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Lambert L.,Taylor B.,Alistair W.
Intensive Care Medicine, September 2014, vol./is. 40/1 SUPPL. 1(S208), 0342-4642 (September 2014) (also published in Anaesthesia, June 2014, vol./is. 69/(118), 0003-2409 (June 2014))
INTRODUCTION. Massive haemorrhage is associated with significant morbidity and mortality. In the context of major trauma managed in a large centre, the use of a massive haemorrhage protocol emphasizing early haemostatic resuscitation reduces mortality (1). However, it is not clear if these models are effective in non-trauma patients (2). There is some concern that these protocols may increase the wastage of blood products which might be a concern in smaller hospitals. (3) OBJECTIVES. To audit the activation of and compliance with a massive haemorrhage protocol in a UK district general hospital. To assess if compliance with the protocol resulted in a difference in mortality, morbidity, length of ICU stay, or use of blood products. METHODS. Retrospective audit over 12 months analyzing the case notes of all patients who had suffered a massive haemorrhage against a massive haemorrhage protocol which emphasizes early haemostatic resuscitation. RESULTS. The protocol was activated in 9 patients, but unfortunately notes were unavailable for one as he was undergoing outpatient treatment. A further 9 patients were identified as having had a massive transfusion, without activation of the protocol, from blood bank data as having been issued emergency uncrossmatched group O blood, or having had more than 10 units of any blood products in a 24 h period. Where a massive haemorrhage protocol was used, 1/8 patients (12.5 %) died. Where a major transfusion was conducted without activation of the protocol, 7/9 patients died (77.8 %). This finding was statistically significant (p = 0.0152) using a 2-tailed fishers exact test. Fewer units of red cells (p = 0.0011) and FFP (p = 0.0034) were used in patients managed according to the protocol, but there was no difference in the use of platelets or cryoprecipitate. Two patients in the group where the protocol had not been activated were given cryoprecipitate despite normal fibrinogen levels, and a further two in this group were not given cryoprecipitate despite fibrinogen levels under 1 g/l CONCLUSIONS. Use of a massive haemorrhage protocol which focuses on rapid haemorrhage control, haemostatic resuscitation and early use of blood is associated with a lower mortality than management of major bleeds without the protocol. This appears to apply in predominantly non-trauma patients in a non-specialist centre. This was a retrospective audit, and the group in whom the protocol was not activated had a higher expected mortality, therefore the results warrant further research.
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