title: Hemostatic Resuscitation in Peripartum Hysterectomy Pre- and Postmassive Transfusion Protocol Initiation.
abstract: BackgroundMassive transfusion protocols (MTPs) have been examined in trauma. The exact ratio of packed red blood cells (PRBC) to other blood replacement components in hemostatic resuscitation in obstetrics has not been well defined.ObjectiveThe objective of this study was to evaluate hemostatic resuscitation in peripartum hysterectomy comparing pre- and postinstitution of a MTP.Study DesignWe conducted a retrospective, descriptive study of women undergoing peripartum hysterectomies from January 2002 to January 2015 who received ≥ 4 units of PRBC. Individuals were grouped into either a pre-MTP institution group or a post-MTP institution group. The post-MTP group was subdivided into those who had the protocol activated (MTP) versus not activated (no MTP). Primary outcomes were estimated blood loss (EBL) and need for blood product replacement. The secondary outcome was a composite of maternal morbidity, including need for mechanical ventilation, venous thromboembolism, pulmonary edema, acute kidney injury, and postpartum infection. A Mann-WhitneyUtest was used to compare continuous variables, and a chi-squared test was used for categorical variables with significance ofp< 0.05.ResultsOf the 165 women who had a peripartum hysterectomy during the study period, 62 received four units or more of PRBC. No significant differences were noted in EBL or blood product replacement between the pre-MTP (n= 39) and post-MTP (n= 23) groups. Similarly, the MTP (n= 6) and no MTP (n= 17) subgroups showed no significant difference between EBL and overall blood product replacement. Significant differences were seen in transfusion of individual blood products, such as fresh frozen plasma (FFP) (MTP = 4, no MTP = 2;p= 0.02) and platelets (plts) (MTP = 6, no MTP = 0;p= 0.03). The use of high ratio replacement therapy for both plasma and plts was more common in the MTP group (FFP/PRBC ratio [MTP = 0.5, no MTP = 0.3;p= 0.02]; plts/PRBC ratio [MTP = 0.7, no MTP = 0;p= 0.03]). There were no differences in the secondary outcome between pre- and post-MTP or MTP and no MTP.ConclusionInitiation of the MTP did result in an increase in transfusion of FFP and plts intraoperatively. At our institution, the MTP is underutilized, but it appears that providers are more cognizant of the use of high transfusion ratios.
authors.affiliation: Department of Obstetrics and Gynecology, Naval Hospital Camp Lejeune, Camp Lejeune, North Carolina.
authors.forename: Eryn H
authors.initials: EH
authors.lastname: Dutta
authors.affiliation: Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, Portsmouth, Virginia.
authors.forename: Aaron T
authors.initials: AT
authors.lastname: Poole
authors.affiliation: Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas.
authors.forename: Faranak
authors.initials: F
authors.lastname: Behnia
authors.affiliation: Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas.
authors.forename: Holly E
authors.initials: HE
authors.lastname: Dunn
authors.affiliation: Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas.
authors.forename: Shannon M
authors.initials: SM
authors.lastname: Clark
authors.affiliation: Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas.
authors.forename: Luis D
authors.initials: LD
authors.lastname: Pacheco
authors.affiliation: Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas.
authors.forename: George R
authors.initials: GR
authors.lastname: Saade
authors.affiliation: Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas.
authors.forename: Gary D V
authors.initials: GDV
authors.lastname: Hankins
mesh_terms: D000328:Adult; D016913:Blood Component Transfusion / Q000379:methods*; D016009:Chi-Square Distribution; D005260:Female; D006487:Hemostasis; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects* / Q000401:mortality; D058725:Peripartum Period; D019106:Postoperative Hemorrhage / Q000628:therapy*; D012151:Resuscitation / Q000379:methods*; D012189:Retrospective Studies; D013781:Texas