A comprehensive review of massive transfusion and major hemorrhage protocols: origins, core principles and practical implementation
Uma revisão abrangente dos protocolos de transfusão maciça e hemorragia grave: origens, princípios fundamentais e implementação prática
David Silveira Marinho, Denise Menezes Brunetta, Luciana Maria de Barros Carlos, Luany Elvira Mesquita Carvalho, Jéssica Silva Miranda
Abstract
Until the beginning of the century, bleeding management was similar in elective surgeries or exsanguination scenarios: clotting tests were used to guide blood product orders and, while awaiting these results, an aggressive resuscitation with crystalloids was recommended. The high mortality rate in severe hemorrhages managed with this strategy endorsed the need for a special resuscitation plan. As a result, modifications were recommended to develop a new clinical approach to these patients, called “Damage Control Resuscitation”. This strategy includes four principles: damage control surgery, minimization of crystalloids, permissive hypotension and hemostatic resuscitation. The latter involves the use of antifibrinolytics, correction of preconditions of hemostasis (calcium, pH and temperature) and the early and rapid restoration of intravascular volume with blood products. To enable timely availability and transfusion of blood products, specific actions in different hospital areas need to be synchronized, which are usually organized through Massive Transfusion Protocols or, as they have recently been rebranded, Major Hemorrhage Protocols (MHPs). Although these bundles of actions represent a paradigm change, essential aspects such as their historical evolution, theoretical foundations, terminology and operational elements have yet to be well explored. Considering the wide application range of these tools (emergency departments, interventional radiology, operating rooms and military fields), it is essential to integrate all professionals involved with severe hemorrhage scenarios in the implementation of the aforementioned protocols, from conception to execution and management. This review paper addresses MHP aspects relevant to anesthesiologists, transfusion services and other areas involved with the care of patients with severe bleeding.
Keywords
Resumo
Até o início do século, o manejo do sangramento era semelhante em cirurgias eletivas ou cenários de exsanguinação: testes de coagulação eram usados para orientar pedidos de hemoderivados e, enquanto aguardavam esses resultados, uma ressuscitação agressiva com cristaloides era recomendada. A alta taxa de mortalidade em hemorragias graves tratadas com essa estratégia endossou a necessidade de um plano especial de ressuscitação. Como resultado, modificações foram recomendadas para desenvolver uma nova abordagem clínica para esses pacientes, chamada de “Ressuscitação de Controle de Danos”. Essa estratégia inclui quatro princípios: cirurgia de controle de danos, minimização de cristaloides, hipotensão permissiva e ressuscitação hemostática. Esta última envolve o uso de antifibrinolíticos, correção de pré-condições de hemostasia (cálcio, pH e temperatura) e a restauração rápida e precoce do volume intravascular com hemoderivados. Para permitir a disponibilidade e transfusão oportunas de hemoderivados, ações específicas em diferentes áreas hospitalares precisam ser sincronizadas, que geralmente são organizadas por meio de Protocolos de Transfusão Massiva ou, como foram recentemente renomeados, Protocolos de Grandes Hemorragias (MHPs). Embora esses pacotes de ações representem uma mudança de paradigma, aspectos essenciais como sua evolução histórica, fundamentos teóricos, terminologia e elementos operacionais ainda precisam ser bem explorados. Considerando a ampla gama de aplicações dessas ferramentas (departamentos de emergência, radiologia intervencionista, salas de cirurgia e campos militares), é essencial integrar todos os profissionais envolvidos com cenários de hemorragia grave na implementação dos protocolos acima mencionados, desde a concepção até a execução e o gerenciamento. Este artigo de revisão aborda aspectos do MHP relevantes para anestesiologistas, serviços de transfusão e outras áreas envolvidas com o cuidado de pacientes com sangramento grave.
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Submitted date:
11/27/2023
Accepted date:
12/12/2024
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