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Wed Jul 25 21:04:47 BST 2007

Hi Karim,
I obviously accept what you say about these publications (and you clearly have better contacts than I regarding the American Military paper as I have not yet seen the whole article), but I think that we all predicted your reply, following your original question,as there has been no definitive publication! However, we are also all well aware that current and traditional practices result in the 'run away train' coagulopathy associated with large volume transfusions so we need to change.  We have ignored coagulopathy and circulation preservation for far too long.

Despite the lack of the definitive paper the publications that do exist and a number of recent reviews at National Trauma and Transfusion meetings have produced quality consensus views that support the 1:1 FFP ratio as the current 'best guess'.  This view has been balanced against numerous studies that describe adverse effects and risk factors of large volume plasma transfusion.

This issue smacks of so many others that the list debates, the obvious old favourite being permissive hypotension in blunt trauma. The definitive trial doesn't exist, but we know that current established protocols have no evidence base and in fact has a growing negative press. 

So what do we do....continue doing what we know doesn't work  and is making our patients worse or do we take the best level of evidence and change under close scrutiny? I appeal to the scientists amongst us....

Regards
Mark

----- Original Message ----
From: Karim Brohi <karimbrohi at gmail.com>
To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Sent: Tuesday, 24 July, 2007 6:58:37 PM
Subject: Re: Massive Transfusion Protocol: What's in YOUR pack?

Mark,

Thanks, but...

-Can J Surg: Dec 2005

This is a mathematical model

-J trauma suppl: June:2006

These are reviews/editorials and have little/no data

-J Trauma: Jan 2007

This has clinical data (hurrah!) but compares resolution of coagulopathy
before ICU to after ICU (ie. before patients stop bleeding to after patients
stop bleeding).

-Surg Commander Holcomb: prelim reports of a definitive 2007 paper out of
> Iraq, which has gone to press I am told (BTS representative)

This retrospective audit of combat casualty victims who receive at least 10
units of blood does show an improvement in survival for those who receive
lower ratios.

I'm not saying 1:1 is wrong at all, but considering how we discuss  the
merits of massive RCTs like NASCIS/CRASH/SAFE, is this now all we need to
change practice??

Anyway, I am still interested in getting a baseline view of how much blood
people are used to ordering for massive transfusions - especially the
general view of the list population at large.  If we do even get round to
trialling this, it will be important to establish a control arm that
accurately reflects current practice.  So:  6 units of blood has gone in,
how much FFP next?

Many thanks

Karim

Cheers
> Mark F
>
>
> ----- Original Message ----
> From: Karim Brohi <karimbrohi at gmail.com>
> To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
> Sent: Monday, 23 July, 2007 6:18:31 PM
> Subject: Re: Massive Transfusion Protocol: What's in YOUR pack?
>
>
> OK.  For those of you who have decided to use 1:1 FFP:RBCs, what evidence
> (published) are you basing this on?
>
> Karim
>
>
> On 23/07/07, Andrew J Bowman <andrewj.bowman at gmail.com> wrote:
> >
> > We did not even have them as guidelines.
> >
> > Andrew
> >
> >
> > On 7/23/07, Hardcastle, Tim, Dr <tch at sun.ac.za> <tch at sun.ac.za> wrote:
> > >
> > > No
> > >
> > > Actually working in countries where "clinical judgement" is still the
> > > prime reason for making decisions rather than following a written set
> of
> > > rules. While protocols may be helpful they are not the gold-standard
> of
> > care
> > > by any means. At best they should be a guideline - deviated from by
> any
> > > worthy clinician with same judgement.
> > >
> > > Tim
> > > Dr T C Hardcastle
> > > M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> > > Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
> > > ATLS  instructor and DSTC Cape Town Course Director
> > > Intern program Coordinator: Surgery
> > > M.Med (Emergency Medicine) Executive Committee member
> > > Clinical Head (Director): Diana Princess of Wales Trauma Unit
> > > Division of Surgery (General) Room 4064
> > > Department of Surgical Sciences
> > > Tygerberg Hospital / University of Stellenbosch
> > > PO Box 19063
> > > Tygerberg 7505
> > > Western Cape
> > > South Africa
> > > e-mail: tch at sun.ac.za
> > > Cell: +27824681615
> > > Office: +27219389281 or 4911 pager 0302
> > >
> > >
> > >
> > > -----Original Message-----
> > > From: trauma-list-bounces at trauma.org
> > > [mailto:trauma-list-bounces at trauma.org]On Behalf Of Andrew J Bowman
> > > Sent: Monday, July 23, 2007 6:47 AM
> > > To: Trauma &amp, Critical Care mailing list
> > > Subject: Re: Massive Transfusion Protocol: What's in YOUR pack?
> > >
> > >
> > > Complacency and lack of trauma foresight. (at least where I have
> worked
> > in
> > > the past)
> > >
> > > Andrew
> > >
> > >
> > > On 7/23/07, Errington Thompson <errington at erringtonthompson.com>
> wrote:
> > > >
> > > > Is there a reason NOT to have a massive transfusion protocol?
> > > >
> > > > E
> > > >
> > > > Errington C. Thompson, MD, FACS, FCCM
> > > > Trauma/Surgical Critical Care
> > > > Author - Letter to America
> > > > Asheville, NC
> > > >
> > > > -----Original Message-----
> > > > From: trauma-list-bounces at trauma.org [mailto:
> > > > trauma-list-bounces at trauma.org]
> > > > On Behalf Of MARK FORREST
> > > > Sent: Sunday, July 22, 2007 7:16 PM
> > > > To: Trauma &amp; Critical Care mailing list
> > > > Subject: Re: Massive Transfusion Protocol: What's in YOUR pack?
> > > >
> > > > Hi Karim,
> > > > The hospital protocol is actually lagging behing the labs own
> practice
> > > and
> > > > they are supporting the new practices of the theatre teams:
> > > >
> > > > A:
> > > > 1- After fourth unit of blood we start requesting 1:1 FFP:Blood
> > > >
> > > > B
> > > > After 6 unit transfusion we now assume that you are already working
> on
> > > an
> > > > established coagulopathy, especially if they are hypothermic
> > > >
> > > > After 6 units, request 2 FFP if  we are employing permissive anaemia
> > > > (target
> > > > 7-8 g/dl). If higher Hb level and haemostasis has been clinically
> > > achieved
> > > > then may give none at this late stage.
> > > >
> > > > NO Factor VIIa if they have a temp less than 35 degree becasue of
> its
> > > > dramatcally reduced function.
> > > >
> > > > C
> > > > Lab clotting result will realistically take about 30 mins to 1 hour,
> > > which
> > > > is obviously useless if still bleeding or operating.
> > > >
> > > > We have no reliable NPT and we do not currently have a TEG as our
> > > > transfusion team believe that it is not a reliable measure
> > > >
> > > > Cheers
> > > > Mark F
> > > > UK
> > > >
> > > >
> > > > ----- Original Message ----
> > > > From: Karim Brohi <karim at trauma.org>
> > > > To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
> > > > Sent: Sunday, 22 July, 2007 10:37:24 PM
> > > > Subject: Massive Transfusion Protocol: What's in YOUR pack?
> > > >
> > > >
> > > > Dear All,
> > > >
> > > > A straw poll if you don't mind on massive transfusion protocols for
> > > > traumatic haemorrhage.  Please base your answers on your current
> > > practice
> > > > or
> > > > your institution's current practice, not latest research / hearsay
> > etc:
> > > >
> > > > A. If you HAVE a massive transfusion protocol in your hospital:
> > > >
> > > >    1. Are you given packs of FFP according to how many units of
> blood
> > > > have been administered?
> > > >        (eg. 2 units of FFP after every 6 units of blood)
> > > >
> > > >    2. How much FFP after how much blood?
> > > >
> > > >    3. If your answer to (1) was NO, what's the make-up of your packs
> > > >
> > > > B. If you have just administered 6 units of blood:
> > > >
> > > >    1. Do you always give a certain amount of FFP or do you wait for
> > > > labs? Which labs?
> > > >
> > > >    2. If you give FFP, how much for those 6 units would you consider
> > > > standard?
> > > >
> > > >    3. What is the minimum that should be given (0 is an acceptable
> > > > answer)
> > > >
> > > > C. Labs:
> > > >
> > > >    1. You send a PT/PTT from the ED or Operating room.  How soon do
> > you
> > > > get it back? (really)
> > > >
> > > >    2. Do you have point of care testing for PT/PTT in the ED & OR?
> > > >
> > > >    3. Do you do thromboelastometry routinely on bleeding trauma
> > > > patients in the ED and OR?
> > > >
> > > > There are no right or wrong answers, as practice varies so
> > widely.  I'm
> > > > just
> > > > trying to see the breadth of responses. So as many replies as
> possible
> > > > please - even from the lurkers :-)
> > > >
> > > > Karim
> > > >
> > > > --
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Massive Transfusion Protocol: What's in YOUR pack?