Initiation and Termination of Massive Transfusion Protocols: Current Strategies and Future Prospects

Machine learning models predict triage levels, massive transfusion protocol activation, and mortality in trauma utilizing patients hemodynamics on admission

BACKGROUND

The effective management of trauma patients necessitates efficient triaging, timely activation of Massive Blood Transfusion Protocols (MTP), and accurate prediction of in-hospital outcomes. Machine learning (ML) algorithms have emerged as up-and-coming tools in the domains of optimizing triage decisions, improving intervention strategies, and predicting clinical outcomes, consistently outperforming traditional methodologies. This study aimed to develop, assess, and compare several ML models for the triaging processes, activation of MTP, and mortality prediction.

METHODS

In a 10-year retrospective study, the predictive capabilities of seven ML models for trauma patients were systematically assessed using on-admission patients' hemodynamic data. All patient's data were randomly divided into training (80 %) and test (20 %) sets. Employing Python for data preprocessing, feature scaling, and model development, we evaluated K-Nearest Neighbors (KNN), Logistic Regression (LR), Decision Tree (DT), Support Vector Machines (SVM) with RBF kernels, Random Forest (RF), Extreme Gradient Boosting (XGBoost), and Artificial Neural Network (ANN). We employed various imputation techniques and addressed data imbalance through down-sampling, up-sampling, and synthetic minority for the over-sampling technique (SMOTE). Hyperparameter tuning, coupled with 5-fold cross-validation, was performed. The evaluation included essential metrics like sensitivity, specificity, F1 score, accuracy, Area Under the Receiver Operating Curve (AUC ROC), and Area Under the Precision recall Curve (AUC PR), ensuring robust predictive capability.

RESULT

This study included 17,390 adult trauma patients; of them, 19.5 % (3385) were triaged at a critical level, 3.8 % (664) required MTP, and 7.7 % (1335) died in the hospital. The model's performance improved using imputation and balancing techniques. The overall models demonstrated notable performance metrics for predicting triage, MTP activation, and mortality with F1 scores of 0.75, 0.42, and 0.79, sensitivities of 0.73, 0.82, and 0.9, and AUC ROC values of 0.89, 0.95 and 0.99 respectively.

CONCLUSION

Machine learning, especially RF models, effectively predicted trauma triage, MTP activation, and mortality. Featured critical hemodynamic variables include shock indices, systolic blood pressure, and mean arterial pressure. Therefore, models can do better than individual parameters for the early management and disposition of patients in the ED. Future research should focus on creating sensitive and interpretable models to enhance trauma care.

Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review

PURPOSE

Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada.

METHODS

After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content.

RESULTS

The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool.

DISCUSSION/CONCLUSION

Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.

Contemporary management of major haemorrhage in critical care

Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).

Damage Control Resuscitation in Traumatic Hemorrhage: It Is More Than Fixing the Holes and Filling the Tank

Damage control resuscitation is the foundation of hemorrhagic shock management and includes early administration of plasma, tranexamic acid, and limited crystalloid-containing products.

Improving blood product management in placenta accreta patients with severe bleeding: institutional experience

BACKGROUND

Placenta accrete spectrum (PAS) is a significant risk factor for postpartum hemorrhage and effective blood product management is critical in ensuring patient safety. In PAS patients undergoing cesarean section (CS) blood transfusion management guided by the combined clinical experience of the anesthesiologist and surgeon with point-of-care coagulation testing appears safe and effective. We describe and evaluate our experience and identify potential areas for improvement with blood product management in this patient population.

METHODS

A retrospective chart review of peri-operative demographic, anesthetic, and obstetric data was conducted for all patients with PAS undergoing CS between 2012 and 2018 at our center. To facilitate a practical evaluation of blood product management, we divided patients into two groups based on the severity of bleeding.

RESULTS

A total of 221 parturients with PAS underwent CS, with 133 in group 1 requiring excessive amounts of transfusion and 88 in group 2 requiring management similar to other uncomplicated CS cases. There were no deaths or instances of disseminated intravascular coagulation, and intensive care unit admission occurred in five cases (2.2%). Patients in group 1 had higher mean nadir values of intra-operative hemoglobin and platelet count. We observed a high rate of missing data for peri-operative measurement of lactate and fibrinogen, PAS grade documentation, and temperature monitoring.

CONCLUSION

Given no significant morbidity or mortality, clinical judgment in experienced centers appears safe for the management of PAS patients undergoing CS. The adoption of an institutional protocol and point-of-care coagulation testing could decrease over-transfusion and associated complications.

Defining the optimal calcium repletion dosing in patients requiring activation of massive transfusion protocol

PURPOSE

Massive transfusion protocols (MTP) commonly result in severe hypocalcemia due to the calcium-binding affinity of citrate in blood components. The purpose of this study is to determine the optimal grams (g) of citrate to repletion calcium (Ca) milliequivalents (mEq) (Citrate:Ca) ratio to reduce 30-day mortality.

METHODS

This was a retrospective, single-centered, cohort study at a level 1 trauma center evaluating trauma and surgical patients in need of MTP activation from January 1, 2010-July 31, 2021. Patients with severe hypocalcemia at baseline, defined as ionized calcium (iCa) <0.9 mmol/L, were compared to patients without severe hypocalcemia. The primary endpoint was to determine the optimal ratio of grams of citrate to calcium mEq to reduce mortality in patients receiving a MTP. Secondary endpoints included mortality at 24 h and 30 days, blood components used in MTP, and type of calcium used.

RESULTS

Overall, 501 patients were screened for inclusion. Of these patients, 193 were excluded, leaving 308 patients, of which 165 patients (53.6%) had an iCa <0.9 mmol/L within 24 h and 143 patients (46.4%) had iCa ≥0.9 mmol/L within 24 h. The ratio of Citrate:Ca for each patient was not significantly associated with mortality at 24 h (P = 0.79) or 30 days (P = 0.91) at a repletion Citrate:Ca ratio of median 1.97 (IQR 1.14-2.91). The rate of mortality was lowest at a Citrate:Ca of 2 in both <24-h mortality and 30-day mortality.

CONCLUSIONS

There were no differences in 24 h or 30 day mortality based on repletion ratios seen in this study. A Citrate:Ca ratio between 2 and 3 in patients undergoing MTP was sufficient to obtain a normalized iCa within 24 h of MTP activation regardless of baseline iCa level. Further prospective studies will be needed to determine the optimal Citrate:Ca ratio.

Multidisciplinary consensus document on the management of massive haemorrhage. First update 2023 (document HEMOMAS-II)

This document is an update of the multidisciplinary document HEMOMAS, published in 2016 with the endorsement of the Spanish Scientific Societies of Anaesthesiology (SEDAR), Intensive Care (SEMICYUC) and Thrombosis and Haemostasis (SETH). The aim of this document was to review and update existing recommendations on the management of massive haemorrhage. The methodology of the update was based on several elements of the ADAPTE method by searching and adapting guidelines published in the specific field of massive bleeding since 2014, plus a literature search performed in PubMed and EMBASE from January 2014 to June 2021. Based on the review of 9 guidelines and 207 selected articles, the 47 recommendations in the original article were reviewed, maintaining, deleting, or modifying each of them and the accompanying grades of recommendation and evidence. Following a consensus process, the final wording of the article and the resulting 41 recommendations were approved by all authors.

Multidisciplinary consensus document on the management of massive haemorrhage. First update 2023 (document HEMOMAS-II)

This document is an update of the multidisciplinary document HEMOMAS, published in 2016 with the endorsement of the Spanish Scientific Societies of Anaesthesiology (SEDAR), Intensive Care (SEMICYUC) and Thrombosis and Haemostasis (SETH). The aim of this document was to review and update existing recommendations on the management of massive haemorrhage. The methodology of the update was based on several elements of the ADAPTE method by searching and adapting guidelines published in the specific field of massive bleeding since 2014, plus a literature search performed in PubMed and EMBASE from January 2014 to June 2021. Based on the review of 9 guidelines and 207 selected articles, the 47 recommendations in the original article were reviewed, maintaining, deleting, or modifying each of them and the accompanying grades of recommendation and evidence. Following a consensus process, the final wording of the article and the resulting 41 recommendations were approved by all authors.

Association between perioperative plasma transfusion and in-hospital mortality in patients undergoing surgeries without massive transfusion: A nationwide retrospective cohort study

Background

An aggressive plasma transfusion is associated with a decreased mortality in traumatic patients requiring massive transfusion (MT). However, it is controversial whether non-traumatic or non-massively transfused patients can benefit from high doses of plasma.

Methods

We performed a nationwide retrospective cohort study using data from Hospital Quality Monitoring System, which collected anonymized inpatient medical records from 31 provinces in mainland China. We included the patients who had at least one record of surgical procedure and received red blood cell transfusion on the day of surgery from 2016 to 2018. We excluded those receiving MT or diagnosed with coagulopathy at admission. The exposure variable was the total volume of fresh frozen plasma (FFP) transfused, and the primary outcome was in-hospital mortality. The relationship between them was assessed using multivariable logistic regression model adjusting 15 potential confounders.

Results

A total of 69319 patients were included, and 808 died among them. A 100-ml increase in FFP transfusion volume was associated with a higher in-hospital mortality (odds ratio 1.05, 95% confidence interval 1.04-1.06, p < 0.001) after controlling for the confounders. FFP transfusion volume was also associated with superficial surgical site infection, nosocomial infection, prolonged length of hospital stay, ventilation time, and acute respiratory distress syndrome. The significant association between FFP transfusion volume and in-hospital mortality was extended to the subgroups of cardiac surgery, vascular surgery, and thoracic or abdominal surgery.

Conclusions

A higher volume of perioperative FFP transfusion was associated with an increased in-hospital mortality and inferior postoperative outcomes in surgical patients without MT.

Development of Machine Learning Models Predicting Estimated Blood Loss during Liver Transplant Surgery

The incidence of major hemorrhage and transfusion during liver transplantation has decreased significantly over the past decade, but major bleeding remains a common expectation. Massive intraoperative hemorrhage during liver transplantation can lead to mortality or reoperation. This study aimed to develop machine learning models for the prediction of massive hemorrhage and a scoring system which is applicable to new patients. Data were retrospectively collected from patients aged >18 years who had undergone liver transplantation. These data included emergency information, donor information, demographic data, preoperative laboratory data, the etiology of hepatic failure, the Model for End-stage Liver Disease (MELD) score, surgical history, antiplatelet therapy, continuous renal replacement therapy (CRRT), the preoperative dose of vasopressor, and the estimated blood loss (EBL) during surgery. The logistic regression model was one of the best-performing machine learning models. The most important factors for the prediction of massive hemorrhage were the disease etiology, activated partial thromboplastin time (aPTT), operation duration, body temperature, MELD score, mean arterial pressure, serum creatinine, and pulse pressure. The risk-scoring system was developed using the odds ratios of these factors from the logistic model. The risk-scoring system showed good prediction performance and calibration (AUROC: 0.775, AUPR: 0.753).

Effectiveness of massive transfusion protocol activation in pre-hospital setting for major trauma

INTRODUCTION

Hemorrhage in major trauma is life-threatening and the activation of the Massive Transfusion Protocol (MTP) was found to reduce the time to transfusion and mortality. The purpose was (i) to verify whether MTP activation identifies patients that require massive transfusions once admitted to the Emergency Department (ED), (ii) to establish whether pre-hospital MTP activation reduces the time to transfusion on arrival at the ED, (iii) to identify the variable that best predicts MTP activation.

MATERIALS AND METHODS

This is a retrospective, single-center study. The MTP was implemented at the end of 2012; it was activated for major trauma in pre-hospital setting on the basis on established criteria. Pre-hospital MTP activation aimed to make blood products available prior to the patients' arrival at the ED. The blood products are transfused when the patient arrives at the hospital.

RESULTS

The MTP was activated in pre-hospital setting in 219 patients. On arrival at the hospital, the Trauma Team Leader confirmed MTP activation in 146 (66.7%) patients. Patients with MTP criteria received a higher amount of blood products than the patients without MTP criteria, median 7 (IQR 2-13) units versus 2 (0-6) units, respectively (P < 0.001). At the same time, patients with a Shock Index ≥ 0.9 received more transfusions (5.5 [2-13] units) compared with patients characterized by a lower SI (2 [0-7.25] units, P = 0.009). 146 patients were transfused in the first hour of ED admission. Poisson's multiple regression shows that the SI is the variable that better predicted MTP activation compared to age, gender and the number of injured sites.

CONCLUSIONS

Pre-hospital MTP activation is useful to identify patients that require an urgent blood transfusion on arrival at the ED. Further analysis should be considered to evaluate the implementation of the Shock Index as a criterion to activate MTP.

Effect of Massive Transfusion Protocol on Coagulation Function in Elderly Patients with Multiple Injuries

Objective

To evaluate the effect of massive transfusion protocol on coagulation function in elderly patients with multiple injuries.

Methods

In this retrospective cohort study, clinical data were collected from a total of 94 elderly patients with multiple injuries, including 44 cases who received routine transfusion protocol (control group) and 50 cases who concurrently received massive transfusion protocol in our hospital (research group). The changes in platelet parameters, coagulation function, and organ dysfunction scores at admission and 24 h after transfusion were compared between the two groups. The 24-hour plasma and red blood cell transfusion volume, length of stay, complications, and mortality of the two groups were analyzed statistically.

Results

Twenty-four hours after blood transfusion, the hematocrit, platelets, and hemoglobin in the research group were higher than those in the control group, while the activated partial thromboplastin time, prothrombin time, thrombin time, fibrinogen, and scores of Marshall scoring system and Sequential Organ Failure Assessment were lower than those in the control group (P < 0.01). The 24-hour plasma transfusion volume was higher, and the length of intensive care unit (ICU) stay and total length of stay were lower in the research group compared with the control group (P < 0.01). No significant difference was found in the mortality rate between the research group and the control group (10.00% vs. 13.64%, P > 0.05). The incidence of complications in the research group was lower than that in the control group (12.00% vs. 31.82%, P < 0.05).

Conclusion

Massive transfusion protocol for elderly patients with multiple injuries can improve their coagulation function and platelet parameters, alleviate organ dysfunction, shorten length of ICU stay, and decrease the incidence of complications, which is conducive to improving the prognosis of patients.

Quality Improvement Project of a Massive Transfusion Protocol (MTP) to Reduce Wastage of Blood Components

Massive transfusion protocols (MTPs) facilitate the organized delivery of blood components for traumatically injured patients. MTPs vary across institutions, and ratios of blood components can change during clinical management. As a result, significant amounts of components can be wasted. We completed a review of all MTP activations from 2015 to 2018, providing an in-depth analysis of waste in our single Level 1 trauma center. An interdepartmental group analyzed patterns of blood component wastage to guide three quality improvement initiatives. Specifically, we (1) completed a digital timeline for each MTP activation and termination, (2) improved communications between departments, and (3) provided yearly training for all personnel about MTP deployment. The analysis identified an association between delayed MTP deactivations and waste (RR = 1.48, CI 1.19–1.85, p = 0.0005). An overall improvement in waste was seen over the years, but this could not be attributed to increased closed-loop communication as determined by the proportion of non-stop activations (F(124,3) = 0.98, not significant). Delayed MTP deactivations are the primary determinant of blood component waste. Our proactive intervention on communications between groups was not sufficient in reducing the number of delayed deactivations. However, implementing a digital timeline and regular repetitive training yielded a significant reduction in wasted blood components.

Transfusion of ABO non-identical platelets increases the severity of trauma patients at ICU admission

BACKGROUND

Transfusion of ABO-compatible non-identical platelets (PTLs), fresh plasma (FP) and red blood cells (RBCs) has been associated with increased morbidity and mortality of recipients. Trauma victims are frequently exposed to ABO non-identical products, given the need for emergency transfusions. Our goal was to evaluate the impact of the transfusion of ABO non-identical blood products on the severity and all-cause 30-day mortality of trauma patients.

METHODS

This was a retrospective single-center cohort, which included trauma patients who received emergency transfusions in the first 24 h of hospitalization. Patients were divided in two groups according to the use of <3 or ≥3 ABO non-identical blood products. The patient severity, measured by the Acute Physiology and Chronic Health Evaluation (APACHEII) score at ICU admission, and the 30-day mortality were compared between groups.

RESULTS

Two hundred and sixteen trauma patients were enrolled. Of these, 21.3% received ≥3 ABO non-identical blood products (RBCs, PLTs and FP or cryoprecipitate). The transfusion of ≥3 ABO non-identical blood products in the first 24 h of hospitalization was independently associated with a higher APACHEII score at ICU admission (OR = 3.28 and CI95% = 1.48-7.16). Transfusion of at least one unit of ABO non-identical PTLs was also associated with severity (OR = 10.89 and CI95% = 3.38-38.49). Transfusion of ABO non-identical blood products was not associated with a higher 30-day mortality in the studied cohort.

CONCLUSION

The transfusion of ABO non-identical blood products and, especially, of ABO non-identical PLTs may be associated with the greater severity of trauma patients at ICU admission. The transfusion of ABO non-identical blood products in the trauma setting is not without risks.

How do I manage severe postpartum hemorrhage?

In the United States, postpartum hemorrhage (PPH) accounts for 4.6% of all maternal deaths and is responsible for major peripartum medical and surgical morbidity. Therefore, a national health priority is to ensure that women who experience severe PPH receive timely, appropriate, and effective treatment. In this article, we describe our system-wide approach for the planning and delivery of women with suspected placenta accreta spectrum disorder, a condition associated with life-threatening blood loss at the time of delivery. We also highlight current evidence related to transfusion decision making and hemostatic monitoring during active postpartum bleeding. Specifically, we describe how we activate and use the massive transfusion protocol to obtain sufficient volumes and types of blood products. We also describe how we use viscoelastic monitoring (thromboelastography) and standard laboratory tests to assess the maternal coagulation profile. Finally, we review the findings of recent studies examining the potential efficacy of tranexamic acid and fibrinogen concentrate as adjuncts for PPH prevention and treatment. We describe how we have incorporated these drugs into PPH treatment protocols at our institution.

Hemoperitoneum in cirrhotic patients in the absence of abdominal trauma

Introduction: Hemoperitoneum can be a life-threating condition in cirrhotic patients who have a limited compensatory reserve during hemorrhagic shock. We aim to review the literature on the different etiologies associated with non-traumatic hemoperitoneum (NTH), summarizing the most relevant conditions associated with spontaneous and iatrogenic peritoneal and retroperitoneal bleeding that may occur in cirrhotic patients and to illustrate the most relevant diagnostic strategies and optimal management. Area covered: This review encompasses the current literature in hemoperitoneum in cirrhotic patients in the absence of abdominal trauma. Established diagnostic procedures, therapeutic interventions and potential novel targets are reported and discussed. Expert opinion: To ensure the optimal management regardless of the underlying etiology of NTH, the first goal for the clinician is to obtain immediate hemodynamic stabilization with supportive measures and to control the source of bleeding. The latter can be achieved with angiographic embolization, which is usually the first choice, or with open surgery. Other therapeutic options according to specific etiologies include transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded anterograde transvenous obliteration (BATO) or intra operative radio frequency (RF).

A regional massive hemorrhage protocol developed through a modified Delphi technique

BACKGROUND

A massive hemorrhage protocol (MHP) enables rapid delivery of blood components in a patient who is exsanguinating pending definitive hemorrhage control, but there is variability in MHP implementation rates, content and compliance owing to challenges presented by infrequent activation, variable team performance and patient acuity. The goal of this project was to identify the key evidence-based principles and quality indicators required to develop a standardized regional MHP.

METHODS

A modified Delphi consensus technique was performed in the spring and summer of 2018. Panellists used survey links to independently review and rate (on a 7-point Likert scale) 43 statements and 8 quality indicators drafted by a steering committee composed of transfusion medicine specialists and technologists, and trauma physicians. External stakeholder input from all hospitals in Ontario was sought.

RESULTS

Three rounds were held with 36 experts from diverse clinical backgrounds. Consensus was reached for 42 statements and 8 quality indicators. Additional modifications from external stakeholders were incorporated to form the foundation for the proposed MHP.

INTERPRETATION

This MHP template will provide the basis for the design of an MHP toolkit, including specific recommendations for pediatric and obstetrical patients, and for hospitals with limited availability of blood components or means to achieve definitive hemorrhage control. We believe that harmonization of MHPs in our region will simplify training, increase uptake of evidence-based interventions, enhance communication, improve patient comfort and safety, and, ultimately, improve patient outcomes.

Burn injury and blood transfusion

PURPOSE OF REVIEW

Blood transfusion is ubiquitous in major burn injury. The present article describes recent research findings directly impacting blood transfusion strategies in major burn injury both in the operating room and the ICU.

RECENT FINDINGS

Transfusion strategies have been the focus of recent burn investigations. First, a randomized prospective trial encompassing both the ICU and operating room reported that a restrictive red blood cell transfusion threshold (7 g/dl) had equivalent outcomes to a traditional threshold (10 g/dl) for burns more than 20% in terms of mortality, infection, length of stay, duration of mechanical ventilation, and wound healing despite receiving significantly fewer transfusions. The second burn transfusion advance addresses coagulation. Although burn patients initially have elevated fibrinogen, thrombocytopenia and other coagulation disorders develop during excision. Blood product repletion should be based on measurements such as thromboelastography in addition to traditional tests. Finally, a recent randomized trial suggests that fresh-frozen plasma and platelets during burn excision more than 20% may decrease transfusion requirements.

SUMMARY

A restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. Repletion of coagulation products should focus on measured deficits of platelets, fibrinogen, and factors.

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.

Damage Control Resuscitation in polytrauma patient

Haemorrhagic shock is one of the main causes of mortality in severe polytrauma patients. To increase the survival rates, a combined strategy of treatment known as Damage Control has been developed. The aims of this article are to analyse the actual concept of Damage Control Resuscitation and its three treatment levels, describe the best transfusion strategy, and approach the acute coagulopathy of the traumatic patient as an entity. The potential changes of this therapeutic strategy over the coming years are also described.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.

Optimum Accuracy of Massive Transfusion Protocol Activation: The Clinician's View

Background

Massive transfusion protocols (MTP) aid in the efficient delivery of blood components to rapidly exsanguinating patients. Unfortunately, clinical gestalt and currently available clinical scoring systems lack the optimal accuracy to prevent blood product wastage (through over-activation), as well as individual patient morbidity and mortality (through under-activation). In order to help refine the MTP activation criteria and protocols, we surveyed clinicians on acceptable over- and under-activation rates for massive transfusions.

Methods

We surveyed Canadian content experts in their respective fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 was comprised of trauma and acute care specialists (TACS), while Group 2 was comprised of clinical and laboratory medicine specialists (CLMS). Between-group differences were examined using Fisher’s exact test and the likelihood ratio. Statistical significance was set at p < 0.05.

Results

We received responses from 35 clinicians in the TACS group and 10 clinicians in the CLMS group. About half (45.7%) of respondents in the TACS group considered an MTP overactivation rate of 5% - 10% acceptable (vs. 60% of the CLMS group; not significant (NS)). Approximately one-third (34.2%) of the respondents in the TACS group considered an MTP under-activation rate of less than 5% acceptable, whereas the majority (60%) of respondents in the CLMS group considered an under-activation rate of less than 5% acceptable (NS). A significantly greater proportion of respondents in the TACS group felt that an anticipated need for > 20 units of packed red blood cells within the next 24 hours was an acceptable criterion for MTP activation. Respondents in the CLMS group were more likely to consider “poor communication” as a reason for blood component wastage.

Conclusion

Similarities in acceptable MTP over- and under-activation rates were noted across specialties. Collaboration between involved parties is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.

Changes in plasma unit distributions to hospitals over a 10-year period

BACKGROUND

There are many influences on a hospital's demand for plasma. Pharmaceuticals are now being administered for many indications instead of plasma, although trauma resuscitation now emphasizes increased and early intervention with plasma. This multinational study evaluated changes in blood center plasma unit distributions over a 10-year period.

STUDY DESIGN AND METHODS

Data on the total number and the ABO groups of plasma unit distributions were obtained from nine American blood collectors (ABCs) and nine national or provincial blood services (NPBS) from 2007 through 2016. Plasma distributions to trauma hospitals by five ABCs and four NPBS were also analyzed.

RESULTS

The overall number of plasma unit distributions from ABCs decreased by 23.1% from 2007 to 2016, but the relative proportion of distributed AB plasma units increased during the same period. The NPBS (excluding the Japanese Red Cross [JRC]) also had a 35.4% decrease in the overall number of plasma unit distributions with an increase in the relative proportion of AB plasma distributions between 2007 and 2016. The JRC, however, reported an increase in the overall number of plasma distributions by 13.5% in 2016 compared to 2007. The proportion of low-titer A plasma distributions increased to 1.6% of total plasma distributions by ABCs in 2016. There was a trend of distributing increasing proportions of group AB plasma units to trauma hospitals over the 10-year period.

CONCLUSION

Although the number of plasma unit distributions has decreased at many blood collectors over time, the proportion of AB units has increased at both ABCs and NPBS.