A Massive Transfusion Protocol to Decrease Blood Component Use and Costs

Hypothesis A massive transfusion protocol (MTP) decreases the use of blood components, as well as turnaround times, costs, and mortality. Design Retrospective before-and-after cohort study. Setting Academic level I urban trauma center. Patients and Methods Blood component use was compared in 132 patients during a 2-year period following the implementation of an MTP; 46 patients who were treated the previous year served as historical control subjects. Intervention Introduction of an MTP that included recombinant factor VIIa for patients with exsanguinating hemorrhage. Main Outcome Measures The amount of each blood component transfused, turnaround times, blood bank and hospital charges, and mortality rates. Results After introduction of the MTP, there was a significant decrease in packed red blood cells, plasma, and platelet use. The turnaround time for the first shipment was less than 10 minutes, and the time between the first and second shipments was reduced from 42 to 18 minutes, compared with historical controls. The decreased use of blood products represented a savings of $2270 per patient or an annual savings of$200 000, despite increased costs for recombinant factor VIIa. There was no difference in mortality in either group; it remained around 50%. Thromboembolic complications did not increase, despite a significant increase in the use of recombinant factor VIIa. Conclusions The MTP resulted in a reduction in the use of blood components with improved turnaround times and significant savings. Mortality was unaffected. The use of recombinant factor VIIa did not increase thromboembolic complications in these patients. Massive transfusion is loosely defined as the transfusion of more than 10 units of packed red blood cells (PRBCs) in a 24-hour period.1,2 Although there have been reports of improved survival after massive transfusion during the last decade, it is unclear what factors are responsible.3 There is increasing evidence that the early coagulopathy seen in trauma patients should be treated aggressively during the initial resuscitation, particularly in those patients requiring massive transfusion.4,5 It has been suggested that a protocol designed to give red blood cells and coagulation factors (ie, plasma and platelets) in prespecified ratios can improve outcomes.6,7 Both military and civilian data suggest that a ratio of 1:1 to 1:2 of fresh frozen plasma to PRBCs is needed to adequately treat coagulopathy in patients undergoing massive transfusions.6,8,9 We developed and instituted a massive transfusion protocol (MTP) at Parkland Health and Hospital System, Dallas, Texas, which was mainly designed for trauma patients with severe, active hemorrhage. The protocol includes giving prespecified amounts of PRBCs, thawed plasma (defined in the “Methods” section), cryoprecipitate, and platelets, as well as the recombinant factor VIIa (rFVIIa). The rationale of this protocol was to improve turnaround time, ie, the time between when the order for the products was received in the blood bank and when the products left the blood bank, as well as to provide component therapy in a more clearly defined proportion to prevent and treat coagulopathy and to reduce the waste that occurred with random product ordering. We sought to examine our experience and outcomes among patients treated using this protocol. We hypothesized that an MTP would improve turnaround times, reduce the use of blood products and associated charges, and possibly decrease mortality

A Massive Transfusion Protocol to Decrease Blood Component Use and Costs

Hypothesis A massive transfusion protocol (MTP) decreases the use of blood components, as well as turnaround times, costs, and mortality. Design Retrospective before-and-after cohort study. Setting Academic level I urban trauma center. Patients and Methods Blood component use was compared in 132 patients during a 2-year period following the implementation of an MTP; 46 patients who were treated the previous year served as historical control subjects. Intervention Introduction of an MTP that included recombinant factor VIIa for patients with exsanguinating hemorrhage. Main Outcome Measures The amount of each blood component transfused, turnaround times, blood bank and hospital charges, and mortality rates. Results After introduction of the MTP, there was a significant decrease in packed red blood cells, plasma, and platelet use. The turnaround time for the first shipment was less than 10 minutes, and the time between the first and second shipments was reduced from 42 to 18 minutes, compared with historical controls. The decreased use of blood products represented a savings of $2270 per patient or an annual savings of$200 000, despite increased costs for recombinant factor VIIa. There was no difference in mortality in either group; it remained around 50%. Thromboembolic complications did not increase, despite a significant increase in the use of recombinant factor VIIa. Conclusions The MTP resulted in a reduction in the use of blood components with improved turnaround times and significant savings. Mortality was unaffected. The use of recombinant factor VIIa did not increase thromboembolic complications in these patients. Massive transfusion is loosely defined as the transfusion of more than 10 units of packed red blood cells (PRBCs) in a 24-hour period.1,2 Although there have been reports of improved survival after massive transfusion during the last decade, it is unclear what factors are responsible.3 There is increasing evidence that the early coagulopathy seen in trauma patients should be treated aggressively during the initial resuscitation, particularly in those patients requiring massive transfusion.4,5 It has been suggested that a protocol designed to give red blood cells and coagulation factors (ie, plasma and platelets) in prespecified ratios can improve outcomes.6,7 Both military and civilian data suggest that a ratio of 1:1 to 1:2 of fresh frozen plasma to PRBCs is needed to adequately treat coagulopathy in patients undergoing massive transfusions.6,8,9 We developed and instituted a massive transfusion protocol (MTP) at Parkland Health and Hospital System, Dallas, Texas, which was mainly designed for trauma patients with severe, active hemorrhage. The protocol includes giving prespecified amounts of PRBCs, thawed plasma (defined in the “Methods” section), cryoprecipitate, and platelets, as well as the recombinant factor VIIa (rFVIIa). The rationale of this protocol was to improve turnaround time, ie, the time between when the order for the products was received in the blood bank and when the products left the blood bank, as well as to provide component therapy in a more clearly defined proportion to prevent and treat coagulopathy and to reduce the waste that occurred with random product ordering. We sought to examine our experience and outcomes among patients treated using this protocol. We hypothesized that an MTP would improve turnaround times, reduce the use of blood products and associated charges, and possibly decrease mortality

Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax

INTRODUCTION: Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32-40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX. METHODS: Prospective RCT comparing 14Fr PCs to 28-32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1-5 (1 = tolerable experience, 5 = worst experience). Unpaired Student\u27s t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P \u3c 0.05. RESULTS: Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375-1087; for PCs vs. 400 ml; IR, 240-700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, I can tolerate it ; IR, 1-2) than CT patients (median, 3, It was a bad experience ; IR, 3-4, P = 0.001). CONCLUSION: In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28-32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience. www.ClinicalTrials.gov Registration ID: NCT02553434

Multi-institutional analysis of neutrophil-to-lymphocyte ratio (NLR) in patients with severe hemorrhage: A new mortality predictor value

BACKGROUND: The neutrophil/lymphocyte ratio (NLR) has been associated as a predictor for increased mortality in critically ill patients. We sought to determine the relationship between NLR and outcomes in adult trauma patients with severe hemorrhage requiring the initiation of massive transfusion protocol (MTP). We hypothesized that the NLR would be a prognostic indicator of mortality in this population. METHODS: This was a multi-institutional retrospective cohort study of adult trauma patients (≥18 years) with severe hemorrhage who received MTP between November 2014 and November 2015. Differentiated blood cell counts obtained at days 3 and 10 were used to obtain NLR. Receiver operating characteristic (ROC) curve analysis assessed the predictive capacity of NLR on mortality. To identify the effect of NLR on survival, Kaplan-Meier (KM) survival analysis and Cox regression models were used. RESULTS: A total of 285 patients with severe hemorrhage managed with MTP were analyzed from six participating institutions. Most (80%) were men, 57.2% suffered blunt trauma. Median (IQR) age, Injury Severity Score, and Glasgow Coma Scale were 35 (25-47), 25 (16-36), and 9 (3-15), respectively. Using ROC curve analysis, optimal NLR cutoff values of 8.81 at day 3 and 13.68 at day 10 were calculated by maximizing the Youden index. KM curves at day 3 (p = 0.05) and day 10 (p = 0.02) revealed an NLR greater than or equal to these cutoff values as a marker for increased in-hospital mortality. Cox regression models failed to demonstrate an NLR over 8.81 as predictive of in-hospital mortality at day 3 (p = 0.056) but was predictive for mortality if NLR was greater than 13.68 at day 10 (p = 0.036). CONCLUSIONS: NLR is strongly associated with early mortality in patients with severe hemorrhage managed with MTP. Further research is needed to focus on factors that can ameliorate NLR in this patient population. LEVEL OF EVIDENCE: Prognostic study, level III