miércoles, 10 de mayo de 2017

Más de transfusión masiva / More on massive transfusion

Abril 20, 2017. No. 2665

La implementación del protocolo de tratamiento para hemorragia masiva reduce la mortalidad en pacientes no traumatizados
Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit.
[Article in English, Spanish]
Med Intensiva. 2016 Dec;40(9):550-559. doi: 10.1016/j.medin.2016.05.003. Epub 2016 Jul 15.
OBJECTIVE: To audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007. DESIGN: A retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007-2012, Group 2) were compared with a historical cohort (2005-2006, Group 1). BACKGROUND: Massive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce. PATIENTS: After excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical). INTERVENTIONS: Our MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications. VARIABLES OF INTEREST: Primary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints. RESULTS: After MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering. Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) - the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15-0.61). CONCLUSIONS: These data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates.
KEYWORDS: Hemorragia no traumática; Hemostasia; Hemostatics; Massive bleeding protocol; Mortalidad; Mortality; Non-trauma bleeding; Protocolo de hemorragia masiva; Tasa transfusional; Transfusion ratio
 Uso del protocolo de transfusión masiva en pacientes civiles con y sin trauma. ¿Qué se puede hacer mejor?
The use of massive transfusion protocol for trauma and non-trauma patients in a civilian setting: what can be done better?
Singapore Med J. 2016 May;57(5):238-41. doi: 10.11622/smedj.2016088.Abstract
Massive transfusion protocol (MTP) is increasingly used in civilian trauma cases to achieve better haemostatic resuscitation in patients requiring massive blood transfusions (MTs), with improved survival outcomes. However, in non-trauma patients, evidence for MTP is lacking. This study aims to assess the outcomes of a newly established MTP in a civilian setting, for both trauma and non-trauma patients, in an acute surgical care unit. METHODS: A retrospective cohort analysis was performed on 46 patients for whom MTP was activated in Changi General Hospital, Singapore. The patients were categorised into trauma and non-trauma groups. Assessment of Blood Consumption (ABC) score was used to identify MTP trauma patients and analyse over-activation rates. RESULTS: Only 39.1% of all cases with MTP activation eventually received MTs; 39.8% of the MTs were for non-trauma patients. Mean fresh frozen plasma to packed red blood cells (pRBC) ratio achieved with MTP was 0.741, while mean platelet to pRBC ratio was 0.213. The 24-hour mortality rate for all patients who received an MT upon MTP activation was 33.3% (trauma vs. non-trauma group: 45.5% vs. 14.3%). The ABC scoring system used for trauma patients had a sensitivity and specificity of 81.8% and 41.2%, respectively. CONCLUSION: MTP may be used for both trauma and non-trauma patients in acute care surgery. Scoring systems to predict the need for an MT, improved compliance to predefined transfusion ratios and regular reviews of the MTP are necessary to optimise MTPs and to improve the outcomes of patients receiving MTs.
KEYWORDS: blood components; massive transfusion protocol; mortality; scoring system; trauma

Reanimación del trauma que requiere transfusión masiva: un análisis descriptivo del papel de la relación y del tiempo.
Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time.
World J Emerg Surg. 2015 Aug 14;10:36. doi: 10.1186/s13017-015-0028-3. eCollection 2015
OBJECTIVE: We aimed to evaluate whether early administration of high plasma to red blood cells ratios influences outcomes in injured patients who received massive transfusion protocol (MTP). 
CONCLUSIONS: Aggressive attainment of high FFP/PRBC ratios as early as 4 h post-injury can substantially improve outcomes in trauma patients.
KEYWORDS: Massive transfusion protocol; Outcome; Transfusion ratio; Trauma

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