Massive Transfusion Protocols for Patients With Substantial Hemorrhage

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Transfusion medicine for the resuscitation of patients with massive hemorrhage has recently advanced from reactive, supportive treatment with crystalloid and red blood cell therapy to use of standardized massive transfusion protocols (MTPs). Through MTPs, medical facilities are able to standardize the most effective posthemorrhage treatments and execute them rapidly while reducing potential waste of blood products. Damage control resuscitation is an example of an MTP, where patients are (1) allowed more permissive hypotension, (2) spared large volumes of crystalloid/colloid therapy (through low volume resuscitation), and (3) transfused with blood products preemptively using a balanced ratio of plasma and platelets to red blood cells. This focused approach improves the timely availability of blood components during resuscitation. However, the use of MTPs remains controversial. This review describes published experiences with MTPs and illustrates the potential value of several MTPs currently utilized by academic transfusion services.

Section snippets

Early Intervention Helps Alleviate Coagulation Disturbances

Military and civilian studies show that the presence of coagulopathy is associated with poorer outcomes in patients with severe hemorrhage.18 Up to 25% of trauma patients exhibit abnormal coagulation parameters at the time of presentation, which is associated with a 3-fold increase in mortality.19, 20 Military patients who had an international normalized ratio of more than 1.5 had a mortality of 30%, compared with 5% in those with hemorrhage but a normal international normalized ratio at

Institution 1

An MTP was established initially for trauma and labor and delivery and later for surgical and critical care patients, which provides for emergency release of 6 U of pRBCs, 4 U of plasma (liquid plasma, p24 plasma, or 5 day plasma), and 1 apheresis platelet (aPLT) unit (Fig 1).7 This order set is compiled and electronically issued within 6-10 minutes after the verbal telephone order to activate the protocol. To facilitate execution of the MTP, 4 U of blood type A and O thawed plasma are also

Impact on Patient Outcomes

Recent data from the US Army's Institute of Surgical Research have shown improvement in outcomes when soldiers requiring MTs received resuscitations with ratios of component types that were similar to whole-blood transfusions.40, 41 Subsequent reports, primarily in the military literature, further supported a component therapy transfusion in ratios of 1 U pRBC/1 U plasma/1 random donor unit of PLTs.6, 24, 42, 43 Casualties who received less than 1 U of plasma for every 4 U of pRBC were

Adjunct Strategies

Fresh whole blood has been successfully utilized in austere environments where component therapy is not available or has been depleted.1, 55, 56 In the most recent conflict in Iraq, military investigators evaluated 100 patients who received whole-blood resuscitation and compared them with 254 patients who received component therapy. The authors found that fresh whole blood performed well compared with component-based resuscitation in patients who required MT, reporting improved 24-hour and

Challenges Associated with Implementation of MTPs and the Focus of Future Research

Adequately powered studies in which the analysis adjusts for injury severity and survivorship bias are necessary in both military and civilian settings to clearly define the optimal ratio of pRBC/plasma in the trauma population. Such studies should also be designed to examine the utility of other adjunct agents such as cryoprecipitate and rFVIIa. Moreover, thus far, virtually all of the literature has focused on trauma hemorrhage. However, there are likely to be differences in the manner in

Conclusions

Current trauma resuscitation of the severely injured patient focuses on restoration of clotting factors, as well as depleted and dysfunctional PLTs through the concept of damage control resuscitation, with proactive transfusion of higher ratio of plasma and PLTs to red blood cells.37 Massive transfusion protocols with higher ratios of plasma and PLTs to pRBCs appear to be associated with improved survival in patients with massive hemorrhage. Further research into this important topic is needed,

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