Transfusing tiny soldiers Ramsey C. Tate, MD. Applying combat-derived massive transfusion protocols to pediatric trauma patients.

Transfusing tiny soldiers

Ramsey C. Tate, MD

Applying combat-derived massive transfusion protocols to pediatric trauma patients

Case

Damage control resuscitation

Massive transfusion protocols

Pediatric massive transfusion protocols

Agenda

Case

Damage control resuscitation (DCR)

Massive transfusion protocols (MTP)

Pediatric massive transfusion protocols

Agenda

GCS 15HR

151BP 100/palp

HR 166BP

60/palp“exhibits transient loss of consciousness”

Trauma code

Emergently taken to OR “Likely to require multiple transfusions”

Grade V liver laceration

Packed red blood cells: 19 unitsFresh frozen plasma: 5 unitsApheresis platelets: 1 unitsCryoprecipitate pooled: 2 unitsRecombinant Factor VIIa: 1 dose

5 million

40%

Massive hemorrhage carries greater than 50% risk of death

Damage Control Resuscitation

Damage Control Resuscitation

Permissive hypotension

Aggressive correction of coagulopathyUse of vasopressors and blood products to maintain hemodynamics and euvolemia

Damage Control Resuscitation

Permissive hypotension

Aggressive correction of coagulopathyUse of vasopressors and blood products to maintain hemodynamics and euvolemia

Hemostatic resuscitation

Death

Damage Control Resuscitation

Acidosis

Hypothermia

Coagulopathy

Death

Damage Control Resuscitation

Acidosis Hypothermia

Coagulopathy

Death

Damage Control Resuscitation

Acidosis Hypothermia

Coagulopathy

Early trauma induced coagulopathy Dilutional coagulopathy

3% of adult civilian trauma patients

3% of adult civilian trauma patients

70% of transfused blood products at trauma centers

Transfusion of more than 10 units of blood

Loss of 50% of blood volume in 3 hours

Ongoing blood loss of 150 mL/hour

5 liters

0.5 liters

5 liters

0.5 liters

Transfusion of one blood volume in 24 hours

Approaches to massive transfusion

Component therapy

Transfusion physician managementMassive transfusion protocol with predetermined blood product administration

Massive transfusion protocol with predetermined blood product administration

Fresh whole blood:

500 mLHct 33-43%Plt 130-350,000Fibrinogen 1500 mgClotting activity 86%Full platelet activityWarm

Fresh whole blood:

500 mLHct 33-43%Plt 130-350,000Fibrinogen 1500 mgClotting activity 86%Full platelet activityWarm

RBC + Platelets + FFP:

660 mLHct 29%Plt 88,000Fibrinogen 750 mgClotting activity 65%Reduced platelet activityCold

Fresh whole blood:

500 mLHct 33-43%Plt 130-350,000Fibrinogen 1500 mgClotting activity 86%Full platelet activityWarm

RBC + Platelets + FFP:

660 mLHct 29%Plt 88,000Fibrinogen 750 mgClotting activity 65%Reduced platelet activityCold

1:1:1

Key components of MTP

Resuscitation with predetermined ratios of blood components

Rapid infusion of warmed blood productsCoordination with transfusion specialists to ensure streamlined delivery of productsMonitoring of coagulation studies to determine the end-point of protocol

Key components of MTP

Resuscitation with predetermined ratios of blood components 1 RBC:1 FFP:1 PlateletRapid infusion of warmed blood productsCoordination with transfusion specialists to ensure streamlined delivery of productsMonitoring of coagulation studies to determine the end-point of protocol

Key components of MTP

Resuscitation with predetermined ratios of blood components

Rapid infusion of warmed blood productsCoordination with transfusion specialists to ensure streamlined delivery of productsMonitoring of coagulation studies to determine the end-point of protocol

Key components of MTP

Resuscitation with predetermined ratios of blood components

Rapid infusion of warmed blood productsCoordination with transfusion specialists to ensure streamlined delivery of productsMonitoring of coagulation studies to determine the end-point of protocol

Key components of MTP

Resuscitation with predetermined ratios of blood components

Rapid infusion of warmed blood productsCoordination with transfusion specialists to ensure streamlined delivery of productsMonitoring of coagulation studies to determine the end-point of protocol

MTP-associated outcomes

Mortality

Decreases in blood product consumption

Improvements in blood product delivery

Decreases in ventilator-associated pneumonia

Decreases in open abdomen days and abdominal compartment syndrome

MTP-associated outcomes

Mortality

Decreases in blood product consumption

Improvements in blood product delivery

Decreases in ventilator-associated pneumonia

Decreases in open abdomen days and abdominal compartment syndrome

All published data are retrospective!

Paterson, 2009

Case report:Pre-surgical planning for 5 yo with ruptured AVM

Paterson, 2009

Case report:Pre-surgical planning for 5 yo with ruptured AVM

This might work in the OR…

… but tough to do in here.

Dehmer and Adamson, 2010

Expert opinion:Adapted Paterson’s protocol

Harborview pediatric MTP

adapted by Brian Johnston

On the horizon

Pediatric MTP in development at UNM

On the horizon

Pediatric MTP in development at UNM

Introduction of ROTEM testing

On the horizon

Pediatric MTP in development at UNM

Introduction of ROTEM testing

PROMMTT Study

Questions?