EMCrit 071 – Critical Questions on Massive Transfusion Protocols with Kenji Inaba - a podcast by Scott D. Weingart, MD FCCM

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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