Red Cell Transfusion LESSONS FROM TRAUMA
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1 Red Cell Transfusion LESSONS FROM TRAUMA Sandro Rizoli, MD PhD FRCSC FACS Professor Surgery & Critical Care Medicine Trauma Program Director Chair Trauma Care
2 Disclosure KCI Canada CSL Behring NovoNordisk
3 Lessons Learned in Trauma 1. It is possible to change practice 2. It is possible to have good trials 3. Still don t know what s right/wrong 4. Practice according to culture
4 Trauma Resuscitation Unique: anemia & oxygenation circulatory volume stop bleeding coagulopathy (complex) acid-base balance temperature, Ca, hyperkalemia ambulance & trauma room It s a metabolic mess!
5 Possible to Change Practice Resuscitation from crystalloid to BLOOD Reasons: XX century = crystalloid is bad brain, lung, bowel edema open abdomen dilution = more coagulopathy more transfusion more hypothermia
6 Possible to Change Practice Crystalloid to BLOOD XXI century = trauma-coagulopathy Bleeding Dilution Hypothermia Acidosis Coagulopathy Etc; etc XXI Century Endogenous Early 25% patients 3x mortality NOT addressed
7 XXI Century Wars Afghanistan & Iraq wars = blood is good! subset patients young, coagulopathic & massive bleeding widespread tissue trauma extremity (tourniquet) blast & explosion logistic, transportation, hospitals Mobile blood bank = fresh whole blood
8 XXI Century Wars Afghanistan & Iraq wars = blood is good! treat massive bleeding = whole blood early DIFFERENT
9 XXI Century Lessons wars transferred home NO whole blood ratio 1:1:1 (RBC:FFP:plat) ONLY blood 1:1:1 = effective concentration clotting factor 65% platelet 55x109/L (37x109/L) hematocrit 26% Anything else = more dilution
10 Retrospective Studies Damage Control Resuscitation 1:1:1 Conventional Duschene 26% 88% Maegele 24% 46% Holcomb 40% 60% Kashuk 8% 40% Scalea No difference Teixeira 26% 90% Zink 26% 55% Median 26% 55%
11 Change in Practice 1. crystalloids are bad 2. whole blood 1:1:1 not perfect best in existence Trauma Centers North America: hypotension = blood transfusion EARLY
12 Transfusion of Plasma, Plat, RBC in a 1:1:1 vs. 1:1:2 PROPPR Randomized Clinical Trial JAMA. 2015;313(5): severely injured patients 12 Trauma Centres Aug 2012 to Dec 2013 No difference mortality 24h & 30d More plasma 7U vs. 5U More platelets 12U vs. 6U No difference complications (ARDS, MOD, VTE, sepsis) Fewer death by exsanguination 24h More patients achieved hemostasis
13 However Massive bleed exchange transfusion replace entire blood volume 90% NO transfusion 1.7% >10U/24h = massive transfusion 46% >10u/24h in PROPPR Early = better outcome in massive bleed
14 Blood & Civilians Civilian = cars & falls, old, not fit, co-morbidities Inappropriate RBC transfusion (Dr. Callum): retrospective study Toronto 4214 admissions 541 transfused RBC 27.5% inappropriate risk: age, penetrating, ISS, coagulopathy more VTE events (MI, stroke)
15 Furthermore More RBC = more plasma Q2u RBC = 10% drop clotting factors 8-10u RBC = 25% clotting factors remain More RBC = more platelets 10-12u RBC = platelet drop by 50% More RBC = more interventions Q2u RBC = 10-20ml calcium gluconate
16 1:1 vs. Lab-Guided TRFL study (Nascimento, CMAJ 2013) feasibility 78 patients 1:1 vs. lab-guided NO clinical benefit mortality, ARDS (p.053) waste blood inappropriate transfusion
17 Possible to Have Good Trials Tranexamic acid: CRASH 2 Lancet ,211 patient RCT TXA lower mortality (3h??) MATTERs Arch Surg 2012 MATTERs 2 JAMA Surg 2013 TXA = lower mortality (transfused) TXA/cryo = mortality & transfusion
18 Different Culture & Perspectives TXA & fibrinogen Europe Fibrinogen (cryo/concentrate): 1 st drop essential level European guidelines = 1.5-2g/L hemoglobin <8 = low fibrinogen ISS>30 = 50% <1g/L need transfusion & mortality Fibrinogen first NOT plasma
19 Different Culture & Perspectives USA = resistance TXA fibrinolysis fatal (black diamond) questions CRASH & physiol. fibrinolysis local evidence plasma fibrinogen (cryo) late or none Canada = TXA accepted low compliance active strategies, pre-hospital interest fibrinogen 1 st
20 Good Trials? More Trials Not always fibrinogen growing fast Less attractive issues: stop bleeding fast superior to transfusion access to OR immediate ($$) under developed = no blood = earlier OR
21 What s Right 1. Best volume replacement? plasma? crystalloid + RBC + fibrinogen? add vasopressors? 2. How identify massive bleeding acceptable start 1:1:1 change asap lab-directed (viscoelastic?) 3. If blind resuscitation, start fibrinogen? TXA must (protocols, blood management program)
22 Lessons Learned 1. Possible change practice crystalloid to blood resuscitation 2. Possible have good trials PROPPR 1:1:1 massive bleed CRASH & MATTERS TXA fibrinogen 3. What s right culture most patients = restrictive, lab-guided most practice depend group
23 Thank you
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