RETROSPECTIVE ANALYSIS OF MASSIVE TRANSFUSION PRACTICE IN NON-TRAUMA RELATED HEMORRHAGIC SHOCK IN A TERTIARY CARE CENTRE Dr. Gayathri.A.M, Dr.S.Sathyabhama, Dr.Debasish Gupta Department of Transfusion Medicine, SCTIMST,Trivandrum

Transfusion support to loss of blood >150ml/min MASSIVE TRANSFUSION ADULT Transfusion of ≥10 red blood cell (RBC) units, which approximates the total blood volume (TBV) of an average adult patient, within 24 hr Transfusion of >4 RBC units in 1hr with anticipation of continued need for blood product support Replacement of >50% of the TBV by blood products within 3 hr Transfusion support to loss of blood >150ml/min PAEDIATRICS Transfusion of >100% TBV within 24 hr Transfusion support to replace ongoing haemorrhage of >10% TBV /min Replacement of >50% TBV by blood products within 3 hr

MAXIMUM SURGICAL BLOOD ORDER SCHEDULE (MSBOS) DESIGNED FOR OUR INSTITUTE NEUROSURGERY CASES CARDIOTHORACIC CASES CASES RBC REQUIREMENT SCHWANNOMA 2 MENINGIOMA ANEURYSM AV MALFORMATION HEMATOMA EVACUATION CASES RBC REQUIREMENT CABG 2 AORTIC DISSECTION 4 AORTIC ANEURYSM AV MALFORMATION HEMATOMA EVACUATION VALVULAR REPAIRS SEPTAL DEFECTS, TOF, TAPVC, PDA INTRA CARDIAC REPAIRS CABG + VALVULAR REPAIR

MASSIVE TRANSFUSION PROTOCOL OF OUR INSTITUTE 5- 15 Kg BODY WEIGHT < 5 Kg BODY WEIGHT PACK RBC FFP PLT CRYO 1 1 (Paed) ½ NIL 2 1 (P) 3 4 1/2 PACK RBC FFP PLT CRYO 1 2 (Paed) NIL 2 2 (P) 3 4 15-40 Kg BODY WEIGHT >40 Kg BODY WEIGHT PACK RBC FFP PLT CRYO 1 2 NIL 3 4 PACK RBC FFP PLT CRYO 1 4 NIL 2 3 6

AIMS & OBJECTIVES MATERIALS AND METHODS To analyse retrospectively the massive transfusion practices and resultant outcome of patients over a period of two years MATERIALS AND METHODS This is a retrospective observational study of all patients who received a massive transfusion for non-traumatic hemorrhagic shock over a two-year period (2016- 2017) The primary outcome was in-patient hospital survival Electronic medical records of 53 non-traumatic patients including both adult and paediatric cases that were admitted and had massive transfusion were assessed

Variables include : Age Sex Body weight Co-morbidities Drug history Diagnosis and nature of surgical procedure Pre-surgical laboratory investigations (Hb, PCV, platelet counts, PT/INR, aPTT, potassium, BUN) & post surgical laboratory parameters Ratio of blood components transfused Period of ICU, Ventilator, Extra- corporeal membrane oxygenator and hospital stay Recovery index

TOTAL CASES SINCE 2 YEARS RESULTS 2800 TOTAL CASES SINCE 2 YEARS 1450 TOTAL CASES: 6750 0.78% GENDER SCORE PAEDS ADULTS CARDIO NEURO MALE 11.3% 1.8% 32.2% 20.7% FEMALE 3.9% 20.8% 7.5%

DIAGNOSIS PROCEDURE

PRE- SURGICAL DRUG INTAKE ASSOCIATED CO-MORBIDITIES PRE- SURGICAL DRUG INTAKE

DISTRIBUTION OF WEIGHT IN ALL CASES DURATION OF HOSPITAL STAY, ICU STAY & VENTILLATOR STAY NO. OF PATIENTS ECMO No. of cases MALE 2 FEMALE 1

INTRA & POST OPERATIVE BLOOD USAGE ADULT PAEDIATRIC

PRE & POST SURGICAL INVESTIGATION COMPARISON p value 0.07 0.6 0.04 0.014 <0.001 15.9 3.83 2.01 1.6 26.13 2.28 31.07 38.32 10.6 13.1

OUTCOME FOLLOWING MASSIVE TRANSFUSION MORTALITY EXPIRED % NEUROSURGERY 2 14.28% CARDIOTHORACIC SURGERY 12 85.72% PATIENTS OUTCOME SURVIVORS (39) 73.58% EXPIRED (14) 26.42%

CARDIOTHORACIC SURGERY (n=12) Post op cardiac tamponade (3 cases) Poor preoperative anticoagulation management and multiple comorbidities (6 cases) On table: Acute uncontrolled bleed in ruptured TAAA (2 cases) CKD on Dialysis (1 case) Ruptured multiple Intra cranial Aneurysm NEUROSURGERY (n=2) MORTALITY ANALYSIS

Statistically insignificant OBSERVATIONS All paediatric cases survived after appropriate massive transfusion protocol Potassium and BUN in all scenarios Hb, PCV, Platelet counts, PT & APTT in expired cases Statistically insignificant

CONCLUSION A good massive transfusion protocol is required to increase the patient survival rates Good orchestration between clinicians, anaesthesiologist and blood center team Appropriate utilisation of blood units Turn around time should be reduced

LIMITATIONS TEG reporting were insufficient to do analysis Baseline D-Dimer investigation not performed

REFERENCES Kevin M S, Kimberly A D, Felix Y L et al. The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion? Transfusion 2010;50:1545-51.258 Norgaard A, Stensballe J, de Lichtenberg T H,et al. Three-year follow-up of implementation of evidence-based transfusion practice in a tertiary hospital. Vox Sang. 2017;112:229-397 1 Shahram P, Hosseinali K, Golnar S, et al. Comparison of the impact of applications of Targeted Transfusion Protocol and Massive Transfusion Protocol in trauma patients. Korean J Anesthesiol 2017; 70: 626-32 Keyvan K, Rachel O, Terrence M Y, et al. Prediction of massive blood transfusion in cardiac surgery. CAN J ANESTH 2006 ;53:781–94 Zoe K M, Gemma C, Susan B, et al. Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review. Transfus Med Rev. 2018;32(1):6-15

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