Treatment of massively bleeding patients: introducing real-time monitoring, transfusion packages and thrombelastography (TEG®)

Background  Continued haemorrhage remains a major cause of mortality in massively transfused patients, many of whom develop coagulopathy. When reviewing transfusion practice for these patients at our hospital, more than 10% received a suboptimal transfusion therapy and survivors had a higher platelet count than non-survivors. We therefore speculated whether the blood bank could improve its service and hence improve the outcome.

Methods  The blood bank introduced monitoring the delivery of blood products and contacted the clinician provided there was an imbalance in the transfusion practice. For massively bleeding patients, transfusion packages, encompassing 5 red blood cells, 5 fresh frozen plasma and 2 platelet concentrates was introduced to improve haemostatic competence. The thrombelastograph (TEG) was implemented, aiding in the diagnosis and treatment of coagulopathy.

Results The fraction of suboptimally transfused patients declined from > 10% to < 3%. The transfusion package administered intraoperatively to patients operated for a ruptured abdominal aortic aneurysm resulted in decreased postoperative transfusion requirements and improved 30-day survival (66% vs. 44%) compared to controls.

 Only performing TEG in patients with a significant bleeding as judged by the anaesthetist reduces the number of analyses by ~85%, whereas those patients with coagulopathy remain identified. The TEG showed 97% predictability in identifying a surgical cause of bleeding in postoperative patients. Ten percent of the massively bleeding trauma patients had hyperfibrinolysis as the major cause of bleeding, whereas 45% were hypercoagulable.

Conclusion  The initiatives from the blood bank has improved the transfusion practice and, hence, survival in massively transfused patients at our hospital.