title: Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit.
abstract: OBJECTIVE
  To audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007.
  
  
  METHODS
  A retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007-2012, Group 2) were compared with a historical cohort (2005-2006, Group 1).
  
  
  BACKGROUND
  Massive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce.
  
  
  METHODS
  After excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical).
  
  
  METHODS
  Our MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications.
  
  
  METHODS
  Primary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints.
  
  
  RESULTS
  After MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering. Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) - the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15-0.61).
  
  
  CONCLUSIONS
  These data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates.
authors.affiliation: Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain.
authors.forename: N
authors.initials: N
authors.lastname: Martínez-Calle
authors.affiliation: Department of Anaesthesia and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain.
authors.forename: F
authors.initials: F
authors.lastname: Hidalgo
authors.affiliation: Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Alfonso
authors.affiliation: Transfusion Medicine, School of Medicine, University of Málaga, Málaga, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Muñoz
authors.affiliation: Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Hernández
authors.affiliation: Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain.
authors.forename: R
authors.initials: R
authors.lastname: Lecumberri
authors.affiliation: Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain. Electronic address: japaramo@unav.es.
authors.forename: J A
authors.initials: JA
authors.lastname: Páramo
mesh_terms: D000328:Adult; D000368:Aged; D001803:Blood Transfusion; D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010949:Plasma; D012189:Retrospective Studies; D014947:Wounds and Injuries
keywords: Hemorragia no traumática; Hemostasia; Hemostatics; Massive bleeding protocol; Mortalidad; Mortality; Non-trauma bleeding; Protocolo de hemorragia masiva; Tasa transfusional; Transfusion ratio