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
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
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
Early trauma induced coagulopathy Dilutional coagulopathy
Transfusion of more than 10 units of blood
Loss of 50% of blood volume in 3 hours
Ongoing blood loss of 150 mL/hour
Approaches to massive transfusion
Component therapy
Transfusion physician managementMassive 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
This might work in the OR…