Drastic times, drastic measures: A case report on massive transfusion

@#Massive intra operative bloodloss require sex pectant measures, efficient coordination among providers, and timely feedback to optimize outcomes. In the Philippines, case reports on massive blood loss and transfusion are lacking. This report describes a 67-year-old female who underwent elective adrenalectomy, nephrectomy, and hepaticresection, with a total intraoperative blood loss of 20 liters in a 13-hour surgery. Efficient conduct of the institution's massive transfusion protocol, multiple press or support, electrolyte and glucose correction, and anticipatory management of associated complications of hypovolemia and transfusion were important elements to successful management. The patient tolerated the surgery and was discharged well after 12 days. In theabsence of more sophisticated monitoring and management options in a low-resource setting, maximizing available means and anticipatory interventions is key.

Research progress on massive transfusion protocol / 中国输血杂志

Massive transfusion protocol (MTP) is a programmatic procedure for massive blood transfusions, which is an important means of patient blood management (PBM) for trauma and massive hemorrhage patients. MTP can be initiated in a variety of modes, including the McLaughlin, ABC and TASH scoring systems and the mode depending on the patient′s hemorheology. After MTP has been activated, blood components should be injected as soon as possible. Generally, red blood cells should be injected first, followed by plasma and platelets injected proportionally. MTP should be based on good damage control measures and good hemostatic treatment, and should try to avoid the waste of blood components.This article reviews the progress of research on MTP in the above aspects.

Plasmin-α2-plasmin inhibitor complex and thrombin-antithrombin complex in risk stratification of massive transfusion in patients with postpartum hemorrhage / 中国输血杂志

【Objective】 To analyze the value of plasmin-α2-plasmin inhibitor complex (PIC) and thrombin-antithrombin complex (TAT) for risk stratification of massive transfusion (MT) in patients with postpartum hemorrhage (PPH). 【Methods】 Clinical data and blood samples of patients with PPH in our hospital from January 2019 to December 2022 were retrospectively analyzed. MT (MT group, n=60) was defined as transfusion of red blood cells≥10 U within 24 h after delivery, and 3.25 ng/mL and PIC level>1.04 μg/mL were independent risk factors for MT after PPH. 【Conclusion】 Elevated TAT and PIC levels are independent predictors of MT in patients with PPH, and their combined predictive efficacy is better.

Puesta al día sobre transfusión masiva / Massive transfusion update / Atualização sobre transfusão maciça

La transfusión masiva plantea desafíos clínicos, organizacionales y logísticos para el personal de la salud en general y los servicios de Medicina Transfusional en particular. No existe una definición universalmente aceptada de transfusión masiva, las definiciones más comúnmente utilizadas se basan en el número de unidades de sangre administradas dentro de un cierto período de tiempo. La mayoría de los eventos de transfusión masiva ocurren en el contexto de hemorragias graves en pacientes quirúrgicos, politraumatizados, con hemorragia gastrointestinal u obstétrica. La reanimación de control de daños y los protocolos de transfusión masiva son las estrategias más utilizadas actualmente para el tratamiento inicial, seguidas de un tratamiento personalizado, dirigido por objetivos, mediante la monitorización de la coagulación en tiempo real mediante estudios viscoelásticos. Existen una serie de controversias alrededor del tratamiento óptimo, incluyendo el uso de sangre total, la relación de hemocomponentes a utilizar, el uso de concentrados de factores de la coagulación, y la indicación óptima del ácido tranexámico. El estudio de los productos ideales para el tratamiento de los pacientes con sangrado masivo se ha convertido en un área de gran interés de la investigación científica. El contexto clínico en el que ocurrió el evento hemorrágico, el número de hemocomponentes transfundidos, la edad del paciente y las comorbilidades son los predictores más importantes de la sobrevida a corto y largo plazo. Esta revisión narrativa explora el estado actual del conocimiento sobre la transfusión masiva, así como los avances que podemos esperar en el futuro cercano.

Massive transfusion poses clinical, organizational and logistic challenges for the health staff in general, and the Transfusion Medicine Services in particular. There is no universally accepted definition for massive transfusion, the most widely used being based on the number of blood units administered in a certain period of time. Most massive transfusion events occur in the context of severe hemorrhage on surgical or multiple-trauma patients or patients with gastrointestinal or obstetric bleeding. Today, damage control resuscitation and massive transfusion protocols are the most common strategies for initial treatment, followed by personalized therapy, goal-directed, my means of monitoring coagulation in real time with viscoelastic studies. There are disputes as to the best surgical treatment, including using whole blood, the relation of blood components to be used, the use of coagulation factor concentrates and the optimal indication of tranexamic acid. The study of ideal products to treat patients with massive hemorrhage has become an area of great interest for scientific research. The clinical context of the hemorrhagic event, the number of blood components transfused, patient's age and comorbilities are the most important predictors for survival in the short and long term. This narrative review explores the current state of affairs on knowledge about massive transfusion, as well as progress to be expected in the near future.

A transfusão maciça apresenta desafios clínicos, organizacionais e logísticos para o pessoal de saúde em geral e para os serviços de Medicina Transfusional em particular. Não existe uma definição universalmente aceita de transfusão maciça; as definições mais comumente usadas são baseadas no número de unidades de sangue administradas em um determinado período de tempo. A maioria dos eventos de transfusão maciça ocorre no contexto de sangramento maior em pacientes cirúrgicos, politraumatizados, com sangramento gastrointestinal ou obstétrico. Atualmente, a ressuscitação para controle de danos e os protocolos de transfusão maciça são as estratégias mais usadas para o tratamento inicial, seguidos por tratamento personalizado e orientado por objetivos usando monitoramento de coagulação em tempo real usando testes viscoelásticos. Há uma série de controvérsias em torno do tratamento ideal, incluindo o uso de sangue total, a proporção de componentes sanguíneos a serem usados, o uso de concentrados de fator de coagulação e a indicação ideal de ácido tranexâmico. O estudo dos produtos ideais para o tratamento de pacientes com sangramento maciço tornou-se uma área de grande interesse na pesquisa científica. O contexto clínico em que ocorreu o evento hemorrágico, o número de hemocomponentes transfundidos, a idade do paciente e as comorbidades são os preditores mais importantes de sobrevida a curto e longo prazo. Esta revisão narrativa explora o estado atual do conhecimento sobre transfusão maciça, bem como os avanços que podemos esperar no futuro próximo.

The impact of massive intraoperative RBC transfusion on laboratory results and prognosis in patients underwent surgery for malignancies / 中国输血杂志

【Objective】 To explore the effects of massive intraoperative RBC transfusion on multiple clinical test indicators and prognosis of patients, underwent tumor surgery in order to provide evidence for rational blood transfusion and effective intervention of complications caused by massive blood transfusion in tumor patients. 【Methods】 A total of 208 patients who underwent tumor resection in our hospital from January 2019 to December 2020 and received intraoperative RBC transfusion(>10 U) were selected as the study subjects. According to the amount of blood transfusion, they were divided into group A: 10~15 U, 144 patients; Group B: >15~25 U, 48 people; Group C: >25 U, 16 people. Data of liver function, coagulation, electrolyte, platelet count and short-term prognosis were collected and compared among 3 groups before and after surgery. 【Results】 No significant difference was noticed in patient pre-operation variables including ALT (U/L), AST (U/L) and TBIL (μmol/L) among three groups recieved massive blood transfusion (P>0.05), while AST was significantly lower than that after operation (P<0.05) : 105.33±238.18 vs 113.50±185.04 vs 291.25±457.33 (P<0.05). After operation, PT (s) (14.12±2.10, 14.79±2.67 and 16.10±4.06), INR(1.25±0.20, 1.31±0.26 and 1.44±0.38) and APTT (s) (30.52±5.63, 34.57±12.80 and 34.80±10.49) extended significantly than those before operation (P<0.05), while Plt (×109/L) decreased significantly (142.32±70.07, 100.04±57.50 and 85.40±41.10)(P<0.05). After operation, serum K+ and Ca2+ decreased significantly, Na+ and Cl- increased significantly, and pH value decreased (P < 0.05). Hospital stay of group C (d) was 33.73±34.62 vs 17.74±14.83 vs 20.92±17.69 (P<0.05). The mortality rate was 2.8%(4/44) vs 6.3%(3/48) vs 18.8%(3/16)(P<0.05), and mortality rate of group C was higher than the other two groups. 【Conclusion】 Postoperative dysfunction of liver and coagulation in tumor patients may be related to intraoperative RBC transfusions and consequent acid-base imbalance and electrolyte disturbance. The more the units of RBC transfused, the more abnormal the patients' clinical indicators, also the longer the hospital stay and the worse the short-term prognosis.

Coagulation functions in a large-dose blood loss/transfusion model by different protocols in vitro / 中国输血杂志

【Objective】 To evaluate common laboratory items in a large-dose blood loss model in vitro using thromboelastogram (TEG), to provide a reasonable infusion solution for clinical massive transfusions. 【Methods】 On March 2nd, 2017, eight healthy blood donors who participated in voluntary blood donation in the Department of Blood Transfusion Medicine of the First Medical Center of the PLA General Hospital were selected to undergo phlebotomy, and an in vitro dilution model of massive blood loss was established based on the previous research, namely Model 1 (M1, given massive transfusion protocol) and Model 2 (M2, given packed red blood cells and plasma) were established. Then blood routine, routine coagulation function, clotting factor activity, TEG of each model were tested. 【Results】 The platelet count in the M1 model was 61.00±10.24 (×109/L), and reduced to 28.83±10.36(×109/L) in M2 (P<0.01). The MA value (mm) of two groups detected by TEG was 29.35±2.37 vs 20.53± 2.76 (P<0.01). In M1 and M2 model, The activities of primary clotting factors respectively decreased to about 40% and 30% to original in M1 and M2. The R value of TEG prolonged to (6.32±0.85) min and (7.27±0.63) min respectively, still within the normal range(baseline 4.97±1.04). The fibrinogen concentration in the M1 and M2 model decreased to (1.10±0.08) g/L and (0.81±0.10) g/L(P<0.01), which had the same variation tendency to Alpha angle of TEG (25.65±4.95 vs 16.63±3.94, P>0.05). 【Conclusion】 MTP with blood components supplemented such as platelet and cryoprecipitate in time has effectively improved the Plt and Fib in vitro large-dose blood loss/transfusion model.

Coagulopatía asociada al trauma en la Unidad de Cuidados Intensivos / Trauma associated coagulopathy in the Intensive Care Unit / Coagulopatia associada a trauma em Unidade de Terapia Intensiva

Resumen: Introducción: la enfermedad traumática es un problema de salud mundial. La coagulopatía asociada al trauma (CAT) constituye una complicación grave, multifactorial y de diagnóstico controversial. Objetivos: valorar la incidencia de CAT, los factores asociados a su desarrollo y su asociación con el pronóstico, en una serie de pacientes traumatizados ingresados a la Unidad de Cuidados Intensivos de nuestro hospital. Pacientes y métodos: estudio prospectivo de todos los pacientes ingresados con diagnóstico de trauma grave a la UCI. Se definió CAT en base a los parámetros clásicos de laboratorio, por la presencia de al menos uno de: INR mayor a 1,3, plaquetopenia menor a 100.000/mm3, y/o aPTT mayor a 38 segundos. Las variables continuas se expresaron como la media ± desvío estándar. Se realizó análisis de chi cuadrado, test exacto de Fisher y regresión logística binaria para estudiar la asociación entre las variables. Se consideró significativo un valor p < 0,05. Resultados: se analizaron 103 pacientes, con media de edad de 33 años y predominio de sexo masculino. Se encontró CAT en 42 pacientes (40,8%), presentándose al ingreso hospitalario en la mayoría de los casos. Los factores de riesgo asociados a CAT fueron: gravedad al ingreso, shock, hipoperfusión, acidosis, transfusión masiva, sangrado significativo (estudio univariado), así como trauma penetrante y disfunción multiorgánica (estudio multivariado). No se encontró asociación significativa entre CAT y mortalidad. Conclusiones: presentamos el primer reporte de este tema en nuestro medio. En nuestra población la CAT es frecuente y se presenta ya al ingreso hospitalario. Se relaciona con la gravedad y el tipo de trauma. Su diagnóstico precoz es clave en el manejo de los pacientes con trauma grave.

Abstract: Introduction: trauma is a global health problem. Trauma-associated coagulopathy constitutes a severe and multifactorial complication whose diagnosis is controversial. Objectives: to assess the incidence of trauma-associated coagulopathy, the factors associated to the development of this condition and their impact on prognosis in a series of trauma patients admitted into the intensive care unit of our hospital. Method: prospective study of all patients admitted to the ICU with a diagnosis of acute trauma. Trauma-associated coagulopathy was defined according to classical laboratory parameters, when it complies with one of the following: International normalized ratio (INR) greater than 1.3, thrombocytopenia smaller than 100000/mm3, and/or aPTT greater than 38 seconds. Continuous variables were expressed as the average ± standard deviation. The chi square analysis, Fisher exact test and binary logistic regression were performed, p < 0,05 being considered significant. Results: 103 patients were analysed, average age was 33 years old and they were mostly male. Trauma-associated coagulopathy was found in 42 patients (40.8 %), and it was seen in most patients at the time they were hospitalized. Risk factors of trauma-associated coagulopathy were the following: severity upon hospitalization, shock, hypoperfusion, acidosis, massive transfusion, significant bleeding (univariate analysis); penetrating trauma and multi-organ dysfunction (multivariate analysis). No significant association between trauma- associated coagulopathy and mortality was found. Conclusions: the study presents the first report on this topic in our country. Trauma associated coagulopathy is rather common in our population and it is seen upon hospitalization. This condition is related to severity and the kind of trauma. Early diagnosis is essential in the handling of patients with severe trauma.

Resumo: Introdução: as doenças traumáticas são um problema de saúde global. A coagulopatia associada a trauma (TAC) é uma complicação diagnóstica séria, multifatorial e controversa. Objetivos: avaliar a incidência de TAC, os fatores associados ao seu desenvolvimento e sua associação com o prognóstico, em uma série de pacientes com trauma internados na Unidade de Terapia Intensiva do Hospital Maciel em Montevidéu, Uruguai. Pacientes e métodos: estudo prospectivo de todos os pacientes admitidos na UTI com diagnóstico de trauma grave. A TAC foi definida com base nos parâmetros laboratoriais clássicos, pela presença de pelo menos um dos seguintes: coeficiente internacional normalizado - INR maior que 1,3, trombocitopenia menor que 100.000 / mm3 e / ou PTTa maior que 38 segundos. As variáveis contínuas foram expressas como média ± desvio padrão. A análise do qui-quadrado, o teste exato de Fisher e a regressão logística binária foram realizados para estudar a associação entre as variáveis. Um valor de p <0,05 foi considerado significativo. Resultados: foram analisados 103 pacientes, com média de idade de 33 anos e predomínio do sexo masculino. A TAC foi encontrada em 42 pacientes (40,8%), apresentando-se na admissão hospitalar na maioria dos casos. Os fatores de risco associados à TAC foram: gravidade na admissão, choque, hipoperfusão, acidose, transfusão massiva, sangramento significativo (estudo univariado); bem como trauma penetrante e disfunção de múltiplos órgãos (estudo multivariado). Nenhuma associação significativa foi encontrada entre CAT e mortalidade. Conclusões: apresentamos o primeiro relatório sobre o tema em nosso meio. Em nossa população, a TAC é frequente e já está presente na admissão hospitalar. Está relacionado à gravidade e ao tipo de trauma. Seu diagnóstico precoce é fundamental no manejo de pacientes com traumas graves.

Transfusão maciça em pacientes vítimas de trauma: uma coorte não concorrente / Massive transfusion in trauma patients: a non-concurrent cohort study

As causas externas estão entre os principais motivos de óbito no mundo e, dentre elas, o trauma se destaca por causar óbitos e incapacitações permanentes. A perda sanguínea maciça é a principal causa de morte evitável no trauma. Nos casos de hemorragias volumosas, a transfusão maciça de hemocomponentes pode ser necessária; entretanto aspectos sobre o procedimento são controversos na literatura. No Brasil, estudos sobre a transfusão maciça, ainda que escassos, ressaltam a elevada mortalidade e a necessidade de maior conhecimento de enfermeiros e equipes sobre a transfusão. Assim, este estudo objetivou analisar os aspectos epidemiológicos das transfusões maciças em pacientes vítimas de trauma, em um hospital referência neste tipo de atendimento em Belo Horizonte, Minas Gerais. Trata-se de um estudo de coorte não concorrente, em que foram analisados os registros de transfusão maciça de 110 pacientes vítimas de trauma, com idade superior a 18 anos, admitidos no período compreendido entre janeiro de 2019 e junho de 2020. Os dados foram obtidos por meio dos registros da agência transfusional do hospital e dos prontuários dos pacientes. Para a análise, foi empregada a estatística descritiva e inferencial, utilizando frequência simples e acumulada, medidas de tendência central e dispersão, análise de perdas de informações, bem como estatística Kappa, estimativa de incidência, estatística de Kaplan-Meier e teste log-rank. Em 78,18% dos casos houve a ocorrência de trauma contuso, provocado por colisões (40,00%) e atropelamentos (18,18%). O maior número de pacientes era do sexo masculino com mediana da idade de 36,5 anos. As Unidades de Suporte Avançado do Serviço de Atendimento Móvel de Urgência conduziram 45,37% das vítimas ao hospital. À admissão, a mediana dos dados dos pacientes indicava alteração do sensório (Escala de Coma de Glasgow 13), pressão arterial sistólica limítrofe (90 mmHg) e taquicardia (110 BPM). Ocorreram 45 óbitos, sendo 19,09% em até 6 horas após a admissão, 12,73% entre 6 e 24 horas e 9,09% após 24 horas da admissão. Infecção, sepse e insuficiência renal aguda foram complicações mais relatadas na internação, sendo os mais acometidos os pacientes vítimas de trauma contuso com traumatismo cranioencefálico. No momento da alta, os pacientes apresentavam alguma limitação, demanda de cuidado ou recomendação de acompanhamento ou nova cirurgia. Em 77,27% dos casos o protocolo de transfusão de emergências foi acionado, e a mediana do tempo entre a admissão e a primeira dispensação de hemocomponente foi de 19 minutos. Índice de choque (com ponto de corte de 0,9) e a escala Assessment of Blood Consumption (com ponto de corte de 2,0) tiveram uma concordância moderada (42,77%/ p<0,001), pelo Teste de Kappa, para predizer a necessidade de transfusão maciça. A incidência de óbitos foi de 40,90%, sendo a densidade para esse grupo de pacientes de 13,57 (10,13-18,17 IC95%) por mil pessoas-dia. A probabilidade de óbitos foi maior entre pacientes que não fizeram uso de plaquetas e ácido tranexâmico, não havendo diferença estatisticamente significativa em relação aos que não usaram tais substâncias. Identificou-se que a probabilidade de óbito dentre os pacientes que fizeram uso de volumes iguais ou superiores a 10 unidades de concentrado de hemácias foi superior àqueles pacientes que usaram volumes menores deste hemocomponente (p <0,05). A análise evidenciou que as vítimas de trauma submetidas à transfusão maciça são homens jovens, com quadro grave e com maior probabilidade de evoluir à óbito quando recebem volumes de concentrado de hemácias superiores a 3000ml. Os resultados fornecem informações que contribuem para a avaliação e acompanhamento destes pacientes, tais como sinais de gravidade e fatores a serem observados em sua evolução e que podem determinar maior probabilidade de óbito. Os dados reforçam, ainda, a importância do cuidado do ambiente pré-hospitalar após a alta.

External causes are among the main reasons off mortality in the world, with trauma accounting for a great number of deaths and permanent disability. Massive blood loss is the leading cause of preventable death in trauma. In cases of massive hemorrhages, massive transfusion of blood components may be necessary, however aspects about this procedure are controversial in the literature. Thus, this study aimed to analyze the epidemiological aspects of massive transfusions in trauma patients admitted in a hospital that is recognized for trauma care in Belo Horizonte, Minas Gerais. This is a non-concurrent cohort study, in which records of massive transfusions of 110 trauma patients aged over 18 years, admitted between january 2019 and june 2020, were analyzed. Data were obtained through the records of the hospital's transfusion agency and the patients' charts. For data analysis, descriptive and inferencial statistics were used, using simple and accumulated frequency, measures of central tendency and dispersion, analysis of information loss, as well as Kappa statistics, incidence estimation and Kaplan-Meier statistics and log-test. rank. In 78.18% of the cases there was the occurrence of blunt trauma, caused by most of the time by collisions (40.00%) and being run over (18.18%). The largest number of patients was male with a median age of 36.5 years. The Advanced Support Units of the Serviço de Atendimento Móvel de Urgência, was responsible for 45.37% of transport of the victims to the hospital. At admission, the median of patient data indicated sensory alteration (Glasgow Coma Scale 13), hypotension (90 mmHg) and tachycardia (110 BPM). There were 45 deaths, 19.09% within 6 hours of admission, 12.73% between 6 and 24 hours after admission, and 9.09% after 24 hours of admission. Infection, sepsis, and acute renal failure were the most reported complications during hospitalization, with patients suffering from blunt trauma with traumatic brain injury being the most affected. At the time of discharge, the patients had some limitation, demand for care or recommendation for follow-up or new surgery. In 77.27% of the cases, the emergency transfusion protocol was activated, and the median time between admission and the first dispensing of blood components was 19 minutes. Shock Index (with a cutoff point of 0.9) and the Assessment of Blood Consumption score (with a cutoff point of 2.0) had moderate agreement (42.77%/p<0.001), by the Kappa test, to predict the need for massive transfusion. The incidence density of deaths for this group of patients was 13.57 (10.13-18.17 95%CI) per thousand person-day. The probability of death was higher among patients who did not use platelets and tranexamic acid, with no statistically significant difference compared to those who did not use these substances. It was identified that the probability of death among patients who used volumes equal to or greater than 10 units of packed red blood cells was higher than for those patients who used smaller volumes of this blood component (p < 0.05). The analysis showed that trauma victims submitted to massive transfusiosns are young men, with severe condition and who are more likely to progress to deth when they receive volume of red blood cells greater than 3000ml. The results provide information that contributes to the assessment and follow-up of these patients, as signs of severity and factors to be observed in its evolution, as well as whic can determine a greater probability of death. They reinforce the importance of caring in pre-hospital environment, during hospital care and after discharge.

Transfusiones masivas en Pediatría / Massive transfusions in Pediatrics

La transfusión masiva es la transfusión de más del 50% del volumen sanguíneo total en 3 horas; 100% en 24 horas o reemplazar la pérdida de sangre en curso de más de 10% del volumen sanguíneo total por minuto. Los pacientes pediátricos requieren transfusión masiva en una variedad de entornos. Existen datos limitados para apoyar estrategias óptimas de transfusión masiva en niños, los datos son extrapolados de adultos y no es lo más conveniente, sin embargo alrededor de 15% de los niños la requieren. La evidencia actual sugiere que en centros donde se realizan transfusiones masivas basadas en protocolos, la morbimortalidad es mucho menor.

Massive transfusion is the transfusion of more than 50 % of the total blood volume in 3 h; 100 % in 24 h or to replace the ongoing blood loss of more than 10% total blood volume per minute. Pediatric patients require massive transfusion in a variety of settings. There are limited data to support optimal mass transfusion strategies in children, the data is extrapolated from adults and is not the most convenient, however, about 15% of children require it. Current evidence suggests that in centers where massive protocol-based transfusions are performed, morbidity and mortality is much lower.

Morbilidad y mortalidad asociadas con protocolos de transfusión masiva en hemorragia obstétrica severa / Morbidity and mortality associated with mass transfusion protocols in severe obstetric hemorrhage

Resumen OBJETIVO: Determinar la morbilidad y mortalidad debidas a la aplicación de protocolos de transfusión masiva en pacientes con hemorragia obstétrica atendidas en cuidados intensivos. MATERIALES Y MÉTODOS: Estudio de una cohorte retrospectiva de pacientes con hemorragia obstétrica severa atendidas en la unidad de cuidados intensivos obstétricos del Hospital Materno Infantil del Instituto de Seguridad Social del Estado de México y Municipios, entre septiembre de 2014 y mayo de 2019. Se compararon tres protocolos de transfusión masiva en los que se aplicaron los derivados de la sangre en relación con la proporción de concentrado eritrocitario, de plaquetas y plasma con las siguientes proporciones: 2:1:1, 1:1:1 y liberal. Para analizar la posible asociación de las complicaciones con la elección de los diferentes protocolos de transfusión masiva, se utilizó un análisis mediante prueba ANOVA y χ2 en el programa SPSS versión 21; se consideró significativo el valor de p < 0.05. RESULTADOS: Se analizaron 75 pacientes con edad promedio de 32.8 años; 63 eran multigestas. La causa principal de la hemorragia obstétrica fue la atonía uterina. 51 de 75 de los protocolos de transfusión masiva fueron liberales, 11 de ellos con una relación 2:1:1 y 4 de 51 de 1:1:1. Las complicaciones fueron: síndrome de insuficiencia respiratoria aguda, lesión renal aguda, lesión renal aguda originada por la transfusión, infecciones y reintervención quirúrgica. Se encontró asociación positiva con: los días de estancia en cuidados intensivos (p = 0.031), reintervención quirúrgica (p = 0.006) y síndrome de insuficiencia respiratoria aguda (p = 0.044) y los protocolos de transfusión masiva liberal respecto de los protocolos con relación 1:1:1. Solo una paciente falleció y ello se asoció con el protocolo de transfusión masiva liberal. CONCLUSIONES: La aplicación de protocolos de transfusión masiva 1:1:1 y 2:1:1 en pacientes con hemorragia obstétrica severa disminuye el riesgo de complicaciones. La mortalidad materna debido a la aplicación del protocolo de transfusión masiva liberal fue de solo un caso en 51 pacientes.

Abstract OBJECTIVE: To determine the morbidity and mortality due to the application of massive transfusion protocols in patients with obstetric hemorrhage treated in intensive care. MATERIALS AND METHODS: study of a retrospective cohort of patients with severe obstetric hemorrhage treated in the obstetric intensive care unit of the maternal and child hospital of the social Security Institute of the State of Mexico and municipalities, between september 2014 and may 2019. three massive transfusion protocols were compared in which blood derivatives were applied in relation to the ratio of erythrocyte concentrate, platelets and plasma with the following ratios: 2:1:1, 1:1:1 and liberal. to analyze the possible association of complications with the choice of the different mass transfusion protocols, an anova and χ2 test was used in the spss version 21 program; the value of p < 0.05 was considered significant. RESULTS: Seventy-five patients with a mean age of 32.8 years were analyzed; 63 were multigrafted. The main cause of obstetric bleeding was uterine atony. 51 of 75 of the mass transfusion protocols were liberal, 11 of them with a 2:1:1 ratio and 4 of 51 of 1:1:1. The complications were: acute respiratory failure syndrome, acute renal injury, acute renal injury originated by transfusion, infections and surgical reintervention. Positive association was found with: days of stay in intensive care (p = 0.031), surgical reintervention (p = 0.006) and acute respiratory failure syndrome (p = 0.044) and liberal mass transfusion protocols with respect to 1:1:1 ratio protocols. Only one patient died and this was associated with the liberal mass transfusion protocols. CONCLUSIONS: The application of 1:1:1 and 2:1:1 mass transfusion protocols in patients with severe obstetric hemorrhage decreases the risk of complications. Maternal mortality due to the application of liberal mass transfusion protocols was only one case in 51 patients.

Study of blood component therapy in obstetrics

Background: Blood transfusion is a life saving measure. Various pregnancy complications and disorders of labor present as risk factors for extra blood loss during pregnancy and cause severe hemodynamic instability. This along with complications due to abortion (spontaneous or induced) and ruptured ectopic pregnancy show up as conditions needing transfusion in the day-to-day practice of obstetrics. In a country like India, limited and fixed resources of blood, forces us to titrate the use of blood and its components. Normally, blood loss during birth is well-tolerated because of changes during pregnancy.Methods: This is a retrospective observational study done at tertiary care hospital. This study is based on study of indoor patients admitted during one year duration. Detailed history and all necessary investigations were carried out. Details regarding blood transfusion were taken indication of blood transfusion, number and type of unit transfused, number of patients given blood components, indications where single unit was transfused. Analysis of the data was done.Results: Anemia followed by antepartum hemorrhage followed by postpartum hemorrhage was the major cause for blood and blood product transfusion. Approximately 60% patients required two units of PCV (Packed Cell Volume) transfusion. Anemia in pregnancy was the major cause of single unit PCV transfusion.Conclusions: A proper knowledge for blood and blood product transfusion is needed to make it available for people who are actually in need and also to decrease the economic burden. Measures to prevent anemia should be implemented. Active management of third stage of labour (AMTSL) should be done to avoid postpartum hemorrhage. Single unit transfusion should be avoided.

Performance of Three Scoring Systems in Predicting Massive Transfusion in Patients with Unstable Upper Gastrointestinal Hemorrhage

PURPOSE: After trauma and surgery, upper gastrointestinal bleeding (UGIB) is the most common condition that can require massive transfusion (MT). The present study aimed to analyze and compare the prognostic performance of the Glasgow-Blatchford (GB), pre-endoscopy Rockall (PER), and modified early warning (MEW) scores for predicting MT in patients with unstable UGIB. MATERIALS AND METHODS: This retrospective observational study included patients with UGIB from March 2016 to February 2018. Receiver operating characteristics analysis was performed to examine the prognostic performance of the GB, PER, and MEW scoring systems. Logistic regression analysis was used to identify independent risk factors for MT, after adjusting for relevant covariates. The primary outcome was MT. RESULTS: Of the 484 included patients with unstable UGIB, 19 (3.9%) received an MT. The areas under the curves (AUCs) of the GB, PER, and MEW scores for MT were 0.577 [95% confidence interval (CI), 0.531–0.621], 0.570 (95% CI, 0.525–0.615), and 0.767 (95% CI, 0.727–0.804), respectively. The AUC of the MEW score was significantly different from those of the GB and PER scores. In multivariate analysis, MEW score was independently associated with MT in patients with unstable UGIB (odds ratio, 1.495; 95% CI, 1.100–2.033; p=0.010). CONCLUSION: In unstable UGIB patients, MEW score had the best prognostic performance for MT among three scoring systems.

Fluid resuscitation in children with multiple trauma / 中国小儿急救医学

Hypovolemia is the most common cause of shock in children with multiple trauma. Early detection and treatment of hypovolemia is very important in the process of trauma resuscitation. Compensatory shock occurs when large amounts of blood are lost, and blood pressure is maintained by tachycardia and vas‐oconstriction. Hypobaric shock is characterized by hypotension and tachycardia. The fluid resuscitation of multiple traumas can be divided into two cases, when the bleeding is under control or not under control. In addition,massive transfusion is closely associated with multiple trauma.

Prognostic Accuracy of Massive Transfusion, Critical Administration Threshold, and Resuscitation Intensity in Assessing Mortality in Traumatic Patients with Severe Hemorrhage: a Meta-Analysis

Higher enhanced computed tomography attenuation value of the aorta is a predictor of massive transfusion in blunt trauma patients

OBJECTIVE: Several scoring systems have been developed to identify patients who require massive transfusion (MT) after major trauma to improve survival. The primary goal of this study was to investigate the usefulness of enhanced computed tomography attenuation values (CTAVs) of major vessels to determine the need for MT in patients with major blunt trauma.METHODS: This single-center retrospective cohort study evaluated patients aged 16 years or older who underwent contrast-enhanced computed tomography scan of the torso after major blunt trauma. The CTAVs of six major vessel points in both the arterial and portal venous phases at initial computed tomography examination were assessed and compared between the MT and the no MT group. The capability of enhanced CTAVs to predict the necessity for MT was estimated based on the area under the receiver operating characteristic curve.RESULTS: Of the 254 eligible patients, 36 (14%) were in the MT group. Patients in the MT group had significantly higher CTAVs at all sites except the inferior vena cava in both the arterial and portal venous phases than that in the no MT group. The descending aorta in the arterial phase had the highest accuracy for predicting MT, with an AUROC of 0.901 (95% confidence interval, 0.855 to 0.947; P<0.001).CONCLUSION: Initial elevation of enhanced CTAV of the aorta is a predictor for the need for MT. A higher CTAV of the aorta should alert the trauma surgeon or emergency physician to activate their MT protocol.

Prediction of massive transfusion in trauma patients in the surgical intensive care units (THAI-SICU study) / 中华创伤杂志(英文版)

PURPOSE@#After damage control surgery, trauma patients are transferred to intensive care units to restore the physiology. During this period, massive transfusion might be required for ongoing bleeding and coagulopathy. This research aimed to identify predictors of massive blood transfusion in the surgical intensive care units (SICUs).@*METHODS@#This is an analysis of the THAI-SICU study which was a prospective cohort that was done in the 9-university-based SICUs in Thailand. The study included only patients admitted due to trauma mechanisms. Massive transfusion was defined as received ≥10 units of packed red blood cells on the first day of admission. Patient characteristics and physiologic data were analyzed to identify the potential factors. A multivariable regression was then performed to identify the significant model.@*RESULTS@#Three hundred and seventy patients were enrolled. Sixteen patients (5%) received massive transfusion in the SICUs. The factors that significantly predicted massive transfusion were an initial sequential organ failure assessment (SOFA) ≥9 (risk difference (RD) 0.13, 95% confidence interval (CI): 0.03-0.22, p = 0.01); intra-operative blood loss ≥ 4900 mL (RD 0.33, 95% CI: 0.04-0.62, p = 0.02) and intra-operative blood transfusion ≥ 10 units (RD 0.45, 95% CI: 0.06 to 0.84, p = 0.02). The probability to have massive transfusion was 0.976 in patients who had these 3 factors.@*CONCLUSION@#Massive blood transfusion in the SICUs occurred in 5%. An initial SOFA ≥9, intra-operative blood loss ≥4900 mL, and intra-operative blood transfusion ≥10 units were the significant factors to predict massive transfusion in the SICUs.

The value of institutional protocols and focused cardiac ultrasound during a case of ultramassive transfusion

A 53-year-old female was admitted to the emergency department with an exsanguinating bleed from the rectum which was of unclear origin. In what could be considered an ultramassive transfusion, 60 units packed red blood cells, 23 units fresh frozen plasma, 20 units platelets, 6 units cryoprecipitate, 30 L of crystalloids, 2 L of colloids, and 4 g of tranexamic acid were transfused over the course of 7 h. An arterio-enteric fistula was diagnosed and treated by an interventional radiologist. The patient recovered rapidly thereafter without any major neurologic, pulmonary, cardiac, or hematologic complications.

Utilidad del índice de choque como valor predictivo para el requerimiento de trasfusión en hemorragia obstétrica / Utility of the shock index in obstetric hemorrhage as a predictive value for the transfusion requirement

Resumen Objetivo: Determinar el punto de corte del índice de choque obstétrico asociado con trasfusión masiva en mujeres con hemorragia obstétrica. Materiales y métodos: Estudio retrospectivo, transversal y analítico efectuado con base en la revisión de los expedientes clínicos de pacientes que ingresaron a la unidad de cuidados intensivos. Cálculo del índice de choque obstétrico al momento del diagnóstico de hemorragia obstétrica. Análisis de los signos vitales, gasometría, tipo de componentes sanguíneos trasfundidos y cantidad de líquidos administrados. Resultados: Se incluyeron 105 pacientes con hemorragia obstétrica; en 65 (61%) el resultado del índice de choque fue ≥ 0.9, de éstas 38 (58%) requirieron trasfusión masiva. El índice de choque obstétrico ≥ 0.9 se asoció, significativamente, con trasfusión masiva (p < 0.001). La pérdida sanguínea fue de 3000 mL (RIC 2000 mL) en pacientes con índice de choque obstétrico ≥ 0.9 vs 2500 mL (RIC 1000 mL) en pacientes con índice de choque obstétrico < 0.9 (p = 0.04). Las mujeres con índice de choque obstétrico ≥ 0.9 mostraron mayor requerimiento de trasfusión de concentrados globulares (p = 0.03) y plaquetarios (p = 0.01). Conclusiones: Un índice de choque obstétrico ≥ 0.9 se asoció con altos requerimientos de trasfusión sanguínea y mayor incidencia de eventos adversos graves, por lo que se recomienda este valor como el punto de corte para predicción de la necesidad de trasfusión masiva.

Abstract Objective: To determine the cut-off point of obstetric shock index associated with massive transfusion in women with obstetric hemorrhage. Materials and methods: We designed a cross-sectional study in women who were admitted to the intensive care unit. The obstetric shock index was calculated at the time of the diagnosis of obstetric hemorrhage. We analyzed vital signs, arterial blood gas, loss of blood, fluid replacement and transfused blood products. Results: One hundred and five women with obstetric bleeding were included, in 65 (61%) the obstetric shock index was ≥ 0.9, of whom 38 (58%) needed massive transfusion. Obstetric shock index ≥ 0.9 was significantly associated with massive transfusion (p < 0.001). The blood loss was of 3000 mL (RIC 2000 mL) in the patients with obstetric shock index ≥ 0.9 compared to 2500 mL (RIC 1000 mL) in patients with obstetric shock index < 0.9 (p = 0.04). Women with obstetric shock index ≥ 0.9 showed more significant requirement of transfusion of package red blood (p = 0.03) and platelets (p = 0.01). Conclusions: An obstetric shock index ≥0.9 was associated with high transfusión requirements and a higher incidence of serious adverse events, this value is recommended as the cut-off point for predicting the need for massive transfusion.

Analysis of safety and efficacy of transfusion indications in patients with massive transfusion / 国际检验医学杂志

Objective To investigate the safety and efficacy of transfusion indication in patients with massive transfusion.Methods 64 patients with surgical perioperative period from December 2014 to December 2016 were selected from our hospital and randomly divided into control group and observation group.The control group adopted the standard of clinical transfusion technology (2000) in People's Republic of China Ministry of Health,and combined with the specific conditions of patients,according to the clinical experience of physicians,the level of blood transfusion Hb was determined,usually between 7-10 g/dL.The observation group was guided by blood transfusion index.The level of 24 h after operation,the flow rate after operation,the time after the operation,the time of postoperative hospitalization,the amount of infusion,the infusion rate and the incidence of complications were compared between the 2 groups.Results The Hb level of the observation group was lower than that of the control group at 24 h after operation,and the postoperative drainage volume was less than that of the control group.The time of postoperative removal was earlier than that of the control group,and the postoperative hospitalization time was shorter than that of the control group.The difference was statistically significant (P＜0.05).The infusion rate of the observation group was less than that of the control group,and the infusion rate was lower than that of the control group,and the difference was also statistically significant(P＜0.05).The incidence of complications in the observation group (3.13％) was lower than that of the control group (15.63％),but the difference was not statistically significant (P＞0.05).Conclusion:the blood transfusion indication score of the patients with large blood transfusion is obvious,and the safety is good,and it has important clinical significance.Conclusion The blood transfusion indication score of the patients with large blood transfusion is obvious,and the safety is good,and it has important clinical significance.

Clinical features of patients with massive transfusion during plastic surgery / 中华医学美学美容杂志

Objective To review the clinical features of the patients received massive transfusion (MT) in plastic surgery department.Methods Ten cases were reviewed.The reason of massive transfusion,the type and dosage of transfusion,the reaction of patients were included.For all the patients,consultation of related department preoperatively was necessary.Based on the through and detailed analysis of the patients' condition,necessary blood product should be prepared ahead of operation.During the therapy,adjustment of treatment plan was made from time to time,according to the patient's condition.Therefore efficient and prompt therapeutic result was achieved.Results In all the 10 MT cases suffered from acute blood loss,2 of them were in hemorrhagic shock before administration.Coagulation disorders happened in 2 patients,and recovered after appropriate treatment.RBC,which was 58.3％ of total amount of transfusion,used most commonly;the second was fresh frozen plasma (FFP),which was 38.6％ according to the total amount.All the patients had satisfactory recovery,without hemolysis or any other functional disorder.Conclusions For MT patients in the Department of Plastic Surgery,the main proposes are to restore and maintain an effective circulatory blood volume,while preventing the coagulation disorder.Also,detailed analysis,through consultation and timely adjustment are of great importance for the MT patients.It is also the essential of an effective perioperative management.