Massive Transfusion in Non-Trauma Patients,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 3376-3376 ◽  
Author(s):  
Lisa M Baumann Kreuziger ◽  
Josh Salzman ◽  
Amar T Subramanian ◽  
Colleen T. Morton ◽  
David J Dries
Keyword(s):  
Hospital Mortality ◽  
Blood Product ◽  
Massive Transfusion ◽  
Factor Vii ◽  
Component Ratio ◽  
Blood Products ◽  
Major Hemorrhage ◽  
Activated Factor Vii ◽  
The Impact ◽  
Transfusion Reactions

Abstract Abstract 3376 Background: Hemorrhagic shock accounts for a significant number of deaths in patients with acute injury. Early administration of multicomponent blood product transfusion in high plasma to red cell ratios have been associated with decreased mortality. Significant bleeding may occur in many settings outside of injury, including abdominal aortic aneurysm (AAA) rupture and postpartum or gastrointestinal hemorrhage. At a Level I Adult and Pediatric Trauma Center, activation of a Massive Transfusion Protocol (MTP) provides immediate release of sets of blood products with high component ratios (i.e. 1 unit plasma for every 1 unit PRBC) for patients with severe injury. The protocol has also been utilized in patients with major bleeding from non-trauma etiologies. To our knowledge, there are no systematic studies of the effectiveness of blood transfusion with high component ratios in non-traumatic hemorrhage; therefore, we performed a retrospective case review of patients transfused via the MTP for non-traumatic indications and outcomes at our institution. Methods: Clinical data for 58 patients with non-traumatic activation of the MTP between October 2009 and May 2011 was reviewed. Medications, laboratory parameters prior to transfusion, medical conditions affecting bleeding, and amount of blood products administered were evaluated. Outcomes including 24 hour and in-hospital mortality and incidence of transfusion reactions including Transfusion Related Acute Lung Injury (TRALI) were assessed. Associations between medications or medical problems and transfused blood products, as well as component ratio on mortality were assessed using logistic regression. Fisher's exact test was used to examine the impact of transfusion reactions including TRALI on mortality. Results: Forty-nine of 58 patients studied (84%) received blood products after activation of the MTP. Patients ranged in age between 19 and 82 years-old (median 61 years) and 69% were male. Thirty eight percent of patients had the MTP activated for vascular catastrophies (AAA), 24% for GI bleeding, 16% for open heart surgery, and 10% for obstetrical complications. Patients on average received 9 units of red blood cells (range 0–39 units), 6.6 units of plasma (range 0–34 units), and 1.5 apheresis units of platelets (range 0–5). Twelve patients (24%) received cryoprecipitate. Administered adjunctive medications included activated factor VII for 11 patients (22%), aminocaproic acid in 14 patients (28%), vitamin K in 15 patients (30%), and desmopressin in 6 patients (12%). The odds of a patient receiving activated Factor VII increased significantly as the units of PRBCs increased (OR = 3.925; 95% CI = 1.15 – 13.38). Concurrent medications most likely to affect bleeding included heparin in 26 patients (53%), aspirin in 18 patients (37%), and warfarin in 4 patients (8%). Active liver failure was seen in 11 patients (22%), renal failure in 16 patients (32%), and one patient with either a hematologic or solid malignancy. Patient's medications or these medical diagnoses were not associated with the amount of blood product transfused. Twenty one patients (43%) died during the hospitalization, and six patients (12% of total) died within the first 24 hours. In hospital mortality for patients with GI hemorrhage was the highest at 66%. No patients died after receiving transfusion for obstetric complications. Influence of ratio of Plasma:PRBC transfusion on in-hospital morality was seen with mortality of 80% in the <1:4 group, 60% in 1:4–1:2 group, and 36% in both 1:2 to 1:1 and ≥1:1 groups. These differences were not statistically significant, however, potentially due to sample size. Three patients experienced signs and symptoms consistent with TRALI but no other transfusion reactions were found. These cases were not associated with mortality (24-hour or in hospital) and were not correlated with the component ratio. Conclusions: MTPs with infusion of blood products with high ratios of plasma to red cells compared to transfusion with low ratios have improved mortality in patients with hemorrhage due to trauma. Our data suggests the applicability of MTP as part of resuscitation in the management of acute hemorrhage in non-trauma settings. Transfusion reactions were infrequent. Therefore, physicians should strive for transfusion of high ratios of Plasma:PRBC in all instances of major hemorrhage. Disclosures: Off Label Use: Use of activated factor VII to assist with cessation of hemorrhage in patients without hemophilia.

scholarly journals Outcome of Major Hemorrhage at a Major Cardiothoracic Center in Patients with Activated Major Hemorrhage Protocol versus Nonactivated Protocol

2021 ◽  
Vol 47 (01) ◽  
pp. 074-083
Author(s):  
Kathryn W. Chang ◽  
Steve Owen ◽  
Michaela Gaspar ◽  
Mike Laffan ◽  
Deepa R. J. Arachchillage
Keyword(s):  
Fresh Frozen Plasma ◽  
Electronic Records ◽  
Blood Products ◽  
Major Hemorrhage ◽  
Fresh Frozen ◽  
Dilutional Coagulopathy ◽  
Baseline Characteristics ◽  
The Impact ◽  
Frozen Plasma ◽  
Baseline Hemoglobin

AbstractThis study aimed to determine the impact of major hemorrhage (MH) protocol (MHP) activation on blood administration and patient outcome at a UK major cardiothoracic center. MH was defined in patients (> 16 years) as those who received > 5 units of red blood cells (RBCs) in < 4 hours, or > 10 units in 24 hours. Data were collected retrospectively from patient electronic records and hospital transfusion databases recording issue of blood products from January 2016 to December 2018. Of 134 patients with MH, 24 had activated MHP and 110 did not have activated MHP. Groups were similar for age, sex, baseline hemoglobin, platelet count, coagulation screen, and renal function with no difference in the baseline clinical characteristics. The total number of red cell units (median and [IQR]) transfused was no different in the patients with activated (7.5 [5–11.75]) versus nonactivated (9 [6–12]) MHP (p = 0.35). Patients in the nonactivated MHP group received significantly higher number of platelet units (median: 3 vs. 2, p = 0.014), plasma (median: 4.5 vs. 1.5, p = 0.0007), and cryoprecipitate (median: 2 vs. 1, p = 0.008). However, activation of MHP was associated with higher mortality at 24 hours compared with patients with nonactivation of MHP (33.3 vs. 10.9%, p = 0.005) and 30 days (58.3 vs. 30.9%, p = 0.01). The total RBC and platelet (but not fresh frozen plasma [FFP]) units received were higher in deceased patients than in survivors. Increased mortality was associated with a higher RBC:FFP ratio. Only 26% of patients received tranexamic acid and these patients had higher mortality at 30 days but not at 24 hours. Deceased patients at 30 days had higher levels of fibrinogen than those who survived (median: 2.4 vs. 1.8, p = 0.01). Patients with activated MHP had significantly higher mortality at both 24 hours and 30 days despite lack of difference in the baseline characteristics of the patients with activated MHP versus nonactivated MHP groups. The increased mortality associated with a higher RBC:FFP ratio suggests dilutional coagulopathy may contribute to mortality, but higher fibrinogen at baseline was not protective.

scholarly journals A SARS-CoV-2-pandémia hatása a vérkészítmény-felhasználásra a Pécsi Tudományegyetemen

2021 ◽  
Vol 162 (43) ◽  
pp. 1717-1723
Author(s):  
Sándor Pál ◽  
Barbara Réger ◽  
Tamás Kiss ◽  
Hussain Alizadeh ◽  
András Vereczkei ◽  
...  
Keyword(s):  
Blood Transfusion ◽  
Blood Cell ◽  
Red Blood Cell ◽  
Blood Product ◽  
Patient Blood Management ◽  
Blood Products ◽  
Blood Management ◽  
Number Of Patients ◽  
Willingness To Donate ◽  
The Impact

Összefoglaló. Bevezetés: A COVID–19-világjárvány betegellátásra gyakorolt hatása hazánkban is jelentős. A vérellátást nehezítette a járványügyi intézkedések következményeként a véradási események elmaradása, a csökkent véradási hajlandóság, továbbá a nehezen megítélhető vérkészítményigény . A „Patient Blood Management” irányelveinek az orvosi gyakorlatban történő egyre szélesebb körű alkalmazása elősegíti az optimális vérkészítmény-felhasználást a transzfúziók lehetőség szerinti elkerülésével. Célkitűzés és módszer: Vizsgálatunk célja a Pécsi Tudományegyetem Klinikai Központjának Janus Pannonius Klinikai Tömbjében a vérkészítmény-felhasználás változásainak felmérése volt a 2020. év első öt hónapjában. Eredmények: A járványügyi intézkedéseket követő időszakban szignifikánsan csökkent a hospitalizált betegeknek (34,08%), a transzfúziót igénylő betegeknek (39,69%) és a felhasznált vörösvérsejt-készítményeknek (46,41%) a száma, valamint az egy betegre jutó felhasznált vörösvérsejt-koncentrátum átlaga (2,61-ről 1,97-re) is. Közel 30%-os arányban csökkent a felhasznált friss fagyasztott plazma egységeinek és a thrombocytakoncentrátumoknak a száma is. Következtetés: A szigorú korlátozások életbe léptetését követően a nehézségek ellenére sikerült elegendő mennyiségű vérkészítményt biztosítani a betegeknek. Az Országos Vérellátó Szolgálat Pécsi Regionális Vérellátó Központja munkatársainak és a klinikusok erőfeszítéseinek köszönhetően a vérkészítményigény és -kínálat között új egyensúly alakult ki, mely megfelelő ellátást biztosított a feltétlenül szükséges transzfúziók kivitelezéséhez. Orv Hetil. 2021; 162(43): 1717–1723. Summary. Introduction: The impact of COVID–19 pandemic on patient care is pronounced also in Hungary. Blood supply was hindered by the reduction of public blood donation events, the reduced willingness to donate, and the difficult predictability of blood product demand as a result of the epidemiological regulations. The wider application of Patient Blood Management guidelines in the medical practice will promote optimal blood product utilization by avoiding transfusions where possible. Objective and method: The aim of our study was to assess the changes in the usage of blood products in the first five months of 2020 at the Clinical Center of the University of Pécs, Janus Pannonius Clinical Building. Results: In the period following the epidemiological measures, we found reduction in the number of hospitalized patients (34.08%), in the number of patients requiring transfusion (39.69%) and in the number of red blood cell products used (46.41%). The number of transfused red blood cell concentrates per patient was also significantly reduced (from 2.61 to 1.97) in this period. The number of transfused fresh frozen plasma units and platelet concentrates also decreased by approximately 30%. Conclusion: After the implementation of the strict restrictions, despite the difficulties, it was possible to provide patients with sufficient blood products. Due to the efforts of both the Regional Blood Transfusion Center of Pécs of the Hungarian National Blood Transfusion Service and of the clinicians, a new balance was established between the demand and the supply of blood products, which provided adequate care for the necessary transfusions. Orv Hetil. 2021; 162(43): 1717–1723.

scholarly journals The Impact of Perioperative Viscoelastic Test Application on Blood Product Usage and Outcome in Cardiac Surgery; Regional Cardiac Surgery Center Experience

2021 ◽  
Author(s):  
Murat Aksun ◽  
Saliha Aksun ◽  
Mehmet Ali Çoşar ◽  
Elif Neziroğlu ◽  
Senem Girgin ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Clinical Experience ◽  
Heart Surgery ◽  
Blood Product ◽  
Open Heart Surgery ◽  
Control Group ◽  
Open Heart ◽  
Blood Products ◽  
Product Use ◽  
The Impact

Objective: Thromboelastography (TEG) is a diagnostic modality that gives information about coagulation. Despite all blood-preserving precautions in open heart surgery there are blood losses and the use of blood and blood products becomes inevitable. TEG is mostly not available in every center and habits, trends and clinical experience in blood use create the possibility of causing unnecessary use of blood and blood products. In this study, it was aimed to determine the effect of the use of thromboelastography on the use of blood and blood products in cardiac surgery. Methods: Two hundred patients between 18-70 years old who underwent open heart surgery were included in the study. After the cardiopulmonary bypass (CPB), the cases were confirmed to have an Activated Clotting Time (ACT) value in the range of 120-150 sec after protamine administration. In 100 patients in the TEG group, the coagulation status was evaluated with TEG and it was decided how to apply blood and blood product use. Blood and blood product use was applied to 100 patients in the control group based on clinical experience and foresight. The total amount of blood and blood product used, fluid balance, need for inotropics, mechanical ventilator time, complications, duration of intensive care and discharge times were recorded. Results: Use of Fresh Frozen Plasma (FFP) at the after CPB in the TEG group was statistically significantly lower than that of the control group FFP (p<0.05). Postoperative FFP and postoperative platelet use in the study group were statistically significantly lower than in the postoperative FFP and postoperative platelet values of the control group (p <0.05). Conclusion: The use of thromboelastography is a very useful monitoring in terms of reducing FFP use after CPB and reducing FFP and platelet usage in the postoperative period. In this way, the unnecessary use of blood and blood products can be prevented.

Intraoperative Resuscitation by Specialized Trauma Nurse Clinicians Improves Adherence to Massive Transfusion Protocol

2020 ◽  
Vol 86 (1) ◽  
pp. 35-41
Author(s):  
L. Andrew May ◽  
Kevin N. Harrell ◽  
Christopher M. Bell ◽  
Angela Basham-Saif ◽  
Donald E. Barker ◽  
...  
Keyword(s):  
Blood Product ◽  
Trauma Registry ◽  
Massive Transfusion ◽  
Blood Products ◽  
Packed Red Blood Cells ◽  
Massive Blood Loss ◽  
Massive Transfusion Protocol ◽  
Nurse Clinicians ◽  
Level I ◽  
Transfusion Protocol

A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007–2015) or TNCs (2015–2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.

scholarly journals High Dose, Prolonged Epsilon Aminocaproic Acid Infusion, and Recombinant Factor VII for Massive Postoperative Retroperitoneal Hemorrhage following Splenectomy

2016 ◽  
Vol 2016 ◽  
pp. 1-4 ◽  
Author(s):  
Alex T. Lee ◽  
Christopher R. Barnes ◽  
Shweta Jain ◽  
Ronald Pauldine
Keyword(s):  
Massive Transfusion ◽  
Aminocaproic Acid ◽  
Massive Hemorrhage ◽  
Factor Vii ◽  
High Dose ◽  
Retroperitoneal Hemorrhage ◽  
Acid Infusion ◽  
Open Splenectomy ◽  
Epsilon Aminocaproic Acid ◽  
The Impact

The antifibrinolytic agentε-aminocaproic acid is used to decrease procedural blood loss in a variety of high risk surgeries. The utility of recombinant factor VII administration in massive hemorrhage has also been reported in a variety of settings, though the impact in a surgical context remains unclear. We describe the case of a patient who underwent massive open splenectomy and developed diffuse retroperitoneal bleeding on postoperative day one. Massive transfusion was initiated, but attempts to control hemorrhage with surgical and interventional radiology approaches were unsuccessful, as was recombinant factor VII administration. Commencement of a high dose aminocaproic acid infusion was followed by a prominent rise in fibrinogen levels and stabilization of the hemorrhage. Indications, dosages, and adverse effects ofε-aminocaproic acid as described in the literature are reviewed.

Adherence to Transfusion Protocols and the Use of Recombinant Activated Factor VII.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 4192-4192
Author(s):  
Louise E Phillips ◽  
Cameron Willis ◽  
Amanda Zatta ◽  
Scott Dunkley ◽  
Peter Cameron ◽  
...  
Keyword(s):  
New Zealand ◽  
Massive Transfusion ◽  
Coagulation Cascade ◽  
Factor Vii ◽  
Off Label Use ◽  
Appropriate Use ◽  
Recombinant Activated Factor Vii ◽  
Off Label ◽  
Activated Factor Vii ◽  
Educational Grant

Abstract Abstract 4192 Background Most hospitals have clinical guidelines for the off-label use of recombinant activated Factor VII (rFVIIa, Novoseven), primarily as part of a massive transfusion protocol. Over the past years rFVIIa has increasingly been used outside the approved indications in haemophilia with inhibitors and Glanzmann's Thrombasthenia, particularly in trauma, cardiac surgery and other critical bleeding episodes. Use in these areas remains controversial. Methods Monash University established the Haemostasis Registry in 2005 (with an educational grant from NovoNordisk Pharmaceuticals) to monitor the use of rFVIIa throughout Australia and New Zealand. More than 95 hospitals are contributing data to the Registry including all major users of rFVIIa in Australia and New Zealand. As part of the process of joining the Registry project, participating hospitals are asked to supply copies of their protocols for use of rFVIIa. Results Approximately 3000 cases of rFVIIa use have been reported to the Register. Major areas of use are cardiac surgery (∼ 41%), other surgery (∼17%) and trauma (∼15%). The majority(77.3%) of hospitals have documented protocols for rFVIIa use. Many of these are similar and are centred around situations of massive transfusion. However, 64.5% of cases of rFVIIa use submitted to the Haemostasis Registry, from hospitals where protocols exist, do not conform with the numerical components of these protocols. Conclusions This is the largest dataset of rFVIIa cases published to date and can now provide greater insight into the actual rather than theoretical use of rFVIIa in Australia and New Zealand. Lack of compliance with hospital protocols for rFVIIa use indicates either that the protocols do not reflect actual and appropriate use or that clinicians need to be further educated regarding what is currently considered appropriate use. In the absence of sound clinical trial evidence, consensus regarding appropriate use has not been achieved. In these circumstances, data from the Haemostasis Registry continues to be important in elucidating the safety and efficacy of rFVIIa and providing important feedback to doctors and hospitals. The Haemostasis Registry is funded through an unrestricted Educational Grant from NovoNordisk Pharmaceuticals Pty Ltd. None of the authors have a financial interest in the outcomes of the study. Disclosures: Off Label Use: Recombinant activated Factor VII (rFVIIa, Novoseven). FVIIa is a naturally occurring initiator of haemostasis. Its recombinant form, rFVIIa, is approved for the treatment of spontaneous & surgical bleeding in patients with haemophilia A or B and with antibodies to either factor VIII or factor IX. It has been extensively used amongst haemophiliacs and appears to enhance clotting at the site of bleeding without systemic activation of the coagulation cascade At high doses rFVIIa binds to the surface of activated platelets and initiates the coagulation cascade at these sites Recently various case series and case reports have reported the efficacy of rFVIIa in patients with life-threatening bleeding in patients with coagulation disturbances but without coagulation inhibitors.

Blood product support

2019 ◽  
pp. 487-496
Author(s):  
Toby Eyre
Keyword(s):  
Patient Education ◽  
Patient Monitoring ◽  
Final Section ◽  
Blood Product ◽  
Immunocompromised Patients ◽  
Red Cell ◽  
Blood Products ◽  
Patients With Cancer ◽  
Transfusion Reactions ◽  
Platelet Transfusions

This chapter covers the use of blood products for patients with cancer. Issues of compatibility, ABO grouping, and rhesus are all discussed. The use of red cell transfusions is explored, covering up-to-date guidelines on their use. Transfusion reactions and their management are also described. The chapter then explores the use of platelet transfusions, as well as commonly seen reactions. There is also a look at specialized aspects of blood product use, including cytomegalovirus testing and irradiated blood products for immunocompromised patients. The final section looks specifically at the nurse's role, including patient education, safety checking, and patient monitoring.

A highly sensitive thrombin generation assay for assessment of recombinant activated factor VII therapy in haemophilia patients with an inhibitor

2011 ◽  
Vol 105 (04) ◽  
pp. 688-695 ◽  
Author(s):  
Ariella Zivelin ◽  
Dardik Rima ◽  
Tami Livnat ◽  
Uri Martinowitz ◽  
Gili Kenet
Keyword(s):  
Thrombin Generation ◽  
Dose Dependence ◽  
Factor Vii ◽  
Sensitive Assay ◽  
Laboratory Assessment ◽  
Recombinant Activated Factor Vii ◽  
Thrombin Generation Assay ◽  
Activated Factor Vii ◽  
The Difference ◽  
The Impact

SummaryBypass agents are the common treatment for haemophilia patients who develop inhibitory antibodies. Laboratory assessment of the efficacy of bypassing agent therapy is a challenge. In the present work we modified the conditions triggering thrombin generation (TG) assay in order to find the most sensitive assay for detection of rFVIIa and its analogue NN1731 in haemophilic plasma. TG was measured in samples of normal plasma, plasma of haemophilia patient with inhibitors, as well as haemophilia induced plasma. Recalcification-induced TG was compared to tissue factor (TF) -induced TG in the presence and absence of rFVIIa and NN1731. Recalcification-induced TG (without TF) in haemophilic plasma yielded baseline flat curves, with increased TG as a consequence of spiking the plasma rFVIIa. Using our system, we observed both dose-dependence and time-dependence of rFVIIa effect on TG. Elevated concentrations of TF mask the difference between rFVIIa-treated and non-treated haemophilic plasma. NN1731 yielded normal-isation of recalcification-induced TG curves (without TF) which may reflect high potency. In conclusion, we suggest that triggering TG by recalcification-only may be the most sensitive assay for determining the impact of bypassing agents in haemophilic plasma, and may serve as a caution surrogate safety marker in future studies.

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