Change in transfusion practice in massively bleeding patients

Management of massive haemorrhage in transfusion medicine services in the Middle East and North Africa

BACKGROUND AND OBJECTIVES

Massive transfusion protocols (MTPs) are critical in managing haemorrhage, yet their utilization varies. There is lack of data on the utilization of MTPs in the Middle East and North Africa (MENA) region. This study aims to assess the degree of utilization of MTPs in the region.

MATERIALS AND METHODS

We conducted a survey to collect data on MTP use, inviting medical directors of transfusion services from various hospitals. Data were analysed to determine the prevalence of MTP utilization, their compositions, challenges in application and areas of future need.

RESULTS

Eighteen respondents participated, representing 11 countries in the region. Thirteen hospitals implemented MTP, and eight included paediatrics. Eleven institutions used more than one definition of massive haemorrhage, with the most common being ≥10 red blood cell (RBC) units transfused for adults and replacement of >50% total blood volume in paediatrics. The majority of sites with MTPs utilized 1:1:1 RBCs:platelets:plasma ratio (70%). Variations were observed in the types and blood groups of components used. Two sites utilized whole blood, while six are considering it for future use. Utilization of adjunctive agents and frequency of laboratory testing varied among the sites. Challenges included the lack of medical expertise in protocol development, adherence and paediatric application. The need assessment emphasized the need for developing regional guidelines, standardized protocols and training initiatives.

CONCLUSION

Although several hospitals have adopted MTPs, variations exist in activation criteria, blood product ratios and monitoring. Challenges include the lack of medical expertise, protocol adherence and addressing paediatric needs. Standardizing protocols, enhancing training and paediatric application are crucial for improving massive transfusion management in the region.

Massive transfusion protocols in the Netherlands. Consensus or confusion?

INTRODUCTION

Transfusion strategy for trauma patients with massive haemorrhage is often incorporated in massive transfusion protocols (MTP). Albeit correct MTP use results in better patient outcome, research regarding the state of MTP knowledge is scarce. The objective of this study is therefore to assess knowledge of local MTP and massive transfusion strategy in the level 1 trauma centres in the Netherlands. Our hypothesis is that actual MTP knowledge is low and transfusion strategy differs.

MATERIALS AND METHODS

Surveys were sent out in January 2020 to all trauma and vascular surgeons, anaesthesiologists, emergency department physicians of the largest level 1 trauma centre (locally, n = 113) and to one trauma surgeon, emergency physician and anaesthesiologist in each of the nine other governmentally assigned level 1 trauma centres in the Netherlands (nationally, n = 27). The respondents were subdivided into a frequent user group (MTP usage ≥ 4 times in 2019) and a non-frequent user group (MTP usage < 4 in 2019). Data are expressed as numbers and percentages.

RESULTS

Response rate was (n = 48; 42%) for the local survey and (n = 14; 52%) for the national survey. Locally, (n = 23; 48%) and (n = 25; 52%) respondents were defined frequent and non-frequent users respectively and national respondents all as frequent users. In total, (n = 13; 27%) of local respondents were aware of the current local composition of the MTP. Respondents indicated to transfuse erythrocytes first, followed by plasma and platelets (local non-frequent users n = 23; 92%, local frequent users n = 21; 91% and national frequent users n = 13; 93%). The indication for platelet transfusion was units erythrocytes transfused (local non-frequent users n = 10; 40% frequent users locally n = 11; 48% and nationally n = 5; 36%) and clinical view (local non-frequent users n = 9; 36%, frequent users locally n = 8; 35% and n<5 nationally. Whereas few respondents claimed (n = 5; 21% non-frequent users locally and n <5 nationally) to transfuse platelets based on platelet counts. Viscoelastic haemostatic assays were performed during MTP, but only by frequent users.

CONCLUSION

The majority of physicians dealing with massive transfusion in trauma patients were not aware of the exact composition of the MTP and consensus regarding transfusion strategy and indication for platelet transfusion was low.

Early coagulation support protocol: A valid approach in real-life management of major trauma patients. Results from two Italian centres

INTRODUCTION

Early coagulation support (ECS) includes prompt infusion of tranexamic acid, fibrinogen concentrate, and packed red blood cells for initial resuscitation of major trauma patients. The aim of this study was to determine the effects, in terms of blood product consumption, length of stay, and in-hospital mortality, of the ECS protocol, compared to the massive transfusion protocol (MTP) in the treatment of major trauma patients.

PATIENTS AND METHODS

A retrospective analysis was conducted using the registry data of two Italian trauma centres. Adult major trauma patients with, or at risk of, active bleeding who were managed according to the MTP during the years 2011-2012, or the ECS protocol during the years 2013-2014 and were considered at risk of multiple transfusions, were enrolled. The primary endpoint was to determine whether the ECS protocol reduces the use of blood products in the acute management of trauma patients. Secondary endpoints were the outcome measures of length of stay in ICU, length of stay in hospital, and mortality at 24-hours and 28-days after hospital admission.

RESULTS

Among the 518 major trauma patients admitted to the trauma centres during the study period, 235 patients (118 in the pre-ECS period and 117 in the ECS period) matched one of the inclusion criteria and were enrolled in the study. Compared with the pre-ECS period, the ECS period showed a reduction in the average consumption of packed red blood cells (-1.87 units, 95% confidence interval [CI], -2.40, -1.34), platelets (-1.28 units; 95% CI, -1.64, -0.91), and fresh frozen plasma (-1.69; 95% CI, -2.14, -1.25) in the first 24-hours. Furthermore, during the ECS period, we recorded a 10-day reduction in the hospital length of stay (-10 days, 95% CI, -11.6, -8.4) and a non-significant 28-day mortality increase.

CONCLUSIONS

The ECS protocol was effective in reducing blood product consumption compared to the MTP and confirmed the importance of early fibrinogen administration as a strategy of rapid coagulation. This novel approach may be adopted in real-life management of major trauma patients.

Fibrinogen for the management of critical obstetric hemorrhage

AIM

In cases of critical obstetric hemorrhage leading to extreme hypofibrinogenemia, fibrinogen is the marker that indicates the critical severity, and early fibrinogen supplementation centering on hemostatic resuscitation is a vital treatment to stabilize a catastrophic condition. In this review, we investigated the effect of fibrinogen level on hemostasis and what we can do to treat hypofibrinogenemia efficiently and improve patients' outcome.

METHODS

We reviewed numerous articles related to hypofibrinogenemia in critical obstetric hemorrhage. Especially, we performed a systematic review on target value of fibrinogen for hemostasis and effectiveness of fibrinogen concentrate. We also reviewed the articles about the methods for early normalization of fibrinogen level such as tranexamic acid, massive transfusion protocol, and point-of-care testing.

RESULTS

The target value of fibrinogen calculated by needs for massive transfusion was 200 mg/dL or 10 mm of A5_FIBTEM . Although fibrinogen concentrate worked poorly on fibrinogen levels within the normal range, it improved the blood fibrinogen levels rapidly when it was administered to critical obstetric hemorrhage patients with serious hypofibrinogenemia. Hence, the volume of FFP transfused could be reduced along with a reduction in the frequency of pulmonary edema due to volume overload.

CONCLUSION

The patient group for which fibrinogen concentrate works most effectively is cases with severe hypofibrinogenemia. Further research is required in the light of evidence. The essence of the transfusion algorithm in critical obstetric hemorrhage is to approach the target value for obtaining hemostasis, ensure an accurate and prompt grasp of the severity using point-of-care testing, introduce a massive transfusion protocol and use tranexamic acid.

Any changes in recent massive transfusion practices in a tertiary level institution?

BACKGROUND & OBJECTIVES

A previous review of transfusion practices in our institution between 1998 and 2008 showed a trend of high ratios of red cells (RC) to plasma (FFP) and platelets to RC towards the later years of review period. The aim of the study was to further evaluate transfusion practices in the form of blood product usage and outcomes following massive transfusion (MT) METHODS: All adult patients with critical bleeding who received a MT (defined as ≥10 units of RC in 24h) in 2008 and between January 2010 and December 2014 were identified. Blood and blood products transfused, in-hospital mortality, 24h and 90-day mortality were analysed for the period 2010-2014. Blood and blood product usage, massive transfusion protocol (MTP) activation and use of ROTEM between 2008 and 2014 were compared.

RESULTS

A total of 190 MT including surgical (52.1%), gastro-intestinal bleeding (25.3%), trauma (11.6%) and obstetric haemorrhage (5.8%) episodes were identified between 2010 and 2014. The overall in-hospital mortality was 26.7% with a significant difference in 24h (p=0.04) and 90-day mortality (p=0.02) between diagnostic groups. Comparing 2008 (n=33) and 2014 (n=23), there was no significant difference in median RC, FFP and platelet units, cryoprecipitate doses and RC:FFP ratio; however there was an increase in number of patients who used cryoprecipitate (54.5% vs 87%, p=0.01).

CONCLUSION

Aligned with haemostatic resuscitation, the trend continues in the form of increased use of plasma and higher RC:FFP transfusion ratios including an increase in number of patients receiving cryoprecipitate.

Evaluation of clinical coding data to determine causes of critical bleeding in patients receiving massive transfusion: a bi-national, multicentre, cross-sectional study

OBJECTIVES

To evaluate the use of routinely collected data to determine the cause(s) of critical bleeding in patients who receive massive transfusion (MT).

BACKGROUND

Routinely collected data are increasingly being used to describe and evaluate transfusion practice.

MATERIALS/METHODS

Chart reviews were undertaken on 10 randomly selected MT patients at 48 hospitals across Australia and New Zealand to determine the cause(s) of critical bleeding. Diagnosis-related group (DRG) and International Classification of Diseases (ICD) codes were extracted separately and used to assign each patient a cause of critical bleeding. These were compared against chart review using percentage agreement and kappa statistics.

RESULTS

A total of 427 MT patients were included with complete ICD and DRG data for 427 (100%) and 396 (93%), respectively. Good overall agreement was found between chart review and ICD codes (78·3%; κ = 0·74, 95% CI 0·70-0·79) and only fair overall agreement with DRG (51%; κ = 0·45, 95% CI 0·40-0·50). Both ICD and DRG were sensitive and accurate for classifying obstetric haemorrhage patients (98% sensitivity and κ > 0·94). However, compared with the ICD algorithm, DRGs were less sensitive and accurate in classifying bleeding as a result of gastrointestinal haemorrhage (74% vs 8%; κ = 0·75 vs 0·1), trauma (92% vs 62%; κ = 0·78 vs 0·67), cardiac (80% vs 57%; κ = 0·79 vs 0·60) and vascular surgery (64% vs 56%; κ = 0·69 vs 0·65).

CONCLUSION

Algorithms using ICD codes can determine the cause of critical bleeding in patients requiring MT with good to excellent agreement with clinical history. DRG are less suitable to determine critical bleeding causes.

Improving outcomes for hospital patients with critical bleeding requiring massive transfusion: the Australian and New Zealand Massive Transfusion Registry study methodology

Background

The Australian and New Zealand (ANZ) Massive Transfusion (MT) Registry (MTR) has been established to improve the quality of care of patients with critical bleeding (CB) requiring MT (≥ 5 units red blood cells (RBC) over 4 h). The MTR is providing data to: (1) improve the evidence base for transfusion practice by systematically collecting data on transfusion practice and clinical outcomes; (2) monitor variations in practice and provide an opportunity for benchmarking, and feedback on practice/blood product use; (3) inform blood supply planning, inventory management and development of future clinical trials; and (4) measure and enhance translation of evidence into policy and patient blood management guidelines. The MTR commenced in 2011. At each participating site, all eligible patients aged ≥18 years with CB from any clinical context receiving MT are included using a waived consent model. Patient information and clinical coding, transfusion history, and laboratory test results are extracted for each patient’s hospital admission at the episode level.

Results

Thirty-two hospitals have enrolled and 3566 MT patients have been identified across Australia and New Zealand between 2011 and 2015. The majority of CB contexts are surgical, followed by trauma and gastrointestinal haemorrhage. Validation studies have verified that the definition of MT used in the registry correctly identifies 94 % of CB events, and that the median time of transfusion for the majority of fresh products is the ‘product event issue time’ from the hospital blood bank plus 20 min. Data linkage between the MTR and mortality databases in Australia and New Zealand will allow comparisons of risk-adjusted mortality estimates across different bleeding contexts, and between countries. Data extracts will be examined to determine if there are differences in patient outcomes according to transfusion practice. The ratios of blood components (e.g. FFP:RBC) used in different types of critical bleeding will also be investigated.

Conclusions

The MTR is generating data with the potential to have an impact on management and policy decision-making in CB and MT and provide benchmarking and monitoring tools for immediate application.

Massive transfusion: an overview of the main characteristics and potential risks associated with substances used for correction of a coagulopathy

Massive transfusion (MT) is an empiric mode of treatment advocated for uncontrolled bleeding and massive haemorrhage, aiming at optimal resuscitation and aggressive correction of coagulopathy. Conventional guidelines recommend early administration of crystalloids and colloids in conjunction with red cells, where the red cell also plays a critical haemostatic function. Plasma and platelets are only used in patients with microvascular bleeding with PT/APTT values >1.5 times the normal values and if PLT counts are below 50×10(9)/L. Massive transfusion carries a significant mortality rate (40%), which increases with the number of volume expanders and blood components transfused. Controversies still exist over the optimal ratio of blood components with respect to overall clinical outcomes and collateral damage. While inadequate transfusion is believed to be associated with poor outcomes but empirical over transfusion results in unnecessary donor exposure with an increased rate of sepsis, transfusion overload and infusion of variable amounts of some biological response modifiers (BRMs), which have the potential to cause additional harm. Alternative strategies, such as early use of tranexamic acid are helpful. However in trauma settings the use of warm fresh whole blood (WFWB) instead of reconstituted components with a different ratio of stored components might be the most cost effective and safer option to improve the patient's survival rate and minimise collateral damage. This manuscript, after a brief summary of standard medical intervention in massive transfusion focuses on the main characteristics of various substances currently available to overcome massive transfusion coagulopathy. The relative levels of some BRMs in fresh and aged blood components of the same origin are highlighted and some myths and unresolved issues related to massive transfusion practice are discussed. In brief, the coagulopathy in MT is a complex phenomenon, often complicated by chronic activation of coagulation, platelets, complement and vascular endothelial cells, where haemolysis, microvesiculation, exposure of phosphatidyl serine positive cells, altered red cells with reduced adhesive proteins and the presence of some BRM, could play a pivotal role in the coagulopathy and untoward effects. The challenges of improving the safety of massive transfusion remain as numerous and as varied as ever. The answer may reside in appropriate studies on designer whole blood, combined with new innovative tools to diagnosis a coagulopathy and an evidence based mode of therapy to establish the optimal survival benefit of patients, always taking into account the concept of harm reduction and reduction of collateral damage.