How would you reduce the red cell transfusion requirements in an actively bleeding multiple trauma patient?

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College answer

Early recognition and identification of location of bleeding (0.5)

Early haemorrhage control with basic haemostatic measures including: (1)

-Direct pressure

-Use of staples for soft tissue bleeding e.g. scalp bleeding

-Use of tourniquets in traumatic amputations

-Avoiding scene delays

Early definitive haemorrhage control with surgery or angiographic techniques (0.5) Avoidance of excessive crystalloid infusion. (0.5)

“Permissive hypotension” is a fluid restriction strategy that limits dilutional coagulopathy, potentially limits clot dislodgement by maintaining a SBP 80-90mmHg.

Initial RCT single centre research (Bickel 1994 NEMJ) in penetrating torso injures showed mortality benefit in delayed fluid resuscitation. Further multi centre RCT research with blunt trauma confirmed the improved mortality in the permissive hypotension group.

The controversy exists in the presence of TBI (traumatic brain injury) and Spinal cord injury (SCI) and the avoidance of secondary brain injury. Brain trauma foundation guidelines aim for an SBP >90 or CPP > 60 to prevent this. Permissive hypotension is not suitable for these patients. There is no evidence for Hb level. The TRICC trial excluded these patients (1.5)

Avoid the lethal triad of hypothermia, acidosis, and coagulopathy.(0.5 mark each) Ensure an ionised Ca2+ > 1 mmol/l. (0.5)

Maintaining fibrinogen > 1.5 g/L. (0.5)

Maintaining platelets > 100 x 109 /L. (0.5)

Recognition of the presence of medications causing coagulopathy or platelet dysfunction such as aspirin, clopidogrel, warfarin or a novel oral anticoagulant. In this instance the provision of platelets, FFP or prothrombin concentrate complexes may be appropriate. (1)

Point of care testing such as thromboelastography to facilitate rapid and targeted coagulopathy correction. (1)

The use of tranexamic acid < 3 hours (CRASH2). (0.5) Appropriate cessation of the massive bleeding protocol. (0.5)

Discussion

Prevent further haemoglobin loss:

  • Minimise acute bleeding
    • Achieve haemostasis early:
      • Potentially, laparotomy prior to CT
      • Damage control surgery rather than primary definitive management
      • Early reduction and control of fractures, eg. pelvic binder and long bone fracture reduction
      • Use of invasive haemostatic devices/techniques such as REBOA is controversial but appears effective
    • Prevent coagulopathy:
      • Correct ionised calcium
      • Correct hypothermia
      • Correct acidosis
      • Correct factor deficiency by proactively transfusing blood products including plasma, platelets and fibrinogen sources
      • Proactively correct pro-fibrinolytic states with tranexamic acid
      • Enhance platelet activity with desmopressin
    • Prevent blood loss by other mechanisms:
      • Practice "permissive hypotension"
    • Avoid the use of crystalloids, which dilute the clotting factors and decrease the oxygen carrying content of the blood
  • Over the medium term:
    • Use paediatric blood tubes and rationalise blood tests to decrease the iatrogenic blood loss rate
    • Use point-of-care microanalysis where possible, to decrease the sampled blood volume

Prevent wasteful use of blood products:

  • Controlled use of massive transfusion; refrigeration and recovery of unused blood products (i.e return them to the blood bank)
  • Encourage the use of intraoperative autotransfusion, eg. cell saver technology
  • Change local transfusion practice
    • Avoid haemoglobin "targets"; aim for clinical endpoints rather than numeric Hb concentration values
    • Avoid the use of empiric massive transfusion protocols; aim to use TEG or ROTEM-guide blood product administration 
  • Distributive justice decisonmaking
    • Engage with trauma team during the resuscitation, identify unsalvageable patients early, and share the moral responsibility for the decision to stop treatment.

Support haemopoiesis:

  • Optimise protein nutrition: ensure appropriate daily protein intake
  • Iron infusion may be necessary
  • Replace haematinics like folate and B12
  • Erythropoietin may be necessary (though this has its own disadvantages)

Exotic techniques

  • Artifical oxygen carriers are available:
    • Modified haemoglobin substitutes
    • Perfluorocarbon
  • Hyperbaric oxygen
  • Increased cardiac output to maintain oxygen delivery in spite of poor oxygen carrying capacity

References

Tinmouth, Alan T., Lauralynn A. McIntyre, and Robert A. Fowler. "Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients." Cmaj 178.1 (2008): 49-57.

Egea-Guerrero, J. J., et al. "Resuscitative goals and new strategies in severe trauma patient resuscitation." Medicina Intensiva (English Edition) 38.8 (2014): 502-512.

Tien, Homer, et al. "An approach to transfusion and hemorrhage in trauma: current perspectives on restrictive transfusion strategies.Canadian journal of surgery 50.3 (2007): 202.

Morrison, J. J., et al. "Intra‐operative correction of acidosis, coagulopathy and hypothermia in combat casualties with severe haemorrhagic shock." Anaesthesia 68.8 (2013): 846-850.

Duchesne, Juan C., et al. "Damage control resuscitation in combination with damage control laparotomy: a survival advantage." Journal of Trauma and Acute Care Surgery 69.1 (2010): 46-52.