Trauma transfusion protocol

[huktonfonix]

what is your hospitals trauma transfusion protocol. Is it 1/1/1 of PRBC/FFP/PLT? 1/1 PRBC/FFP after 5 u PRBC? when do you decide to give cryo and other adjuncts (factor VII). We'ev recently had a string of fairly high transfusion traumas and since my institution apparently doesnt have a clearly defined transfusion policy I was wondering what everyone else is doing. Here it seems to depend on where the attending on at the time was trained although the trend seems to be toward the 1/1/1 per the trauma surgeons. prior to this if I have a choice I've been following a protocol published in a 2005 ASA newletter I believe from Parkland hospital in Dallas. 5 prbc/2ffp per shipment. 1 pooled unit PLT every 2nd shipment and I believe Factor VII is given on the third shipment.

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[InductionAgent]

I have had a very similar experience. The anesthesiology faculty in the abscence of any gross coagulopathy tend to be more in favor of 5-8 units PRBCs before 1/1/1. The trauma surgeons are big on the 1/1/1 from the beginning, citing results from recent military literature.

The military studies were done on massive traumas being treated in the field, so the results are more applicable in some situation than others. For instance, last year there was a trauma in which the surgeons reported no coagulation issues on the field, an INR came back as 1.2, yet the trauma surgeon insisted that we give another 3 units FFP to equalize the PRBCs already given simply because of that study. I hung one unit FFP infused slowly to semi-appease him.

If the 1/1/1 practice is going to be adhered to, it makes whole blood seem more desirable, to reduce the number of donors to whom the recipient is exposed.

 

[Noyac]

We are setting ours up as we speak. We are probably going with 1/1 after we have given 4 units of PRBC's. I'll get back when we are done.

 

[jwk]

I have had a very similar experience. The anesthesiology faculty in the abscence of any gross coagulopathy tend to be more in favor of 5-8 units PRBCs before 1/1/1. The trauma surgeons are big on the 1/1/1 from the beginning, citing results from recent military literature.

The military studies were done on massive traumas being treated in the field, so the results are more applicable in some situation than others. For instance, last year there was a trauma in which the surgeons reported no coagulation issues on the field, an INR came back as 1.2, yet the trauma surgeon insisted that we give another 3 units FFP to equalize the PRBCs already given simply because of that study. I hung one unit FFP infused slowly to semi-appease him.

If the 1/1/1 practice is going to be adhered to, it makes whole blood seem more desirable, to reduce the number of donors to whom the recipient is exposed.

We don't do a lot of big trauma, but more OB disasters than we would like to see simply due to our volume. I don't think we're anywhere near 1/1/1, especially early on - I guess I can see it approaching that with a massive resuscitation however, but it's kind of hard to predict, at least in our practice population.

As the example above indicates, a little more evidence-based practice instead of a cookbook approach would seem to be more common-sense.

 

[coprolalia]

We are setting ours up as we speak. We are probably going with 1/1 after we have given 4 units of PRBC's. I'll get back when we are done.

This is about what we do. We also pretty much automatically give 1g CaCl2 after four units without checking the iCa++.

Maybe UTSouthwestern can chime in, since he trained at Parkland.

-copro

 

[Gator05]

We aim for 1:1 red:ffp, plt every 8-10 red maybe. I like to add cryo if this is ongoing and rapid, ie following the first FMS bucket.

What are you using to guide specific replacement? We've found that while PoC helps with INR, plt counts can take far too long. We'll send off TEG's every 15-30 min, and I think this helps a lot; you don't need to wait until the end of the TEG run to see your slope and where your MA is heading.

One source mentioned CaCl2 supplementation whenever RBC infusion >150mL/min if I recall correctly. We treat it like candy.

 

[ZA_Gasman]

We aim for 1:1 red:ffp, plt every 8-10 red maybe. I like to add cryo if this is ongoing and rapid, ie following the first FMS bucket.

What are you using to guide specific replacement? We've found that while PoC helps with INR, plt counts can take far too long. We'll send off TEG's every 15-30 min, and I think this helps a lot; you don't need to wait until the end of the TEG run to see your slope and where your MA is heading.

One source mentioned CaCl2 supplementation whenever RBC infusion >150mL/min if I recall correctly. We treat it like candy.

Wish we had such good lab support. Ours can't give an INR in 45min even if we sit there glaring at them. Wish we could get 1:1 rbc:ffp, we look at about 3-4:1 if we're lucky (and 25% of the FFPs don't break on defrosting - Yeah, we defrost them in a bucket in theatre ourselves)...

 

[jetproppilot]

I have had a very similar experience. The anesthesiology faculty in the abscence of any gross coagulopathy tend to be more in favor of 5-8 units PRBCs before 1/1/1. The trauma surgeons are big on the 1/1/1 from the beginning, citing results from recent military literature.

.

Thats very interesting.

Havent done alotta trauma since residency........but the (many) bleeding AAAs I've done in the past few years are similar to a GSW or whatever trauma has ensued...I dont think we came close to 1/1/1 on any case I've done.

Conversely though, seems that if youre bleeding to death , dying from coagulopathy seems like alot higher risk than worrying about transfusion-acquired viruses....so maybe that kinda thinking (1/1/1) makes sense.

Whaddya guys think?

 

[Noyac]

Thats very interesting.

Havent done alotta trauma since residency........but the (many) bleeding AAAs I've done in the past few years are similar to a GSW or whatever trauma has ensued...I dont think we came close to 1/1/1 on any case I've done.

Conversely though, seems that if youre bleeding to death , dying from coagulopathy seems like alot higher risk than worrying about transfusion-acquired viruses....so maybe that kinda thinking (1/1/1) makes sense.

Whaddya guys think?

Your right and the bleeding AAA is as bad or worse than most any trauma we see. I just had one die this week due to inability to repair a totally f*cked aorta. The damned thing kept tearing and falling apart as we removed the x-clamp. Anyone ever seen pledgets really work, not me. Problem is, I could keep his pressure just where I wanted it the whole time but his aorta was **** and couldn't be repaired. 25 units of blood, 8 FFP, 6 Plts and he was solid as a rock. Labs were great with a mild acidosis. Surgeon looks at me and says I can't fix this. So I now had a decision to make. I didn't like the position I was in at all.

 

[huktonfonix]

Why were you the one who had to make the decision? It seems like it would be the surgeons call in this case since it is a surgical issue that they cant repair. Still sucks though.

 

[Noyac]

Why were you the one who had to make the decision? It seems like it would be the surgeons call in this case since it is a surgical issue that they cant repair. Still sucks though.

I wasn't making that decision. I meant that I just didn't like choosing to turn off the drips and/or ventilator on someone that was still alive. So I didn't.

 

[militarymd]

The bleeding AAA is a little different from a trauma in that USUALLY with a AAA, you don't develop the "oxygen debt" that you see with traumas....

Where you bleed....lose adequate O2 delievery for a while Ala Shires dog model ....before you begin resusucitation....

So, in general, trauma patients ...or patients with larger "oxygen debts" are more likely to develop DIC and bleed.

Just my 1/2 cent.

 

[Noyac]

The bleeding AAA is a little different from a trauma in that USUALLY with a AAA, you don't develop the "oxygen debt" that you see with traumas....

Where you bleed....lose adequate O2 delievery for a while Ala Shires dog model ....before you begin resusucitation....

So, in general, trauma patients ...or patients with larger "oxygen debts" are more likely to develop DIC and bleed.

Just my 1/2 cent.

I have done more than my share of trauma but I wouldn't go as far as saying that I have done more than anyone here. But i have rarely seen DIC, I mean full blown DIC, in any of my trauma pts. However, the last AAA I just did was blue in the ER on arrival. Sats in the 70's, definitely tolerable but definately low. The vast majority of the traumas I see are saturating better than this. So I am not following your train of thought here, Mil. I agree that the O2 deficit is a precursor to DIC but I can;t agree with the trauma vs AAA. Just my 1/4 cent.

 

[militarymd]

Depends on what type of trauma and what type of AAA's you're doing...

I said "usually" ...

I rarely give more than a couple of units of blood while doing AAA's..even with my worst vascular guys ...both in pp and in the military.

but with the trauma, and I only did trauma while in the Gulf..none in PP....we were hanging blood like there was no tomorrow.....and DIC was usually the least of these people's worries.

that's my 1/8 cent.

 

[Noyac]

Depends on what type of trauma and what type of AAA's you're doing...

I said "usually" ...

I rarely give more than a couple of units of blood while doing AAA's..even with my worst vascular guys ...both in pp and in the military.

but with the trauma, and I only did trauma while in the Gulf..none in PP....we were hanging blood like there was no tomorrow.....and DIC was usually the least of these people's worries.

that's my 1/8 cent.

Ditto.

I was thinking of the ruptured AAA.

 

[jetproppilot]

Ditto.

I was thinking of the ruptured AAA.

Me too.

Hence the wording bleeding AAA in my post.