1. No category

Massive Transfusion
Protocols- Saving
Lives 1:1:1 units at a
Time
Michael White, MD, FACS
Detroit Receiving Hospital
Hemorrhage accounts for
50% deaths in first 24 hrs
Hemorrhage accounts for
80% of deaths in operating
room
Sihler and Napolitano: Chest 2009;136:1654-1667
Markers of Blood Loss
¡  Blood loss
¡  Base deficit
¡  Hypotension
¡  Coagulopathy
¡  Number of Units of blood transfused
Study included 169 patients receiving at least 1 unit PRBC /24
Defined Massive Transfusion as 3 units PRBC/1 hr.
1. Coined phrase Critical Administration Threshold
2. Threshold chosen based on logistic regression
MT designation identified only 33% of deaths
CAT designation identified 75% of deaths
MT patients the Hazard ratio was 1.82
Identifying Patients that
need massive transfusion
Assessment of Blood Consumption (ABC) Score
Correctly Classified= 84-87%
PPV=55%
NPV=97%
ACS TQIP: Massive
Transfusion in Trauma
¡  ABC Score of two or more
¡  Persistent hemodynamic instability
¡  Active bleeding requiring operation or
angioembolization
¡  Blood transfusion in the trauma bay
Inclusion Criteria
1.  > 16 yrs
2.  > 1 unit PRBC in 1st 6 hrs
3.  Required highest level activation
Exclusions
1. Transfers in from another hospital
2. Declared dead within 30 min of admit
3. > 5 min CPR prior to or within 30 min admit
4. Prisoner
5. Burn injury greater than 20%
6. Pregnancy
7. Inhalation injury
To be included in analysis had to receive at least 3 units of blood
Deaths from hemorrhagic shock
1.  60 % deaths from hemorrhage occurred within 6 hrs
2.  90% deaths from hemorrhage occurred within 24 hrs
Deaths after 24 hrs were do to MOF and Brain injury
% Pts. without
Plasma
% Pts. without
Platelets
30 minutes
67
99
3 hours
10
28
Additional Inclusion Criteria:
Predicted to need a MT
1. ABC score of > 2
2. Judgment of physician
Additional exclusion criteria:
1. Do not resuscitate order
2. Enrolled in another study
3. Received more than 3 units blood
product prior to inclusion
4. Opted out of study
Category
1:1:1
1:1:2
Penetrating
Trauma
185(54.7)
173(50.6)
Blunt trauma
157(46.4)
173(50.6)
HR > 120
148(44.0)
152(44.6)
SBP< 90
127(38.5)
128(39.0)
Base Excess< -4
mmol/L
238(74.8)
239(79.4)
ISS(median)
26.5
26
MT(10 Units/24hrs)
153(45.3)
160(46.8)
CAT(3 units/hr.)
281(83.1)
314(91.8)
75% patients had an operation or interventional radiologic procedure
Massive Transfusion Protocol
¡  Most hemorrhagic death occur early
¡  MT protocol that ensures rapid defined ratio
blood delivered is important
¡  Identification of these patients that need a MT
¡  Control source of bleeding
¡  Initiate a MT protocol
¡  MT protocol Is associated with decreased
mortality from hemorrhagic shock when utilized in
a 1:1:1 vs. 1:1:2 ratio without increase in
complications