Which Product Is Ideal for You?

Summary

Importance of massive transfusion events (MTE): according to the American College of Surgeons (ACS) Committee on trauma, ACS-verified trauma centers should have an MTE protocol in place; also important in the practice of anesthesiology; time is the key element in treatment of trauma; after trauma, patients often die early as a result of hemorrhagic shock

Studies: PROPPR trial — found no statistically significant difference in the primary outcomes with 1:1:1 resuscitation vs 1:1:2 resuscitation, but the time-to-death curve showed most patients die within the first 3 hr; Resuscitation Outcomes Consortium data — show that survival decreases precipitously over the first few hours after trauma in patients with shock alone or traumatic brain injury and shock; PAMPer trial — patients who received plasma in the prehospital setting had a dramatic survival advantage; fatalities in the standard-care group occurred within the first few hours after trauma; retrospective study — among combat casualties, patients who received blood products on a medivac helicopter had a significantly lower mortality rate; transfusion in ≤15 min had the greatest benefit for survival; retrospective analysis of the PROPPR trial — every 1-min delay in massive transfusion was associated with a 5% increase in mortality; RePHILL trial — looked at patients who received prehospital administration of blood products vs standard crystalloid; reported no difference in mortality or lactate clearance; however, the median time between the request transport and arrival at the emergency department was significantly longer (1.5 hr) in this trial than in those showing an advantage for early administration of blood products

Massive resuscitation (MR): not necessarily 1:1:1 transfusion, but 1:1:1 resuscitation can be a part of a MR; MR does not automatically correct coagulopathy; among patients who are bleeding, only ≈10% have coagulopathy at the scene of injury (such patients need to be identified); MR is superior to crystalloids for managing the coagulopathy; MR does not necessarily indicate that the patient needs a full cooler of blood

Definitions of MR: administration of ≥10 U of red blood cells (RBCs) in 24 hr (commonly used and often considered the standard definition); >4 U of RBCs in 4 hr (associated with increased mortality); described as a critical administration threshold (eg, ≥3 U of RBCs within the first hour of resuscitation) or resuscitation intensity, ie, number of units of a blood product within 30 min; definitions vary by institution and reflect the intensity of resuscitation that is associated with a clinical outcome (eg, mortality, organ failure); defined by Cotton as early delivery of balanced blood component therapy, with minimization of crystalloid resuscitation, the implementation of which requires multidisciplinary efforts; MTE protocols aim to ensure early identification of, and communication about, patients needing MR

Study conclusions: the PROPPR trial demonstrated that providing early, balanced resuscitation of plasma is feasible and results in better outcomes than those achieved with crystalloids; a review article shows that early initiation of protocols for trauma exsanguination, MTE, and MR is associated with decreased mortality, compared with relying on crystalloids or delaying care

Scoring systems: many are available for identifying patients requiring MT; most use the commonly accepted definition of ≥10 U of RBC within 24 hr as a reference standard; most have reported sensitivities and specificities, but these values depend on the prevalence of MTEs at a given location (usually, comprise ≤10% of admissions); reports on MT scoring systems typically show high specificity (a high proportion of true-negative results and few false-positive results); scoring systems primarily serve as screening tests; positive predictive value — helps to determine whether the scoring system is useful as a diagnostic test; not reported by many studies

Assessment of Blood Consumption (ABC) scoring system (Cotton et al, 2010): now considered almost a reference standard for scoring systems; a positive ABC score is the presence of any 2 from a list of 4 criteria (ie, penetrating mechanism of injury, positive Focused Assessment Sonography for Trauma [FAST] examination, systolic blood pressure [SBP] ≤90 mm Hg at arrival, and heart rate [HR] ≥120 beats per min at arrival); the initial description compared the ABC score with the Trauma-Associated Severe Hemorrhage (TASH) score and McLaughlin score, both of which require laboratory values and use of complicated mathematical formulas, and found that it performed equally well; the advantages of the ABC scoring system are that it is user friendly, can be performed at the bedside, and relies on clinical variables; in the validation study of the ABC score, the receiver operating characteristic curve differed among the 3 institutions included, suggesting that the scoring system needs to be tailored to the specific institution and the capabilities and patient population of that institution

Shock index: frequently used during the prehospital assessment of vital signs; calculated by dividing HR by SBP; according to the initial description, a shock index score >1 significantly increases risk for MT; Revised Assessment of Bleeding and Transfusion (RABT) score (Joseph et al, 2018) — replaced HR and SBP in the ABC score with shock index >1 and pelvic fracture in patients potentially requiring MT; with ≥2 positive items, negative predictive value was good and sensitivity, specificity, and positive predictive value were significantly better, compared with the standard ABC score; conclusion — while none of the scoring systems are perfect, they can be helpful in early identification of patients needing MT

Recognition of need for MT: PROMMTT study — evaluated the accuracy of surgeons’ predictions about the need for MT in patients being treated for trauma; while surgeons believed that half of the patients evaluated would require MT, MT was needed in only one-third of patients designated by the clinicians (positive predictive value was poor); retrospective study — evaluated MT initiated on the basis of “physician gestalt”; physicians correctly identified patients needing MT in ≈73% of cases, but identification occurred after the patient was brought to the operating room in >50% of cases; it was determined that 80% of patients requiring MT would have been identified by early use of the ABC score; given the risk for death in the first few hours after trauma, this delay in recognition is highly significant