Podcast 71 – Critical Questions on Massive Transfusion Protocols with Kenji Inaba

Today, I got to interview Kenji Inaba; an incredibly prolific trauma surgeon from USC/LA County, California. He is the SICU director and surgical critical care fellowship director. If you flip through any issue of the Journal of Trauma, odds are good that Kenji will have an article there.

Here are the questions I got to ask:

From the military studies, 1:1 (PRBCs to FFP) has emerged as the goal during hemostatic resuscitation. The civilian data is less robust, but there are cohort studies out there. Some of them suffer from survival bias and confounding by indication, but enough is out there for most of US trauma centers to attempt to meet the 1:1 goal? What are you folks doing at USC?

This excellent editorial (Resuscitation 82 (2011) 627–628) discusses the problems with 1:1 civilian studies and why we should shoot for this ratio anyway.

What is your transfusion goal with your 1:1. We are giving a mix of PRBC and FFP whenever the patient’s MAP drops below 65 and we don’t even bothering looking at the labs to determine which of these two products the patient needs. We are using them just like some saline in the dehydrated patient. If their MAP drops below our goal, they get the PRBC and FFP 1:1 until we get the MAP back up. How about you folks?

For more on this see Rich Dutton’s Interview

Where do platelets fit into the mix? At many hospitals they are not available in large amounts and most places are using old platelets and non-type-specific platelets. Some of your own work is on this very subject, should we be matching 1:1 with platelets as well? How about if we only have old, non-type-specific products?

See Kenji’s Paper on the topic of old platelets.

Now most of our European and Canadian Colleagues have moved to concentrates instead of FFP and platelets. They use PCCs and fibrinogen concentrates in the initial stages of the hemostatic resuscitation. Is this the future?

 

Are you using TEG or ROTEM, if so how does this fit into the picture? Should it be available in the ED, the OR?

 

Let’s talk TXA. I interviewed Tim Coats, one of the lead authors of Crash 2, last week—he advocates using it with any trauma patient who will need any amount of PRBCs, and to give it as early as possible. I think I agree with him. When are you USC guys giving TXA?

 

MATTERs trial shows that intermittent boluses may be effective rather than starting the infusion. We are giving the 10-minute bolus in the trauma room and then deferring infusion to the STICU if the patient still has active bleeding. Starting an infusion in the trauma bay can be frustrating when we are trying to pour blood products in. How about you?

 

Are you using Rh specific in males? If you give O+ to an Rh – male are you giving rhogam?

This is the AAST Plenary Paper (J Trauma 2012;72(1):48) we mentioned

I am a member of the Kenji fan club; I think you folks will be as well after hearing his sincerity and brilliance.

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Comments

  1. Minh Le Cong says:

    Nothing like crumbs that fall from the master’s table!

  2. Robert Sault says:

    Awesome podcast! Informative.

  3. Wm Arsenault says:

    Awesome cast!

    Who should govern MTPs?
    Trauma? Hematology? EM?

    My institution has a robust MTP but I would like more light shed on the governing of such a protocol. Can protocols such as this be used in smaller community centers without the enormous blood bank capabilities of an academic center?

    • I think the only way MTP can work is all players mentioned have a seat at a table.

      In a small hospital in can work, but they need to call for a delivery from the regional blood bank as soon as MTP is activated. One of those little cars can deliver an enormous number of products. Whatever is not used can be sent back.

  4. Houtan Sareh, MD says:

    Hey scott,
    Great interview. During the interview parameters for the monitoring of acute hemorrhage were briefly discussed. I would like to add that the scvo2 might serve as a reliable continuous marker of acute hemorrhage. Scalea and colleagues performed a small study (actually 2 studies: 1st animal model followed by human study) showing the correlation between acute hemorrhage and changes in scvo2. [journal of trauma 1990].
    Keep up the fantastic work.
    Houtan
    University of Maryland

    • Absolutely, Dr. Scalea’s work was particularly relevant to the elderly in whom other signs may be difficult to use clinically.

  5. Hi

    Just listened to two fantastic podcasts on shock & massive transfusion.
    I was wondering when you start using your 1 to 1 ratio?

    From the start or once you hit 6 Units. Listening to Rick Dutton suggested straight away.

    Is it a case of whether you think you are going to be transfusing huge amounts?

    • if we predict they will need massive by gestalt or abc score; otherwise we start after 4 units in our shop, Kenji starts after 6 units.

  6. Hi Scott,
    great podcast!
    I was wondering if you can speak more about 1:1 ratio vs. >1:1 ratios.
    what are some pros and cons. And are we going away from 1:1 ratio now?

    -shah

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