Challenges to improving patient outcome following massive transfusion in severe trauma

ABSTRACT

Introduction: Uncontrolled hemorrhage with trauma-induced coagulopathy (TIC) still represents the most common cause of preventable death after trauma. Timely diagnosis and treatment including bleeding control and hemostatic resuscitation to correct TIC are important, as death from exsanguination occurs rapidly. Recognizing who requires an early massive transfusion together with the initiation of corresponding massive transfusion protocols (MTPs) is key to outcome.

Areas covered: This expert review summarizes the current state of MT including the activation and termination of MTPs, complications of MT, and strategies for refinement in the administration of blood products in order to avoid harmful over-transfusion.

Expert opinion: MTPs should be initiated and continued until normal physiologic parameters are reached and definitive control of bleeding is achieved. Hospitals should develop their own MTPs, guided by evidence, and according to local infrastructure, logistics, needs and patient populations. Massive transfusion, defined as > 10 units of packed red blood cell concentrates (pRBCs) within the first 24 hours of hospital admission, can be life-saving, but is not without complications. MTPs are currently being refined through targeted and early goal-directed approaches which include functional coagulation testing assays to better guide the administration of blood products and hemostatic agents once the patient is stabilized.

KEYWORDS:

• Hemorrhage
• massive transfusion
• resuscitation
• trauma
• outcome

Article Highlights

• Uncontrolled haemorrhage with trauma-induced coagulopathy (TIC) still represents the most common cause of preventable death after trauma and timely diagnosis and treatment including the activation of massive transfusion protocols are key for improved outcome.

• The overall term of massive transfusion (MT) remains ill defined and there is still lack of consensus what constitutes a massive transfusion and a massive transfusion protocol (MTP)

• Activation and cessation of massive transfusion protocols remain nebulous and reliant on clinician gestalt given the dynamics of the patient´s condition during the later sequalae.

• Prediction models and scores including different combinations of clinical and laboratory parameters may support clinical decision making but mostly lack prospective validation.

• Massive transfusion is not without risks and protocols are subject to refinement as novel technologies are being developed and tested in the times of evolving precision medicine.

Declaration of Interest

M Maegele has received travel support, lecture and advisory board fees and research support from Astra Zeneca, Bayer, Biotest, CSL Behring, Portola Inc., TEM International/IL-Werfen and LFB Biomedicaments. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.