POSTPARTUM HEMORRHAGE MASSIVE TRANSFUSION Professor Vice Chairman of Quality & Patient Safety Director, Division of Maternal-Fetal Medicine Department of Obstetrics & Gynecology Chief Quality Officer Obstetrics & Gynecology Gary A. Dildy, M.D.
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POSTPARTUM HEMORRHAGE
MASSIVE TRANSFUSION
Professor
Vice Chairman of Quality & Patient Safety
Director, Division of Maternal-Fetal Medicine
Department of Obstetrics & Gynecology
Chief Quality Officer
Obstetrics & Gynecology
Gary A. Dildy, M.D.
Disclosures
Gary A. Dildy, M.D. is co-inventor of the
Belfort-Dildy Obstetrical Tamponade System;
assigned to B&D Medical Development LLC
of Park City, UT of which he is a Manager;
manufactured and marketed by Clinical
Innovations in Salt Lake City as the ebbTM
Complete Tamponade System for use in
treating postpartum hemorrhage.
BLOOD COMPONENT THERAPY
Abbreviations
ATLS Advanced Trauma Life Support
aPLT Apheresis Platelets
BCT Blood Component Therapy
Cryo Cryoprecipitate
CT Component Therapy
FFP Fresh Frozen Plasma
LP Liquid Plasma
MT Massive Transfusion
PPH Postpartum Hemorrhage
PRBC Packed Red Blood Cells
WFWB Warm Fresh Whole Blood
PREVENTABLE MATERNAL MORTALITY
DUE TO POSTPARTUM HEMORRHAGE
Berg 2005
500,000+ deliveries
NC 1995-1999
Studied 108 MM
PPH #2 cause (14%)
93% preventable
Clark 2008
1,461,270 deliveries
USA 2000-2006 (HCA)
Studied 95 MM
PPH #3 cause (12%)
73% preventable
Berg CJ, Harper MA, Atkinson SM, Bell EA, Brown HL, Hage ML, Mitra AG,
Moise KJ Jr, Callaghan WM. Preventability of pregnancy-related deaths: results
of a state-wide review. Obstet Gynecol 2005;106:1228-34.
Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GDV.
Maternal death in the 21st century: causes, prevention and relationship to
cesarean delivery. Am J Obstet Gynecol 2008;199(1):36.e1-5.
PPH protocols in US academic
obstetric anesthesia units
Hospital
Characteristics
PPH Protocol
Yes
N = 40
PPH Protocol
No
N = 20
P
Annual delivery volume (n) 3900 (2550-5200) 2300 (1900-3600) 0.002
Annual cesarean rate (%) 30 (29-36) 31 (29-39) 0.73
PPH rate (%) 5 (3-7) 5 (3-7) 0.69
Kacmar RM, Mhyre JM, Scavone BM, Fuller AJ, Toledo P. The use of postpartum hemorrhage
protocols in United States academic obstetric anesthesia units. Anesth Analg 2014;119:906-10.
Sentinel Event Alert Issue 44
26 January 2010
“Preventing Maternal Death”
2. Identify specific triggers for responding to changes
in the mother’s vital signs and clinical condition and
develop and use protocols and drills for responding
to changes, such as hemorrhage and pre-
eclampsia. Use the drills to train staff in the
protocols, to refine local protocols, and to identify
and fix systems problems that would prevent optimal
care.
Knight et al. BMC Pregnancy and Childbirth 2009
All PPH Atonic PPH
SEVERE POSTPARTUM HEMORRHAGE
McLintock & James . Obstetric hemorrhage. J Thromb Haemost. 2011;9(8):1441-51.
BLOOD COMPONENT THERAPY
In A Nut Shell
WHOLE BLOOD (500 mL)
Packed Red Cells (1U = 200-250 mL) 1U increases Hematocrit 3%
Platelets (1U = 50 mL) 6 pooled U increases platelet count 30K/uL
* Plateletpheresis (1U = 6-8 pooled singles = 250 mL)
Fresh Frozen Plasma (1U = 200-300 mL) 1U increases fibrinogen 7-10 mg/dL
Cryoprecipitate (1U = 20 mL)
Factor I, VIII, XIII, vWF, fibronectin 10 pooled U increases fibrinogen 70 mg/dL
Temp
(C)
1 to 6
20 to 24
-18
-18
TRANSFUSION
Recent Practice
Traditional strategies based on ATLS guidelines Start resuscitation with crystalloid followed by PRBCs
Use of other blood products based on laboratory tests
Massive Transfusion (MT) Replacement of > 50% of blood volume in 12-24 hours
Transfusion of > 10 U PRBC in 24 hours
Recent MT protocols at many centers Have not recommended the infusion FFP until after 4-10
U of PRBCs have been given
Many guidelines do not include recommendations for PLTs pending laboratory data
Feldbuch der Wundarznei by Hans von Gersdorff (1517)
http://en.wikipedia.org/wiki/Battlefield_medicine
Quick
Review
of the
Literature
MASSIVE TRANSFUSION
Combat & Trauma Experience
Series Setting N CT Studied Findings
Borgman 2007 Combat 246 FFP:RBC 1:1
Gonzalez 2007 Civilian 97 FFP:RBC 1:1
Sperry 2008 * Civilian 415 FFP:PRBC >=1:1.5
Holcomb 2008 Civilian 467 FFP:RBC
PLT:RBC
1:2
1:2
Maegele 2008 Civilian 713 pRBC : FFP <0.9
Spinella 2009 Combat 354 WFWB v CT WFWB > CT
Perkins 2009 Combat 694 aPLT:RBC 1:8
Zink 2009 Civilian 466 FFP:RBC
PLT:RBC
Higher ratios
MASSIVE TRANSFUSION
Combat Casualties
In patients with combat-related
trauma requiring massive
transfusion, a FFP:RBC ratio is
independently associated with
improved survival, primarily by
decreasing death from hemorrhage.
Concluded that MT protocols
should utilize 1:1 ratio of FFP:RBC
for hypocoagulable patients with
traumatic injuries.
Borgman et al. The ratio of blood products transfused affects
mortality in patients receiving massive transfusions at a combat
support hospital. J Trauma 2007;63(4):805-13.
Retrospective chart review
of 246 patients at a US
Army combat support
hospital in Iraq received MT
MASSIVE TRANSFUSION
16 Civilian Level I Trauma Centers
Review of 466 MT trauma cases during 2005-2006
Survival was increased in patients transfused high FFP:RBC (≥1:2)
high PLT:RBC (≥1:2)
No change in deaths due to MSOF
Holcomb et al. Increased plasma and platelet to red blood cell ratios
improves outcome in 466 massively transfused civilian trauma
patients. Ann Surg 2008; 248:447.
MASSIVE TRANSFUSION
16 Civilian Level I Trauma Centers
Zink et al. A high ratio of plasma and platelets to packed red blood
cells in the first 6 hours of massive transfusion improves outcomes
in a large multicenter study. Am J Surg 2009;197(5):565-70.
466 MT cases
during 2005-2006
TRAUMA & COAGULOPATHY
Military Approach
Rapid identification of coagulopathic patients
Frequent use of recombinant human factor VIIa
Rapid treatment of acidosis
Avoidance of hypothermia
Prompt initiation of 1:1:1 resuscitation ratios with RBCs, prethawed universal donor AB plasma,
and apheresis platelets
with conversion to fresh whole blood as soon as this can be obtained
Hess, JR. Blood and coagulation support in trauma care. Hematology Am
Soc Hematol Educ Program 2007;187-91.
Holcomb et al. Damage control resuscitation: directly addressing the early
coagulopathy of trauma. J Trauma 2007; 62:307-310.
BLOOD COMPONENT THERAPY
Massive Transfusion
Military
Battlefield
Level I
Trauma Center
L & D
?
MASSIVE TRANSFUSION
Postpartum Hemorrhage
Stanford Univ Med Ctr
Blood products 6 U PRBC
4 U FFP or LP
1 U aPLT
Lab assessment CBC & PLT
PT / PTT / Fibrinogen
Recombinant Factor VIIa
Burtelow et al. How we treat: management of life-threatening
primary postpartum hemorrhage with a standardized massive
transfusion protocol. Transfusion 2007;47:1564-72.
Massive Transfusion Protocol
Pack A
4 U PRBC
4 U FFP
Pack B
4 U PRBC
4 U FFP
1 U PLT
1-10 U Cryo
SMH 2010
Massive Transfusion Protocol
SMH 2010
When to activate the MTP in
Obstetrics
Hemorrhage expected to be massive (>50% BV within 2 hours)
Bleeding continues after 4 U PRBC within e.g. 1-2 hrs
Systolic BP <90 mmHg & P >120 bpm c uncontrolled bleeding
Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An update
on the use of massive transfusion protocols in obstetrics. Am J Obstet
Gynecol 2016;214:340-4.
The MTP in Obstetrics
Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An update on the use of
massive transfusion protocols in obstetrics. Am J Obstet Gynecol 2016;214:340-4.
POINT OF CARE
Handheld Analyzers
https://www.abbottpointofcare.com/products-services/istat-handheld
http://www.alere.com/us/en/product-details/epoc-blood-analysis-system.html
i-STAT® epoc®
Blood Gases (pH, Hgb)
Electrolytes (K, iCa)
Chemistries
Coagulation (PT)
Hematology (Hgb & Hct)
Glucose
Cardiac markers
Thromboelastography
Thromboelastography [TE] 1948 Hartert
Clot development, stabilization and
dissolution…reflects in vivo hemostasis
Thromboelastography (TEG®)
Haemonetics Corporation
http://www.haemonetics.com/
Thromboelastometry (ROTEM®)
Tem International GmbH
https://www.rotem.de/en/
r-TEG criteria for Transfusion
Activated clotting time (ACT) time to beginning of clot formation (seconds)
Correlated with coagulation factor activity and thrombin generation
ACT > 110 treated with plasma
Angle (α) rate of clot strength increase (degrees)
Correlated with fibrinogen concentration and function
Angle < 66° treated with cryoprecipitate
Maximum amplitude (MA) maximal clot strength achieved (millimeters)
Correlated with platelet–fibrinogen interactions
MA < 54 mm treated with platelets
Percent clot lysis (LY30) 30 minutes after MA is achieved (%)
Correlated with fibrinolysis
LY30 > 3% treated with tranexamic acid (TXA)
Einersen PM, Moore EE, Chapman MP, Moore HB, Gonzalez E, Silliman CC,
Banerjee A, Sauaia A. Rapid-thrombelastography (r-TEG) thresholds for goal-directed
resuscitation of patients at risk for massive transfusion. J Trauma Acute Care Surg
2016 Oct 31. [Epub ahead of print] PubMed PMID: 27805995.
Online Resources
POSPTARTUM HEMORRHAGE
Blood Transfusion…Conclusions
PPH is a major cause of maternal mortality
Most maternal deaths due to PPH are preventable
Many preventable deaths are due to inadequate BCT
New MTP data from military & civilian trauma centers
Limited published experience with MTP in L&D for PPH
Lethal Triad of coagulopathy, hypothermia, & acidosis
Don’t forget hyperkalemia and hypocalcemia
Have, practice (Sim) and use PPH and MTP guidelines
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