Editorial
Need for multidisciplinary massive transfusion protocol for non-trauma patient
Necesidad de Protocolo de Transfusión Masiva Multidisciplinar en Paciente No Traumático
a Servicio Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain
b Grupo de Trabajo de Hemoderivados. SEMICYUC
c Coordinador Grupo de Trabajo de la Sociedad Española de Transfusión Sanguínea “Hemoterapia basada en sentido común”, Instituto Aragonés de Ciencias de la Salud, Servicio de Hematología y Hemoterapia, Hospital San Jorge, Huesca, Spain
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Quintana-Díaz, J.A. García Erce" "autores" => array:2 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Quintana-Díaz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0015" ] ] ] 1 => array:4 [ "nombre" => "J.A." "apellidos" => "García Erce" "email" => array:1 [ 0 => "jagarciaerce@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Trabajo de Hemoderivados. SEMICYUC" "etiqueta" => "b" "identificador" => "aff0015" ] 2 => array:3 [ "entidad" => "Coordinador Grupo de Trabajo de la Sociedad Española de Transfusión Sanguínea “Hemoterapia basada en sentido común”, Instituto Aragonés de Ciencias de la Salud, Servicio de Hematología y Hemoterapia, Hospital San Jorge, Huesca, Spain" "etiqueta" => "c" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Necesidad de Protocolo de Transfusión Masiva Multidisciplinar en Paciente No Traumático" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">At this moment, massive transfusion (MT) (replacements predefined protocols 1/1/1 and the use of concentrated blood coagulations factors) and the use of direct anticoagulants (monitoring and antidote) are the two trending topics relating to critically ill and bleeding patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The urgent need for a predefined treatment of hemostasis, as well as a quick and safe anticoagulant treatment reversion in bleeding patients with or without trauma, and the availability of dynamic and quick diagnostic tests and algorithms to guide professionals who work in these areas, represent a real medical necessity.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Massive bleeding (MB) is considered a serious health problem with an unknown incidence, and it has different causes that include: multiple trauma; postpartum and surgery disorders; and gastrointestinal bleeding.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a> Even though medical technology has advanced, MB has been related to higher morbidity and mortality, reaching 50% in some studies, depending on causes and its treatment.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Its management should be multidisciplinary and immediate. However, it is found that there is great variability in daily clinical practice. We need to establish consensus proposals that serve as an application pattern in the prevention, diagnosis, rapid response, assessment and application of appropriate therapeutic control measures.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Classical definition of MB is arbitrary and with low clinical significance.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The most common definitions are: blood loss at a 150<span class="elsevierStyleHsp" style=""></span>ml/min rate for more than 10<span class="elsevierStyleHsp" style=""></span>min; loss of a complete blood volume within 24<span class="elsevierStyleHsp" style=""></span>h; critical bleeding that requires transfusion of 4 RBP within the first hour; loss of 1–1.5 of the effective circulating volume within 24<span class="elsevierStyleHsp" style=""></span>h; loss of 50% of the effective circulating volume <span class="elsevierStyleItalic">within three hours and threatens life resulting in MT</span>.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Nevertheless any <span class="elsevierStyleItalic">of</span> these definitions can easily activate a specific massive transfusion protocol (MTP).</p><p id="par0025" class="elsevierStylePara elsevierViewall">In recent years, based on the Danish civil experience<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and military medical practice in Afghanistan and during the Gulf war,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> some definitions have changed, especially those relating to trauma associated coagulopathy which is defined as “<span class="elsevierStyleItalic">an hemorrhagic situation caused by hypocoagulability and hyperfibrinolisis environment secondary to multiple factors</span>”, classical hemotherapy schemes, the early use of fresh frozen plasma (FFP) (not only as a fibrinogen source), point of care monitoring devices and changes in therapeutic objectives.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Even though we can consider these definitions (administration of blood products by predefined rates and/or concentrated coagulation factors guided by viscoelastic tests) a new paradigm in the treatment of a bleeding patient,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> there are still a lot of doubts that have no answers in the few available clinical trials. We still don’t know which is the best dose, ratio, administration time, sequence or volume of the blood products. Usually critically ill patients cannot be compared with those included in the military trial, which makes the interpretation of outcomes complex.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This issue of <span class="elsevierStyleItalic">Medicina Intensiva</span> includes an interesting trial<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> of real clinical practice – even though it is a single centre, retrospective study – about the influence in the utilisation of a MT Protocol related to early mortality (24<span class="elsevierStyleHsp" style=""></span>h), mid-term (30 days) in non-trauma patients with MB. Activating MTP reduced mortality significantly. Because of the characteristics of this study, controlling confounding factors is a limitation and external validity is questioned; therefore it could be interrelated as an association rather than a cause effect result. In this context, it would be interesting to know the experience of other centres, and whether the results could be generalised through analysis of surveys and records. In the meantime we should work with the existing trials and try to provide an MTP in our hospitals, or at least investigate the results in the centres that have implemented it.</p><p id="par0040" class="elsevierStylePara elsevierViewall">There are very few quality studies about this subject in Spain and the international experience is almost all focused on the trauma patient.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Providing MTP has adaptable characteristics that could be applied to other hospitals.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In this trial MTP is activated by the Transfusion Service (old local “Blood Bank”).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This means that there is an experienced leader who has been trained in coagulopathy and hemotherapy, who is able to control the use of blood products and to interpret the obtained test results. This leader can also avoid delays in activation of MTP in patients admitted. In this trial, technology plays an important role because specific software is needed to activate the MTP algorithm.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, it is important to elaborate MTP, have the knowledge and availability of blood products and a leader in charge to coordinate the treatment of the bleeding patient, and help solve logistical problems specific to each centre. We believe that clinical practice done by Intensive Care physicians related to transplant coordination could also be applied in the treatment of the bleeding patient (taking into account that the critical patient expends more blood products second only to hematologic patients) and the Transfusion Service and Coagulation Laboratories need to take a more active role.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We would like to recognize the effort these authors<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> have made in this multidisciplinary trial that combines hemotherapy and hemostasis in MB. The trial, Documento de Sevilla de Alternativas a la Transfusión Sanguínea,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> has already shown that different specialties in Spain can work together for the good of our patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">Dr. García Erce has lectures and moderated tables in congresses and conferences with scholarships or funding from Vifor-Spain, Sandoz, Amgen, Alexion, Braun, GSK, Octapharma, Novartis and Sanofi.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postoperative bleeding and coagulation disorders" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.H. 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| 2021 Enero | 50 | 34 | 84 |
| 2020 Diciembre | 53 | 36 | 89 |
| 2020 Noviembre | 33 | 24 | 57 |
| 2020 Octubre | 47 | 45 | 92 |
| 2020 Septiembre | 55 | 28 | 83 |
| 2020 Agosto | 78 | 15 | 93 |
| 2020 Julio | 31 | 32 | 63 |
| 2020 Junio | 43 | 23 | 66 |
| 2020 Mayo | 42 | 16 | 58 |
| 2020 Abril | 39 | 27 | 66 |
| 2020 Marzo | 32 | 18 | 50 |
| 2020 Febrero | 62 | 41 | 103 |
| 2020 Enero | 53 | 30 | 83 |
| 2019 Diciembre | 38 | 27 | 65 |
| 2019 Noviembre | 50 | 33 | 83 |
| 2019 Octubre | 40 | 29 | 69 |
| 2019 Septiembre | 37 | 26 | 63 |
| 2019 Agosto | 48 | 27 | 75 |
| 2019 Julio | 27 | 25 | 52 |
| 2019 Junio | 33 | 10 | 43 |
| 2019 Mayo | 51 | 38 | 89 |
| 2019 Abril | 21 | 23 | 44 |
| 2019 Marzo | 22 | 31 | 53 |
| 2019 Febrero | 30 | 37 | 67 |
| 2019 Enero | 28 | 32 | 60 |
| 2018 Diciembre | 53 | 49 | 102 |
| 2018 Noviembre | 94 | 50 | 144 |
| 2018 Octubre | 100 | 23 | 123 |
| 2018 Septiembre | 56 | 16 | 72 |
| 2018 Agosto | 30 | 16 | 46 |
| 2018 Julio | 40 | 11 | 51 |
| 2018 Junio | 53 | 21 | 74 |
| 2018 Mayo | 44 | 11 | 55 |
| 2018 Abril | 54 | 9 | 63 |
| 2018 Marzo | 38 | 12 | 50 |
| 2018 Febrero | 27 | 9 | 36 |
| 2018 Enero | 56 | 27 | 83 |
| 2017 Diciembre | 30 | 15 | 45 |
| 2017 Noviembre | 53 | 17 | 70 |
| 2017 Octubre | 35 | 23 | 58 |
| 2017 Septiembre | 106 | 16 | 122 |
| 2017 Agosto | 185 | 17 | 202 |
| 2017 Julio | 31 | 17 | 48 |
| 2017 Junio | 37 | 24 | 61 |
| 2017 Mayo | 49 | 37 | 86 |
| 2017 Abril | 52 | 35 | 87 |
| 2017 Marzo | 60 | 1 | 61 |
| 2017 Febrero | 7 | 5 | 12 |
| 2017 Enero | 12 | 11 | 23 |
| 2016 Diciembre | 26 | 22 | 48 |
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