Clinical review: Canadian National Advisory Committee on Blood and Blood Products - Massive Transfusion Consensus Conference 2011: report of the panel

Abstract

In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.

Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage

“…The treatment of major haemorrhage with the use of formulaic shock packs is a recent trend based on retrospective studies of military casualties, which suggested that mortality was lowest in those given a 1:1:1 ratio of packed red cells, FFP and platelets [8,9]. A Consensus Panel of the Canadian National Advisory Committee on Blood and Blood Products examined the evidence for this approach in 2011 [10]. It concluded that the survivorship bias has probably contributed substantially to the observed reduction in mortality seen in retrospective studies, and that there was a lack of evidence to support 1:1:1 blood component ratios as a standard of care.…”

Massive transfusion in the trauma patient: Continuing Professional Development

“…25 Further, the Canadian National Advisory Committee on Blood and Blood Products has published a consensus developed at the Massive Transfusion Consensus Conference (June 2011, Toronto, Canada) that survivorship bias comprises a major obstacle in the proper interpretation of retrospective associations between transfusion ratios and trauma outcome, and limited scientific evidence currently exists to support ratio-driven (e.g., 1:1:1 ratios of RBC, plasma, and platelet units) transfusion protocols. 26 The effect of survivorship bias was shown compellingly by Snyder et al who confirmed a survival benefit with highratio transfusion in their cohort of 134 patients, but only when the ratio was characterized at 24 hr post-admission. 27 Conversely, when the transfusion ratio was analyzed as a time-dependent covariate, the survival benefit was not shown.…”

Emergency assessment of hemostasis in the bleeding patient

“…Broadly speaking, rapid assessment of hemostasis may include standard hemostasis assays like prothrombin time (PT), PTT, fibrinogen, and platelet count or it may rely on viscoelastic whole-blood hemostasis assays [2]. Rapid hemostasis testing may be carried out in the clinical laboratory [3,4], in a satellite laboratory [5], or as point-of-care testing in the operating room or trauma suite [6][7][8][9][10][11].…”