Conflicts of interest Bayer LFB BMS-Pfizer Octapharma - - PowerPoint PPT Presentation

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Conflicts of interest Bayer LFB BMS-Pfizer Octapharma - - PowerPoint PPT Presentation

Mar 04, 2023 435 likes •866 views

29/11/2013 How do I treat massive bleeding? Red blood cell / plasma / platelet ratio and massive transfusion protocols Anne GODIER Service dAnesthsie-Ranimation Hopital Cochin Paris G roupe d I ntrt en H mostase P

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Red blood cell / plasma / platelet ratio and massive transfusion protocols

Anne GODIER

Service d’Anesthésie-Réanimation Hopital Cochin Paris

Groupe d’Intérêt en Hémostase Périopératoire

How do I treat massive bleeding?

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Conflicts of interest

  • LFB
  • Octapharma
  • CSL-Behring
  • Bayer
  • BMS-Pfizer
  • Boehringer-Ingelheim
  • Léo
  • Sanofi

Acknowledgement

  • Pr Sophie Susen (Lille)
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1:1:1 ratio

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Coagulopathy

Massive transfusion Severe trauma Post-partum haemorrhage Major surgery (cardiac & aortic surgery) Gastrointestinal bleeding Liver transplantation

Massive bleeding

Mortality

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Trauma-induced coagulopathy

Dilution Hypothermia Acidosis Fluid loading Shock Massive bleeding Coagulopathy

trauma patient

Trauma induced coagulopathy Trauma-induced coagulopathy Massive RBC transfusion

Adapted from Brohi K, Ann Surg 2007*

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Trauma-induced coagulopathy

Dilution Hypothermia Acidosis Fluid loading Shock Massive bleeding Coagulopathy Acute traumatic coagulopathy Tissue Injury

trauma patient

Trauma induced coagulopathy Trauma-induced coagulopathy Massive RBC transfusion

Adapted from Brohi K, Ann Surg 2007*

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Trauma-induced coagulopathy

Dilution Hypothermia Acidosis Fluid loading Shock Massive bleeding Coagulopathy Acute traumatic coagulopathy Tissue Injury Inflammation Fibrinolysis systemic anticoagulation

activated protein C

trauma patient

Trauma induced coagulopathy Trauma-induced coagulopathy Massive RBC transfusion platelet dysfonction

Adapted from Brohi K, Ann Surg 2007*

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Trauma-induced coagulopathy

Dilution Hypothermia Acidosis Fluid loading Shock Massive bleeding Coagulopathy Acute traumatic coagulopathy Tissue Injury Inflammation Fibrinolysis systemic anticoagulation

activated protein C

trauma patient

Trauma induced coagulopathy Trauma-induced coagulopathy Massive RBC transfusion platelet dysfonction

Adapted from Brohi K, Ann Surg 2007*

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  • On-scene: TAC = trauma-associated coagulopathy

On-scene injury

Normal 20 (44%)

Normal 16 (36%)

Early onset of coagulopathy in trauma

Non-overt TAC 22 (49%) TAC 3 (7%)

TAC 1 (2%) Non-overt TAC 3 (7%) Normal 16 (36%) TAC 5 (11%) Non-overt TAC 15 (33%) Normal 0 (0%) TAC 3 (7%) Non-overt TAC 0 (0%)

On-scene and trauma resuscitation room coagulation status Floccard B, et al. Injury 2012;43:26–32

Admission

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Reduced Coagulation Factor Activity

Facteur FII FV FVII FIX FX FXI

Jansen JO, J Trauma 2011

Severe trauma patients

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10-15 mL/kg 30 mL/kg Fibrinogène g/L +0.4 +1.0 II % +16 +41 V % +10 +28 VII % +11 +38 IX % +8 +28 X % +15 +37 XI % +9 +23 XII % +30 +44

Br J Haematol 2004;125:69-73

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10-15 mL/kg 30 mL/kg Fibrinogène g/L +0.4 +1.0 II % +16 +41 V % +10 +28 VII % +11 +38 IX % +8 +28 X % +15 +37 XI % +9 +23 XII % +30 +44

Br J Haematol 2004;125:69-73

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Plasma

  • coagulation factors
  • fibrinogen
  • 1 FFP = 400 mg of fibrinogen
  • proteins, including immunoglobulins and albumin
  • volume expansion with high oncotic pressure
  • Preclinical studies
  • less pro-inflammatory than artificial colloids
  • protective effects on endothelial permeability and vascular stability

Pati S. J Trauma 2010; 69 Suppl 1:S55-63.

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Increasing plasma:RBC ratio

  • Transfusion with high ratio
  • Ratio = plasma number / RBC number
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246 trauma patients with massive transfusion

(>10 RBC)

1:1.4 FFP:RBC 1:2.5 mortality 1:8

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246 trauma patients with massive transfusion

(>10 RBC)

1:1.4 FFP:RBC 1:2.5 mortality 1:8

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Military trauma studies: beneficial effect of high FFP:RBC ratio

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military civilian trauma studies

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Mortality in patients undergoing massive transfusion n=3400

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Mortality in patients undergoing massive transfusion n=3400

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Limitations

  • retrospective studies (or cohort studies)
  • missing data
  • analytical bias
  • survival bias
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april 2013 Recommendation 26 We recommend the initial administration of plasma [fresh frozen plasma (FFP) or pathogen-inactivated plasma] (Grade 1B) or fibrinogen (Grade 1C) in patients with massive bleeding. If further plasma is administered, we suggest an optimal plasma:red blood cell ratio of at least 1:2. (Grade 2C)

Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R.

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Platelet : RBC ratio?

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The prevalence of abnormal results of conventional coagulation tests on admission to a trauma center

Hess JR, Lindell AL, Stansbury LG, Dutton RP, Scalea TM.Transfusion. 2009;49:34-9

Records of all patients admitted to a large urban trauma center during 2000 through 2006

N=23 000

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Retrospective data regarding platelet transfusion

mortality variation between trauma receiving large amount of platelets copared to small amount %

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Retrospective data regarding platelet transfusion

low ratios high ratios mortality mortality variation between trauma receiving large amount of platelets copared to small amount % %

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april 2013 We recommend that platelets be administered to maintain a platelet count above 50 × 109/l. (Grade 1C) We suggest maintenance of a platelet count above 100 × 109/l in patients with ongoing bleeding and/or TBI. (Grade 2C)

Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R.

UPDATED GUIDELINES TEMPORARY VERSION

Increasing platelet:RBC ratio is associated with a mortality decrease For massive transfusion platelet units must be part of the second transfusion package Platelets must be transfused with a platelet:RBC ratio between 1:5 and 1:1. This ratio may be close to 1:1

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Increasing ratios is not enough

t

1:1:1

Ratio : a time-dependent variable

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*

Mortality of trauma patients grouped by deficit status

Ratio = FFP / RBC Deficit = RBC - FFP

O

≤2 >6

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Reducing transfusion delay

carefully constructed massive transfusion protocol

  • local agreement with the blood bank
  • products available as soon as possible
  • healthcare professionals
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Protocol : 10 RBC 4 FFP 2 platelets  ratio 1:2.5

* *

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Reducing transfusion delay

carefully constructed massive transfusion protocol

  • local agreement with the blood bank
  • products available as soon as possible
  • healthcare professionals
  • which blood products?
  • number?
  • sequence?
  • transfusion package
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Packs

Godier A, Samama M, Susen S. Curr Opin Anesthesiol 2012

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Packs

Godier A, Samama M, Susen S. Curr Opin Anesthesiol 2012

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Immediate availability of plasma in the 1st pack

Thawing plasma

Freeze-dried plasma thawed AB group plasma stored for immediate availability together with O group RBC radio wave-based thawing technology

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1:1:1 ratio in blood transfusion: many argues in massive transfusion non massively transfused patients?

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Mortality in patients undergoing surgery without massive transfusion

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  • increase in complications
  • no improvement in survival
  •  in complications

as  volumes of plasma

number of units of plasma transfused in 12 hours

  • verall complications
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  • increase in complications
  • no improvement in survival
  •  in complications

as  volumes of plasma

number of units of plasma transfused in 12 hours

  • verall complications
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  • increase in complications
  • no improvement in survival
  •  in complications

as  volumes of plasma

number of units of plasma transfused in 12 hours

  • verall complications
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Conclusion: Management of massive bleeding

  • A growing body of evidence supports that high ratios improve outcome
  • Only in massive bleeding
  •  minority of patients
  • Only a small aspect of massive bleeding management
  • immediate delivery of blood products
  • through pre-established protocols
  • FFP/PLT/RBC ratios matter to define the content of packs immediately

available within the golden hour.