Optimal Massive Transfusion Ratios - Essay Example

Research Critique      Research Article Critique Article: Blood transfusion Massive Transfusions: New Insights Chest 2009, 136:1654-1667 Sihler, K., and Napolitano, L. Purpose: The purpose of this article is to establish the appropriate optimal massive transfusion ratios together with damage control resuscitation strategies and advances in trauma care and coagulation therapy. Background: Massive transfusion is defined as the application of more than 10 units of packed, red blood cells (PRBCs) to a patient, or blood transfusion of over one blood volume within 24hrs. However, various definitions exist with some becoming adopted as protocols of MT (Sihler & Napolitano, 2009). Uncontrolled hemorrhage can engender three life threatening conditions; acidosis, hypothermia and coagulopathy. While trauma leads the cause of death in military and civilian trauma, a consensus on the standardization of MT protocol is yet to be developed. Almost all causes of hemorrhage shock may need MT. The use of MT also occurs frequently in the management of patients with GI bleeding as well as emergent surgical procedures. Early diagnosis of coagulopathy and treatment has demonstrated considerable benefits (Greer et al., 2010). The lack of a clear and explicit protocol elicited the need for this study to determine the appropriate protocol for MT. Methodology: The study involved a retrospective analysis of two predominant groups of populations including military, combat patients and civilians in medical centers, from 1987 up to 2007. The inclusion criteria involved patients with blunt and penetrating trauma as well as patients who required emergency surgeries and MT surpassing their blood volume within a 24 hour period. The study by Schreiber and others (2007) compared the results between 247 patients in a combat hospital who received MT and 311 patients within the same facility who did not receive MT (Sihler& Napolitano, 2009). Another similar study by McLaughlin and others (2008), which is analyzed within the article, involved the assessment of data from an Iraqi combat support hospital to determine the mortality rates associated with MT. The two studies highlighted above created the precedence for the study by identifying the problem and establishing epidemiologic information. Later additional analysis of the research problem looked at a total of 15 related studies, which presented mean transfusions and their related mortality rates under varying studies. Results: The retrospective study setting precedence for the analysis in this study by Sihler & Napolitano (2009) showed that there was a significantly high rate of mortality rate among patients that underwent MT. The study, which was conducted in a military hospital, showed that the deaths of patients that had undergone MT were at a 39% rate, whereas those that did not undergo MT were at 1%. Patients that underwent MT received 17.9 stored units of PRBCs together with 2.0 units of fresh whole blood. These patients were compared to 311 patients that did not undergo MT who received 1.1 units of PRBCs and 0.2 whole blood units within the same facility. In a similar study conducted by Wudel et al (1991), 92 patients suffering from blunt trauma who received >20 blood units were examined. The study demonstrated that patients who received 33 PRBC’s units had a 48% mortality rate (Wudel et al., 1991). Vaslef et al (2002) also conducted a retrospective study on 44 patients receiving more than 50 units of blood in their first day. With regards to the study, the patients received 33±14 PRBCs units and a mortality rate of 57% was established. However, the research done by Como et al in 2004 on 147 trauma patients who received >10 units of PRBC’s suggested a 10-60% reduction in mortality rate when patients received 25 units PRBC’s, 24 units fresh frozen, plasma (FFP) and 16 units of platelets (PLT), respectively (Vaslef et al., 2002). In 2007 Borgman et al published a study that highlighted the significance of damage control resuscitation strategies in connection to MT. The study included 246 trauma patients at a US Army combat support hospital. In the study, each patient received MT of >10 units of PRBC’s in 24 hours along with plasma in ratios. The mortality of the plasma/PRBC ratio groups included 1:8, 65%; 1:2.5, 34%; and 1:1.4, 19%. The addition of FFP/PRBC ratios decreased mortality significantly. The review also described the outcome of MT in a study of the general patient population patients who received MT with >10 PRBCs units. The causes for the need of MT included 21% GI bleeding, 46% trauma, and 14% of leaking abdominal aneurysm. The 43 patients in entirety received 824 units of PRBCs, 457 frozen plasma units and 370 platelets units. This figure represents 16% of blood products used in a year. The survival rate was 60% with 44% of patients reporting severe coagulopathy and 74% rate of mortality. 13% of the patients also experienced extreme thrombocytopenia (Sihler& Napolitano, 2009). Conclusion Massive transfusion still represents the principal treatment for severe hemorrhage (Sihler & Napolitano, 2009). Modern protocols in massive transfusion cases involving hemorrhage have demonstrated increased rates of survival in patients suffering from trauma and other excessive hemorrhage forms. The marked improvement in survival rates and reduction of mortality is due to the use of rfVIIA that has been reported to reduce MT coagulopathic effects. According to Sihler and Napolitano (2009), this change in protocol may have promoted the use of blood liberally, but extra studies need to be conducted to establish definitive protocol limits. Comments After careful review of the study, it became apparent that inconsistencies in the management of massive transfusions are widespread among many institutions. Initially, there were no explicit protocols to be pursued in the resuscitation processes. However, the studies reviewed within this article have helped in building knowledge towards the development of a common protocol in hemorrhagic situations requiring resuscitation. Currently, blood is the only option for the treatment of severe hemorrhagic shock (Sihler& Napolitano, 2009). Institutions have been without MT protocols for hemorrhagic situations, partly because there have been no reliable and valid studies to support a common protocol. I am still struck after reading these articles that although whole blood is discussed and is considered favorable because of its coagulation factors that many institutions do not utilize it. It clearly emerges that there have been no definitive research studies to determine the best protocol to pursue in cases requiring resuscitation. As such, there is a need for further research into how to develop a common protocol and implement its application across the board. Additionally, the fact that whole blood has been cited as the best option requires that further studies be conducted to develop knowledge on how blood would be used in place of other resuscitation elements. This should include a clear determination of why blood is better than other elements used as part of the evidence-based support of this practice. References Greer, S., Rhynhart, K. Gupta, R. & Corwin, H. (2010). New developments in massive transfusion in trauma. Current Opinion in Anaesthesiology, 32 (2), 246-250. Schreiber, M. A. Perkins, J. Kiraly, L. Underwood, S. Wade, C. & Holcomb, J. B. (2007). Early Predictors of Massive Transfusion in Combat Casualties. Journal of the American College of Surgeons, 205 (4), 541-545 Sihler, K.C. & Napolitano, L.M. (2009). Massive Transfusion:New Insights. CHEST, 1654-1667. Vaslef, N., Knudsen, N.W., Neligan P. J. & Sebastian, M. W. (2002). Massive transfusion exceeding 50 units of blood products in trauma patients. Journal of Trauma, 53 (2), 295-296. Wudel, J.H., Morris, J. A., Yates, K., Wilson, A., & Bass, S. M. (1991). MT: Outcome in blunt trauma patients. Journal of Trauma, 31(1), 1–7 Read More