Surgery News - January 2008 - (Page 11) J A N U A RY 2 0 0 8 • SURGERY NEWS TRAUMA 11 Massive-Transfusion Protocol Cuts Costs BY BRUCE JANCIN Else vier Global Medical Ne ws C O L O R A D O S P R I N G S — Institution of a massive-transfusion protocol for critically injured hemorrhaging patients at one renowned urban level I trauma center resulted in an average savings of $2,270 per patient in reduced blood bank costs— but no change in mortality, Dr. Terence O’Keeffe reported at the annual meeting of the Western Surgical Association. The massive-transfusion protocol at Parkland Memorial Hospital in Dallas was designed to preempt postinjury coagulopathy by providing an increased amount of coagulation components to patients expected to require at least 10 U of packed red blood cells (RBCs) in 24 hours. A key element of the Parkland protocol is that it isn’t guided by standard coagulation tests performed before or during transfusions. “Those tests take upwards of 30 minutes and therefore don’t accurately reflect the true coagulation profile of these rapidly exsanguinating patients at the time blood products are being transfused,” explained Dr. O’Keeffe of the University of Texas at Dallas. He presented a retrospective study com- For those patients who require more paring blood component usage and clinical outcomes in 132 patients during the than 6 shipments, numbers 7 and above first 2 years after introduction of the pro- consist of 2 U of fresh frozen plasma, 5 U tocol in mid-2004 with a group of 46 his- of RBCs, and cryoprecipitate, but no factoric controls who underwent massive tor VIIa. Mortality was 52% in the patients mantransfusion in the 12 months prior to imaged after implementation of plementation of the protocol. the protocol and 50% in the The two groups were comhistoric controls. Significantly parable in their demographics fewer units of RBCs, fresh and mean Injury Severity frozen plasma, and platelets scores. were used under the protocol. The massive-transfusion In addition, the mean turnprotocol is initiated by the ataround time between delivery tending surgeon and continof the first and second shipues until the surgeon ends it. ments of blood products deThe first of the continuous shipments consists of either 5 Significantly fewer creased from 42 minutes in the preprotocol era to 18 minutes. U of O-negative RBCs and 2 U units of RBCs, Waste of blood product fell of fresh frozen plasma with fresh frozen from 5% to less than 1%. AB if the patient’s blood group plasma, and The mean $2,270 savings in isn’t known, or 5 U of type-speplatelets were blood bank costs was achieved cific RBCs and 2 U of fresh used. despite the increased use of frozen plasma if cross-matchDR. O’KEEFFE costly recombinant factor VIIa. ing has been done. This 1:2.5 ratio of fresh frozen plasma to RBCs is Although factor VIIa is considered conmaintained throughout the protocol. troversial because of concerns that the poPlatelets are delivered along with the 2 U tent procoagulant might cause thromof fresh frozen plasma and 5 U of RBCs boembolic events, the incidence at in shipments 2, 4, and 6, while cryopre- Parkland was 1.1% under the protocol cipitate and recombinant factor VIIa are and 0.8% in controls, Dr. O’Keeffe observed. included in shipments 3 and 6. Despite the lack of mortality benefit with this protocol, preliminary analysis indicates that it did confer advantages, including lower hospital charges, fewer ICU days, and a shorter total length of stay, he added. Discussant Dr. Stephen Cohn, an ACS Fellow who is professor and chair of the department of surgery at the University of Texas at San Antonio, expressed some reservations about the study. He pointed out that the study’s reliance upon historic controls makes it somewhat vulnerable to various biases. Dr. O’Keeffe agreed that definitive answers require a randomized controlled trial, but added that such a study would be “exceedingly difficult” to perform. Although several audience members expressed disappointment about the lack of mortality benefit, Dr. O’Keeffe countered that it’s not surprising given the severity of injuries. “It’s the gunshot wound or stab wound they came through the door with that’s going to kill them,” Dr. O’Keefee said. “Although we can improve our resuscitation, we can’t affect the underlying injuries any more than we’ve already done with our surgical techniques,” he concluded. ■ Gunshot Wound Protocol Allows Early Discharge B Y M I C H E L E G. S U L L I VA N Else vier Global Medical Ne ws N E W O R L E A N S — Hemodynamically stable patients with isolated lower extremity gunshot wounds and no associated fractures can be safely discharged from the emergency department on the basis of a good ankle-brachial index, according to a review of more than 300 patients. Dr. Javid Sadjadi of the University of California, San Francisco, said this algorithm had 100% specificity for ruling out other injuries, and carried a 98% negative predictive value—only 3 of 182 patients discharged from the ED had to be readmitted for wound complications. The protocol study, presented at the annual clinical congress of the American College of Surgeons, retrospectively analyzed 362 patients admitted to the ED for an isolated gunshot wound to a lower extremity. The mean age of the patients was 26 years. Those who were admitted with signs of arterial hemorrhage, shock, distal ischemia, or significant vascular injury were taken to the operating department for exploration and treatment, or received angiography to determine the level of vascular injury. Those who met the protocol inclusion criteria (182) were discharged from the ED after an average of 9 hours. All patients were hemodynamically stable and had no physical exam findings indicating vascular injury, no fracture, and an ankle-brachial index of 0.90 or greater compared with the uninjured leg. On follow-up, there were no cases of ischemia or limb loss. Three patients returned with complications. Two patients had superficial wound infections that were treated locally and with intravenous antibiotics. Another patient was admitted with delayed compartment syndrome secondary to pseudoaneurysm of a branch of the popliteal artery. This patient received embolization; after treatment, he retained full function of the leg. The early-discharge protocol saved money, Dr. Sadjadi said. The cost of treating the 182 patients was $180,600. If all these patients had received noninvasive ul- trasound exams, the cost would have risen to $289,000, and if they had received arteriograms, the cost would have been $325,400. “Early discharge not only saves resources but results in direct cost savings to our medical center and to our county,” Dr. Sadjadi said, noting that only about 10% of the patients in the study carried private health insurance. The protocol’s weak spot is the inability of the ankle-brachial index to identify a possible pseudoaneurysm, Dr. Sadjadi said. “You may have a pseudoaneurysm of an artery but intact flow to the foot, and thus the AB index would miss this complication.” To address this weakness, the protocol has been modified. “We now include duplex ultrasound imaging on any stable patients with good AB index who have a wound track that might place the trajectory of the missile in proximity to a vessel,” Dr. Sadjadi explained. ■ http://www.nashvillesurg.com http://www.nashvillesurg.com
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.