HOW I TREAT PATIENTS WITH MASSIVE HEMORRHAGE

RBC bagThis is the rather peculiar title of an great summary paper on the transfusion pratice in massive hemorrhage, mainly focusing on trauma. It describes the background, evidence and use of 1:1:1 transfusions as well as pro-hemostatics and the use of TEG/ROTEM in an easy to follow fashion. This is incorporated into the description of the slightly different approaches of two large Level 1 trauma centers with very active blood banks and transfusion docs, in Copenhagen and Houston, TX. A recommended read on current practice.

Timely transfusions save lives
The article spends time on explaining how blood transfusions, including early plasma and platelets, in combination with pro hemostatics and viscoelastic hemostatic assays (TEG/ROTEM) helps save lives. It goes on to explain how and when the two centres activate massive transfusions and how they play it from there.

MTP

TEG/ROTEM
Both hospitals use TEG/ROTEM for guiding transfusions, but only after the initial massive hemorrhage is somewhat under control. Under high volume transfusions, TEG/ROTEM won’t be done quick enough to be a meaningful guide, so they stick to 1:1:1 for this first phase.

They will then move into a goal directed phase, where TEG/ROTEM is actively used to guide plasma and platelet transfusions. They also use TEG/ROTEM to trigger the use of pro-hemostatics like fibrinogen and cryoprecipitate, and also use the Ly30 to guide the need for Tranexamic Acid.

Keep in mind TEG/ROTEM are great assays for evaluating the hemostatic capacity of the blood. But keep in mind that TEG/ROTEM can’t measure pharmacological platelet inhibition (aspirin, plavix and its offspins), you’ll need Multiplate or similar for that.

Houston use RapidTEG to speed up TEG coagulation and results. The article includes the two slightly different TEG treatment algorithms from both centers.

1:1:1
The article goes into detail without losing the overview. So they follow 1.1.1 transfusion ratios, but discuss how this isn’t validated, and how early institution of plasma and platelets (instead of RBCs only) might be more important than the actual ratio. Transfusion packs might help, not neccessarily because they deliver 1:1:1, but because they deliver plasma and platelets with the RBCs, ensuring that plasma and platelets are also given early.

They mention mentioned the PROPPR (Pragmatic, Randomized Optimal Platelets and Plasma Ratios) trial that we’ve mentioned here before. PROPPR is now finished and might come up with some answers on ratios when published.

Both centres focus on blood components in massive hemorrhage, and mostly stay away from crystalloids, and of course colloids. The biggest surprise of the article is how the Houston centre mentions they still occasionally use some colloids in trauma. We’re very sure this is a big no-no, so Houston might have a problem. Apart from that, it all makes sense.

Summary
Great article – an easy and practical read, as well as cramming in a lot of research and comments on current transfusion practice. It’s also great to see slight differences between two large and dedicated centres. It helps adjust to the real world that the article aknowledges how two slightly different takes can both be valid. There is nothing sensationally new in this article, but a great overview over current practice and the thoughts behind them.

“How I treat patients with massive hemorrhage”, Blood, Nov. 2014.

For Scandinavian speakers, there’s a more comprehensive look at the thinking behind transfusions and bleeding patients, at this link with a report written by the Copenhagen group with Pär Johansson and his apprentice Jakob Stensballe, both anaesthetists by training, but now working with the blood bank and transfusions. They are big on the transfusion scene. Link in Danish:
Transfusionsmedicinsk behandling og monitorering af blødende patienter

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