Massive Transfusion in Non-Trauma Patients,

Hemorrhagic shock accounts for a significant number of deaths in patients with acute injury. Early administration of multicomponent blood product transfusion in high plasma to red cell ratios have been associated with decreased mortality. Significant bleeding may occur in many settings outside of injury, including abdominal aortic aneurysm (AAA) rupture and postpartum or gastrointestinal hemorrhage. At a Level I Adult and Pediatric Trauma Center, activation of a Massive Transfusion Protocol (MTP) provides immediate release of sets of blood products with high component ratios (i.e. 1 unit plasma for every 1 unit PRBC) for patients with severe injury. The protocol has also been utilized in patients with major bleeding from non-trauma etiologies. To our knowledge, there are no systematic studies of the effectiveness of blood transfusion with high component ratios in non-traumatic hemorrhage; therefore, we performed a retrospective case review of patients transfused via the MTP for non-traumatic indications and outcomes at our institution.

Clinical data for 58 patients with non-traumatic activation of the MTP between October 2009 and May 2011 was reviewed. Medications, laboratory parameters prior to transfusion, medical conditions affecting bleeding, and amount of blood products administered were evaluated. Outcomes including 24 hour and in-hospital mortality and incidence of transfusion reactions including Transfusion Related Acute Lung Injury (TRALI) were assessed. Associations between medications or medical problems and transfused blood products, as well as component ratio on mortality were assessed using logistic regression. Fisher's exact test was used to examine the impact of transfusion reactions including TRALI on mortality.

Forty-nine of 58 patients studied (84%) received blood products after activation of the MTP. Patients ranged in age between 19 and 82 years-old (median 61 years) and 69% were male. Thirty eight percent of patients had the MTP activated for vascular catastrophies (AAA), 24% for GI bleeding, 16% for open heart surgery, and 10% for obstetrical complications. Patients on average received 9 units of red blood cells (range 0–39 units), 6.6 units of plasma (range 0–34 units), and 1.5 apheresis units of platelets (range 0–5). Twelve patients (24%) received cryoprecipitate. Administered adjunctive medications included activated factor VII for 11 patients (22%), aminocaproic acid in 14 patients (28%), vitamin K in 15 patients (30%), and desmopressin in 6 patients (12%). The odds of a patient receiving activated Factor VII increased significantly as the units of PRBCs increased (OR = 3.925; 95% CI = 1.15 – 13.38). Concurrent medications most likely to affect bleeding included heparin in 26 patients (53%), aspirin in 18 patients (37%), and warfarin in 4 patients (8%). Active liver failure was seen in 11 patients (22%), renal failure in 16 patients (32%), and one patient with either a hematologic or solid malignancy. Patient's medications or these medical diagnoses were not associated with the amount of blood product transfused.

Twenty one patients (43%) died during the hospitalization, and six patients (12% of total) died within the first 24 hours. In hospital mortality for patients with GI hemorrhage was the highest at 66%. No patients died after receiving transfusion for obstetric complications. Influence of ratio of Plasma:PRBC transfusion on in-hospital morality was seen with mortality of 80% in the <1:4 group, 60% in 1:4–1:2 group, and 36% in both 1:2 to 1:1 and ≥1:1 groups. These differences were not statistically significant, however, potentially due to sample size. Three patients experienced signs and symptoms consistent with TRALI but no other transfusion reactions were found. These cases were not associated with mortality (24-hour or in hospital) and were not correlated with the component ratio.

MTPs with infusion of blood products with high ratios of plasma to red cells compared to transfusion with low ratios have improved mortality in patients with hemorrhage due to trauma. Our data suggests the applicability of MTP as part of resuscitation in the management of acute hemorrhage in non-trauma settings. Transfusion reactions were infrequent. Therefore, physicians should strive for transfusion of high ratios of Plasma:PRBC in all instances of major hemorrhage.

Off Label Use: Use of activated factor VII to assist with cessation of hemorrhage in patients without hemophilia.