Transfusión masiva / Massive transfusion

Abril 18, 2017. No. 2663

Transfusión masiva y manejo del paciente traumatizado: enfoque fisiopatológico del tratamiento Graciela Zunini-Fernández, Karina Rando-Huluk, Francisco Javier Martínez- Pelayo, Ara Lizeth Castillo-Trevizo Cir Cir 2011;79:473-480 Resumen La hemorragia masiva es una de las principales causas de muerte y paro cardiaco intraoperatorio. Su mortalidad varía entre 15 y 54%. La presencia de acidosis, hipotermia y coagulopatía son elementos de pronóstico ominoso. En esta revisión se describen las causas que perpetuán la hemorragia en el sangrado masivo, las particularidades del daño tisular controlado y no controlado, el valor de los exámenes de laboratorio para el diagnóstico de coagulopatía, y las guías actuales del manejo con líquidos y hemoderivados. La respuesta frente al sangrado requiere una adecuada comunicación del equipo quirúrgico con el banco de sangre, para así asegurar el suministro de los hemocomponentes adecuados en cantidad y calidad, instalación de medidas para evitar la hipotermia y disponibilidad de sistemas de infusión rápida. Palabras claves: Hemorragia masiva, cirugía, traumatismo, transfusión. PDF Transfusión en trauma Víctor Hugo González Cárdenas Rev Colomb Anestesiol 2012;40:287-92 - Vol. 40 Núm.4 DOI: 10.1016/j.rca.2012.05.017 Resumen La transfusión masiva es considerada como pieza fundamental en el manejo agudo de la hemorragia masiva. Si bien los protocolos existentes no estandarizan su uso, sí recomiendan su aplicación oportuna y una dosificación ajustada al tipo de hemoderivado, una relación proporcionada entre hemocomponentes y coadyuvancia justa de medicamentos, así como técnicas que promuevan el control de la hemorragia y prevengan síndromes desencadenantes de muerte. Esta revisión no sistemática tiene como objetivo resumir los conceptos actuales sobre el manejo agudo de la hemorragia masiva relacionada con trauma desde una perspectiva no quirúrgica.La búsqueda de artículos se limitó a los últimos 10 años, y se realizó en bases de datos primarias y secundarias; todo ello terminó en una técnica de bola de nieve. PDF La puntuación de transfusión masiva como una ayuda de decisión para la reanimación: Aprender cuándo activar y desactivar el protocolo de transfusión masiva. The Massive Transfusion Score as a decision aid for resuscitation: Learning when to turn the massive transfusion protocol on and off. Callcut RA1, Cripps MW, Nelson MF, Conroy AS, Robinson BB, Cohen MJ. J Trauma Acute Care Surg. 2016 Mar;80(3):450-6. doi: 10.1097/TA.0000000000000914. Abstract BACKGROUND: Previous work proposed a Massive Transfusion Score (MTS) calculated from values obtained in the emergency department to predict likelihood of massive transfusion (MT). We hypothesized the MTS could be used at Hour 6 to differentiate who continues to require balanced resuscitation in Hours 7 to 24 and to predict death at 28 days. METHODS: We prospectively enrolled patients in whom the MT protocol was initiated from 2005 to 2011. Data including timing of blood products were determined at Hours 0, 6, 12, and 24. For each patient, transfusion needs were defined based on either an inappropriately low hemoglobin response to transfusion or a hemoglobin decrease of greater than 1 g/dL if no transfusion. Timing and cause of death were used to account for survivor bias. Multivariate logistic regression was used to determine independent predictors of outcome. RESULTS: A total of 190 MT protocol activations were included, and by Hour 6, 61% required 10 U or greater packed red blood cells. Calculated at initial presentation, a revised MTS (systolic blood pressure < 90 mm Hg, base deficit ≥ 6, temperature < 35.5°C, international normalized ratio > 1.5, hemoglobin < 11 g/dL) was superior to the original MTS (including heart rate ≥ 120 beats per minute, Focused Assessment With Sonography in Trauma [FAST] status, mechanism) or the Assessment of Blood Consumption (ABC) score for predicting MT (area under the curve [AUC] MT at 6 hours, 0.68; 95% confidence interval [CI], 0.57-0.79; at 24 hours, 0.72; 0.61-0.83; p < 0.05). For those alive at Hour 6, the revised MTS was predictive of future packed red blood cell need (AUC, 0.87) in Hours 7 to 12, 24-hour mortality (AUC, 0.95), and 28-day mortality (AUC, 0.77). For each additional positive trigger of the MTS at Hour 6, the odds of death at 24 hours and 28 days were substantially increased (24-hour odds ratio, 4.6; 95% CI, 2.3-9.3; 28-day odds ratio, 2.2; 95% CI, 1.5-3.2; p < 0.0001). CONCLUSION: Early end points of resuscitation adopted from the components of the revised MTS are predictive of ongoing transfusion. Failure to normalize these components by Hour 6 portends a particularly poor prognosis. LEVEL OF EVIDENCE: Prognostic study, level 3. PDF Vacante para Anestesiología Pediátrica El Hospital de Especialidades Pediátricas de León, Guanajuato México  ofrece un contrato laboral en el departamento de anestesiología  Informes con la Dra Angélica García Álvarez  angy.coachanestped@gmail.com o al teléfono 477 101 8700 Ext 1028

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Trauma agudo / Acute trauma

Abril 19, 2017. No. 2664

Identificación temprana de pacientes que requieren transfusión, embolización, o cirugía hemostática para hemorragia traumática. Protocolo de revisión sistemática Early identification of patients requiring massive transfusion, embolization, or hemostatic surgery for traumatic hemorrhage: a systematic review protocol. Tran A1,2, Matar M3, Steyerberg EW4, Lampron J3, Taljaard M5,6, Vaillancourt C6,7. Syst Rev. 2017 Apr 13;6(1):80. doi: 10.1186/s13643-017-0480-0. Abstract BACKGROUND: Hemorrhage is a major cause of early mortality following a traumatic injury. The progression and consequences of significant blood loss occur quickly as death from hemorrhagic shock or exsanguination often occurs within the first few hours. The mainstay of treatment therefore involves early identification of patients at risk for hemorrhagic shock in order to provide blood products and control of the bleeding source if necessary. The intended scope of this review is to identify and assess combinations of predictors informing therapeutic decision-making for clinicians during the initial trauma assessment. The primary objective of this systematic review is to identify and critically assess any existing multivariable models predicting significant traumatic hemorrhage that requires intervention, defined as a composite outcome comprising massive transfusion, surgery for hemostasis, or angiography with embolization for the purpose of external validation or updating in other study populations. If no suitable existing multivariable models are identified, the secondary objective is to identify candidate predictors to inform the development of a new prediction rule. METHODS: We will search the EMBASE and MEDLINE databases for all randomized controlled trials and prospective and retrospective cohort studies developing or validating predictors of intervention for traumatic hemorrhage in adult patients 16 years of age or older. Eligible predictors must be available to the clinician during the first hour of trauma resuscitation and may be clinical, lab-based, or imaging-based. Outcomes of interest include the need for surgical intervention, angiographic embolization, or massivetransfusion within the first 24 h. Data extraction will be performed independently by two reviewers. Items for extraction will be based on the CHARMS checklist. We will evaluate any existing models for relevance, quality, and the potential for external validation and updating in other populations. Relevance will be described in terms of appropriateness of outcomes and predictors. Quality criteria will include variable selection strategies, adequacy of sample size, handling of missing data, validation techniques, and measures of model performance. DISCUSSION: This systematic review will describe the availability of multivariable prediction models and summarize evidence regarding predictors that can be used to identify the need for intervention in patients with traumatic hemorrhage. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017054589. KEYWORDS: Embolization; Massive transfusion; Prediction model; Surgery; Traumatic hemorrhage PDF  Ácido tranexámico en pacientes con trauma. Barreras para usarlo entre los cirujanos de trauma y emergencia Tranexamic Acid (TXA) in Trauma Patients: Barriers to Use among Trauma Surgeons and Emergency Physicians. Alburaih A1. Emerg Med Int. 2017;2017:4235785. doi: 10.1155/2017/4235785. Epub 2017 Feb 20. Abstract Objective. Tranexamic Acid (TXA) is currently the only drug with prospective clinical evidence supporting its use in bleeding trauma patients. We sought to better understand the barriers preventing its use and elicit suggestions to further its use in trauma patients in the state of Maryland. Methods. This is a cross-sectional study. Results. The overall response rate was 38%. Half of all participants reported being familiar with the CRASH-2 trial and MATTERs study. Half reported being aware of TXA as part of their institution's massive transfusion protocol. The majority of participants felt that TXA would have a significant positive impact on the survival of trauma patients. A majority also felt that the use of TXA would increase if its administration was the responsibility of both trauma surgeons and emergency physicians. Conclusion. Only half of responders reported being aware of TXA as being part of their institution's massive transfusion protocol. Lack of awareness of the clinical data supporting its use is a major barrier. However, most trauma providers and emergency physicians do have a favorable view of TXA and support its incorporation into massive transfusion protocols. We believe that more studies of this kind on both state and national level are needed. PDF Vacante para Anestesiología Pediátrica El Hospital de Especialidades Pediátricas de León, Guanajuato México  ofrece un contrato laboral en el departamento de anestesiología  Informes con la Dra Angélica García Álvarez  angy.coachanestped@gmail.com o al teléfono 477 101 8700 Ext 1028

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

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] Martínez-Calle N1, Hidalgo F2, Alfonso A1, Muñoz M3, Hernández M1, Lecumberri R1, Páramo JA4. Med Intensiva. 2016 Dec;40(9):550-559. doi: 10.1016/j.medin.2016.05.003. Epub 2016 Jul 15. Abstract 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 PDF  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? Wijaya R1, Cheng HM2, Chong CK1. Singapore Med J. 2016 May;57(5):238-41. doi: 10.11622/smedj.2016088.Abstract INTRODUCTION: 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 PDF 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. Peralta R1, Vijay A1, El-Menyar A2, Consunji R1, Abdelrahman H1, Parchani A1, Afifi I1, Zarour A3, Al-Thani H1, Latifi R4. World J Emerg Surg. 2015 Aug 14;10:36. doi: 10.1186/s13017-015-0028-3. eCollection 2015 Abstract 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 PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org