Massive Hemorrhage Resuscitation
in Trauma Anesthesia

Meng Wang (王萌), MD          
Lixin Liu (刘立新), MD

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The recommendations for resuscitation of massive hemorrhage in trauma patients have continued to evolve over the past 50 years. From the initial finding of the presence of dilutional coagulopathy, to the heated debate on choosing crystalloids versus colloids infusion, there are still many areas filled with controversy that still await definitive answers. In this month’s newsletter, we would like to briefly discuss the Massive Transfusion Protocol (MTP) and its utilization in clinical practice in a Q&A format.

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What is damage control resuscitation (DCR) in trauma setting?

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Damage control resuscitation focuses on the following 3 aspects:

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1. Hypotensive resuscitation or permissive hypotension:  
   Less fluid and blood products to maintain SBP at 80-100 mmHg unless head trauma or hemorrhagic shock is present. The rationale is to reduce bleeding before surgery gains source control of the hemorrhage;
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2. Choice of blood products over crystalloids for volume replacement: DCR concept led to the introduction of MTP, which proposes early and aggressive transfusion of FFP and platelet to prevent coagulopathy and hemorrhagic shock. Both timing and total volume are of paramount importance;
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3. Early correction of coagulopathy based on protocol-driven (ratio-guided) or lab-driven (point of care guided) strategies:
   This is a rapidly evolving area. Ratio-guided approach means to transfuse with a preset ratio of pRBC/FFP/Platelet without modification. Point of care-guided approach entails real-time monitoring of coagulation status using ROTEM or TEG devices to guide the individualized supplementation of hemostatic agents.

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What is the definition of Massive Transfusion?

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Commonly accepted definition is >10units of pRBCs in 24 hrs.  However, from a practical standpoint, requirement for > 4 RBC units in 1 hour with ongoing need for transfusion, or blood loss > 150 ml/min with hemodynamic instability and need for transfusion are reasonable definitions in the setting of a MTP situation.

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What is the actual activation pathway?

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It varies by institution. A typical pathway starts with activation by a physician in response to a patient with massive bleeding. The activation could be via telephone and/or a dedicated runner/transporter to the blood bank. Each cooler usually contains 6u pRBC (O pos for male/female>50 yo, O neg for female <50yo) and 4u FFP inside with 1u platelet on top of it. Once activated, the blood bank will insure the timely availability of blood products until MTP is ended.

When to initiate Massive Transfusion Protocol (MTP)?

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Early identification of patients requiring MTP has been evaluated by assigning a value of 0 or 1 to the following four parameters: penetrating mechanism, positive FAST (Focused Assessment Sonography in Trauma) for fluid, arrival blood pressure <90 mm Hg, and arrival pulse >120 bpm. A score of 2 or more is considered positive. The score is 75% sensitive and 85% specific.

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What is the optimal plasma: RBC or platelet: RBC ratio?

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The truth is we don’t know. The 1:1:1 regiment has gained popularity over the past several years supported by results which showed decreased mortality from mostly military studies and further strengthened by some civilian studies. However, survival bias prevails in more than half of the studies.  Patients who dies early upon admission are much more likely to receive a lower FFP:pRBC ratio since we almost always transfuse pRBC before FFP for bleeding trauma patients. More prospective randomized studies are needed to evaluate the ideal ratio.

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What else to consider during resuscitation?

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1. Limiting the use of crystalloid;
2. Timely monitoring of acid-base status and lactate level to assess adequacy in tissue perfusion and oxygen delivery;
3. Correcting the electrolytes abnormalities;
4. Maintaining fibrinogen level.

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When to stop MTP?

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Once hemorrhage is controlled, a restrictive transfusion strategy is necessary to minimize complications (SIRS TRALI infection etc). pRBC transfusion is generally required for persistent base deficit, lactic acidosis, signs of end organ ischemia, and low mixed venous oxygenation.

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What are the complications of MTP?

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FFP administration has been associated with an increase in ARDS/TRALI/multi organ failure. For non-massively transfused trauma patients (<10u pRBC within 12 hours), plasma administration is associated with increased complications (ARDS, multiple organ dysfunction, pneumonia, and sepsis) with no improvement in survival.

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