Massive transfusion: New Protocol

Bhavani Shankar Kodali MDAnesthesiologist-in-Chief, Interim Chairman

Brigham and Women’s Hospital

Associate ProfessorHarvard Medical School

Goal of this presentation

• Are we on the right track?

• What is our current practice?

“Obstetrics Anesthesia”

“Obstetrics is a bloody business”

1970’s

- maternal deaths due to bleeding

= 13%

1990’s

- maternal deaths due to bleeding

~ 1.3%

Presently

- 1 per 100,000 25-30% maternal deaths WorldwidePreventable

Conventional Management of Hemorrhage

Fluids

Colloids

Blood

Plasma

3:1

Platelets depending on the number

246

22 Level 1 trauma

Obstetric hemorrhage

Whole Blood Bedside Assay

platelets

**Balanced ratios of blood products**Blood viscoelastic assays

Initial Labs

How did we achieve these results

• 1:1:1• Cryoprecipitate• Ca• Temperature of the patient• RiaSTAP

Massive Transfusion

Department of Anesthesiology, Perioperative and Pain Medicine

Brigham and Women’s Hospital

Massive Transfusion

• Definition – Transfusion of ≥10 units of blood products in 24

hours – Replacement by transfusion of more than 50% of

blood volume in 12 to 24 hours

• Hemorrhage is the leading cause of death in the first hour after trauma and accounts for 50% of death in the first 24 hours

Coagulopathy

• Coagulopathy is associated with trauma in 25-38% of patients; it is also associated with a 4-fold increase in mortality

• Acute Coagulopathy of Trauma (ACoT)– Associated with severe injury– PT, aPTT, thrombin time >1.5 times normal

limit– Coagulopathy: higher mortality (46% vs. 11%)1

1Brohi K et al J Trauma 2003

Assessment of Coagulopathy

• Early recognition is associated with improved survival• Conventional coagulation testing (PT, PTT, platelet count,

fibrinogen)• Rapid Thromboelastography (TEG)

– Comprehensive assessment of coagulation abnormalities– Faster results– Correlated with conventional testing

Activating Massive Transfusion Protocol at BWH

• Pharmacy = x27153• Blood bank = x27290• Criteria at BWH

– > 4 PRBC in 1 hour– > 10 PRBC in 24 hours