![Page 1: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/1.jpg)
Massive transfusion: New Protocol
Bhavani Shankar Kodali MDAnesthesiologist-in-Chief, Interim Chairman
Brigham and Women’s Hospital
Associate ProfessorHarvard Medical School
![Page 2: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/2.jpg)
Goal of this presentation
• Are we on the right track?
• What is our current practice?
![Page 3: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/3.jpg)
![Page 4: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/4.jpg)
“Obstetrics Anesthesia”
![Page 5: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/5.jpg)
“Obstetrics is a bloody business”
![Page 6: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/6.jpg)
1970’s
- maternal deaths due to bleeding
= 13%
1990’s
- maternal deaths due to bleeding
~ 1.3%
Presently
- 1 per 100,000 25-30% maternal deaths WorldwidePreventable
![Page 7: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/7.jpg)
Conventional Management of Hemorrhage
Fluids
Colloids
Blood
Plasma
3:1
Platelets depending on the number
![Page 8: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/8.jpg)
246
![Page 9: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/9.jpg)
![Page 10: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/10.jpg)
22 Level 1 trauma
![Page 11: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/11.jpg)
![Page 12: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/12.jpg)
![Page 13: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/13.jpg)
Obstetric hemorrhage
![Page 14: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/14.jpg)
![Page 15: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/15.jpg)
Whole Blood Bedside Assay
![Page 16: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/16.jpg)
![Page 17: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/17.jpg)
![Page 18: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/18.jpg)
![Page 19: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/19.jpg)
platelets
![Page 20: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/20.jpg)
**Balanced ratios of blood products**Blood viscoelastic assays
![Page 21: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/21.jpg)
![Page 22: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/22.jpg)
![Page 23: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/23.jpg)
![Page 24: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/24.jpg)
Initial Labs
![Page 25: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/25.jpg)
![Page 26: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/26.jpg)
How did we achieve these results
• 1:1:1• Cryoprecipitate• Ca• Temperature of the patient• RiaSTAP
![Page 27: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/27.jpg)
Massive Transfusion
Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital
![Page 28: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/28.jpg)
Massive Transfusion
• Definition – Transfusion of ≥10 units of blood products in 24
hours – Replacement by transfusion of more than 50% of
blood volume in 12 to 24 hours
• Hemorrhage is the leading cause of death in the first hour after trauma and accounts for 50% of death in the first 24 hours
![Page 29: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/29.jpg)
Coagulopathy
• Coagulopathy is associated with trauma in 25-38% of patients; it is also associated with a 4-fold increase in mortality
• Acute Coagulopathy of Trauma (ACoT)– Associated with severe injury– PT, aPTT, thrombin time >1.5 times normal
limit– Coagulopathy: higher mortality (46% vs. 11%)1
1Brohi K et al J Trauma 2003
![Page 30: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/30.jpg)
Assessment of Coagulopathy
• Early recognition is associated with improved survival• Conventional coagulation testing (PT, PTT, platelet count,
fibrinogen)• Rapid Thromboelastography (TEG)
– Comprehensive assessment of coagulation abnormalities– Faster results– Correlated with conventional testing
![Page 31: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/31.jpg)
Activating Massive Transfusion Protocol at BWH
• Pharmacy = x27153• Blood bank = x27290• Criteria at BWH
– > 4 PRBC in 1 hour– > 10 PRBC in 24 hours
![Page 32: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/32.jpg)
![Page 33: Massive transfusion: New Protocol Bhavani Shankar Kodali MD Anesthesiologist-in-Chief, Interim Chairman Brigham and Women’s Hospital Associate Professor](https://reader036.vdocument.in/reader036/viewer/2022062407/56649c9e5503460f9495eb65/html5/thumbnails/33.jpg)