PAH M&M 10-24-13

Attending/CRNA/SRNA: Springstead/Feeney/Garcia

Operation: PSF T10-Pelvis, L2-L3 Lami

Complication: massive blood loss

History

66 yo female presents for her 9th back surgery PSH: Lumbar Lami x2, Intrathecal thoracic pain

pump, THR, Lumbar Fusions, Rotator Cuff PMH: GERD, RLE DVT, Vertigo Meds: protonix, amtriptyline, clonazepam,

vicodin, pyridium, zolpidem, tizanidine Allergies: Bactrim, Percocet, NSAIDs, Cipro,

Terazosin Wt: 47kg

Pre-op Labs

CBC: WBC 6.5, Hgb 11.2, Hct 33.2, Plt 307

CMP: WNL

Coags: WNL

Estimated Blood Volume: 3,055cc

Case Management

2 large bore IVs, RIJ triple lumen, CVP, A-line

Smooth IV induction, ETT with TIVA Prone on jackson table Neuromonitoring

Issues…

No T&C morning of surgery No IVC filter placed pre-op

(20% recurrence risk) 4,700cc of blood loss over 5hours

Interventions

T&C sent Requested PRBCs, FFP, Plts, Cryo

Level 1 infuser obtained from 3rd floor

Intraoperative I&O Totals

EBL: 4,700cc UO: 1,100cc

Crystalloid: 4,500cc Colloid: 1,250cc Cell Saver: 875cc PRBCs: 10units (3,000cc) FFP: 4units (1,200cc) Platelets: 3 six packs (750cc) Cryoprecipitate: 10units (100cc)

(1:2.5:0.5)

Postoperative Labs

ABG: pH 7.42, pCO2 35, pO2 248, HCO3 22.7, BE

-1.4 CBC:

WBC 12.2, Hgb 10.4, Hct 29.7, Plt 134 CMP:

Glucose: 157, BUN/Creat: 6/0.52, Na/K: 139/3.4, Ca: 7.8

Coags: PT 16.4, PTT 39, INR 1.5

Post-Op Course:

Day 1: extubated in ICU Day 3: ileus/nausea, bilateral L3 pedicle

fx Day 4: DOE, CT chest to r/o PE.

Large left pleural effusion

Key Points

Factors that contributed to outcome:Pt was relatively healthy, no cardiac

hx, extra hands, anticipated large blood loss and preemptively placed central line.

Ways to improve:Massive transfusion protocol

-PAH only has one for OB patients

Basics Review

Coagulation Abnormalities with Massive Blood Transfusions: Transfused blood lacks platelets, Factors 5 and 8 Diffuse bleeding s/p transfusion is caused by thrombocytopenia Treatment = platelets, FFP, Cryo

Platelets in stored blood are nonfunctional after 1-2 days.

All procoagulants are present in FFP – EXCEPT PLATELETS!

Cryoprecipitate contains factors concentrated factors 8, 1, 13

One unit PRBCs increases Hct 3-4% or 1g/dL 1cc/kg RBCs will increase Hct 1% One unit of platelets increases plt count 5,000-10,000. Massive transfusion = one complete blood volume

within 24 hours.

HUP Exsanguination Protocol - 2011

Initial activation response: (1:1.6:1.6) PRBCs – 10 FFP – 6 Plts – 1 six pack

Continued activation: (1:1.5:1) PRBC – 6 FFP – 4 Plts – 1 six pack

Factor VIIa 90mcg/kg After 2nd dose must be approved by pharmacy

Identifying who needs MTP…

2012 AAST - Prospective Observational Multicenter Major Trauma Transfusion Study (PROMMTT)

Involved 1,245pts from 10 Level I trauma centers 297 patients received massive transfusion

CITT & ABC triggers ABC: penetrating injury, + FAST, SBP <90, HR >120

2 or more points = pt likely to receive MT CITT: SBP <90, Hgb <11, INR >1.5, BD >6, Temp <35.5

“Parameters that can be obtained early in the initial evaluation are valid predictors for determining the likelihood of massive transfusion”

Penetrating injury and HR least valid, INR most valid Cannot currently link ABC/CITT to nontrauma patients

First 6 hours…

(2009) Retrospective study involving 16 Level 1 Trauma Centers 1,489 pts – of which 466 were MT pts

Looked at outcomes in patients who received high ratio transfusions within first 6 hours 6hr mortality lowest in patients who received > or

= 1:1:1 PRBC:FFP:PLT <1:4 37% and >1:1 2% 6hr mortality

No difference in pulmonary complications s/p resuscitation In fact, pts who received highest PRBC:PLT ratio had

fewer ventilator dependent days Advocate for early FFP and Platelet

administration

Resuscitation Strategies…

(2010) 4 year retrospective study Included trauma pts requiring DCL &

>10units PRBCs Damage Control Resuscitation vs.

Conventional Resuscitation Efforts Compared pt variables, labs, intraop

resuscitation, 30 day survival rate and LOS between DCR and CRE pts

Included 196 pts with blunt/penetrating injuries at Level 1 trauma center

CRE vs. DCR

Damage Control Resuscitation (DCR) “Close ratio massive transfusion protocol” 1:1 FFP to PRBCs 1:2 Platelets to PRBCs Minimal crystalloids (4L) –

counterproductive Conventional Resuscitation Efforts (CRE)

Aggressive crystalloid resuscitation (14L) 1:4 FFP to PRBCs 1:6 Platelets to PRBCs

Findings…

ICU LOS: DCR = 11 days CRE = 20 days

30 Day Survival: DCR = 73.6% CRE = 54.8%

CRE patients arrived to ICU volume overloaded with tissue hypoperfusion, hypothermia, coagulopathy and increased mortality

Massive Transfusion Activation in GMS Patients….

2013 – Retrospective study from U. Pitt 164pts = 100 trauma and 64 GMS Current MTP = 1:1:0.5 PRBC:FFP:PLT MTP activation automatically provides set ratio from

the blood bank (Based on ABC – similar to HUP) MTP accelerates delivery of blood products from BB

~ 7-17min faster Overactivation affects resource allocation

53% in GMS vs. 19% Trauma Both GMS and Trauma waste significant amount of plts

Despite overactivation – still advocates for MTP in GMS patients to improve delivery time and patient outcome

Massive Transfusion & Organ Failure

(2008) Journal of Trauma, Injury, Infection and Critical Care High ratios of FFP:PRBC associated with

increased risk of organ failure? 264 pts Postop complications/organ failure reduced

when blood products delivered asap via predetermined protocol. No change in renal failure or inflammatory response Decreased pneumonia, pulmonary failure, open

abdomens, abdominal compartment syndrome

Storage Duration of Erythrocytes (2013) Anesthesiology – Cleveland Clinic Retrospective study examined association

between storage duration and postop mortality in general surgery patients

What are the concerns: Changes in erythrocyte membrane, decreased

2,3 DPG, Nitric oxide, K+ Increased mortality, LOS, intubation time,

infections, multi organ failure Patient vs. Transfusion?

Current limited data among noncardiac surgical patients

Oxy-hemoglobin Dissociation Curve

The goods.

63,319 patients from 2005-2009 10,090 transfused 6,994 patients

1-41units given per patient ASA 1-5 (80% were ASA 3 or higher) 3 groups of storage duration

<14 days 14-28 days >28 days

This study excluded patients who had units with a difference storage duration greater than 5 days.

The outcomes.

19,462 units of allogenic PRBCs administered

1,178 deaths No association found between length of

storage and post-op mortality over 2 years

This data cannot be extrapolated to cardiac surgery.

Did not look at morbidity. Several prospective studies are currently

ongoing…

References Brenner, M., Bochicchio, G., Bochicchio, K., Ilahi, O., Rodriguez, E., Henry, S., et al.

(2011). Long-term impact of damage control laparotomy. Archives of Surgery, 146, 395-399.

Callcut, R. A., Cotton, B. A., Muskat, P., Fox, E. E., Wade, C. E, Holcomb, J. B., et al. (2012). Defining when to initiate massive transfusion: A validation study of individual massive transfusion triggers in PROMMTT patients. Journal of Trauma and Acute Care Surgery, 74, 59-68.

Cotton, B. A., Au, B. K., Nunez, T. C., Gunter, O. L., Robertson, A. M., Young, P. P. (2009). Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. The Journal of Trauma, Injury, Infection, and Critical Care, 66, 41-49.

Duchesne, J. C., Kimonis, K., Marr, A. B., Rennie, K. V., Wahl, G., Wells, J. E., et al. (2010). Damage control resuscitation in combination with damage control laparotomy: a survival advantage. Journal of Trauma, Injury, Infection and Critical Care, 69, 46-52.

McDaniel, L. M., Neal, M. D., Sperry, J. L., Alacron, L. H., Forsythe, R. M., Triulzi, D., et al. (2013). Use of a massive tranfusion protocol in nontrauma patients: activate away. Journal of the American Collage of Surgeons, 1103-1108.

Saager, L., Turan, A., Dalton, J. E., Figueroa, P. I., Sessler, D. I., Kurz, A. (2013). Erythrocyte storage duration is not associated with increased mortality in noncardiac surgical patients. Anesthesiology, 118, 51-58.

Zink, K. A., Sambasivan, C. N., Holcomb, J. B., Chisholm, G., Schreiber, M. A. (2009). A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. The American Journal of Surgery, 197, 565-570.