The coagulopathy of massive transfusion

Intraoperative platelet and plasma improves survival in patients operated for a rAAA: a follow-up evaluation

OBJECTIVES

Continued haemorrhage remains a significant contributor to mortality in massively transfused patients. We found that early administration of platelets and plasma reduced mortality from 54% to 36% in rAAA patients. The aim of the present evaluation was to evaluate whether reduced mortality in rAAA patients related to a pro-active transfusion therapy is maintained.

DESIGN

Single-centre observational study.

METHODS

Mortality of patients operated for rAAA 2006-07 was compared to that of patients operated 2004-05 (intervention group; n=50) and 2002-04 (control group, n=82).

RESULTS

64 consecutive patients with rAAA received, similar to the intervention group, more platelets (5 and 4 vs. 0 units, P<0.05) and plasma (12 and 11 vs. 7 units, P<0.05) intraoperatively and had a higher platelet count (158 and 155 vs. 69 x 10(9)/L, P<0.0001) upon arrival at the intensive care unit and the 30-day mortality remained reduced (24% and 36% vs. 56%, P<0.01 and P=0.02, respectively) as compared to the control patients.

CONCLUSIONS

Early administration of platelets and plasma, together with red blood cells maintained reduced mortality in patients operated for rAAAin a 18 month period.

Evidence for indications of fresh frozen plasma

There continues to be a general but unfounded enthusiasm for fresh frozen plasma (FFP) usage across a range of clinical specialties in hospital practice. Clinical use of plasma has grown steadily over the last two decades in many countries. In England and Wales, there has not been a significant reduction in the use of FFP over the last few years, unlike red cells. There is also evidence of variation in usage among countries--use in England and Wales may be proportionately less per patient than current levels of usage in other European countries and the United States. Plasma for transfusion is most often used where there is abnormal coagulation screening tests, either therapeutically in the face of bleeding, or prophylactically in non-bleeding subjects prior to invasive procedures or surgery. Little evidence exists to inform best therapeutic plasma transfusion practice. Most studies have described plasma use in a prophylactic setting, in which laboratory abnormalities of coagulation tests are considered a predictive risk factor for bleeding prior to invasive procedures. The strongest randomised controlled trial (RCT) evidence indicates that prophylactic plasma for transfusion is not effective across a range of different clinical settings and this is supported by data from non-randomised studies in patients with mild to moderate abnormalities in coagulation tests. There are also uncertainties whether plasma consistently improves the laboratory results for patients with mild to moderate abnormalities in coagulation tests. There is a need to undertake new trials evaluating the efficacy and adverse effects of plasma, both in bleeding and non-bleeding patients, to understand whether the "presumed" benefits outweigh the "real risks". In addition, new haemostatic tests should be validated which better define risk of bleeding.

The role of blood transfusion in the management of upper and lower intestinal tract bleeding

Patients with gastrointestinal (GI) haemorrhage use 13.8% of all red blood cell transfusions in England. This review addresses the evidence for red blood cell, fresh frozen plasma and platelet transfusions in acute and chronic blood loss, from both the upper and lower intestinal tract. It reviews the indications for transfusion in GI bleeding, the haematological consequences of massive blood loss and massive transfusion, and the importance of managing coagulopathy in bleeding patients. It also looks at the safety and risks of blood transfusion, and provides clinicians with evidence to reduce unnecessary transfusion. Large controlled clinical trials of blood transfusion specifically in GI bleeding are required, along with further research into the use of adjuvant therapies such as recombinant activated factor VIIa. Changing clinician behaviour to reduce inappropriate blood transfusion remains a key target for future transfusion research.

Transfusion medicine during the summer of 2006: lessons learned in northern Israel

In July 2006 a Hizballah attack erupted at the Lebanon-Israel border. Reported here is the experience of the Rambam Health Care Campus--a level I trauma center--during 33 days of warfare. Two hundred ninety-five soldiers and 209 civilians were admitted to the emergency department (ED). Forty-eight wounded soldiers (16%) and 12 civilians (6%) had transfusion. Twenty soldiers and 1 civilian had massive transfusions. The ratio between packed red blood cells and fresh frozen plasma (FFP) used for patients who had massive transfusion was 3:2. In these patients, the median prothrombin time international normalized ratio and partial thromboplastin time increased during the first 2 hours after admission from 1.29 to 1.51 and from 33.6 to 39 seconds, respectively. Twenty patients who had massive transfusion survived. Patients with an injury severity score of at least 16 had a higher need for blood products than others, with a lower severity score, with a mean packed red blood cells unit transfusion of 7 vs 4 (P = .03) and FFP transfusion of 13 vs 1.5 (P = .002), respectively. In conclusion, we observed that early transfusion of FFP to casualties with penetrating wounds requiring massive transfusion is needed to overcome the coagulopathy present. The presence of a transfusion service representative on-site in the ED is recommended to ensure proper identification and labeling of blood samples. Real-time consultations provided by a transfusion medicine physician in the operation theater was also found to be essential.

Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients

Anemia commonly affects critically ill patients. The causes are multifactorial and include acute blood loss, blood loss from diagnostic testing and blunted red blood cell production. Blood transfusions are frequently given to patients in intensive care units to treat low hemoglobin levels due to either acute blood loss or subacute anemia associated with critical illness. Although blood transfusion is a life-saving therapy, evidence suggests that it may be associated with an increased risk of morbidity and mortality. A number of blood conservation strategies exist that may mitigate anemia in hospital patients and limit the need for transfusion. These strategies include the use of hemostatic agents, hemoglobin substitutes and blood salvage techniques, the reduction of blood loss associated with diagnostic testing, the use of erythropoietin and the use of restrictive blood transfusion triggers. Strategies to reduce blood loss associated with diagnostic testing and the use of hemostatic agents and erythropoietin result in higher hemoglobin levels, but they have not been shown to reduce the need for blood transfusions or to improve clinical outcomes. Lowering the hemoglobin threshold at which blood is transfused will reduce the need for transfusions and is not associated with increased morbidity or mortality among most critically ill patients without active cardiac disease. Further research is needed to determine the potential roles for other blood conservation strategies.

Causes and consequences of critical bleeding and mechanisms of blood coagulation

Pharmacists who practice in the critical care setting require a solid background on the causes and consequences of bleeding, as well as the mechanisms of hemostasis. This article provides an overview of these topics. Bleeding and outcomes as a result of surgery and trauma, from medical and pharmacologic causes, and in obstetrics and gynecology are discussed. Patients with brain trauma, those with inherited and acquired bleeding disorders, and patients undergoing therapeutic anticoagulation are addressed, as these are populations at special risk for severe bleeding. Bleeding events as a result of hypothermia, acidosis, and disseminated intravascular coagulation are also discussed, as is the pathophysiology of massive blood loss. Traditional and newer cell-based models of coagulation mechanisms are described and compared. Application of this information in pharmacy practice will help ensure that therapies to manage and arrest blood loss are used appropriately in a wide variety of clinical scenarios.

How we treat: management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol

Management of massive, life-threatening primary postpartum hemorrhage in the labor and delivery service is a challenge for the clinical team and hospital transfusion service. Because severe postpartum obstetrical hemorrhage is uncommon, its occurrence can result in emergent but variable and nonstandard requests for blood products. The implementation of a standardized massive transfusion protocol for the labor and delivery department at our institution after a maternal death caused by amniotic fluid embolism is described. This guideline was modeled on a existing protocol used by the trauma service mandating emergency release of 6 units of group O D- red cells (RBCs), 4 units of fresh frozen or liquid plasma, and 1 apheresis unit of platelets (PLTs). The 6:4:1 fixed ratio of uncrossmatched RBCs, plasma, and PLTs allows the transfusion service to quickly provide blood products during the acute phase of resuscitation and allows the clinical team to anticipate and prevent dilutional coagulopathy. The successful management of three cases of massive primary postpartum hemorrhage after the implementation of our new massive transfusion protocol in the maternal and fetal medicine service is described.

Massive blood transfusion and trauma resuscitation

AIMS

To review the massive transfusion practice at a Level I adult Trauma Centre during initial trauma reception and resuscitation.

METHODS

All trauma patients presenting to The Alfred Emergency & Trauma Centre and receiving a transfusion of five units or more of packed red blood cells within 4h of presentation over a 26-month period were included in this study. Patient demographics, clinical characteristics, injuries, surgical management and volume of blood transfused were analysed with mortality as the primary endpoint. Initial clinical features and injuries predictive of massive transfusion were also analysed.

RESULTS

There were 119 patients who received a transfusion of five units or more of packed red blood cells (PRBCs) within 4h of presentation. The median Injury Severity Score of this group of patients was 34.0 (IQR 26-48) and mortality was 27.7%. The median number of packed red blood cell transfused was 8.0 (IQR 6-14) in the 1st 4h. Initial clinical features and injuries independently associated with a larger volume of blood transfused were initial hypotension, fractures of the pelvis, kidney injuries, initial acidaemia, and thrombocytopaenia. The Injury Severity Score, initial coagulopathy measured by APTT and the presence of head injuries were the independent predictors of mortality.

CONCLUSIONS

The volume of blood transfused during trauma resuscitation was not found to be an independent predictor of mortality. Prospective studies into transfusion practice and clinical features of patients during the trauma resuscitation phase requiring massive transfusion are needed to establish evidence-based guidelines for massive transfusion.

The impact of major surgery on blood coagulation factors and thrombin generation

We studied the blood coagulation system of 14 patients with metastatic malignancies before and after they had undergone major surgery. In addition to measuring a battery of coagulation factors, we assessed the function of the system with assays of whole blood thrombin generation. With the exceptions of factor VIII (fVIII), which increased, and fibrinogen and fIX, which did not change, the activities of all the pro- and anticoagulant proteins were significantly lower postoperatively. However, the thrombin generating capacity of the system was relatively preserved. Although the integral of thrombin activity over time was lower after surgery, the mean peak thrombin concentration was unchanged and the time to clot formation was shortened. Similar changes could be reproduced by lowering the concentrations of pro- and anticoagulant factors together in control blood samples. Therefore, simultaneous reductions in pro- and anticoagulant proteins postoperatively worked to maintain the functional integrity of the blood coagulation system.

The blood bank: from provider to partner in treatment of massively bleeding patients

BACKGROUND

Continued hemorrhage remains a major cause of mortality in massively transfused patients of whom many develop coagulopathy. Reviewing transfusion practice for these patients, we found that at our hospital more than 10 percent received a suboptimal transfusion therapy and that survivors had a higher platelet count than nonsurvivors. We therefore investigated whether the blood bank could improve its service and hence improve the outcome.

METHODS

The blood bank introduced monitoring of the delivery of blood products and contacted the clinician provided there was an imbalance in the transfusion practice. For massively transfused patients, transfusion packages, including five red blood cells, five fresh-frozen plasma, and two platelet concentrates, were introduced to improve hemostatic competence. The Thrombelastograph (TEG) Haemostatic System (Haemoscope Corp., Niles, IL) was implemented, aiding in the diagnosis and treatment of coagulopathy.

RESULTS

The fraction of suboptimally transfused patients declined from more than 10 percent to less than 3 percent. The transfusion package administered intraoperatively to patients operated on for a ruptured abdominal aortic aneurysm resulted in decreased postoperative transfusion requirements and improved 30-day survival (66% vs. 44%) compared with controls. Performing TEG alone in patients with significant bleeding as judged by the anesthetist reduced the number of analyses by approximately 85 percent, while those patients with coagulopathy remained identified. The TEG showed a 97 percent predictability in identifying a surgical cause of bleeding in postoperative patients. Ten percent of the massively bleeding trauma patients had hyperfibrinolysis as the major cause of bleeding, whereas 45 percent were hypercoagulable.

CONCLUSION

The initiative from the blood bank has improved the transfusion practice and, hence, survival in massively transfused patients at our hospital.

Noninfectious complications of blood transfusion

CONTEXT

Serious noninfectious complications are far more likely to occur than viral disease transmission from blood component transfusion.

OBJECTIVE

To compile a comprehensive list of the noninfectious risks of transfusion, examples of published risk estimates, and summaries of recent information regarding cause, prevention, or management of noninfectious transfusion risks.

DATA SOURCES

Information was obtained from peer-reviewed English-language medical journal publications since 1990.

CONCLUSIONS

Early complications, although potentially more serious, usually occur less frequently (<1 in 1000 transfusions) than late complications, which often affect more than 1% of recipients. Areas of active investigation and discussion include acute hemolytic reactions, transfusion-related acute lung injury, red cell alloimmunization, platelet transfusion refractoriness, and transfusion immunosuppression. Continued effort toward research and education to promote recognition and prevention of noninfectious complications associated with blood components is warranted.

Proactive administration of platelets and plasma for patients with a ruptured abdominal aortic aneurysm: evaluating a change in transfusion practice

BACKGROUND

Continued hemorrhage remains a major contributor of mortality in massively transfused patients and those who survive have a higher platelet (PLT) count and a shorter prothrombin time and activated partial thromboplastin time (APTT) than nonsurvivors. It was considered that early substitution with PLTs and fresh-frozen plasma (FFP) would prevent development of coagulopathy and thus improve survival.

STUDY DESIGN AND METHODS

Survival of patients undergoing surgery for a ruptured abdominal aortic aneurysm (rAAA) was compared after implementing a proactive transfusion therapy encompassing two pooled buffy-coat PLT concentrates (PBPCs) immediately when a rupture of the aorta was suspected and again 30 minutes before aortic unclamping together with FFP administered in a 1:1 ratio to the amount of red blood cells (RBCs) with that of a control group receiving transfusion therapy according to existing recommendations.

RESULTS

The intervention group (n = 50) had a higher PLT count at arrival at the intensive care unit compared to the control group (n = 82; 155 x 10(9)/L vs. 69 x 10(9)/L; p < 0.0001), shorter APTT (39 sec vs. 44 sec; p < 0.001), fewer postoperative transfusions (RBCs, 2 vs. 6; FFP, 2 vs. 4; and PBPCs, 0 vs. 1; p < 0.01), and a higher 30-day survival rate (66% vs. 44%; p = 0.02).

CONCLUSION

This study suggests that proactive administration of PLTs and FFP improves coagulation competence, reduces postoperative hemorrhage, and increases survival in massively bleeding rAAA patients.

The evidence-based use of FFP and cryoprecipitate for abnormalities of coagulation tests and clinical coagulopathy

There continues to be a general but unfounded enthusiasm for fresh frozen plasma (FFP) or frozen plasma (FP) usage across a range of clinical specialties in hospital practice. Plasma for transfusion is most often used where there are abnormal coagulation screening tests, either therapeutically in the face of bleeding, or prophylactically in nonbleeding patients prior to invasive procedures or surgery. Little evidence exists to inform best therapeutic transfusion practice, and most studies describe plasma use in a prophylactic setting. Laboratory abnormalities of coagulation are considered by many clinicians to be a predictive risk factor for bleeding prior to invasive procedures or in other clinical situations where bleeding risk exists, and plasma for transfusion is presumed to improve the laboratory results and reduce this risk. However, most guideline indications for the prophylactic use of plasma for transfusion are not supported by evidence from good-quality randomized trials. Arguably, the strongest randomized controlled trial (RCT) evidence indicates that prophylactic plasma for transfusion is not effective across a range of different clinical settings, and this is supported by data from nonrandomized studies in patients with mild to moderate abnormalities in coagulation tests. There is a need to undertake new trials evaluating the efficacy and adverse effects of plasma, both in bleeding and non-bleeding patients, to understand whether the presumed benefits outweigh the real risks. In addition, new hemostatic tests that better define the risk of bleeding and monitor the effectiveness of the use of FFP should be validated. Last, there is an opportunity to develop effective educational strategies aimed at addressing understanding and compliance with recommendations in guidelines.

Rescue treatment with recombinant factor VIIa is effective in patients with life-threatening bleedings secondary to major wound excision: a report of four cases

Major burn wound excision is associated with excessive perioperative blood loss. Treatment of massive microvascular bleeding represents a special problem in the burn setting, characterized by extensive damage at the capillary level, and resulting in a profound blood loss; which together with the consumptive states makes adequate replacement therapy with coagulation factors and platelets difficult. We described our experience with rescue treatment with rFVIIa in four patients undergoing major wound excision, developing life-threatening perioperative bleeding, and not responding to conventional therapy. Hemostasis was achieved within 15 minutes of intravenous rFVIIa administration, at a dose of 100 microg/kg, in all patients. No treatment-related adverse events, in particular, no thromboembolic events were observed. We conclude that rFVIIa may be an effective hemostatic treatment for patients undergoing major wound excision developing life-threatening bleedings.

Medical complications of surgical treatment of adult spinal deformity and how to avoid them

STUDY DESIGN

Review article of medical complications related to adult spinal deformity surgery.

OBJECTIVE

To identify medical complications related to surgery for adult spinal deformity and suggest ways to minimize their occurrence and to avoid them.

SUMMARY OF BACKGROUND DATA

Medical complications are a major consideration in adult spinal deformity surgery. Few studies have been done to identify the medical complication rate in relation to these procedures.

METHODS

We review the literature pertaining to medical complications regarding spinal deformity surgery.

RESULTS

Urinary tract infections are the most frequently seen complication. Additionally, pulmonary complications are the most common life-threatening complication. Medical complications are a frequent occurrence with adult deformity spinal surgery.

CONCLUSIONS

Awareness of the presentation, treatment, and prevention of medical complications of deformity surgery may allow minimization of their occurrence and optimize treatment should they occur.

Experiences with frozen blood products in the Netherlands military

For peacekeeping and peace enforcing missions abroad the Netherlands Armed Forces decided to use universal donor frozen blood products in addition to liquid products. This article describes our experiences with the frozen blood inventory, with special attention to quality control. It is shown that all thawed (washed) blood products are in compliance with international regulations and guidelines. By means of the -80 degrees C frozen stock of red cells, plasma and platelets readily available after thaw (and wash), we can now safely reduce shipments and abandon the backup 'walking' blood bank, without compromising the availability of blood products in theatre.