoing bleeding through source control and correction of coagulopathy. Achieving these goals may require massive transfusion of blood products. Although use of blood products may be lifesaving, dose-related adverse effects are well described. Complications of massive transfusion include interdependent derangements such as coagulopathy, hypothermia, acidosis, and electrolyte abnormalities, as well as infectious and immunomodulatory phenomena. This article explores the pathogenesis, implications, prevention, and treatment of these complications through the use of massive transfusion protocols. Particular attention is given to the optimal ratio of blood products transfused in large volume resuscitation and prevention of secondary coagulopathy. Obse...
Despite significant advances in trauma management including pre-hospital care, rapid evacuation, fluid management and 'damage control' surgery, mortality from hemorrhagic shock remains the number one cause of death in civilian and military trauma victims. The complexity of this injury is compounded by alterations in the coagulation system with a tendency towards a hypocoagulable state, although the coagulation systems' response under these conditions is not fully understood, and is skewed by only testing the pro-coagulant arm. Data from our latest battle fields suggests that reconstituting components of blood to resemble whole blood have better survival profile than conventional component approach or directed therapy. These data are retrospective and as such cannot reliably account for the 'survival effect' where those who survive will receive larger amounts of components at a higher ratio. Early recognition of associated coagulopathy in trauma patients is essential to improve outcome. Unfortunately, our understanding of trauma related coagulopathy is limited at best, and favors the pro-coagulant deficiency state since most, if not all studies rely on testing this arm. As we begin the second decade of this century, an enthusiastic call by some of our trauma surgical colleagues to resort to 1:1:1 ratio of major components (RBC, Plasma and Platelets) may be appropriate for some patients, but may put others at risk of worse outcome and possible higher delayed mortality. More convincing data to replace this exuberant enthusiasm is clearly needed. Until these data are available, guidelines for MTP and treatment of the hemorrhaging trauma patient are desperately needed to guide clinicians at the bedside. The COBM of the ASA has put together a SAMPLE recommendation for such a protocol. We encourage the ASA members to read it and collaborate with their hospital transfusion service and/or blood bank to implement a protocol based on the information provided, adjusted to local needs. A massive transfusion protocol (MTP) is activated by a clinician in response to a patient that is experiencing massive bleeding. The responsible clinician activates the MTP either by phone or any other mechanism. Once a patient is in the protocol, the blood bank is able to insure rapid and timely availability of blood components to facilitate resuscitation.
Transfusion of Blood Products in Trauma: An Update
The Journal of Emergency Medicine, 2010
e Abstract-Background: Blood transfusion in the management of severely injured patients can be lifesaving. These patients are susceptible to developing early coagulopathy, thus perpetuating bleeding. Objectives: This article presents recent advances in both the civilian and military clinical arena to improve the treatment of trauma patients with severe hemorrhage, the use of agents to support coagulation, perspectives on restrictive transfusion strategies, and transfusion-related risks. Discussion: Massive blood transfusion is an adjunct to surgical care. The volume of blood products transfused and the ratio of blood components have been associated with increased morbidity and mortality rates. The adverse clinical effects of transfusion and the limited supply of blood products have resulted in modern resuscitation protocols to limit the volume of blood transfused. Conclusion: A restrictive blood transfusion strategy and the use of hemostatic agents may decrease morbidity and mortality in trauma patients, but insufficient data are available for their use in trauma patients. Massive transfusion should reflect an equal ratio of packed red cells and plasma to limit coagulopathy. Prospective randomized trials are needed to standardize an effective protocol.
Massive transfusion practice in non-trauma related hemorrhagic shock
Journal of Critical Care, 2018
Evidence suggests that trauma patients with hemorrhagic shock requiring massive transfusion have improved outcomes if resuscitated with a prescribed massive transfusion protocol (MTP). However, there is limited data regarding the efficacy of MTP in non-trauma patients. Methods: This was a retrospective observational study of all patients who received a massive transfusion protocol for non-traumatic hemorrhagic shock over a four-year period. The primary outcome was in-patient hospital survival. We dichotomized recipients of MTP into survivors versus non-survivors, comparing outcomes of interest within the categories by nonparametric testing. Summary statistics expressed as median (interquartile range). Results: Fifty-nine patients were reviewed, with the median age of 59.0 (35.0-71.0) years old. Thirty-three (56%) patients survived. Survivors were younger, 57.0 (30.0-67.0) versus 64.0 (53.5-71.5) years old (p=0.047), and had lower sequential organ failure assessment scores (6.0 (3.0-8.0) versus11.5 (9.5-13.0); p = 0.008). Patients on the medical service receiving MTP had an increased risk of mortality (odds ratio 4.26; p = 0.02). Conclusion: Over half of the patients receiving massive transfusion protocols for their nontrauma related hemorrhagic shock survived. Survivors were younger, were less acutely ill, and on non-medical services. Further research is needed to investigate best practice for transfusion in non-trauma related hemorrhagic shock.
Transfusion approaches in trauma
Haemorrhage, massive transfusion and coagulopathy are the most important factors affecting outcome in severely injured patients. More than 50 per cent of patients with massive hemorrhage die, and for those who die within hours of the injury event, it is often the most common cause of death. Recent research has led to a new appreciation of the central role of coagulopathy in trauma care. An acute traumatic coagulopathy has been identified relatively recently. Developing early in the postinjury phase, it is present at admission in one of four trauma patients and is associated with a four-fold increase in mortality. Acute coagulopathy of trauma occurs in patients with shock and is characterized by systemic anticoagulation and hyperfibrinolysis. There is evidence that implicate activation of the protein C pathway in this process. Control of bleeding is extremely challenging in the presence of an established coagulopathy. In current clinical practice, coagulopathy treatment remains widely varying and often ineffective. Increasing availability of point-of-care devices has encouraged new concept for managing massive blood loss. Modern transfusion strategies are based on bedside coagulation monitoring with specific real time goal-directed administration of antifibrinolytics, coagulation factor concentrates, and blood products in modified ratio.
Massive transfusion and nonsurgical hemostatic agents
Critical Care Medicine, 2008
Background: Hemorrhage in trauma is a significant challenge, accounting for 30% to 40% of all fatalities, second only to central nervous system injury as a cause of death. However, hemorrhagic death is the leading preventable cause of mortality in combat casualties and typically occurs within 6 to 24 hrs of injury. In cases of severe hemorrhage, massive transfusion may be required to replace more than the entire blood volume. Early prediction of massive transfusion requirements, using clinical and laboratory parameters, combined with aggressive management of hemorrhage by surgical and nonsurgical means, has significant potential to reduce early mortality. Discussion: Although the classification of massive transfusion varies, the most frequently used definition is ten or more units of blood in 24 hrs. Transfusion of red blood cells is intended to restore blood volume, tissue perfusion, and oxygen-carrying capacity; platelets, plasma, and cryoprecipitate are intended to facilitate hemostasis through prevention or treatment of coagulopathy. Massive transfusion is uncommon in civilian trauma, occurring in only 1% to 3% of trauma admissions. As a result of a higher proportion of penetrating injury in combat casualties, it has occurred in approximately 8% of Operation Iraqi Freedom admissions and in as many as 16% during the Vietnam conflict. Despite its potential to reduce early mortality, massive transfusion is not without risk. It requires extensive blood-banking resources and is associated with high mortality. Summary: This review describes the clinical problems associated with massive transfusion and surveys the nonsurgical management of hemorrhage, including transfusion of blood products, use of hemostatic bandages/agents, and treatment with hemostatic medications.