Publicaciones científicas

Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit.

14-jul-2016 | Revista: Medicina Intensiva

Martínez-Calle N (1), Hidalgo F (2), Alfonso A (1), Muñoz M (3), Hernández M (1), Lecumberri R (1), Páramo JA (4).
(1) Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain.
(2) Department of Anaesthesia and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain.
(3) Transfusion Medicine, School of Medicine, University of Málaga, Málaga, Spain.
(4) Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain 


OBJECTIVE:
To audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007.

DESIGN:
A retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007-2012, Group 2) were compared with a historical cohort (2005-2006, Group 1).

BACKGROUND:
Massive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce.

PATIENTS:
After excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical).

INTERVENTIONS:
Our MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications.

VARIABLES OF INTEREST:
Primary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints.

RESULTS:
After MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering.

Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) - the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15-0.61).

CONCLUSIONS:
These data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates.

CITA DEL ARTÍCULO  Med Intensiva. 2016 Jul 14. pii: S0210-5691(16)30097-3. doi: 10.1016/j.medin.2016.05.003